Bridging the Gap. James Eugene Munson
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.