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“It does not matter how slowly you go as long as you do not stop.”

Confucius

The first question we are asked by cancer patients is, “What can Chinese medicine do for cancer?” As traditional Chinese medicine (TCM) doctors treating patients in various stages of this disease, we are familiar with this query but learning how to respond came carefully with time. Those who seek complementary therapy, like Chinese medicine, during their cancer experience, whether it is early diagnosis or in the midst of cyclical chemotherapy, are well-informed as to how conventional medicine will treat their cancer. What they are less familiar with is the breadth and scope of TCM oncology. Therefore, the question above is a pivotal moment for trained Oriental medicine practitioners to introduce this system of medicine that optimizes the body’s ability to heal. Current statistics indicate that 1:2 men and 1:3 women will be diagnosed with cancer and over half will receive some form of complementary therapy.¹ This book aims to introduce the patient, caregiver, medical doctor or complementary healthcare provider to the valuable, rich therapy of TCM oncology. In addition, we hope to better prepare the Chinese medicine practitioner for the complexity of cancer management because it is likely that at some point every Chinese medicine practitioner will be sitting across from a cancer patient.

This clinical preparation is an integral component to the Chinese medical profession and particularly crucial as the practice of IO gains momentum. It’s philosophy is rooted in patient-centered care, with goals to reduce side effects of conventional treatment, improve quality of life and support emotional wellbeing. These outcomes are achieved through complementary therapies including acupuncture, bodywork, naturopathic medicine, and meditation to name a few. While patient empowerment is central to this subject, the spectrum of care is structured around evidence-based medicine as an adjunct to Western oncology protocols. As such, modalities such as moxibustion that do not meet the rigid scientific standards set forth by the medical community are often discouraged or dismissed as not having therapeutic value. Acupuncture, however, has been researched endlessly and with enough scrutiny that it is an accepted form of supportive therapy.

An extremely thorough systematic review of integrative oncology programs worldwide found that an increasing number of multifaceted facilities exist. Out of the 29 sites reviewed, acupuncture is offered at 41% of these locations.² There is reference to “Traditional Chinese Medicine” as an offered service, but it falls in less than 2% of program centers.³ We can conclude that moxibustion, Chinese dietary therapy and herbal medicine are subsequently not available, indicating the limited degree to which the full-spectrum of what TCM offers is presented. Despite the breadth and longevity of the medicine, harnessed by a vast range of therapeutic abilities, the reality is that TCM practitioners limit their scope when it comes to integrative cancer care. The cause for this trend can be linked to several identifiable factors.

The barriers to seamless collaboration among holistic and conventional medical doctors are extensive. In cancer management, these challenges are acutely present and frequently frustrating. Communication among oncologists and natural medicine doctors is influenced by several factors. For example, it becomes difficult to dialogue as a collaborative unit when there is not a shared facility. The same systematic review noted above found that only 41% of the IO centers offer conventional treatments and complementary therapies in the same location. In private practice, patients are either self-referred based on a personal recommendation or another healthcare provider suggested acupuncture to alleviate side effects. It is rare to receive a note, email, or call from an oncologist to discuss patient care. A survey of Chinese medicine practices in Northern California demonstrated these findings by reporting that only 2% of TCM providers were consulted by a biomedical physician.⁴ In contrast, of the same respondents only 8% reported they always initiate communication. Thus, illustrating a lack of dialogue among all providers involved in the patient’s care and an opportunity to improve this collaborative dynamic.

The disconnect between doctors, as well as with patients, diminishes the therapeutic value of Chinese medicine before it can even begin, causing practitioners to limit their practice approaches and submit to basic, palliative protocols. This is not to say that focusing on improving the quality of life before, during or after cancer treatment is without importance or purpose. However, this resignation to solely mitigate side-effects of allopathic treatment compromises the integrity of the profession and stunts the advancement of Chinese medicine in a modern medical world. This became the turning point in our clinical focus, choosing to explore beyond the safe nest of private practice to search for collaborative relationships among cancer management providers. We cautiously hoped to discover integrative philosophies that respectfully valued our medicine and vice-versa.

We quickly discovered that although a common vision of whole-person, patient-centered medicine is shared among integrative oncology systems, the methods and applications are diverse. The role and placement of Chinese medicine therapies was largely limited to acupuncture. We began to question how the concept of integrative oncology was truly integrative, which lead to the purpose of this book. First, we wish to present the current definitions and terrains of integrative oncology, as well as identify how Chinese medicine is practiced within them. This introduces the reader into the dynamics of integrated medicine and the obstacles Eastern doctors face despite attempts to collaborate care for the health of a shared patient. Second, as traditional medicine practitioners who have learned from the long line of teachers that come before us, we inherently value the sharing of concepts, clinical applications and humbly contribute to the evolution of Chinese medicine for new students or seasoned practitioners seeking to learn and apply these approaches.

The most significant obstacle TCM practitioners contend with, which is introduced early in Chinese medical education, is a legal consideration. By law, a provider who is not a licensed oncologist cannot treat cancer. The risk of a malpractice lawsuit leads very few TCM practitioners to claim that treatment goals are to “treat cancer.” The survey of licensed acupuncturists again sheds light on this issue with just 32% reporting they utilize TCM to treat the cancer itself.⁵ The study did not indicate why providers choose not to treat the cancer, and while a myriad of possibilities can be imagined, we reason the main impediment is related to legality. So, although Chinese medical schools educate students on the properties of certain herbs, like bai hua she she cao (oldenlandia diffusa), that have antineoplastic effects in high concentrations, it is prohibited for that purpose. Similarly, many patients have been told by their oncologists not to continue acupuncture if there is risk of infection due to neutropenia, a condition of low white blood cells. More frequently than not, patients heed this warning from their doctor and TCM treatments are postponed. Ironically, this is precisely the time when Chinese medicine can increase white blood cells and immunity by careful and regular application of moxibustion, as well as herbal medicine and nutritional recommendations. This is another window of opportunity for our profession to educate and inform the patient and, if possible, the doctor, to not compromise the safe, therapeutic capacity of this medicine.

As our journey into this specialty evolved we became acutely aware it is not only Western medical facilities that have singled out acupuncture (above other TCM modalities) exclusively for the purpose of cancer management. It appears also, classically-trained acupuncturists in private practice tend to rely solely on needling treatments for cancer patients. There may be minimal inclusion of indirect moxibustion on ST-36 (zu san li) for immunity, but rarely have we observed more than this. This is not to say these techniques are irrelevant, as acupuncture is inherently valuable in its ability to lessen symptoms of nausea, vomiting, fatigue or pain as a result of conventional oncology treatments. For the purpose of this topic, we again refer to the survey of over 400 TCM practitioners who reported that of the modalities that encompass Chinese medicine, including moxibustion, herbal prescription, dietary advice and exercise, acupuncture was used by 98% of the practitioners and regarded as the most useful for oncology patients.⁶ By comparison, moxibustion was used by 17.3% for cancer care and dietary advice was a mere 35%.⁷ This imbalance must be remedied. As doctors of Chinese medicine, the onus of understanding and incorporating multiple modalities to treat disease is upon us. The individual components of TCM are like spokes on a wheel, which give it strength and balance. Without all the spokes, there is still a functional wheel that serves a purpose, but the structural integrity of the wheel is compromised. With all of the spokes to balance the wheel, it is stronger, more efficient, and leads to a faster desired destination.

The importance of being a well-rounded practitioner with respect to being adept at all the major modalities in TCM is consistently repeated throughout Chinese medical literature. Classical scholar of such texts, Paul U. Unschuld identifies this concept in at least four chapters of the Su Wen, the seminal text of Chinese medicine. He delves into this idea confirming the integral value of multifaceted skills and techniques. From the message of Su Wen Chapter 12, he reflects, “To be unaware of even one of these approaches is to be unable to confront the advance of a disease at all stages of its development…”⁸ The wheel must be complete, the spokes equally important to the mechanism in order to optimize its function and outcome. A superb excerpt from Su Wen Chapter 24 clearly illustrates how physicians were committed to the breadth of therapeutic modalities⁹:

“When the physical appearance is joyful, while the mind suffers, the disease emerges in the vessels. Treat it with cauterization and piercing. When the physical appearance is joyful and the mind is joyful [too], the disease emerges in the flesh. Treat it with needles and [pointed] stones. When the physical appearance suffers while the mind is joyful, the disease emerges in the sinews. Treat it with poultice and stretching [exercises]. When the physical appearance suffers and the mind suffers [too], the disease emerges in the gullet and in the throat. Treat it with the one hundred drugs.”

In this passage we can identify multiple approaches employed by the doctor according to disease presentation, interestingly in both body and mind. Cauterization refers to burning, which we correlate now to modern day direct moxibustion or heat therapy. Piercing is referenced and akin to modern day needling technique known as pricking therapy or bloodletting. The needles used in this early form of acupuncture were made of sharp stones. Poultices maintain a long history in any era or region of medicine, used as topical herbal remedies. In this passage, exercise is referred to as stretching, an invaluable modality practitioners must also encourage in moderate amounts for cancer patients. As dedicated doctors of this system of medicine, we feel called to contribute and offer clinical guidelines for true integrative medicine practices that macro-level institutions may employ, as well as the clinician in private practice. We must become masters of the modalities, as the medicine intends.

It is for this reason an overview of the history of Chinese medicine oncology is where our book begins, inviting the reader to dig a bit deeper, delve into the classical texts that are our timeless teachers. Whether for the uninitiated person who wishes to learn more about medicine of the East, the TCM student, or seasoned practitioner, returning to the root of the medicine is valid and necessary. While this can be a laborious task as a reader, particularly for the clinician wanting to skip over the scientific history and behavior of a disease and get straight into treatment approaches, we encourage the reader to familiarize oneself with the historical framework of cancer. TCM is a practice that has evolved and refined itself over thousands of years. Its inception began with the Huang Di Nei Jing, composed during the Han Dynasty (206 B.C.E.-220 C.E.). It is a compilation of two texts, Su Wen and Ling Shu, both integral to the foundation, principles and techniques we embrace today. Modern Chinese medicine doctors can treat a wide variety of diseases because of these classical works. The principles of yin-yang theory, excess and deficient, interior and exterior, cold or hot are as timeless as the texts they are presented in, profoundly capable of being applied to the common cold or cancer. While Chinese medicine is not considered “evidence-based,” its foundation is unchanged nor has it wavered since its development, unlike the practice of modern, reductionist Western medicine. Chinese medical therapies are able to adapt to biomedical advancements. Its flexible nature allows itself to interpret modern medicine into its own constructs to yield successful therapeutic outcomes.

From the discourse of the East, we briefly shift our historical lens to the West. Just as physicians in the ancient East observed and treated various malignancies, so did the doctors in the West. The famous physician Hippocrates known as the “father of medicine,” played an integral role in early cancer theory and diagnosis. His primary hypothesis on the cause of cancer was explained by the concept of the four humors or body fluids: blood, phlegm, yellow and black bile. He theorized that disease developed due to an imbalance of these substances. This interpretation of disease correlates to Chinese medicine’s early understanding of tumor formation and pathogenic causes. Historical insights such as these will be explored and are particularly interesting when juxtaposing early cancer theories, treatments and diagnoses of both medical cultures.

The individual historical perspectives serve as a vantage point in our assessment of integrative oncology practices. This overview derives from experiences as doctoral interns in IO facilities, mentorships with licensed medical doctors, oncology dieticians and complimentary cancer providers. These professional opportunities were significant to the development of this material, enabling a bird’s eye view of integrative medicine. We do not intend to outline numerous discrepancies of IO programs, as we are equally indebted to modern medicine capabilities. At this point in biomedicine, we must rely upon conventional therapies as they provide the possibility of curing aggressive diseases like cancer. Our scope of practice is greatly limited in the West, and while measures toward integration are happening, they are dictated by science and sadly, Chinese medicine is not recognized as such at this time. Fortunately, however, we hold the tools to mitigate the harsh cytotoxic effects of chemotherapeutic agents, radiation, pharmaceutical side-effects, as well as addressing the emotional terrain of cancer diagnosis. Chinese medicine practitioners who commit to this endeavor, with skill, focus and determination can facilitate innate healing of the individual, optimizing the body’s capacity to fight the cancer and essentially, treat it.

For licensed practitioners, this serves as a jumping off point into clinical guidelines. We chose not to divide the content of this book by cancer type. Our goal is to highlight each modality that comprises Chinese medicine, building upon each pillar to create a foundation of clinical understanding and therapeutic purpose for refined cancer management. This enables the clinician to reference specific modalities as appropriate, and in that way become more comfortable integrating the medicine. We begin with the core elements of diagnosis in TCM oncology. From this vantage point a pathway into acupuncture therapy, Chinese herbal medicine, diet, exercise and manual therapy is illuminated. As with everything in Chinese medicine we also must reflect on the shen, or spirit. Its relationship to disease is deeply rooted in the constitution and, we feel, cannot be ignored in cancer care. Consequently, we are committed to the system of the eight-extraordinary meridians (EEM) to address emotional complexities of the cancer experience. As the famous Chinese physician, Li Shi-Zhen once stated, “If physicians are not aware of such theories of the extraordinary channels, they will remain in the dark as to the cause of disease.”¹⁰

Additionally, as students of Chinese medicine and novice practitioners who knew very little about oncology, we struggled extensively in learning how best to begin an intake with a cancer patient. There were no guidelines that integrated our knowledge of Chinese medicine with Western oncology. We aim to rectify that situation by presenting a framework for a basic TCM oncology intake that the licensed practitioner can modify. This enables seamless coordination with the patient’s conventional cancer treatment plan in order to treat the physical and emotional side-effects, concurrent health issues and encourage collaboration among providers. All of these components to integrative cancer care will be presented in case studies from our clinical experience to demonstrate the capacity of Chinese medicine, the value of using it as a system with multiple modalities at play and emphasizing its merit in integrative oncology. It is in this spirit of sharing, challenging concepts and methods while contributing to the evolution of health and wellness that we write this book.

References

Abrams, D. I., & Weil, A. (2009). Integrative Oncology. New York, NY: Oxford University Press.

Chace, C., & Shima, M. (2010). An Exposition on the Eight Extraordinary Vessels. Seattle, Washington: Eastland press.

Seely, D., & Young, S. (2012). A Systematic Review of Integrative Oncology Programs. Retrieved September 10, 2018, from http://www.current-oncology.com/index.php/oncology/article/view/1182/1078

Unschuld, P. U. (2003). Huang Di Nei Jing Su Wen: Nature, knowledge, imagery in an ancient Chinese medical text: With an appendix, the doctrine of the five periods and six qi in the Huang Di Nei Jing Su Wen. Berkeley, CA: University of California Press.

¹ Seely, 2012

² Seely, 2012

³ ibid

⁴ Abrams et al., 2009

⁵ Abrams et al., 2009

⁶ Abrams et al., 2009

⁷ ibid

⁸ Unschuld, 2003

⁹ ibid

¹⁰ Chase et al., 2010