Exploring TCM Approaches to Bleeding in Cancer Patients
Cancer patients frequently develop bleeding complications, such as gastric bleeding in gastric cancer patients, bloody stools in colorectal cancer patients or those with radiation enteritis, vaginal bleeding in cervical and vaginal cancer patients, hemoptysis in lung or laryngeal cancer patients, hematuria in kidney and bladder cancer patients, and subcutaneous bleeding in leukemia patients. Many advanced cancer patients with low platelets also develop nosebleeds, purpura, and various other hemorrhagic symptoms.
Generally, when a cancer patient develops bleeding symptoms, the condition is already serious. Treatment at this point should follow the principle of "when the condition is acute, treat the branch (biao)", quickly resolving the bleeding problem. Once the bleeding is controlled, then treat both the branch and the root together, using traditional Chinese medicine, Western medicine, or integrated Chinese-Western medicine to control the proliferation of cancer cells.
There are many causes of bleeding in cancer patients. Rupture of a tumor can cause bleeding; thrombocytopenia leading to coagulation dysfunction can also cause bleeding; and portal hypertension in patients with cirrhotic ascites can also lead to bleeding.
Traditional Chinese medicine holds that the causes of bleeding in cancer patients include the following: (1) blood-heat causing reckless movement of blood; (2) spleen failing to govern blood; (3) blood stasis obstructing the collaterals. There are correspondingly three treatment principles: (1) cooling blood to stop bleeding; (2) supplementing qi and fortifying the spleen to stop bleeding; (3) dispelling stasis to stop bleeding.
The cooling-blood-to-stop-bleeding method mainly targets bleeding due to reckless movement of blood caused by blood-heat, with symptoms including bright red or purplish red blood, fever and irritability, dry throat and thirst, a red tongue with yellow coating, scanty dark urine, and constipation. Representative formulas include Liangdi Dihuang Decoction, Huanglian Jiedu Decoction, Huaihua Powder, and Shihui Powder. Commonly used herbs include Water Buffalo Horn (Shuiniujiao), Raw Rehmannia (Shengdihuang), Coptis (Huanglian), Tree Peony Bark (Mudanpi), Lalang Grass Rhizome (Baimaogen), Thistle (Daji), Lesser Thistle (Xiaoji), Lotus Node (Oujie), Arborvitae Twig (Cebaiye), Eclipta (Hanliancao), Agrimony (Xianhecao), Madder (Qiancao), Arnebia Root (Zicaogen), and Bletilla (Baiji).
Supplementing qi and fortifying the spleen to stop bleeding mainly addresses the syndrome of spleen failing to govern blood that occurs in patients with spleen deficiency and qi deficiency. Such patients generally have relatively large bleeding volume, such as gastric bleeding in gastric cancer patients and vaginal bleeding in cervical cancer patients (called benglou in TCM). After bleeding, patients feel fatigued and weak, with a pale white tongue coating, a deep, fine, weak pulse, dizziness, and faintness. Treatment for such patients should focus on supplementation; in severe cases with desertion syndrome, first use Dosing Ginseng Decoction (Dushen Tang) urgently to rescue, then use a compound formula of Astragalus (Huangqi), Atractylodes (Baizhu), Ginseng (Renshen), Codonopsis (Dangshen), Poria (Fuling), Angelica (Danggui), Donkey Hide Gelatin (Ejiao), Carbonized Human Hair (Xueyu Tan), Carbonized Sanguisorba (Diyu Tan), and Agrimony (Xianhecao) to treat both root and branch. Representative formulas include Huangqi Danggui Buxue Decoction, Guipi Decoction, and Renshen Yangrong Decoction.
Besides gastric cancer and cervical cancer, which can cause massive bleeding, lung cancer patients sometimes also experience massive hemorrhage. I once emergently treated a lung cancer patient with massive bleeding: the lung tumor had ruptured, and hemoptysis filled a basin. Western medicine tried various hemostatic methods, all without effect. The patient's family asked me to find a way, so I had them take a large dose of Bletilla (Baiji, 60–100 g) decocted in water and drink it frequently; the patient's hemoptysis was rapidly resolved within a few hours. After the hemoptysis was greatly reduced, I then used modified Guipi Decoction to regulate and tonify the body, while combining some detoxifying and anticancer herbs to slow the development of the lung tumor.
Patients undergoing radiotherapy and chemotherapy whose blood counts are greatly affected after treatment may also present with spleen failing to govern blood; at such times, treatment can only follow the approach of supplementing qi, fortifying the spleen, and stopping bleeding. My experience is to simultaneously use large doses of hemostatic herbs such as Agrimony (Xianhecao) and Male Fern (Fengweicao), and adopt the approach of supplementing qi, fortifying the spleen, and nourishing blood to improve the patient's anemia.
The stasis-dispelling-and-bleeding-stopping method mainly targets patients with blood stasis syndrome. Such patients generally discharge purplish-black blood, even with clotted masses; besides bleeding, they usually also have pain with a fixed location. Most of these patients already have thrombosis, so treatment should use blood-activating and stasis-resolving formulas or herbs. Commonly used formulas include Siwu Decoction or Taohong Siwu Decoction; commonly used herbs include Salvia (Danshen), Angelica (Danggui), Sichuan Lovage Rhizome (Chuanxiong), Rehmannia (Shengdi), Peach Kernel (Taoren), Safflower (Honghua), Eupolyphaga (Dibiechong), Notoginseng (Sanqi), Flower Stalactite (Huaruishi), Arborvitae Twig (Cebaiye), and Madder (Qiancao).
Radiation enteritis causes chronic diarrhea and bloody stools year-round; such patients need both hemostasis and antidiarrheal treatment. My experience in recent years is to use Pig Skin Decoction (Zhufu Tang) combined with Huaihua Powder, plus Agrimony (Xianhecao), Purslane (Machixian), Chinese Pulsatilla (Baitouweng), Fraxinus Bark (Qinpi), and Male Fern (Fengweicao), made into an electuary or boiled into a jelly for the patient to take long-term. Because the course of treatment for such patients is generally long, it is difficult for them to adhere to taking decoctions.
Traditional Chinese medicine also has the method of warming the meridians to stop bleeding, but in my experience this hemostatic method has very little opportunity for application in cancer patients, and even if used, it should be done cautiously.
Commonly used hemostatic Chinese patent medicines include Yunnan Baiyao capsules, Sanqi capsules, and Huaijiao pills. Among the individual herbs I use, those with good hemostatic effects are Bletilla (Baiji), Agrimony (Xianhecao), and Male Fern (Fengweicao). Bletilla mainly treats gastric and pulmonary bleeding; Agrimony mainly addresses bleeding caused by thrombocytopenia; Male Fern can treat almost all types of bleeding disorders and also has antitumor effects. Unfortunately, it is a folk medicinal herb that has not yet attracted widespread attention, and it is unavailable in most pharmacies.
If using a single herb alone to stop bleeding, the dosage must be large; if the dose is too small, the hemostatic effect will not be obvious. Once the bleeding problem is controlled, the dosage of hemostatic herbs should be reduced. When there is no bleeding, excessive use of hemostatic herbs both wastes medicinal materials and may cause unnecessary side effects.
However, even when hemostasis is successful, cancer patients should not stop using all hemostatic herbs, because the risk factors for bleeding are still present. Using an appropriate amount of hemostatic herbs helps prevent rebleeding. Patients undergoing chemotherapy and taking targeted drugs can also use some hemostatic herbs to help prevent the risk of platelet decline.