Some Understandings and Clinical Experience in Treating Cancer with Oral Chinese Medicine

Review

Humankind has a very long history of understanding cancer.

In the Zhou Li (Rites of Zhou) from the pre-Qin period, there is already a record of the "yongyi" (ulcer physician), a doctor who specifically treats tumor-like ulcer diseases. The ulcer physician's duty was to treat "zhongyong" (swelling ulcers), which included what we today call various benign and malignant tumors. Japan and Korea, deeply influenced by traditional Chinese medicine, still name tumor diseases with the word "swelling ulcer."

In ancient Egyptian papyri from 3,500 years ago, the earliest records of superficial tumors already appear. The first human dissection 2,500 years ago deepened human understanding of tumors into the body. The ancient Greek Hippocrates began to describe malignant tumors of the stomach and uterus, and for the first time called them karkinos (cancer), meaning a crab with claw-like projections that crawls and invades.

The Roman physician Galen, 2,000 years ago, proposed a new understanding of tumors, dividing them into tumors following the course of nature, tumors exceeding the course of nature, and tumors violating the course of nature. This shows that doctors then already recognized that the development of some tumors is uncontrolled.

In modern times, with the development of medical technology, human understanding of tumors has deepened. Both diagnostic and therapeutic techniques have advanced by leaps and bounds compared with antiquity. The use of multidisciplinary comprehensive treatment plans—surgical treatment, medical chemotherapy, nuclear-medicine radiotherapy, molecular targeted therapy, and biological immunotherapy—has made outstanding contributions to improving patient survival.

But even now, human understanding of tumors remains at a limited level. For what reason does a person actually develop a tumor? How should a tumor be treated to be cured? After the tumor is removed, how can one ensure the patient does not relapse? There are as yet no clear answers. Chinese and foreign medical scientists are still in the exploratory stage in understanding and treating this disease.

As early as 3,500 years ago, China's Yin-dynasty oracle bone inscriptions already recorded tumor-type diseases. The Zhou Li · Tianguan not only records the profession of the "ulcer physician" but also proposes treatment principles for swelling-ulcer diseases, advocating the combination of internal and external treatment. Internal treatment: "attack with the five poisons, nourish with the five qi, treat with the five medicines, harmonize with the five flavors." External treatment: "incantation-medicine, and the cutting and killing preparation." Here, incantation-medicine is medicine applied externally; cutting means using knife or needle-like instruments to remove pus and blood; killing means using corrosive medicines to corrode away dead human tissue. "Harmonizing with the five flavors" further emphasizes the role of dietary therapy.

In the Huangdi Neijing, records of tumor-type diseases are much richer: "xiliu" (accumulated nodule), "changtan" (intestinal polyp), "pijie" (glomus binding), "shijia" (stony abdominal mass), "xiben" (pulmonary accumulation), "yeke" (dysphagia), "gezheng" (diaphragm syndrome), "weifan" (stomach reflux), "liyong" (malignant ulcer), and so on, all resemble today's various malignant tumors. The "Yongju" (Ulcer and Abscess) chapter of the Neijing is the earliest TCM monograph on tumor-type diseases.

The Nan Jing (Classic of Difficulties) inherited and developed the content of the Huangdi Neijing. The Nan Jing contains detailed descriptions of diseases resembling today's liver cancer, gastric cancer, lung cancer, and pancreatic cancer, such as "xiben," "feigi" (fat qi), and "piqi" (glomus qi).

In the Jingui Yaolue of the Later Han's Zhang Zhongjing, there is also a dedicated chapter, "On the Pulse, Symptoms, and Treatment of the Five Zang Wind-Cold Accumulation Diseases," which states: "Ji (accumulation) is a zang disease; it never moves. Ju (gathering) is a fu disease; it flares at times, with shifting wandering pain, and is treatable. Gu-qi causes pain below the ribs that resolves on pressure and recurs; this is gu-qi. The great method for all accumulations: a pulse tight and fine, adhering to the bone, indicates accumulation."

Zhang Zhongjing not only recognized tumor-type diseases but also distinguished their benign and malignant degrees and different prognoses. Many formulas recorded in Zhang Zhongjing's Shanghan Lun and Jingui Yaolue—such as Taoren Chengqi Tang, Xia Yuxue Tang, Dahuang Zhechong Wan, Guizhi Fuling Wan, and Biejia Jian Wan—are still commonly used formulas and patent medicines in oncology. Zhang Zhongjing's series of prescriptions also blazed a trail for later generations in the method of activating blood and resolving stasis and in using insect medicines to treat cancer-type diseases.

In the Qianjin Fang of the Tang-dynasty Sun Simiao, the concept of the "five ying and seven liu" (five goiters and seven tumors) was first proposed. The five ying are stone ying, qi ying, fatigue ying, qi ying, and worry ying; the seven liu are flesh liu, bone liu, fat liu, stone liu, pus liu, blood liu, and polyp. His Qianjin Yaofang also records a condition resembling today's breast cancer: "When a woman's or girl's nipple develops small, shallow, hot sores that itch and, on scratching, discharge yellow fluid, spreading and lengthening, and which a hundred treatments do not cure, dragging on for months or years, it is called du ru (jealous breast)." This symptom description closely resembles Paget's disease of the breast. Sun Simiao also valued the use of insect medicines in treating tumor diseases; the anti-cancer insect medicines he frequently used include wugong (centipede), quanxie (scorpion), chantui (cicada slough), and jiangcan (stiff silkworm), which remain common clinical anti-cancer Chinese medicines today.

In the Zhouhou Beiji Fang, the Jin-dynasty Ge Hong said: "All Zheng-jia abdominal masses mostly arise gradually; if only noticed when already firm and large, they are naturally hard to treat. When there is a zheng or binding in the abdomen, it harms eating and drinking, and the person grows progressively emaciated." Ge Hong already recognized that tumor development is a slow and gradual process, and that tumor diseases have a poor prognosis and are hard to treat.

The Zhubing Yuanhou Lun of the Sui-dynasty Chao Yuanfang also has dedicated chapters—the "Jiju Hou," "Yeke Hou," and "Zhengjia Bing Zhu Hou"—specifically discussing tumor-type diseases. It also records ascites-like symptoms resembling those of today's advanced tumor patients: "If the accumulation drags on for years, the person becomes all skin and bones, the abdomen grows large, and death ensues."

The Weiji Baishu by the Song-dynasty Dongxuan Jushi was the first work to mention ai (cancer). He used "yan" (i.e., "rock") to describe malignant tumors, and from this character developed today's character "cancer." This book points out that the characteristic of cancer is being as hard and immovable as a rocky cliff, and able to spread and spread everywhere. The Song-dynasty Yang Shiying described cancer as having "a poison-root hidden deep"; this inspired later physicians to treat tumors with the idea of resolving toxin and dispersing nodules.

By the Jin-Yuan period, Chinese medicine entered a flourishing era. The four great Jin-Yuan masters each had discussions on tumor-type diseases, and the thinking on treating tumors grew richer. The currently used methods of tonification (bu), purgation (gong), downward draining (xia), support (tuo), clearing (qing), and dispersing (xiao) all had their beginnings in this period. Zhu Danxi's idea of nourishing yin and downbearing fire, Li Dongyuan's spleen-stomach theory, Zhang Zihe's attacking-and-downpurging method, and Liu Wansu's theory of fire-heat as a cause of disease all had a far-reaching influence on TCM treatment of tumors in the Ming-Qing period and even today.

Especially in this period, Zhang Jingyue and Zhao Xianke's emphasis on the kidney and the life-gate, together with Li Dongyuan's idea that the spleen and stomach are the acquired foundation, jointly promoted the formation of the fundamental idea of modern TCM oncology's support-the-right treatment—the idea of tonifying the kidney and fortifying the spleen.

The Ming-dynasty Wang Qishi, in his work Li Xuyuan Jian, went further, proposing: "There are three roots of treating deficiency: lung, spleen, and kidney. The lung is the heaven of the five zang, the spleen is the mother of the hundred bones, and the kidney is the root of life and destiny. Treating the lung, the spleen, and the kidney completes the way of treating deficiency." The Qing-dynasty Ye Tianshi pointed out the important role of stomach yin, stating: "Preserve one portion of fluids, and there is one portion of life force." Wang Qishi's emphasis on lung yin and Ye Tianshi's emphasis on stomach yin and fluids compensated for the shortcomings of the kidney-tonifying, spleen-fortifying idea.

As Wang Qishi said: "There are two systems of treating deficiency, governed only by the lung and spleen. Human illness is either yang deficiency or yin deficiency. Those with prolonged yang deficiency also become yin-deficient, but in the end yang deficiency is the root. Those with prolonged yin deficiency must become yang-deficient, but in the end yin deficiency is the root. In all cases where yang deficiency is the root, the treatment has a system, governed by the spleen. Where yin deficiency is the root, the treatment has a system, governed by the lung."

These physicians together laid the foundation for the support-the-right approach to cancer. Later, Zhang Xichun often added Zhimu (Anemarrhena), Maidong (Ophiopogon), and Tiandong (Asparagus) to spleen-fortifying, kidney-tonifying medicines, also to prevent damaging lung and stomach yin when warming and tonifying spleen and kidney yang.

What truly systematized and theorized the TCM treatment of cancer-type diseases were the three great schools of TCM external medicine that formed in the Ming-Qing period.

As early as the Song-Yuan period, there were specialized external-medicine physicians and external-medicine works, such as the Song-dynasty Chen Ziming's Waike Jingyao and the Yuan-dynasty Qi Dezhi's Waike Jingyi. The Ming-dynasty Shen Douheng's Waike Qixuan and Xue Ji's Waike Fahui were also important works of TCM external medicine.

But the systematic therapeutic thinking of TCM external medicine was formed mainly by: the Orthodox school, represented by the Ming-dynasty Chen Shigong (named for his work Waike Zhengzong); the Quansheng school, represented by the Qing-dynasty Wang Weide (named for his work Waike Zhengzhi Quansheng Ji); and the Xinde school, represented by the Qing-dynasty Gao Bingjun (named for his work Yangyi Xinde Ji). Even today, our clinical treatment of tumors is still deeply influenced by these three schools.

Chen Shigong proposed: "The distinction in medicine is internal and external; treating the external is harder than treating the internal. Why? Internal symptoms may not reach the exterior, but external symptoms must root in the interior." So Chen Shigong held that, in treating external diseases, one must both attend to external diagnostic and therapeutic techniques and value internal medicine as the root.

On external treatment, Chen Shigong advocated "opening the door to let out the thief," making it the first priority to bring the toxin outward. He often used wound enlargement and drainage, or knife-needle and corrosive medicines to remove necrotic tissue. Chen Shigong also recorded various relatively advanced surgical techniques of the time, such as nasal polyp removal, sequestrum removal, removal of foreign bodies from the pharynx, tracheal or esophageal suturing, and amputation, as well as external methods such as kaozhi san (cauterizing hemorrhoid powder), kaozhi ding (cauterizing hemorrhoid nails), and the thread-draining method.

On internal treatment, Chen Shigong advocated mainly the dispersing (xiao), supporting (tuo), and tonifying (bu) methods. Influenced by Li Dongyuan, Chen Shigong especially valued the role of the spleen and stomach. He proposed: "Although ulcers and abscesses belong to external medicine, medication is the same as for internal damage," emphasizing that "treating sores relies entirely on spleen earth." Patients should restrain diet, guard against wind-cold, abstain from anger and joy, spare themselves from toil, protect the spleen and stomach, and regulate the body with medicines and food.

The formulas created by Chen Shigong—such as Herong Sanjian Wan, Awei Huapi Gao, and Sanpin Yiqiang—are still widely used today; these are also the formulas I commonly use in clinical treatment of tumor patients.

Wang Weide founded the external-medicine pattern-differentiation and treatment principle based on yin and yang, valuing yin-yang differentiation of sores, ulcers, and abscesses. In treatment he advocated "valuing dispersal and fearing support," contributing a large number of ancestral secret formulas. Among them, Xihuang Wan (today called Xihuang Wan), Xiaojin Dan (today called Xiaojin Wan), Xingxiao Wan (today called Niuhuang Xingxiao Wan), and Yanghe Tang are all famous TCM anti-cancer formulas still in use today.

Wang Weide pointed out: "Treating ulcers and abscesses by channels has spread throughout the world; treating separately by the two divisions of yin and yang is my family alone." Before Wang Weide, most scholars were confined by TCM's six-meridian treatment and zang-fu pattern differentiation, treating ulcers and abscesses by the six meridians and zang-fu. Wang Weide alone pushed back against the crowd and proposed treating separately by yin and yang, embodying the important Huangdi Neijing idea that "in treating disease one must seek its root, the root being yin and yang."

Wang Weide pointed out: "All red ulcers are yang-excess syndromes, with qi and blood hot and the toxin stagnant; white abscesses are yin-cold syndromes, with qi and blood cold and the toxin congealed. For both, the key is to open the couli (texture); once the texture is opened, the red ulcer's toxin settles and pain stops, and the white abscess's cold transforms and blood moves. Those who treat by channels and miss pattern treatment, thinking the medicine matches the channel, in fact go against the pattern. In the world, are there no people who die from yin abscesses? If one treats separately by yin deficiency and yang excess, ulcers and abscesses have no fatal syndrome."

Wang Weide's original insight is very important and grasps the root of tumor-type diseases. I myself am deeply influenced by Wang Weide and have repeatedly used Xihuang Wan and Yanghe Tang to treat tumor diseases, with gratifying results.

But Wang Weide's views are not without bias. Later, the late-Qing external-medicine master Ma Peizhi pointed out that many doctors of the time, influenced by Wang Weide, abused formulas such as Yanghe Tang and Xihuang Wan to treat cancer, with disastrous results.

So Ma Peizhi said of Yanghe Tang: "This formula, for treating yin syndromes, has no equal; used correctly, it cures at once. It must never be used for breast rock (ru-yan); those with yin deficiency and heat, or whose ulcers have been open for a long time, must not touch it with their lips." (See the Ma-commented Waike Zhengzhi Quansheng Ji.) Of course, Ma Peizhi's own comments are also biased; I have myself used Yanghe Tang to treat breast cancer (ru-yan) differentiated as a yin syndrome, with good effect.

Moreover, Wang Weide's claim that treating by channels is worthless is also very one-sided. Today's hepatobiliary-series cancers, treated according to shaoyang syndrome with the Bupleurum series of formulas, have good results. So one cannot say that treating by channels is worthless.

Gao Bingjun was influenced by the Warm Disease school that rose in the Qing, valuing the sanjiao syndrome and disease patterns. He proposed: "Those in the upper part all belong to wind-warmth and wind-heat, because wind tends to move upward; those in the lower part all belong to damp-fire and damp-heat, because water tends downward; those in the middle mostly belong to qi depression and fire depression, because qi and fire both arise in the middle." He established the method of seeking cause by region, providing a simple and practical approach to diagnosing and treating external diseases and pointing out the principles of clinical medication.

I have personally seen several contemporary TCM masters treat cancer with the Warm Disease approach, with quite good results: for example, Kong Sibo habitually uses Wuwei Xiaodu Yin, Pei Yongqing habitually uses Sanren Tang, and Zhao Shaoqin habitually uses Shengjiang San and other famous Warm Disease formulas to treat cancer, all with good efficacy. Among cancer patients, those with blocked sanjiao and disordered ascending-descending qi are also quite common; so the Xinde school founded by Gao Bingjun also has clinical efficacy. Many contemporary TCM colleagues, embracing the Fire God school, look down on the Warm Disease school; this kind of narrow sectarianism is most undesirable.

Since the late-Qing Wang Qingren (author of Yilin Gaicuo), Tang Rongchuan (author of Xuezheng Lun), and Zhang Xichun (author of Yixue Zhongzhong Canxi Lu) valued the role of blood stasis in cancer-type diseases, the method of activating blood and resolving stasis has gradually become one of the most important therapeutic approaches for tumor diseases. Wang Qingren's Gexia Zhuyu Tang and Shaofu Zhuyu Tang are commonly used modern TCM anti-cancer formulas. Zhang Xichun's Shiquan Yuzhen Tang is also a commonly used clinical anti-cancer formula.

In 1971, Folkman proposed that tumor growth and metastasis are angiogenesis-dependent, and that blocking angiogenesis is an effective strategy to contain tumor growth. In 1976, Gullion found that premalignant tissue cells acquire angiogenic capacity as they evolve into cancer. In recent years, modern medical workers have conducted extensive and in-depth research on the mechanism of tumor angiogenesis and achieved more results. In the precancerous state, the lesion has no blood vessels; but in early cancer, there are punctate or small blood-flow signals; by the progressive stage, blood-flow signals within the tumor are abundant. This has become a consensus in tumor medicine.

Modern pharmacological experiments have also confirmed that many blood-activating, stasis-resolving Chinese medicines and formulas have a clear ability to inhibit tumor angiogenesis. For example, the anti-cancer action of Xihuang Wan is believed to be related to its blocking of tumor angiogenesis and destruction of vessels already formed within the tumor, and it is dose-dependent. Animal experiments confirm that, within the dose range animals can tolerate, the larger the dose and the higher the instantaneous blood-drug concentration, the stronger Xihuang Wan's ability to inhibit intratumoral vessels.

The achievements of contemporary TCM anti-cancer work are even more spectacular. Professor Yu Rencun was the first to propose that the fundamental mechanism of tumor disease is righteous deficiency with evil excess, so treatment should be based on supporting the righteous and dispelling the evil. Professor He Ren was both a TCM master and a tumor patient himself, and his understanding of tumor disease is very deep. His twelve-character principle—"constantly support the righteous, dispel evil at the right time, treat according to the pattern"—highly summarizes the basic treatment principle of TCM anti-cancer. Old physician Sun Bingyan is known for treating cancer with using poison to attack poison; Professor Sun Guizhi is known for valuing the spleen and stomach and commonly using heat-clearing and toxin-resolving therapy. These anti-cancer masters have all opened new avenues for TCM anti-cancer work.

In summary, all disease can be reduced to what the Huangdi Neijing says: "Where the evil gathers, the qi must be deficient"; "When the righteous qi is stored within, the evil cannot interfere." Cancer is no exception. As a systemic disease, cancer's pathogenesis is related both to evil excess and to decline of the body's righteous qi. As Li Zhongzi said in the Yizong Bidu: "The formation of accumulation is due to insufficient righteous qi, after which the evil takes up residence; it is like petty men at court because of the decline of noble men."

So the cause of cancer, fundamentally, is righteous deficiency and evil excess; in treatment, one should also base oneself on supporting the righteous and dispelling the evil. But when to support and when to dispel, how to support and how to dispel, and how strongly to do each, truly test a doctor's basic skill and experience.

A passage from Li Zhongzi's Yizong Jinjian highly summarizes the principles to grasp in treating cancer: "Righteous qi and evil qi cannot stand together; like the low and the high, when one prevails the other fails. The evil grows daily, the righteous dwindles daily; if not attacked and removed, death follows. But if the attack is too hasty, the righteous is in turn injured. The three methods of early, middle, and late stages must be explained. In the early stage, the evil has just arisen, the righteous is still strong and the evil still shallow, so the body can bear attack. In the middle, the illness has lasted a while, the evil is deeper and the righteous weaker, so it can bear both attack and tonification. In the late stage, the disease has long endured, the evil has invaded, and the righteous is exhausted, so it can bear only tonification. For accumulation, by definition, is built day by day, not in a single morning or evening; so removing it must also be gradual. Too hasty and the righteous is injured; once the righteous is injured, it cannot transform and transport, and the evil instead becomes fixed."

This thinking of Li Zhongzi's is precisely the guiding thought that a tumor physician should carry through from start to finish when diagnosing and treating a cancer patient. Modern patients: not only does having cancer itself destroy their righteous qi, but surgery, radiotherapy, and chemotherapy also destroy their righteous qi. So the problem of righteous deficiency and evil excess is widespread. As a physician, one must, according to the patient's concrete physical state, differentiate deficiency and excess, and grasp the measure and force of attack and tonification, in order to achieve the effect of "keeping the person alive to treat the disease."

Xu Lingtai said: "In a sick person, if the original qi is unharmed, though the illness is severe he does not die; if the original qi is harmed, though the illness is light he dies. So one who decides life or death by examining the disease looks not at the severity of the illness but at the survival or loss of the original qi." Zhang Jingyue also pointed out: "There has never been a case where the righteous qi recovered and the evil did not retreat, nor one where the righteous qi was exhausted and life did topple." Even Zhang Zihe, famous for downward attacking, said: "When using medicine, further examine the lightness or heaviness. If the block has lasted long, carefully avoid lightly attacking; even if you attack it open, you must consider future trouble, and should first moisten and nourish."

So Li Zhongzi himself, in treating accumulation-type diseases, had the following characteristics: first, according to the patient's concrete state, he attacked for a few days, then tonified for a few days, cycling thus. Second, in his medication—for example, his Yinyang Jiji Wan—he started from the minimum dose, letting the patient increase the dose day by day; once the patient developed loose stools, he restarted from the minimum dose and gradually increased again. This treatment method attends to the patient's righteous qi, never forgetting to dispel evil while supporting the righteous, and never forgetting to support the righteous while dispelling evil; treating slowly and gently, it fully embodies the principle that medicine should be safe and effective.

But one must not hesitate and advance slowly, only supporting the righteous and never dispelling evil. Some doctors are timid and dare only prescribe gentle peace formulas that support the righteous, hoping the righteous will recover and the tumor will resolve on its own. So they never leave the range of such tonics as Sijunzi Tang, Siwu Tang, Guipi Tang, Buzhong Yiqi Tang, and Shiquan Dabu Tang, not daring to move a step forward; this, too, will delay the patient's treatment.

In the Shiyong Zhongyi Neixue (Practical TCM Internal Medicine) edited by Academician Wang Yongyan, the author, when discussing the role of righteous and evil qi in disease, mentions the importance of righteous qi, but also emphasizes that evil qi is the chief culprit causing disease. Merely supporting the righteous without dispelling evil will also delay the patient and miss the therapeutic opportunity.

So what are the specific TCM approaches to dispelling evil in anti-cancer treatment? Modern TCM oncology, based on the records of TCM classics through the ages and on modern pharmacological research, roughly summarizes the anti-tumor treatment principles as follows: heat-clearing and toxin-resolving; yang-warming and collateral-unblocking; blood-activating and stasis-resolving; phlegm-dissipating and fluid-routing; qi-regulating and stagnation-dispersing; downward draining and water-expelling; hardness-softening and nodule-dispersing; astringing and securing; and using poison to attack poison.

This is because our TCM community, based on historical records of tumor diseases and on clinical observation, has summarized the pathogenic factors of tumors as mainly: insufficient righteous qi, disordered qi movement, irregular diet, internal accumulation of toxin-evil, injury by the seven emotions, binding of blood stasis, and congelation of phlegm-dampness. Hence this consensus on the basic principles of treating cancer.

In fact, in tumor treatment one should also add emotional regulation, dietary regulation, and exercise regulation, but this part must be accomplished mainly by the patient. As the Huangdi Neijing says, "The physician is the branch, the disease is the root"; in treating disease, the physician, as the "branch," is only secondary, while the patient is the root. The patient regulating his own emotions, changing his diet and sleep habits, exercising, and managing emotions and weight has a great influence on the therapeutic effect; in a certain sense, these are the truly decisive factors in whether a cancer patient can survive long-term.

Traditional TCM holds that people fall ill through internal causes, external causes, and causes neither internal nor external. Internal causes are the seven emotions—joy, anger, worry, thought, grief, fear, and fright—plus dietary and fatiguing damage and bedroom damage. External causes are the six excesses—wind, cold, dryness, dampness, summerheat, and fire. Causes neither internal nor external are injuries from accidents. The causes of tumor diseases are complex, with every factor playing a role in tumor occurrence. To stop the boiling by lifting the pot is less good than to remove the firewood; it is very important that the patient actively participate in finding and correcting the causes of his illness; one cannot rely on the doctor's treatment alone.

Sometimes it is even necessary for the patient's family to recognize that the patient's cancer may also be related to a bad family environment; family disharmony is an important cause of cancer in some patients. For example, in discussing the causes of ru-yan (breast rock/breast cancer), medical scholars through the ages have held that strained interpersonal relations such as discord between mother-in-law and daughter-in-law, or between husband and wife, are an important cause. "Shirong" (loss of splendor—thyroid cancer, lymphoma, or lymph-metastatic tumor) is related to the patient's loss of former wealth and status and ensuing depression, hence the name "loss of splendor." So cancer treatment is not merely a medical problem but also a family and social problem.

TCM treatment principles and methods for cancer

Let me introduce one by one the treatment principles and methods for cancer formed in contemporary TCM. TCM treats disease following the order of principle-method-formula-medicine. In TCM, the therapeutic method is subordinate to the treatment principle; only after the principle is fixed does the method follow. The overall TCM treatment principle for tumor diseases, in summary, is: tonify the deficient, pare the hard, scatter the bound, clear the hot, warm the cold, and warm the fatigued. From these principles arise many therapeutic methods. Below I briefly discuss these methods.

• The method of supporting the righteous and securing the root

A tumor patient has both a local evil-excess accumulation-type disease and a systemic deficiency disease of declining zang-fu function. So Professor He Ren specifically proposed that in treating tumors one should "constantly support the righteous." Earlier I mentioned the support-the-rightive ideas of tonifying the kidney and spleen, supplementing lung qi, and nourishing stomach yin. These are all common support-the-root approaches.

But each patient is a concrete individual, and in clinical treatment there is no support-the-rightive approach that fits all patients. The doctor must, according to the patient's concrete state, prescribe a targeted formula, harmonize yin and yang, supplement qi and blood, and build up original qi, so that the patient recovers righteous qi. Generally, tonifying Chinese medicines and formulas follow the ideas of: supplementing qi, supplementing blood, supplementing both qi and blood, fortifying the spleen, tonifying the kidney, supporting yang, and nourishing yin.

Common qi-supplementing formulas include Sijunzi Tang, Buzhong Yiqi Tang, Shengmai Yin, and Yuping Feng San; common qi-supplementing herbs include Renshen (ginseng), Huangqi (Astragalus), Baizhu (Atractylodes), Dangshen (Codonopsis), Taizishen (Pseudostellaria), Shanyao (Dioscorea), Baibiandou (white hyacinth bean), Huaishanyao, Fuling (Poria), Gancao (licorice), and Dazao (jujube).

Common blood-supplementing formulas include Siwu Tang and Danggui Buxue Tang; common blood-supplementing herbs include Danggui (Angelica), Ejiao (ass hide glue), Shudi (rehmannia), Baishao (white peony), Ziheche (placenta), Lujiaojiao (deer antler glue), and Jixueteng (Spatholobus).

Common dual qi-and-blood supplementing formulas include Bazhen Tang, Guipi Tang, and Shiquan Dabu Tang.

Common yin-nourishing formulas include Liuwei Dihuang Wan and Dabuyin Wan; yin-supplementing herbs include Shengdi (raw rehmannia), Guiban (turtle shell), Biejia (soft-shelled turtle shell), Mohanlian (Eclipta), Nüzhenzi (Ligustrum), Tiandong (Asparagus), Huangjing (Polygonatum), Maidong (Ophiopogon), Yuzhu (Polygonatum odoratum), and Jiaogulan (Gynostemma).

Common yang-supplementing formulas include Jingui Shenqi Wan and Yougui Wan; common yang-supporting herbs include Fuzi (aconite), Rougui (cinnamon bark), Duzhong (Eucommia), Lujiaojiao, Buguzhi (Psoralea), Yinyanghuo (Epimedium), Xianmao (Curculigo), Roucongrong (Cistanche), and Bajitian (Morinda).

In addition, Xiaojianzhong Tang and Huangqi Jianzhong Tang, used to treat deficiency fatigue, are also tonifying formulas I commonly use. In supporting the root, one need not be confined to a single approach; many patients are in a state of dual yin-yang deficiency, dual qi-blood deficiency, or deficiency of spleen, lung, and kidney all at once. At such times the physician should, according to the patient's concrete state, act on multiple fronts to supplement the patient's deficiencies.

When giving support-the-rightive treatment, one should guard against over-tonifying in one direction and over-tonifying. One should also note that today's patients, once ill, are basically like frightened birds, already taking all kinds of health supplements on their own; in this situation, overusing tonics is likely to bring side effects. For example, ginseng-abuse syndrome, or the "fire rising, pot drying" of excessive yang support caused by aconite.

Currently, promoted by merchants, ginseng, lingzhi (Ganoderma), deer antler, cordyceps, sea cucumber, and various related products are very popular among cancer patients. Doctors should correct patients' mistaken beliefs about tonics, fully understand the various health supplements and tonics patients are taking on their own, and prevent the disaster of reckless tonification.

• The method of clearing heat and resolving toxin

The Huangdi Neijing has the treatment principles of "treat heat with cold" and "warm the warmed." Some cancer patients show heat-toxin, warmth-heat, fire-toxin, or blood-heat signs: a rapid, forceful pulse, dry stool or heat dysentery, yellow-red urine, a burnt-yellow, dry tongue with little coat, thirst, and irritability. For these patients with obvious heat signs, treatment should focus on clearing heat and resolving toxin.

Modern pharmacology has also confirmed that Pugongying (dandelion), Lianqiao (forsythia), Jinyinhua (honeysuckle), Banzhilian (Scutellaria barbata), Baihua Sheshicao (Oldenlandia), Chonglou (Paris), Shandougen (Sophora tonkinensis), Kushen (Sophora flavescens), Huangqin, Huangbai (phellodendron), Yuxingcao (Houttuynia), Xiakucao (prunella), Baijiangcao (patrinia), Chuanxinlian (Andrographis), Zhizi (gardenia), Mudanpi (moutan), Digupi (lycium bark), Shishangbai, Tufuling (Smilax glabra), Machixian (portulaca), Banlangen (isatis root), Daqingye, Sheng Shigao (raw gypsum), and Shuiniujiao (buffalo horn) do have reasonably good anti-cancer effects.

Heat-toxin is both a major cause of tumors and one of the pathogenic patterns when tumors invade and change. The heat in tumor patients is basically interior heat. But each patient's heat is not quite the same: there is lung heat, stomach heat, liver heat, heat in the qi aspect, heat in the blood aspect, and various cases of damp-heat intertwined. In treatment, one must conduct the four examinations in detail, carefully differentiate patterns, and compose the formula reasonably according to the patient's concrete state.

Xianfang Huoming Yin, Yunü Jian, Wuwei Xiaodu Yin, Simiao Yong'an Tang, Niubang Jiejí Tang, and Huanglian Jiedu Tang are all historically famous representative heat-clearing, toxin-resolving formulas that can be used to treat tumor diseases.

Heat-clearing and toxin-resolving medicines easily injure the spleen and stomach; those with spleen deficiency and diarrhea should use them cautiously, or pair them with spleen-fortifying, qi-boosting herbs, with stagnation-resolving and food-digesting herbs, and with kidney-warming, astringing-securing herbs. Moreover, such medicines should not be taken in large doses for long periods; if long-term use is needed, consider processing them into pills or powders, or reducing the dose and treating slowly. It is also necessary to let the patient take the medicine for three to five days and pause for a day or two, to prevent excessive injury to the spleen and stomach.

Currently, heat-clearing and toxin-resolving formulas have become the most widely used formulas in TCM oncology clinics, and their drawbacks are also great. Some patients take heat-clearing decoctions without a break all year round, until in the end they injure spleen yang, cannot eat, and suffer serious consequences.

I once treated a patient from Dongying, Shandong, and one from Guilin; both, after using heat-clearing and toxin-resolving formulas for too long, could not even drink water, their appetites badly ruined. My experience is to first treat such patients with Xiaojianzhong Tang or Xiaojianzhong Tang minus yitang (malt sugar), or with Guizhi Tang, to regulate the spleen and stomach; generally after three to five days the appetite gradually recovers and they desire food. Then use formulas like Guipi Tang or Buzhong Yiqi Tang to restore the patient's original qi.

I once treated a patient from Guilin who, after taking ya-dan-zi (Brucea javanica) for a time, could only be kept alive on nutrient fluids, unable to eat for a long time, vomiting whenever he ate, bedridden for a long time. After I treated him with Xiaojianzhong Tang for a week, he could not only eat and drink but also ride his bicycle out to exercise. Later I used other medicines to regulate him, extending his life for a time and improving his quality of life.

• The method of warming yang and unblocking collaterals

According to the treatment principle of "treat cold with heat," patients whose cause is cold congealing and blood stasis should use the method of warming yang and unblocking collaterals.

Wang Hongxu, author of the Waike Zhengzhi Quansheng Ji, is the representative of using yang-warming, collateral-unblocking to treat yin abscesses. The name of his ancestral famous formula "Yanghe Tang" means "once yang harmony turns, ice and snow melt." I have used this formula clinically many times, with obvious effect, and I am deeply impressed by this yang-warming, collateral-unblocking approach.

Patients with cold congelation and blood stasis often have yang-deficiency signs: a slow pulse, aversion to cold, loose or normal stool, clear, long urine; even some patients show sore and weak loins and knees and frequent urination. Cold congelation is often accompanied by blood stasis; this type of yang-deficiency patient needs warming-type Chinese medicines to warm yang and unblock collaterals; one must not abuse heat-clearing and toxin-resolving medicines, treating cold with cold, or the disease must worsen.

Common yang-warming, collateral-unblocking formulas include Yanghe Tang, Guizhi Wutou Tang, and Mahuang Xixin Tang; common herbs include Fuzi, Guizhi (cinnamon twig), Mahuang (ephedra), Xixin (asarum), Rougui, Ganjiang (dried ginger), Shengjiang, Congbai (scallion white), Lujiaojiao, Lujiaoshuang (deer antler frost), Lurong (deer antler), Bajitian, Yinyanghuo, Xianmao, Weilingxian (Clematis), Chuanwu (Aconitum carmichaelii), Caowu (Aconitum kusnezoffii), Duzhong, Xuduan (Dipsacus), Buguzhi, Yizhiren (Alpinia oxyphylla), and Tusizi (Cuscuta).

• The method of activating blood and resolving stasis

The blood-activating, stasis-resolving method embodies the treatment principle of "pare the hard." It is a great TCM anti-cancer method; from antiquity to the present, its formulas are too many to count. From Zhang Zhongjing's Xia Yuxue Tang, Biejia Jian Wan, Dahuang Zhechong Wan, and Taoren Chengqi Tang in the Jingui Yaolue and Shanghan Lun, to Wang Qingren's six classic Zhuyu Tang and Zhang Xichun's Huoluo Xiaoling Dan, all are famous blood-activating formulas. Siwu Tang plus Taoren (peach kernel) and Honghua (safflower) becomes the blood-activating Taohong Siwu Tang. Danshen Yin, for stomachache due to qi stagnation and blood stasis caused by gastric cancer and the like, and Haifu San, which activates blood and stops pain—these famous blood-activating formulas play a large role in cancer treatment.

Common blood-activating, stasis-resolving herbs include Danshen (Salvia), Chishao (red peony), Taoren, Honghua, Sanqi (pseudoginseng), Yujin (curcuma), Jianghuang (turmeric), Yanhusuo (Corydalis), Ruxiang (frankincense), Moyao (myrrh), Sanleng (Sparganium), Ezhu (Curcuma zedoaria), Shuizhi (leech), Quanxie (scorpion), Wugong (centipede), Banmao (blister beetle), Tubiechong (Eupolyphaga), Shijianchuan (Salvia chinensis), Xuejie (dragon's blood), Ercha (catechu), Sumu (sappwood), and Chuanshanjia (pangolin scales). Blood-activating, stasis-resolving herbs are widely present in various famous anti-cancer formulas.

But when applying the blood-activating method, one must note carefully: patients whose tumor has already ulcerated and who have a bleeding tendency must not be given blood-activating herbs, lest the condition worsen. Patients with portal hypertension and gastric bleeding should avoid blood-activating herbs; if unavoidable, they must be paired with hemostatic herbs such as Baiji (Bletilla), Xianhecao (agrimony), Diyu tan (charred Sanguisorba), Puhuang tan (charred Typha), and Xueyu tan (charred human hair).

Some scholars' research shows that the blood-activating, stasis-resolving method may promote hematogenous metastasis of cancer. Animal experiments show that blood-activating herbs such as Danshen, Chishao, and Shuizhi can promote hematogenous metastasis of cancer, so some scholars say blood-activating herbs must not be abused. But other scholars have found that when blood-activating herbs are paired with spleen-fortifying, water-draining Baizhu and Fuling, they do not promote hematogenous metastasis. Chinese medicine is rarely used alone to treat disease, and whether a compound formula promotes hematogenous metastasis has not yet been much studied. Given that this question is still controversial, one should be as cautious as possible in using such formulas and herbs.

My own practice confirms that blood-activating, stasis-resolving herbs can indeed shrink tumors, even eliminate them. Because in most cases I prescribe compound formulas, it is hard to speak separately of the role and side effects of the blood-activating herbs within them.

As with heat-clearing herbs, blood-activating herbs must not be used long-term; long-term use risks causing gastric bleeding and cardiovascular or cerebrovascular events. My personal habit is to use, alongside blood-activating herbs, a moderate amount of hemostatic Chinese medicines such as Baiji, Xianhecao, and Fengweicao (Pteris multifida), creating an opposing-yet-complementary effect. This opposing-yet-complementary approach is common in TCM formulas. For example, in some yang-supporting formulas, a moderate amount of yin-nourishing herbs is added to help protect yin fluids. Just as Shenqi Wan, amid a large group of kidney-tonifying herbs, also adds a small amount of Zexie (Alisma) to drain kidney turbidity, preventing over-tonification of the kidney and the patient's developing yin excess or yang hyperactivity.

Generally, cancer patients with skin like fish scales, a dark, sallow complexion, varicose veins or stasis spots under the tongue, cyanotic lips and tongue, localized pain with a fixed location, worse at night and lighter by day, and a rough pulse all show signs of blood stasis. Applying the blood-activating method to such patients helps relieve the condition.

Fifth, the method of dissipating phlegm and dispersing nodules.

Phlegm-fluid retention is the body's excess yin fluids, retained in the body, forming the kind of lesion the Japanese Kampo physician Dōmoto Shinkyū called the body's own water retention and water-poisoning. Zhu Danxi said: "On a person's body, upper, middle, and lower, lumps are mostly phlegm." TCM has always held that strange diseases should be blamed on phlegm. So dissipating phlegm and dispersing nodules is an important means of treating cancer.

Common phlegm-dissipating, nodule-dispersing herbs such as Banxia (Pinellia), Chenpi (tangerine peel), Dannanxing (bile Arisaema), Gualou (Trichosanthes), Shancigu (Cremastra), Zhebeimu (Zhejiang fritillary), Chuanbeimu (Sichuan fritillary), Tubeimu (Bolbostemma), Tinglizi (descurainia), Haifushi (pumice), Muli (oyster shell), Longgu (dragon bone), Qianhu (Peucedanum), Xingren (apricot kernel), Baijiezi (white mustard seed), Juhong (red tangerine peel), Baibu (Stemona), Ziwan (Aster), Jiegeng (platycodon), Baiqian (Cynanchum), Xuanfuhua (Inula), Yuanzhi (Polygala), Shichangpu (Acorus), and Zhuru (bamboo shavings) also have a clear inhibitory effect on cancer growth.

The famous phlegm-dissipating, nodule-dispersing formulas Erchen Wan, Juhua Huatan Wan, and Jupi Zhuru Tang have, for some cancer patients whose clinical symptoms present as nausea, vomiting, and cough, not only a good anti-tumor effect but also an immediate symptom-relieving effect.

Cancer patients undergoing chemotherapy or taking targeted drugs also often develop various gastrointestinal adverse reactions, nausea and vomiting being the most common. I mostly treat these with Erchen Wan or Jupi Zhuru Tang, with obvious effect.

Sixth, the method of draining water and excreting dampness.

"Water-dampness causing mischief" is a common symptom in tumor patients. The water-damp evil is both a pathogenic factor of tumors and a pathological product of malignant tumors. Cancer patients, by the middle and late stages, universally develop cachexia. Ascites, pleural effusion, pericardial effusion, pelvic effusion, and limb edema are quite common. So using water-draining, dampness-excreting herbs early in cancer patients both drains dampness and prevents the onset of various cachexias.

Common water-draining, dampness-excreting herbs such as raw Huangqi, Yiyiren (Coix seed), Fuling, Zhuling (Polyporus), Baizhu, and Cheqiancao (plantain herb) can clearly improve patients' quality of life and prolong survival. So when I treat cancer patients, even those without obvious cachexia, I usually include some water-draining herbs. Especially for primary or secondary liver cancer patients and ovarian tumor patients prone to ascites, the earlier the water-draining, dampness-excreting herbs are used, the better.

Dampness and water are most closely related to the three zang of lung, spleen, and kidney. The lung governs the regulating of waterways; the spleen governs the transportation and transformation of water-dampness; the kidney is the water zang, and when the kidney is deficient, water-dampness floods. In addition, the bladder and kidney are exterior-interiorly paired, so water-dampness also relates to the bladder. So water draining and dampness excreting should start from the lung, spleen, kidney, and bladder. Fortifying the spleen, boosting the kidney, supplementing lung qi, and promoting recovery of the bladder's qi-transformation function will help expel the water-dampness that is causing mischief in the patient.

But water draining and dampness excretion is also the hardest part of treating the various complications of cancer patients. When most patients develop cachexias such as pleural or ascitic fluid, they are usually not far from the end. Because of the influence of modern medicine, especially because some Western doctors, out of personal prejudice, oppose patients using Chinese medicine, many patients seek TCM help only after developing severe cachexia. Generally, by then, TCM treatment is too late.

There are very many TCM water-draining, dampness-excreting formulas. Among classical formulas, the Linggui Zhu series mostly have a water-draining effect. The Shenqi Wan series also have a water-draining effect; the former mainly fortifies the spleen, the latter mainly tonifies the kidney. Fangji Fuling Tang, Huangqi Fangji Tang, and even Guipi Tang all have a water-draining, dampness-excreting effect; these are also famous spleen-fortifying, water-draining formulas. For patients with yang deficiency and water flooding, one should use formulas such as Zhenwu Tang to warm and tonify spleen and kidney yang, in order to achieve a water-draining effect. Ji Jiao Li Huang Wan is the representative formula for draining the lung and expelling water. Zhizi Yinchen Tang is the famous formula for jaundice and edema caused by damp-heat pouring downward. I have even used Guizhi plus Fuling Tang to treat pleural and ascitic fluid, with good effect.

Which plan to choose for draining water and excreting dampness should depend on the patient's constitutional state and cannot be generalized.

Common water-draining, dampness-excreting herbs include Yiyiren, Huangqi, Fuling, Fulingpi (Poria peel), Zhuling, Zexie (Alisma), Cheqianzi (plantago seed), Cheqiancao, Dafupi (areca peel), Qumai (Dianthus), Huashi (talc), Bianxu (polygonum aviculare), Sangbaipi (morus bark), Yumixu (corn silk), Bamaogen (imperata root), Cangzhu (atractylodes), Huoxiang (agastache), Peilan (eupatorium), Qianghuo (notopterygium), Fangfeng (saposhnikovia), Niuxi (achyranthes), Chixiaodou (red bean), Mugua (quince), Tongcao (rice-pith), Yinchenhao (artemisia capillaris), Houpo (magnolia bark), and Laifuzi (radish seed).

In addition, among foods, winter melon, radish, bottle gourd, calabash, loofah, Job's tears, and red beans all have a reasonably good water-draining, dampness-excreting effect. One may suggest patients use dietary therapy instead of drug therapy. I often suggest patients stew these foods with silver carp or crucian carp as a substitute for water-draining medicine. When stewing, one can wash the winter melon peel and bottle-gourd peel; after peeling, put the peels into the stew with the vegetables and meat, and remove the peels when eating. Stewing and eating with the peel gives a better water-draining, dampness-excreting effect.

Long-term, large-dose use of water-draining, dampness-excreting herbs also brings side effects. With too many water-draining herbs, the patient develops side effects such as chapped skin, dry stool, dry mouth, and frequent urination. So when using medicine one should follow the principle of stopping once the disease is reached. Preventive water-draining, dampness-excreting therapy can be replaced by dietary therapy. Professor He Ren, all his life, used only two herbs—raw Huangqi and Yiyiren—cooked together into porridge. To prevent fortifying the spleen from harming the kidney, it is also necessary to add a moderate amount of kidney-tonifying herbs such as Gouqizi (lycium fruit) and Sangshen (morus fruit).

Seventh, the method of downward draining and water expulsion.

Advanced cancer patients, especially end-stage ones, frequently have difficulty passing stool or urine. With the evil having no exit, yin block or yang block gradually forms, and edema, guan-ge (block-and-reject), or intestinal obstruction appears. At such times one must use some downward-draining, water-expelling formulas to wash away repletion evil and unblock the sanjiao.

Downward-draining, water-expelling medicines are mostly fierce and have large side effects. But advanced tumor patients in modern society, after surgery, radiotherapy, chemotherapy, and targeted therapy, are mostly frail; when using drastic downward-draining agents, one must especially take care to protect righteous qi. The doctor must closely observe the patient's changes. When using fierce downward-draining, water-expelling herbs, once the patient's stool and urine move, one should promptly switch to a milder formula; even if there is medicine left unfinished, it need not be completed.

The Chengqi Tang series of formulas has a good effect on the dry, bound stool of advanced patients and on the constipation of patients with incomplete intestinal obstruction. The doctor should not tire of palpating the patient's periumbilical area; if the periumbilical area is board-like and knotted, one may consider using the Chengqi Tang series to unblock the stool. If the abdomen is soft, even if the patient has not defecated for days, one must not rashly use the downward method.

In using the Chengqi Tang series, one should fully consider the patient's constitution. If the patient is reasonably strong, one may use the more drastic of the Chengqi formulas—Da Chengqi Tang, Xiao Chengqi Tang, and Taoren Chengqi Tang. The frail, when using Chengqi Tang, should consider combining with the tonifying method. One may use attack-and-tonify-in-one formulas such as Xinjia Huanglong Tang to unblock the six fu. Or, like Zhang Zhongjing, first give Tiaowei Chengqi Tang, observe the patient's reaction, then decide. If, after taking Tiaowei Chengqi Tang, the patient can pass gas but the stool has not yet moved, then, as appropriate, increase the downward-purging force.

What I personally commonly use is my own modified Zengye Chengqi Tang—that is, on the basis of Zengye Chengqi Tang, add a moderate amount of Baishao and Danggui, Huomaren (hemp seed), Juemingzi (cassia seed), and other herbs that nourish yin and fluids, moisten the intestines to unblock the bowels, and clear and drain liver fire.

Besides difficulty passing stool, there is also the condition of severe difficulty urinating. Generally, one uses some drastic water-draining formulas to unblock the urine. But I personally do not recommend using fierce water-expelling medicines such as Zhouche Wan, Shi Zao Tang, or Zilong Wan to treat the cachexia of advanced cancer patients; from what I have seen, advanced cancer patients who abuse such drastic downward-draining, water-expelling medicines mostly cannot be saved.

These medicines are fierce and seem more suitable for pleural or ascitic fluid due to pleurisy or peritonitis in patients who are still reasonably robust. These drastic downward-draining, water-expelling medicines mostly greatly damage original qi, and pleural or ascitic fluid does not, once drained away, stay gone forever. Many patients' pleural or ascitic fluid clears in the morning and rises again in the afternoon; clears at night and rises again the next morning. If one has not found a root-treating method and merely uses such fierce water-expelling medicines for momentary relief, the future trouble is endless.

For advanced cancer patients with particularly severe blockage of both stool and urine, one should instead use the steadier approach of spleen-fortifying water draining, qi-transforming water draining, and kidney-tonifying water draining, combined with formulas that regulate the qi mechanism of the sanjiao, regulating slowly, prolonging the patient's life as much as possible and reducing suffering. A few patients, under this steady approach, can also pass through the danger period and regain a period of higher-quality survival. I have treated several end-stage ascites patients without using too many water-draining herbs, instead emphasizing fortifying earth and tonifying the kidney and regulating the qi mechanism; the patients' condition improved greatly, and in the end the cachexia even disappeared completely.

• The method of soothing and regulating the qi mechanism

Qi stagnation is one of the important mechanisms of malignant tumors; middle- and late-stage malignant tumor patients, nine in ten, are accompanied by qi stagnation and blocked sanjiao. Especially in patients with breast, lung, esophageal, gastric, liver, gallbladder, pancreatic, or colon cancer, qi stagnation is even one of the important causes of their cancer.

Patients with late-stage cancer fever are also often accompanied by qi stagnation symptoms. Cancer-fever patients tend simultaneously to have fullness and oppression in the chest and diaphragm, distending pain in the epigastrium, sticky, unpleasant stool, and difficult urination; with damp-heat bound together like oil poured over noodles, ordinary exterior-releasing fever medicines are not very effective. At such times one must use formulas that both transform dampness and regulate the qi mechanism, such as Dayuan Yin, Sanren Tang, and Shengjiang San, before it works. In treating severe qi stagnation in advanced cancer patients, I especially like to compose formulas based on Shengjiang San, and the results are mostly satisfactory.

Mild intestinal obstruction and intestinal gas can also be treated with attack-and-tonify-in-one, qi-unblocking formulas such as Houpo Renshen Banxia Shengjiang Tang. If accompanied by mild cachexia, one may also refer to the composing logic of Sanren Tang: unblock the qi mechanism while regulating the waterways, giving the evil a way out.

There are many qi-soothing, qi-regulating formulas; I will not enumerate them all here, and in clinical use one may choose according to the concrete situation. For counterflow qi rising, one can use Xuanfuhua Daizheshi Tang; for turbid qi hard to descend, one can use Muxun Shunqi Wan and the like.

Female patients show qi stagnation more often than male patients. So in some common anti-cancer formulas for female patients, adding a moderate amount of Xiangfu (cyperus) and similar herbs often gives good results.

Common qi-regulating, stagnation-dispersing herbs include Bayuezhi, Juye (tangerine leaf), Zisuye (perilla leaf), Zisuzi (perilla seed), Jupi, Chenpi, Zhishi (immature bitter orange), Zhiqiao (bitter orange), Xiangfu (cyperus), Yujin, Chuanlianzi (toosendan), Foshou (Buddha's hand), Qingpi (green tangerine peel), Wuyao (lindera), Sharen (amomum), Muxiang (auklandia), Tanxiang (sandalwood), Chenxiang (aquilaria), Jiangxiang (dalbergia), Shidi (persimmon calyx), Dingxiang (clove), Dafupi, Xuanfuhua, Houpo, Gualou, Xiebai (allium macrostemon), Shenqu (medicated leaven), Shanzha (hawthorn), Laifuzi, Maiya (barley sprout), Guya (rice sprout), Binglang (areca), Chaihu, and raw Maiya.

Of course, qi stagnation also has something to do with the patient's personality; for example, patients who love to get angry, or who are prone to depression, easily develop qi stagnation. Among tumor patients, many have long been in a state of emotional suppression. After falling ill, some patients, having suffered such a major blow to life, cannot recover, remaining gloomy and unhappy, and easily develop qi stagnation.

Professor He Ren, when treating cancer patients, likes to combine Ganmai Dazao Tang into a compound formula; in fact this formula is a very good one for treating emotional depression and also has a good sleep-aiding effect. I often follow Professor He Ren and combine such a formula into a large compound. Professor Zhao Shaoqin, treating cancer patients, also likes to use Xiangfu and other qi-regulating herbs. Another old physician I know, surnamed Wei, likes to use a medium dose of Chaihu in his prescriptions as a liver-soothing, depression-relieving herb. Zhu Liangchun likes to use raw Maiya, because raw Maiya also has the effect of soothing the liver and resolving depression.

Ninth, the method of softening hardness and dispersing nodules.

Cancer lumps are hard and gathered into masses, so according to the treatment principles of "pare the hard" and "scatter the bound," treating malignant tumors cannot be without the method of softening hardness and dispersing nodules. Tumors are called "rock" because they are as hard as rock. The TCM hardness-softening, nodule-dispersing herbs can soften tumors. Patients often find, when taking TCM for tumors, that tumors they can feel on the body surface have softened. This is the action of the hardness-softening herbs.

TCM holds that the salty flavor softens hardness; hence most hardness-softening, nodule-dispersing herbs are classified among the salty flavors. Common ones include Haizao (seaweed), Kunbu (kelp), Haifushi, Walengzi (cockle shell), Haipiaoxiao (cuttlebone), Biejia, Guiban (turtle shell), Dibiechong, Naosha (sal ammoniac), Pengsha (borax), Gualou, Zhebeimu, Chuanbeimu, Baijiezi, Fabanxia, Dannanxing, Yiyiren, Zaojiaoci (gleditsia spine), Shancigu, Huangyaozi (dioscorea bulbifera), Tianzhuhuang (bamboo sap), Xingren, Bayuezhi, Dilong (earthworm), Wubeizi (gall nut), Xiakucao, and Maozhuacao.

The famous TCM anti-cancer formulas Haizao Yuhu Tang and Xiaoying Wuhai Yin are representative formulas composed mainly of hardness-softening, nodule-dispersing herbs. These formulas have good effects in treating thyroid cancer, lymphoma, breast cancer, gastric cancer, liver cancer, lung cancer, and other cancers.

Tenth, the method of astringing and securing.

Astringency can secure collapse. Tumor patients often show signs of righteous-qi deficiency and dissipation-securing disease: incessant sweating, spontaneous sweating, night sweating, sweating only on the head, incessant diarrhea, spermatorrhea, colored vaginal discharge, metrorrhagia in women, frequent nighttime urination, and urinary incontinence. When body fluids leak outward, spirit and qi are greatly affected, and it constitutes great psychological pressure on the patient.

For such patients, on the basis of pattern differentiation, one should value using some astringent, securing herbs. Common ones include Buguzhi, Wuweizi, Baishao, Roudoukou (nutmeg), Yingsuke (poppy shell), Shiliupi (pomegranate peel), Huangqi, Fangfeng, Muli, Bietaogan (wilted peach), Nuodaogen (rice-root), Mahuanggen (ephedra root), Qianshi (euryale), Lianzirou (lotus seed meat), Longgu, Sangpiaoxiao (mantis egg case), Chishizhi (halloysite), and Fuxiaomai (light wheat).

In addition, I once heard of a TCM physician, heir to a family tradition skilled in treating cirrhosis and liver cancer, who was skilled in using rice-straw ash as an astringent, securing medicine. Rice-straw ash both stops diarrhea and stops bleeding. This physician mostly treated disease with powders, telling patients to take rice-straw ash together with his powder as a wash; the dose of rice-straw ash was even greater than that of his powder, and the older the straw the better. This is also an astringing approach.

Representative astringing formulas include Yuping Feng San for sweating, Sishen Wan for diarrhea, and Suoquan Wan for frequent urination. In addition, the cheap patent medicine Fukuan Pian, used for incessant diarrhea caused by radiation enteritis in cancer patients, has good effect; I have used it many times, always with success, except that this medicine is not easy to obtain. Fukuan Pian is a compound patent medicine composed of some folk herbs and Cheqianzi.

• The method of using poison to attack poison

The method of using poison to attack poison is, from antiquity to the present, the most commonly used TCM internal and external method for treating malignant diseases such as tumors. These poisons-to-attack-poisons truly have a good inhibitory effect on the cancer patient's tumor; used well, they can even completely eliminate the cancerous tumor in the patient. Arsenic trioxide, refined from arsenic (pi-shuang), is used to treat leukemia with marked effect, recognized throughout the world. Modern pharmacology has also confirmed that certain components of many TCM poison-attacking-poison herbs indeed have a cytotoxic effect on cancer.

TCM holds that a malignant disease like a tumor, whatever its cause, having long entrenched itself in the body, must lead to internal accumulation of cancer-toxin. If the cancer-toxin knotted within is not attacked and removed, the poison evil remains a hidden danger in the body, and at the first opportunity will harm the person. So one must use poisonous substances to attack the toxin and eat away the sores, vigorously killing cancer cells.

Common clinical poison-attacking-poison herbs in TCM include Banmao, Wugong, Quanxie, Fengfang (wasp nest), Bihu (gecko), Sachan (toad), Langdu (stellera), Dibiechong, Liuhuang (sulfur), Tenghuang (garcinia), Xionghuang (realgar), Pishuang (arsenic), Qianglang (dung beetle), Changshan (dichroa), Sheng Banxia (raw pinellia), Tiannanxing (arisaema), Maqianzi (strychnos), Badou (croton), Ganqi (dry lacquer), Yangjinhua (datura), Wutou (aconite root), Fuzi, Qingfen (calomel), Dujiaolian (typhonium), and Baimazi (castor bean).

Poison-attacking-poison herbs are often used together with downward-draining herbs; the attack method links attack and purgation. The poison-attacking herbs attack the toxin and eat away sores, while the downward-draining herbs, first, open a way out for the poison evil, and second, help the poison-attacking herbs be rapidly expelled from the body, avoiding accumulation of poison in the body that would cause multi-organ damage. One should also pair some support-the-rightive herbs, so as not to over-injure the righteous during the purgation.

I once came into contact with a lung cancer patient who, on his own, used inhalation: he placed arsenic in a container, heated it, and inhaled the arsenic fumes through his nose, while taking, by mouth, a decoction made of 10-30 Dazao and an appropriate amount of Badou cream. Here arsenic is the key poison-attacking, sore-eating medicine; Badou both attacks poison and has a strong purgative effect; Dazao both moderates the harshness of Badou and arsenic and supports the righteous. On and off, he used this method to treat himself for years, and his condition remained good.

This treatment seems simple but actually hits the mark. Using inhalation rather than oral administration ensures that arsenic enters the lung tissue to the greatest extent; Badou cream assists arsenic in attacking poison, while also helping the poisonous medicines and cancer-toxin be expelled from the body in time; and Dazao supports the righteous and secures the root.

In Hebei, I once visited an old man who, by family tradition, used poison-attacking herbs to treat cancer. This old man habitually used twenty-one herbs—Banmao, Bihu, Baihuashe (krait), Xingren, Taoren, Wugong, Quanxie, and others. According to each patient's different condition, he selected several of these twenty-one herbs, made them into a powder, and had patients take it washed down. According to feedback from some of his patients, the effect was good.

This old man's medication had a characteristic: he gave only a small amount at a time, first prescribing only three days' medicine, and the dose of each herb in the first prescription was also very small. If the patient showed no toxic reaction after taking it, he would cautiously add a little more; subsequent prescriptions were generally also only for seven days. After long treatment, he could prescribe half a month's worth. Once the condition eased, he followed the principle of stopping once the disease was reached and stopped the medicine. This experience is worth borrowing.

I also often use poison-attacking herbs, but generally not the violently toxic ones like arsenic, because such violently toxic medicines are now nationally controlled drugs, hard for patients to obtain, and clinically using arsenic is truly unsafe. If the measure is not well judged, it can at any time cause the patient's death and a medical accident.

Poison-attacking herbs have large side effects; in use one must pay close attention to safety, and as far as possible use patent medicines that have passed clinical trials. The physician must also be familiar with the toxic reactions of the various poisons; if the patient develops toxic side effects, one must handle them promptly. Generally, toxic reactions mainly appear in the following areas:

First, allergic reactions. This is the most common toxic side effect after taking poisonous TCM herbs or patent medicines, with diverse clinical forms, fever and skin allergy being the most common. Most present as allergic drug rash or urticaria-like dermatitis; severe cases may develop exfoliative dermatitis, allergic purpura, or even anaphylactic shock.

Second, digestive system reactions, also one of the more common toxic side effects in clinic. Main clinical manifestations include nausea, vomiting, abdominal distension, diarrhea, constipation, poor appetite, and indigestion; severe cases may develop gastrointestinal bleeding, jaundice, liver damage, drug-induced liver injury, toxic hepatitis, or even death.

Third, cardiovascular system reactions, mainly presenting as chest tightness, palpitations, arrhythmia, elevated or lowered blood pressure, heart failure, and in severe cases patient death.

Fourth, respiratory system reactions, mainly presenting as cough, hemoptysis, difficulty breathing, acute pulmonary edema, and respiratory failure.

Fifth, nervous system reactions, mainly presenting as numbness of lips, tongue, and limbs, dizziness, headache, irritability, convulsions, seizures, confusion, coma, and even death.

Sixth, urinary system reactions, mainly presenting as back pain, increased or decreased urination, and even acute renal failure or death; some may even show renal tubular shedding.

Seventh, hematopoietic system reactions, mainly presenting as leukopenia, falling granulocytes, hemolytic anemia, aplastic anemia, purpura, and even death.

How to reduce or avoid these side effects? My own experience is to learn from Li Zhongzi: combine several poisons, reduce the dose of each single poison, and lower its side effects. At the same time, poisons are generally made into pills or powders, and the patient is allowed to increase the dose step by step, observing his own bodily reaction as he goes; if some mild toxic side effects appear, immediately stop the medicine for a day or two, wait for the body to recover on its own, or use an appropriate amount of milk, mung bean soup, radish soup, or licorice soup to detoxify.

One must not rashly use a large dose at once. Although TCM does have the concept of a "medicine-induced dramatic response," the physician must not abuse large doses of poison in pursuit of such a response, causing injury to the patient's body.

When using poison medicines, one must also rely on modern medical testing to watch for changes in the patient's liver and kidney function. If the patient's liver or kidney function is abnormal, immediately stop the medicine and take relevant drugs to improve liver and kidney function. Or, for patients prone to abnormal liver or kidney function, when giving poison-attacking medicines, simultaneously pair common liver-protecting drugs such as Hugan Pian, Fule Jiaonang, or Silybin capsules, and kidney-protecting drugs such as Shenqi Wan.

• The method of preventing change and intercepting progression

TCM emphasizes treating disease before it arises, but the idea of treating before disease is not merely about preventing illness; it also includes preventing change in already-present disease. Zhang Zhongjing, in the Jingui Yaolue, has a classic passage: "Seeing liver disease, knowing the liver transmits to the spleen, one must first fortify the spleen." This is an idea of preventing change in existing disease. According to TCM's holistic theory, the human body is a whole; when a zang-fu or meridian falls ill, over time it will transmit to other zang-fu or meridians. If the physician prevents early and blocks this transmission, he can win the patient better quality of life and longer survival.

For cancer patients, treating before disease arises is already too late, but for them, preventing change in existing disease is very important. The late Professor Jiang Chunhua of Shanghai once proposed the treatment concept of "twisting and intercepting therapy" for preventing change in existing disease; I borrow his term here and summarize this concept in the four characters "prevent change and intercept."

For example, for patients with ovarian cancer, liver cancer, secondary liver cancer, mesothelioma, lung cancer, or secondary lung cancer, pleural or ascitic fluid is a common complication. In treating these patients, one must always prevent them from developing cachexia. My experience is that, whether or not these patients already have cachexia, one should, in the medicine or in the dietary ingredients, add some mild-natured water-draining, dampness-excreting herbs such as Fuling, Yiyiren, and Cheqianzi. This lowers the probability that the patient will develop cachexia.

If one must wait until cachexia appears before treating, then, as the Huangdi Neijing puts it, it is like "forging weapons when the battle begins, or digging a well when one is thirsty"; it takes enormous effort, and the success rate is relatively low.

Or again, cancer fever is a complication that many cancer patients frequently develop. If, before cancer fever appears in the cancer patient, one moderately adds Chaihu and Huangqin to the patient's decoction, it can effectively curb the onset of cancer fever, and is also very good for improving the patient's liver function and preventing the patient from developing shaoyang pivot malfunction and inward transmission of the disease.

This is an experience I learned from Old Physician Wei, a consulting doctor at a Beijing Tong Ren Tang pharmacy. He often added Chaihu and Huangqin to some cancer patients' decoctions, both helping protect the patient's liver and preventing cancer fever. He was very popular with patients in his lifetime because of his excellent results in treating cancer. After he died a few years ago, some of the patients he had treated showed me the prescriptions they had used; I greatly admired this idea of his of early prevention, and have since used it myself with my own patients. Generally, patients taking the Chaihu series of formulas rarely develop abnormal liver function or complications such as cancer fever.

It is just that Chaihu and Huangqin used together have a sweat-releasing effect, so for preventive treatment the dose should be as small as possible. At the same time, over these years I have tried pairing them with Wuweizi, which has an astringent effect and also protects the liver, clearly reducing the sweating patients show after taking the medicine. Although Chaihu has the drawback of robbing liver yin, if, for some patients with insufficient liver yin, one pairs it with some liver-yin-protecting herbs such as Baishao and Biejia, there is no obvious disadvantage.

There are also some cancers prone to complications such as bleeding and anemia, such as gastric cancer and mesothelioma; when prescribing, one should moderately consider adding a small amount of hemostatic and blood-supplementing herbs.

Some patients who have long followed me in clinic have a higher quality of life and longer survival because I have woven this preventive idea into my therapeutic approach throughout treatment.

Thirteenth, the method of large-compound comprehensive treatment

Cancer patients rarely have only one problem; some have very complex conditions, with both deficiency and excess syndromes, both phlegm-dampness and blood stasis, and some even with cold and heat mixed together. Treating them cannot be solved simply with one approach. So oncology patients often need several approaches combined; this is what Professor Qiu Peiran called the large-compound comprehensive treatment method—using a relatively large prescription that covers every aspect. There are herbs to support the righteous, to expel dampness, to clear heat, and to attack downward.

Mr. Shi Jinmo, one of the late four great physicians of Beijing, and Old Physician Jiao Shude were very skilled at combining several prescriptions or herb pairs. This method of using large compounds can solve multiple problems in patients with complex conditions.

In clinic, large prescriptions are often criticized by TCM colleagues, and patients sometimes do not understand, but some problems are complex and severe and cannot be solved without a large prescription. At such times one should explain to the patient why such a prescription is needed; if the patient and family understand the use of large prescriptions, one may use them.

Large prescriptions contain many herbs with complex composition logic and sometimes some unforeseeable side effects, so the method of taking them needs attention. For example, I myself often give large prescriptions to advanced cancer patients, but I explain the taking method: at the start, one dose of decoction is divided over two or even three days, with a small amount taken each time, observing the body's reaction; if there is no intolerable reaction and there is slight improvement, one may moderately increase the dose, gradually increasing to a dose more suitable to the patient's body; this makes the medication much safer.

Fourteenth, the method of slow treatment with pills

Decoctions sweep; pills are slow. Treating cancer is work requiring long-term persistence. When the patient's condition is severe, one must use decoctions to rapidly stabilize the body; once the condition has eased, one may switch to pills for slow treatment.

The compounding of pills must also follow TCM's individualized, pattern-differentiated character. Basically, after treating for a time and seeing the patient's condition basically stable with normal liver and kidney function, I slightly adjust the decoction the patient has long taken, and instruct the patient either to process it himself or to have the pharmacy process it into pills to slowly stabilize the condition.

The late Sichuan TCM physician Li Changda, the late Shanxi TCM physician Professor Men Chunde, and the late famous anti-cancer physician Liang Xiuqing were all skilled at using slow pill treatment to solve cancer patients' problems. Doctor Li Changda rarely prescribed decoctions; most patients he treated were directly given a prescription to have processed into honey pills.

For chronic disease patients, slow regulation with pills, whether from the therapeutic effect or from the economic angle, is a good choice. Pills are much cheaper than decoctions. Moreover, pills allow better control of the dose and are less likely to cause great harm to the body. Some poison-attacking medicines, taken as pills internally, are also better than in decoctions. Some herbs unsuitable for decoction, such as Hupo (amber) and Qingdai (indigo naturalis), work better in pills.

In the past, when pills and elixirs were made, they would be refined once and then set aside for a time to remove their fiery qi. Taoist physicians in particular valued alchemy, which is a good way to sterilize and reduce toxicity. Modernly, cobalt and other radioactive substances are used for radiation sterilization, but the cost is high and beyond ordinary people. Modern patients who make their own pills, once they have made them, can consider baking them in a microwave or oven; this baking also serves to sterilize and reduce toxicity, and for some animal medicines it can also break down large molecules hard for the body to absorb into small, absorbable ones, enhancing efficacy.

Slow pill treatment must follow the principle of gradual withdrawal. If the patient's condition is severe, decoctions must still be used; for example, some ascites patients find pills too slow, and must first use decoctions to quickly reduce their suffering, then gradually use pills for the slower plan. Once on pills, one must also gradually reduce the dose and frequency. For example, start at three times a day; once the condition eases, reduce to twice; once further eased, reduce to once a day to consolidate. Later, one may switch to taking the medicine once every two days to prevent relapse.

Generally, cancer patients take medicine for a long time; most need to take it for five years or more, even for life. Gradual withdrawal reduces the patient's suffering from medication and also lightens the economic burden, so the patient can persist long-term.

Fifteenth, the method of doctor-patient rapport

This is a term proposed by the late TCM professor Qiu Peiran: in the course of treating disease, doctor and patient mutually trusting, understanding, and accommodating each other has a great effect on the patient's recovery. Some patients frequently change doctors; some doctors are cold to patients during treatment, and there is mutual distrust and non-accommodation. The patient's adherence to the doctor is then very low, and treatment is hard to maintain.

Cancer treatment has a long course. The longer a doctor treats a patient, the more familiar he is with the patient's condition, and the more he understands the patient's sensitivity and side reactions to various drugs; the better the efficacy and the smaller the side effects. So some have even proposed that the anti-cancer doctor should be like the patient's health nanny, knowing his own patients' condition thoroughly, not pursuing the number of patients treated, but raising the quality of treatment as much as possible.

This requires that the patient trust the doctor and the doctor accommodate the patient; when doctor and patient are in rapport, there is a bond between them. The doctor should be candid: which problems he can handle and which he cannot, he should tell the patient truthfully. The therapeutic effect he may be able to achieve, the adverse reactions and medication risks that may exist, and the costs that may arise during treatment, should also be explained to the patient in advance. Only after gaining the patient's understanding should the doctor-patient relationship be established.

Once treatment begins, the doctor should closely watch the patient's medication reactions and bodily changes. The patient should also take the initiative to report his condition promptly, and the doctor adjusts his approach at any time according to the patient's changes. This close communication means that even a doctor of middling level can achieve relatively good results.

I often meet patients who, after seeing a doctor for less than a week, hurriedly rush to another doctor. This kind of desperate, panic-stricken seeking always ends poorly. Cancer is a worldwide medical problem; if patients and their families have unrealistic, excessively high expectations of treatment, the doctor is best off telling them, before establishing a formal doctor-patient relationship, that such expectations are unrealistic. If the patient and family cannot adjust their expectations, the doctor had better gently refuse such patients, to avoid serious later medical disputes.

On problems he cannot handle, the doctor should also candidly advise the patient to seek other doctors. Do not feel that doing so is making a fool of oneself; in my experience, in most cases, if we cannot solve a problem but give the patient some suggestion to seek another doctor's help, and the problem is eventually solved, the patient will be sincerely grateful to the doctor, and will not laugh at his skill merely because he could not solve the problem.

Cancer treatment should by nature be multidisciplinary collaboration. For some patients, integrated Chinese-Western medicine gives more reliable results; for others, pure TCM may be more beneficial. All this should be explained clearly to the patient. Neither doctor nor patient should hold prejudices; I often give popular-science talks to patients who believe only in TCM or only in Western medicine, telling them to seek care rationally. For example, some breast cancer patients with surgical opportunities fear surgery; I persuade them to have the operation, telling them that if they do not operate, later, when the breast cancer ulcerates, it will be very hard to manage.

Only candid and full communication can win the understanding and support of the patient and family, and the patient's and family's understanding and support are crucial for the treatment ahead.

The causes of cancer are very complex; some relate to the patient's lifestyle. For example, esophageal cancer is related to liking hot food; liver cancer to drinking; the pickled vegetables many people like contain the carcinogen nitrite; hotpot and barbecue and similar foods all contain high levels of carcinogens; cigarettes and the cooking fume from kitchen stir-frying induce lung cancer, and so on. These require the patient's cooperation and also require the doctor to make demands of the patient; above all, the patient must be able to psychologically accept and adhere to the doctor. Without a good doctor-patient relationship, it is hard to persuade the patient to accept the doctor's advice.

Cancer treatment is a world medical problem; whether TCM or Western medicine, in treating cancer it is hard to achieve particularly satisfactory results. Cancer is both an organic lesion and has psychogenic pathogenic factors. Once cancer patients learn they have cancer, most develop negative emotions such as fright, despair, anger, and inferiority. In treating cancer, one needs not only the doctor's superb skill but also his ability to comfort the patient and help the patient build a positive, optimistic mindset.

Treating cancer is also a process of continuous exploration and self-growth for the doctor. In treating disease, the doctor experiences many moments of parting and death, and sees the various agitated emotions of patients' families; so it makes high demands on the doctor's own mental hygiene and doctor-patient communication skills. The road ahead is long; I will continue to explore it on this path.