Clinical Practice Issues
Bob Flaws, Dipl.Ac., CH, FNAAOM, FRCHM
Chinese Medical Treatment of Malignant Lymphoma
Lymphomas are a heterogenous group of neoplasms arising in the lymphatic tissues and lymph nodes. The two main types of this group of disorders are Hodgkin's disease and non-Hodgkin's lymphoma (NHL). There are approximately 6,500 new cases of Hodgkin's disease diagnosed in the United States each year, and another 50,000 new cases of NHL. Chemotherapy or radiotherapy cure most patients with Hodgkin's disease. However, for NHL, the five-year survival rates range from 26% for those with high-risk factors to 73% for those with low-risk factors.1
Chinese Medicine's View of Lymphoma
In Chinese medicine, the main clinical signs and symptoms of what is called malignant lymphoma in Western medicine fall under the traditional categories of shi fu ("stone flat abscesses"); shi rong ("loss of luxuriance"); e he ("malignant kernel"); tan he ("phlegm kernel"); fei ji ("lung accumulation"); and ji ju ("accumulations and gatherings"). In terms of pathogenesis, externally, lymphoma may be due to wind and heat drying the blood and congealing fluids into phlegm (where wind simply means an invisible pathogen). Internally, it is due to damage by the Seven Effects and overtaxation, leading to the engenderment of phlegm dampness.
This emphasis on phlegm is due to the fact that, in Chinese medicine, all lymph node enlargement is seen as a type of phlegm nodulation. In general, the root of this disease is seen as vacuity, while its tip or branches are types of repletion. What this means is that the underlying disease mechanisms of this condition are a spleen, and possibly kidney, yang vacuity.
In Chinese medicine, the spleen and kidneys are the two main viscera that control the metabolism of water fluids. If, for any reason, such as overtaxation, either of these viscera becomes too weak to transform and transport water fluids, these fluids will collect and accumulate, transforming into evil dampness. If evil dampness then lingers and endures, and is either frozen by cold or cooked by heat, it may congeal into phlegm.
This phlegm is considered the branch repletion. Because A) one of the main causes of spleen vacuity is liver depression in turn due to emotional stress and frustration; B) the liver controls coursing and discharge, i.e., the free flow of the qi; and C) lack of free flow of qi also results in the accumulation of phlegm and dampness, the three main viscera involved in this disease are the liver, spleen and kidneys. In the initial stage, a patient's symptoms are mostly yin cold symptoms.
However, as time goes on, qi, phlegm and damp depression may transform heat (another branch repletion), which eventually damages and consumes liver and kidney yin. The functioning of the viscera and bowels eventually becomes so disturbed that the body can no longer engender and transform qi and blood, thus leading to a profound qi and blood vacuity.
Based on the above pathomechanisms, there are five main Chinese medical patterns discriminated in patients with lymphoma:
1) cold and phlegm congelation and stagnation;
2) qi depression and phlegm binding;
3) wind heat and blood dryness;
4) liver-kidney depletion and detriment;
5) qi and blood dual vacuity.2
These patterns describe a rough progression from early to end stages of this disease, with the qi and blood dual vacuity pattern describing the extreme prostration, weakness and cachexia of the pre-exit condition. Likewise, pattern number four, liver-kidney depletion and detriment, describes the middle-to-late stage and/or the side-effects of chemotherapy and radiation. The signs and symptoms of this stage include the gradual enlargement of lumps which are hard and immovable, accompanied by bodily emaciation; loss of skin luster; vexatious heat in the five hearts (an irritating heat in either or all of the palms of the hands, soles of the feet and precordial region); night sweats; a thin, small tongue with scanty fur; and a fine, rapid, forceless pulse.
In actuality, this is not just a liver-kidney depletion and detriment pattern by a qi and yin vacuity compounded by phlegm nodulation. Because in real-life patients this pattern includes spleen qi vacuity, there is also fatigue; lassitude of the spirit; lack of strength; loss of appetite; and possible nausea.
Integrated Chinese-Western Medicine
In China, it is believed that when it comes to the treatment of cancer, Western medicine alone is too heroic and often damages the patient's own immunity, while Chinese medicine alone is too slow even though it takes the whole patient into account.
Therefore, most Chinese patients with cancer use what is called zhong xi yi jie he, or integrated Chinese-Western medicine, thus attempting to get the best of both worlds. While even in China it is believed that radiotherapy and chemotherapy are the most effective treatments for malignant lymphoma, the side-effects of these therapies inevitably lead to a decrease in the body's immunity.
Therefore, it is important to protect the righteous qi of the body at the same time as combating the cancer.3 Such supporting of the body's righteous or healthy qi is referred to by the words fu zheng pei ben, which means "supporting the righteous and banking the root."
Combining Chemotherapy and Chinese Medicinals
In Chinese medicine, chemotherapy is regarded as a species of "using toxins to combat toxins." According to Sun Bing-yan, a famous traditional Chinese medical cancer specialist, although most cancers develop in a cold, damp internal terrain or bodily constitution, most cancers are also a species of localized heat toxins.4
Because chemotherapeutic agents are strongly "attacking" according to the logic of Chinese medicine, they easily damage the righteous qi. Because they tend to be hot in nature, they also can engender their own evil or pathological heat. Therefore, in terms of Chinese medicine, the side-effects of chemotherapy tend to fall into the categories of qi vacuity; yin vacuity; and heat toxins. Consequently, the medicinals used to treat the side-effects of chemotherapy tend to be a combination of qi supplements, yin supplements and heat-clearing, toxin-resolving medicinals.
Below is a formula given by Pan Ming-ji for supplementing the righteous and banking the root during chemotherapy for malignant lymphomas:
Herba oldenlandiae diffusae cum radice (bai hua she she cao), 40g;
Tuber asparagi cochinensis (tian men dong), 30g;
Fructus ligustri lucidi (nu zhen zi), 15g;
Sclerotium poriae cocos (fu ling), 15g;
Sclerotium polypori umbellate (zhu ling), 12g;
Rhizoma atractylodis macrocephalae (bai zhu), 15g;
Herba agrimoniae pilosae (xian he cao), 15g;
Tuber curcumae (yu jin), 12g;
Rhizoma dioscoreae bulbiferae (huang yao zi), 12g;
Radix astragali membranacei (huang qin), 15g;
Radix pseudostellariae heterophyllae (tai zi shen), 15g;
Flos lonicerae japonicae (jin yin hua), 9g;
Radix glycyrrhizae (gan cao), 3g.
The above are daily dosages. The medicinals are boiled in water for 45 minutes to one hour, then the medicinal liquid is poured off and reserved, while the dregs are thrown away. The medicinal liquid is divided into three even doses and administered orally morning, noon and night 15 minutes to one-half hour after meals.
This is repeated daily for as long as is deemed appropriate by the prescribing physician; however, typically not less than two to several weeks.
Within this formula, bai hua she she cao and jin yin hua clear heat and resolve toxins. In particular, bai hua she she cao is one of the main cancer-combating medicinals in Chinese medicine.
It is used for a wide variety of malignancies. Tian men dong and nu zhen zi enrich yin. Huang qi, tai zi shen, xian he cao, bai zhu and fu ling all supplement the spleen and boost the qi. In addition, tai zi shen also enriches yin. Zhu ling seeps dampness. However, modern research has shown that it and fu ling are both cancer-combating medicinals. Huang yao zi is a phlegm-transforming, nodulation-scattering medicinal and, as stated above, in Chinese medicine, lymphadenopathy is categorized as "phlegm nodulation."
This medicinal is used in Chinese medicine as empirically specific for the treatment of any lymph node swelling or enlargement. Yi jin rectifies the qi and quickens the blood, dispersing stagnation and dispelling stasis. Gan cao clears heat and resolves toxins at the same time it harmonizes all of the other medicinals in the formula, meaning it helps protect the spleen and stomach against the harsh effects of some of the other medicinals in this formula.
In real-life clinical practice, this formula would be tailored to each patient's personal Chinese pattern. This might mean the addition or subtraction of medicinals or the increase or decrease of doses of specific medicinals. For instance, if the patient displays signs and symptoms of marked spleen-stomach vacuity and the presence of cold evils, the dosages of bai hua she she cao and jin yin hua should be reduced, and warming medicinals such as cortex cinnamomi cassiae (rou gui) and dry rhizoma zingiberis (gan jiang) might be added.
If chemotherapy has resulted in nausea and vomiting, uncooked rhizoma zingiberis (sheng jiang), caulis bambusae in taeniis (zhu ru), rhizoma pinelliae terantae (ban xia), pericarpium citri reticulatae (chen pi), flos inulae racemosae (xuan fu hua) and/or haemititum (dai zhe shi) might be added.
For even more fluid dryness evidenced by thirst, dry mouth, and a parched throat, tuber ophiopogonis japonicae (mai men dong), rhizoma anemarrhenae aspheloidis (zhi mu) and radix trichosanthis kirlowii (tian hua fen) might be added. If there are palpable nodes, spica prunellae vulgaris (xia ku cao), concha ostreae (mu li), bulbus fritillariae thunbergii (zhe bei mu) and herba sargassii (hai zao) might be added.
Combining Radiotherapy and Chinese Medicinals
In Chinese medicine, radiotherapy is also seen as a hot, attacking therapy. In fact, in ancient China and Tibet, large cones of folium artemisiae argyii (ai ye) were burnt directly on the skin over tumors as a primitive (and extremely painful) way of burning them out of the body.
Therefore, when Chinese medicinals are used in tandem with radiation, they are commonly prescribed based on the principles of supporting the righteous and nourishing yin, clearing heat and resolving toxins. Below is a typical Chinese medicinal formula for use in tandem with radiation for lymphoma:
Herba oldenlandiae diffusae cum radice (bai hua she she cao), 20g;
Tuber asparagi cochinensis (tian men dong), 15g;
Tuber ophiopogonis japonici (mai men dong), 15g;
Radix salviae miltiorrhizae (dan shen), 15g;
Rhizoma imperatae cyclindricae (bai mao gen), 15g;
Uncooked radix rehmanniae (sheng di), 15g;
Radix astragali membranacei (haung qi), 15g;
Radix pseudostellariae heterophyllae (tai zi shen), 15g;
Sclerotium polyposi umbellate (zhu ling), 12g;
Sclerotium poriae cocos (fu ling), 12g;
Rhizoma atractylodis macrocephalae (bai zhu), 12g;
Rhizoma polygonati (huang jing), 9g;
Cortex radicis moutan (dan pi), 9g;
Radix glycyrrhizae (gan cao), 3g.
This formula is cooked and administered the same as the other formula. Most of the ingredients in this formula have also been discussed above. Of those that have not, sheng di, dan shen and dan pi clear heat, cool and quicken the blood, and transform stasis. Likewise, bai mao gen clears heat and cools the blood at the same time it clears heat from the stomach and lungs, thus treating both thirst and nausea.
Huang jing, like tai zi shen, supplements the qi while simultaneously enriching yin. Similar to the above, this formula would be modified by the addition and subtraction of various medicinals based on the unique presentation of the individual patient. Changes to such a base formula are often made every several days, and not less than once per week.
According to Wu Jun-ju and Bai Yong-bo, when Chinese medicinals are administered based on the patient's personal pattern discrimination either during chemotherapy and radiation or afterwards, during remission, this can preserve and consolidate the therapeutic results achieved by these therapies.5
Further, in terms of preventing this condition's metastasis or spread, they say that it is important to treat it vigorously. They also emphasize the importance of regulating one's mental-emotional life to insure one's mind and emotions are smoothly and easily flowing.6
Representative Chinese Research
Li Yuan-xi, et al. reported on the treatment of 27 cases of mid-stage malignant lymphoma. In this study, all 27 patients were treated with chemotherapy at the same time as internally administered Chinese medicinal formulas, depending on their personal pattern discrimination.
Fourteen patients in the study were categorized as displaying the pattern of qi stagnation and phlegm binding; three presented the pattern of qi stagnation and blood stasis; six presented the pattern of qi and yin dual vacuity; and four presented the pattern of qi and blood dual depletion.
At the end of the study, 13 patients were judged to be in full remission; six cases showed signs of partial remission. Therefore, the overall effectiveness rate of this treatment protocol was said to be 70.37%.7
Zhang Yu-qin treated 40 cases of non-Hodgkin's lymphoma based on enriching yin combined with chemotherapy and radiation. Five different formulas with personalized additions and subtractions were used depending on whether the patients presented with
1) lung-stomach yin vacuity;
2) heart yin vacuity;
3) liver-stomach yin vacuity;
4) damp heat obstructing the center (i.e., nausea and vomiting); and/or
5) intestinal bowel binding and repletion (i.e., constipation).
The one-year survival rate was 80% (32/40); the five-year survival rate was reported as 65.6% of those who had survived one year (21/32).8
Li Dan treated 30 cases of malignant lymphoma using a combination of Chinese medicinals based on pattern discrimination and chemotherapy. The patterns used by Li included:
1) obstruction by phlegm, dampness and (blood) stasis;
2) spleen-stomach vacuity weakness with qi stagnation and blood stasis;
3) qi and yin dual vacuity;
4) heat toxins congesting and exuberant;
5) qi and blood dual depletion. At the end of this study, 10 cases were judged to be in total remission; 18 were considered in partial remission.9
Although these clinical audits do not meet the "golden standard" of current Western medical research, they do suggest that the combined use of Western and Chinese medicines in the treatment of lymphoma bears further investigation in the West.
1. Beers MH, Berkow R (eds.) The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 1999, p. 955-962.
2. Wu Jun-yu, Bai Yong-bo. Xian Zai Nan Zhi Bing Zhong Yi Zhen Liao Xue (The Chinese Medical Diagnosis and Treatment of Modern, Difficult to Treat Diseases). Beijing: Chinese Medicine Ancient Books Publishing House, 1993, p. 725.
3. Pan Ming-ji. Cancer Treatment with Fu Zheng Pei Ben Principle. Translated by Cai Jin-fen, et al. Fuzhou: Fujian Science and Technology Publishing House, 1992, p. 371.
4. Sun Bing-yan. Cancer Treatment and Prevention with Traditional Chinese Medicine. San Mateo, CA: Offete Enterprises, Inc., 1991, p. 9-10.
5. Wu and Bai, op. cit., p. 723.
6. Ibid, p. 726.
7. Li yuan-xi, et al. Zhong Hua Zhong Liu Za Zhi (The Chinese Journal of Oncology) 1988, #1, p. 61.
8. Zhang Yu-qin. Zhong Yi Za Zhi (The Journal of Chinese Medicine) 1981, #7, p. 41.
9. Li Dan. Shan Dong Zhong Yi Zi Zhi (The Shandong Journal of Chinese Medicine) 1982, #1, p. 20.
Bob Flaws, Dipl.Ac., CH, FNAAOM, FRCHM
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