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Breast Cancer Part 2: Etiology, Pattern Differentiation, and Adjunctive Therapies from a Chinese Medical Perspective
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Breast Cancer Part 2:  Etiology, Pattern Differentiation, and Adjunctive Therapies from a Chinese Medical Perspective

Monica Kaderali, L.Ac.
Karen Christensen, L.Ac.


"Through awareness of the body we remember who we really are." 
- Jack Kornfield, The Wise Heart

       

      In China, TCM complementary cancer care means herbal medicine.  Herbs are used to combat the side effects of conventional treatments or to potentiate their effectiveness.  There are clinics in the States that operate similarly, Tai Lahans in Seattle treats mostly cancer patients and works closely with doctors.  The L.Ac.'s at the Pine Street Clinic in San Anselmo, California also work with people who have cancer.  However the majority of acupuncturists work as independent practitioners and still very few of us work in integrated clinics.  Cancer patients are referred to us by our regular means - insurance lists, word of mouth.  The patients you might typically see are those in the throes of conventional treatment looking for something to help augment their immune system before the next round of chemotherapy.  Sometimes the cancer patient will be a past patient, coming to you with a recent diagnosis.  Most likely, a patient you are currently seeing is developing breast cancer, as a ductal carcinoma in situ will need 7-10 years to develop into a barely palpable, 1 cm tumor (1).  Thankfully, there are many resources available for the TCM practitioner to use Chinese medicine to help patients with breast cancer.  Some of these resources are websites, books, and even LinkedIn groups.  (Please see Appendix 4 for a list of resources.)

       At the cancer clinic in Santa Barbara where we compiled our experience, Chinese herbal medicine was sometimes offered to patients on a case-by-case basis, but mostly in the form of patent medicines for branch treatments (Ma Zi Ren Wan for opiate-induced constipation, Bu Zhong Yi Qi Tang for chemo-therapy induced diarrhea).  Although we were given some space to use herbs, there were several main reasons why it was not advantageous for us to do so.  The first was due to the fact that the patients were already taking an upwards of 20-30 supplements or medications, and the potential for interactions was intensified.  Any negative side effect garnered suspicion of the Chinese medicinals.  In the end, we mostly erred on the side of caution, using patented formulas made in the U.S. that were well-researched and efficacious.  This practice gave the doctors and patients trust in Chinese medicine, and they would even ask for them ("I think Jane would benefit from some of your poo pills.") 

       Throughout the course, we do include theoretical Chinese herbal base formulas that fit the common breast cancer patterns, but do not necessarily have experience using those formula for those patterns. For that type of clinical herbal experience, we direct you to the incredible work of Tai Lahans in her book, Integrating Conventional and Chinese Medicine in Cancer Care.

       Little to no source material exist on how to use acupuncture with breast cancer patients, which was the impetus for writing this course.  Inherently there are some problematic aspects of giving acupuncture to a cancer patient - acupuncture is a draining technique, indicated for excess conditions, whereas herbal medicines tonify.  Obviously we feel that that acupuncture can still be beneficial to breast cancer patients.  Hopefully you will benefit from our clinical experience using acupuncture on cancer patients stages I-IV.   We also compiled never-before-seen translations of acupuncture points used for cancer, and offer our expertise on positioning, number of needles, and appropriateness of treatment.

-Monica Kaderali L.Ac. & Karen Christensen L.Ac.

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Introduction

       Breast cancer is the most common form of cancer in women and the leading cause of death in women between 40 and 55 years of age.  Increasingly patients are using Chinese medicine as an adjunct to their biomedical treatment for breast cancer.  This course is best taken in two sections.  The first part, Breast Cancer Part I:  Risk factors, Diagnosis, and Treatment from a Biomedical Perspective discusses how biomedicine identifies, stages, and treats breast cancer and what the current risk factors are from a Western medical viewpoint.  We encourage you to take that course first, so you will have a framework of reference.  In this second part, you will learn the disease from a Chinese medical point of view. 

       To date, pharmaceutical drugs and devices are the only FDA-approved treatments for cancer.  Since it is is illegal to claim that a substance has efficacy in the treatment of cancer unless the FDA has approved the claim, it is therefore illegal to claim that an unapproved substance or modality (herbs, acupuncture) can treat cancer. There's no specific "alternative medicine" section of the FDCA that says this; it's part of the overall structure of the Food, Drug and Cosmetics Act. 

       Furthermore, it is false advertising for an alternative medical practitioner to claim that she can treat cancer.  Because the claim can not be proved scientifically, the statement is considered "false advertising" and thus the speaker can be prosecuted for violating the FTC (Federal Trade Commission) Act.

       Many states, including California, have regulated cancer treatment at the state level.  In California, for example, the restriction on cancer treatment has been inferred from California Health and Safety Code Section 109300 et seq. (2).  It is incumbent upon you, the practitioner, to be fully informed of the restrictions surrounding cancer care in your state.  Upon approving this course, the California Acupuncture Board requested that we make it clear that as California-based acupuncturists, we do not treat cancer.

       It costs millions of dollars to have a drug approved and Big Pharma companies are practically the only ones that can afford the incredible cost.  When an herb, supplement, food, or method of treatment is not FDA approved, this may mean nothing about its efficacy, but instead that a lack of funding was available to support clinical trials.  It is interesting to note that pharmaceutical companies are one of the largest lobbying sectors in Washington, which is no surprise considering that cancer is big business for the U.S. economy.  In 2011, the Pharmaceutical industry spent $235,807,106.00 lobbying in Washington (3).  (This is almost twice the amount of money than the second runner up, the Insurance industry). In 2010, a breast cancer patient spent in treatment an average of $23,000 in the first year of diagnosis alone (4).


China

       In China and Korea, Chinese medicine is integrated into conventional treatment, and in this case, Chinese medicine is synonymous with herbal medicine (1).  Herbs are commonly administered to a cancer patient to mitigate side effects from chemotherapy or radiation that might cause a suspension of treatment, like if the patient's red blood count became too low or if gastrointestinal function was impaired (2). 

       Using Chinese herbal medicine in an integrated fashion with biomedical treatment has a long way to go in this country.  However, the TCM practitioner can still legally play a vital role in helping a cancer patient by:

- Patient education in prevention

- Mediation of side effects brought about by the biomedical treatments of chemotherapy, hormone therapy, and surgery through acupuncture, moxa, Chinese herbal medicine, etc.

- Enhancement of biomedical treatment by promoting bowel movements, etc. to facilitate removal of toxins
- Prevention of recurrence after conventional treatment has commenced (a time when there is little to nothing offered by Western medicine) 
- Palliative care, when the disease has been deemed incurable.  In cases like this, a practitioner may also be working alongside hospice services.

We hope that this course will enable you to help your patients in these ways.


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Etiology of Breast Cancer
    
       The newest consensus on cancer etiology according to Western medicine is that cancer is a multi-factorial disease:  a series of genetic, environmental, and lifestyle aggravations over time weaken the body and create an environment for tumorgenesis.  It comes as no surprise that in TCM, this viewpoint has been in place for generations.  Over time, our Vital or Righteous Qi (Zheng Qi), can slowly become weakened by one or a combination of several internal and external factors.  In a weakened state, the body is ripe for any disease.  

External factors:  Wind, Dampness, Fire Toxins
Wind
       The Chinese medical adage "Wind is the chief of the hundred diseases" is also true for breast cancer.  External Wind, either on its own or in combination with Cold or Heat, is tenacious in starting disease, due to its ability to penetrate the skin and impair Wei Qi. 

       When Wind is combined with Heat, it can eventually produce Fire Toxins.  Fire Toxins will attack the Zang-Fu organs and channels culminating in disease.  When Wind combines with Cold, it seems to be drawn to the deficient channels and can bind with Blood to form lumps (5).

       It is interesting to note that air pollution is considered a pathogenic Wind (1).  We know that certain cancer rates are higher in industrial-polluted areas.

Dampness
       Dampness obstructs Qi, and when accumulated causes Heat and Phlegm, and eventually tumors.  Invasion of pathogenic Damp can cause nipple discharge (5).   

Fire Toxins
       Fire Toxins can be from exposures from chemicals (like DDT and nitrites) or an unresolved infection that left smoldering, burned up the Yin and fluids and created some sort of stasis (1). Exposure to ionizing radiation like X-rays (as in mammograms) is considered an endogenous Fire Toxin (1).  Fire Toxins can invade the Zang fu organs and the blood and ying level to cause breast cancer with inflammatory characteristics, like Inflammatory Breast Cancer. 
 
Emotional, Sociological & Lifestyle factors
       The normal flow of Qi can be disrupted by the emotions that trigger the channels.  With breast cancer, there is often a complex emotional component.

       It is common for a breast cancer patient to have a history of emotional and/or physical abuse, which is often internalized by the patient.  These emotional and psychological insults can fester feelings of shame, betrayal, inadequacy, or anger. These emotions become buried in the chest, the domain of the Heart and Lungs, traversed by the Liver, Stomach, and Chong channels. 

       Although all of the seven emotions can disturb Qi, Blood, and the Zang fu, the most common are:

You - Sadness or grief
       Related to the Lungs, you can play a big role in many diseases. Pessimism and anxiety are associated with the lungs.  High anxiety, like in a panic attack, blocks the Lung Qi and suppresses respiration, thereby weakening the body's Wei Qi (6).  If the Lung Qi is impaired, this can cause heat, fluid, and blood congestion in the chest.

Nu - Anger
       The emotion related to the Liver is nu which is translated as anger or irritation.  Anger makes the Qi ascend and can damage the Liver and blood.  Anger can also invade the digestive organs and cause loss of appetite, diarrhea or constipation (6). 

       A balanced Liver creates a kind, unselfish person.  Someone with a Liver energy imbalance can appear stubborn, perhaps rude, and may be self-admittedly a Type A personality characterized by being hyper-driven and over-worked.  This Type A person epitomizes the Wood overacting on Earth in the control cycle.

       The Liver channel runs through the armpit and chest.  Most breast cancers occur in the upper 1/4th quadrant of the breast, the part closest to the armpit.  Unresolved emotional issues will result in Qi blockage, an etiological factor in breast cancer.

Si - Worry
       The emotion related to the Spleen is si, which is translated as worry, pensiveness, and over-thinking.   Worry prevents Qi flow and can lead to Stomach disorders, as it causes Qi to stagnate in the Middle Jiao.  Having chronic worry leads to Spleen Qi deficiency and Dampness (6).

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Emotional & Sociological Factors, Continued

Overwork
       The role of the modern day woman is much different than in years past.  Extended families used to live together and share the child rearing and household duties. Now it is common for a woman to work full time, raise children, and maintain household duties.  Unbelievably, many women do all of this as single mothers.  Adding to this are social pressures, whether self-imposed or actual, which can have a big influence on a woman's contentment and happiness.  The modern-day "Supermom" is overtaxed, wiry and yin deficient, surviving on caffeine and a lousy diet.

       As TCM practitioners, we know that overwork burns both Kidney and Liver yin and leads to Spleen Qi deficiency, amongst other things.  All of these chronic deficiencies weaken our Vital Qi and make way for pathology.  Counseling a woman on the importance of avoiding over-taxation is a great service you can give your patients.  Many women need permission to slow down.

Stress
       Stress is an epidemic in our society.  It comes at us from many directions, and some people are burdened with more significant stress than others.

       Dealing with stress is imperative to prevent and treat breast cancer.  Anytime our bodies experience stress, the hormone cortisol is released.  This begins an intricate stress cascade that affects nearly every organ and regulatory system in our body.  In Chinese Medicine, cortisol acts like a Fire Poison and burns away the yin of our body.

Inadequate Sleep
       From a biomedical point of view, we know that human growth hormone is secreted during sleep, which is vital for repairing damaged tissue.  Studies prove that sleeping less than the optimal number of hours (7-9 hours per night) over long periods of time hinders our immune function and disrupts hormone levels in the body.

       From a TCM perspective, the Wei Qi moves inward to circulate and survey for 12 cycles during the night.  This is the Qi that protects us from disease.  Without sleep, the Wei Qi is unable to perform its surveillance, rendering us ripe for attack.

       In the clinic, we observed that many breast cancer patients had a history of insomnia.  Others confessed to simply being poor sleepers, waking often or early, and that these sleep patterns were chronic.  In a large-scale survey of 363 people newly diagnosed with breast cancer, researchers found that 40% reported bad sleep habits like keeping the lights on while sleeping or sleeping during the daytime (7).

Elimination
     
  Daily bowel movements imply that the Spleen/Stomach unit is in strong working order.   After the Essence from the food is absorbed, the waste is conveyed through the Large Intestine.  Constipation, on the other hand, is a symptom of channel and organ disharmony. 

       Our bodies rely on the downward and outward movement of toxins through our liver, kidneys, bladder and bowels.  If there is a prolonged period of blockage in the Lower and Middle Jiaos because our bowels are not eliminating waste and toxins, then this will eventually translate to the Upper Jiao.  Qi, and eventually Blood, Heat, and Fire Toxins will accumulate in the channels and organs of the Upper Jiao.  If we clear the embers below, we put out the fire above.

       Constipation is also a common result of long term Liver qi stagnation.  We know that chronic Liver qi stagnation can eventually affect the entire channel, including the breast and axilla.

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Internal Factors

Disharmony of Qi/Blood

       Qi moves the Blood.  When Qi becomes impeded the movement of Blood slows, causing it to pool, eventually congealing and turning into Blood Stasis.

       Congealed Blood will lead to Heat, and Heat dries up the Jin Ye and Yin, our normal body fluids.  This causes a systemic, deficient-type heat. There is always Yin deficiency present in a cancer patient.

       The Stomach channel runs directly through the breast, and improper food intake (both the food itself and the manner in which it is consumed) can result in Qi blockage, and eventually Blood Stasis and Heat.  This pattern is a main etiological factor in breast cancer.

Zang Fu Deficiencies
Spleen
       Eating foods high in fat and/or sugar, eating at irregular times, and eating while watching TV or working, can lead to Spleen and Stomach deficiency. We know from modern research that cancers occur more frequently in those who eat a high fat diet.  This is also true with hyperinsulinemia, as breast tumors were found to have up to 3 times as many insulin-like factors (1).  In the field of holistic nutrition as it pertains to cancer, the consensus is that sugar "feeds" cancer. All cancer diets should be very low in glucose. 

       Spleen deficiency from the improper assimilation of food leads to Blood deficiency.  This creates Damp accumulations and stasis rising from deficiency and accumulation.  High fat and high sugar foods contribute directly to the damp environment of the Middle Jiao as well, giving a cumulative effect of pathology.
 
       Chemicals from the food we eat reside in fatty tissue, as chemicals are fat-soluble.  The more fat you have on your body, the more toxins are present in your body.  Chemicals promote free-radical damage to cells and irregular and malignant cellular replication.

       Hormones also reside in the body's fatty tissue, like the breast.  Some foods containing insecticides, phthalates, and components of plastics that line most canned foods like Bisphenol A (BPA) act as xeno-estrogens in our bodies and load up in the fatty tissue.  While natural estrogens are excreted by the body in a timely fashion, xeno-estrogens persist in the body for years because they do not bind to the proteins that would eliminate them from the body (1).  Xeno-estrogens should be considered a Fire Poison in Chinese Medicine.  Breast cancer is commonly a hormone-driven cancer, so when there is an estrogen, progesterone, or androgen driven cancer, part of the treatment protocol must include clearing these poisons.

Kidney
       The Chong and Ren rely on the Essence Qi from the Kidneys. If the Essence Qi becomes depleted, it predisposes the Chong and Ren to disharmony, ultimately leading to Fire Poison (1). 

       In both Eastern and Western Medicine, aging itself is a risk factor for cancer as most breast cancer occurs in people over the age of 50 (1).  Referring to our discussion earlier about overwork as it applies to the etiology of breast cancer, our busy lives lend themselves to the burning and draining of Kidney Essence.  Chronic stress is another factor that drains our Kidney Essence.

Lung
       The Lungs circulate the Wei Qi.  When the lungs are impeded, immunity is affected.  When the lung is injured by emotion, as mentioned above, this can influence deep breathing, which leads to an inability to oxygenate the blood at a normal level.  Lowered oxygenation of tissue leads to lower Wei Qi levels (1).

Liver
       A Liver deficiency can affect the Blood, causing it to stagnate.  The Liver houses and is responsible for the free-flow of blood to female sex organs, including the breasts.  When Liver blood is stagnant, qi and blood accumulation in the breast may follow.

     Liver Qi constraint leads to Heart Qi stasis according to the five phase cycle.  Combined with Lung Qi stasis from emotional factors, the entire chest area can become stagnant, leading to Blood and Phlegm stasis.

     Liver Qi stasis that creates Kidney yin deficiency contributes to abnormal hormonal levels (1).

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Internal Factors Continued

Disharmony of Chong and Ren
       The Chong and Ren channels are very important in women, and the Chong and Ren rely upon the Essence Qi of the Kidneys.  Therefore any Kidney deficiency will affect the Chong and Ren.

     In menopause the Chong and Ren channels, which are strongly linked to blood, can become dissonant.  This is equivalent to estrogen and progesterone levels changing and declining in menopausal women.  Because the uterus and heart/chest are connected internally by the Chong channel, when the downward flow of menses stops, the blood that formally was released via the menstrual cycle can become stagnant in the chest area (1).   


       During and after menopause, some women choose to go on HRT (hormone replacement therapy).  The addition of the synthetic hormones to the body creates heat.  Combined with the propensity of menopausal Qi and Blood to accumulate in the upper regions of the body, this leads to heat and blood stagnation in the chest and breast area.  This is commonly seen in the clinic and you would look for red tongue with purple sides. 

Channel Anatomy
       Keeping Chinese meridian pathways top-of-mind is a good strategy when multiple patterns are present and the case is confusing.  The Liver channel runs through the flank and side breast and armpit.  Again, most breast cancers occur in upper 1/4 quadrant of the breast, the part closest to the armpit.  The Stomach channel passes through the nipple.  The pathways of the Chong and Ren go through the chest and the uterus and heart/pericardium and breast are connected internally by the Chong.  The organs of the chest are the Heart and Lung. 

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Tumor & Pattern Diagnosis

Tumor Differentiation as per Chinese Medicine
       There are four types of tumors defined in Chinese medicine.   A Blood stasis tumor feels hard with clear borders and it does not move underneath the fingers when palpated.  Phlegm stasis, causing a phlegm tumor, is characterized by soft lumps that can be moved with palpation.  There may be nipple discharge and there is normally no pain.  A Fire Poison tumor is a fast-moving tumor and is characterized by a red rash on the nipple and the skin of the breast.  This tumor category corresponds best to Inflammatory Breast Cancer.  A Damp tumor is notable for swellings with oozing and soft movable lumps.  Damp tumors are less defined than Phlegm tumors.  An example of a Damp tumor would be a tumor that has broken through to the skin and has created an ulcerous-type lesion (1).

Breast Cancer Pattern Differentiation
            Michael Broffman et al believe the three primary breast cancer diagnostic patterns are at root a deficiency of kidney jing, deficiency of heart yin, and deficiency of spleen qi. This serves to remind us that when we see these three patterns emerging, our role in prevention is paramount (8). 

    Li Piewen cites the following as 5 patterns as the most dominant. (See Appendix 1 for extended formulas).  The last pattern is taken from Tai Lahan's Integrating Chinese Medicine with Conventional Cancer Care. We found that pattern, Liver Qi Stagnation with Spleen Deficiency and rebellious Stomach Qi to be the most prevalent pattern in the clinic.

Phlegm-Damp due to Spleen/Stomach Deficiency  
Symptoms Firm and lumpy tumors in the breast and armpit area, sallow facial complexion, tiredness, cold hands and feet, oppression of the chest and distention of the stomach, reduced appetite, loose stools.
Pulse Slippery, thready, wiry, or slippery
Tongue Pale, teeth marks, white, greasy coating
Treatment Principle Fortify the Spleen and transform Phlegm, soften hardness and dissipate lumps.
Base Herbal Formula Xiang Sha Liu Jun Zi Tang with modifications
Disharmony of Chong and Ren  
Symptoms                      Firm lumps in the breast that are painful on pressure, irregular menstruation, aching and limpness in the low back and legs, distention in breast before menses, weakness in low back, tinnitus, chronic or dry sore throat, frequent UTI, insomnia, five palm heat, subjective feeling of heat
Pulse Rapid, thin, irregular, wiry, slippery, thready
Tongue -Red tongue with scanty tongue coat with dots
-Dry tongue with cracks and dry coat
-Pale and thing with white coating
Treatment Principle Harmonize Chong and Ren, enrich the Liver and supplement the Kidneys
Base Herbal Formula Liu Wei Di Huang Wan with modifications
*Note:  Liu Wei Di Huang Wan has been found to lower estrogen levels in premenopausal women but slghtly raise them in postmenopausal women (1).  Menopausal status must be considered before giving this formula.

Accumulation of Stasis and Toxins  
Symptoms                      Firm and immovable lumps in the breast with burning heat and pain, skin above lump is dull purple with an indistince border which may include swelling, irritability, dry mouth, afternoon fever, shortness of breath, lack of strength, constipation, reddish urine, dizziness, tinnitus, night sweats, hot flashes, five palm heat, thirst, dry mouth
Pulse Thready, rapid, slippery

Tongue
Dry, red or dull red body with yellow coat
Treatment Principle Clear Heat and Relieve Toxicity, transform Blood stasis and dissipate lumps.
Base Herbal Formula Tao Hong Si Wu Tang with Jin Yin Hua Gan Cao Tang with modifications

Liver Depression and Qi Stagnation  
Symptoms                       Firm breast lumps with distention and pain but w/o any change in skin color.  Chronic headaches, hiccough, dry heaves, depression/frustration, impatience, sadness, oppression in the chest and/or distention in the hypochondrium, poor appetite, bitter taste in mouth, dry throat, dizziness, breast distention before mestruation, palpitations, poor sleep, restless sleep, restless leg syndrome, irritability, moodiness, dry skin
Pulse  Rapid, wiry, choppy, thready
Tongue  Dark or dull tongue with spots, dry thin yellow coat
Treatment Principle  Dredge the Liver and regulate Qi, transform Phlegm and dissipate lumps
 Base Herbal Formula  Xia Yao San with modifications

Deficiency of Qi and Blood  
Symptoms                         Late-stage breast cancer characterized by lumps in the breast with erode and then ulcerate giving off foul-smelling, thin, clear exudate, accompanied by dry and lusterless skin, mental fatigue, emaciation, pale facial complexion, reduced appetite, dizziness, shortness of breath, sweating, insomnia, clear urine, loose stools
Pulse Deep, thready, forceless
Tongue Pale with a yellow or thick, greasy, tongue coat
Treatment Principle Supplement Qi and nourish the Blood, relieve toxicity
Base Herbal Formula Yi Qi Yang Rong Tang with Shi Quan Da Bu Tang with modifications
Liver Qi Stagnation with Spleen Deficiency leading to rebellious Stomach Qi  
Symptoms Epigastric distention, belching, heartburn, nausea, vomiting, post prandial fatigue, IBS symptoms, constipation prior to menses, diarrhea at onset of menses
Pulse Slippery, full
Tongue -Red sides
-Large, pale, flabby, greasy tongue coat
Treatment Principle Move Liver qi and blood, harmonize Spleen/Stomach
Base Herbal Formula See Appendix 1
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Diagnosis from a TCM Perspective:  Observation, Palpation, Listening, Smelling, Asking 


       There are a myriad of symptoms a patient might present with that can alert the practitioner to further explore the possibility that cancer may be present, which would of course require a referral to a M.D.  Sudden weight loss and fatigue are two main symptoms to look for, although in the clinic sudden weight loss does not occur with most breast cancer patients.  Many do complain of fatigue.  Some patients may mention a negative change in body odor and of halitosis well before any cancer diagnosis has been officially made.  This type of information can alert the practitioner to "screen" the organ systems for disharmony.

       Some may in fact complain of a breast lump, although it is important to note that early breast cancer usually does not cause any pain.  Pain occurs when the tumor pushes upon adjacent tissues or when there is metastasis to bone, for example.  To reiterate, most breast cancer occurs in the upper 1/4 quadrant of the breast, the part closest to the armpit.

       Certain types of tumors cause dryness or puckering of the skin, others cause a red rash. Early Inflammatory Breast Cancer is often mistaken for mastitis so getting an immediate referral is appropriate at this stage.  For a review of breast anatomy, lymphatic system, risk factors, and types of breast cancer, please refer to the course:  Breast Cancer Part 1:  Risk Factors, Diagnosis, and Treatment from a Biomedical Perspective.

Observation (Inspection)
       Diagnosis of a patient begins the moment they walk into your office.  As Chinese medical practitioners, we know the importance of observation in our diagnosis and this is especially true with cancer patients.  At first glance, note the color and luster of a patient's Shen, consistency of their gait, and clarity of their focus. 

• Is the patient suddenly limping?  Think of bone metastasis.
• Is the patient short of breath walking into your office?  Think of lung metastasis.
• Is the patient unable to take a deep breath without pain in the ribcage?  Think of bone metastasis.

Observation of Vitality
       Does the patient have spirit, a sparkle in their eyes, and the ability to respond to questions with clarity and general high energy?  This tells a general balance between the presence of Qi, Blood, Yin and Yang versus strength of the pathogen.

Observation of Color
     Note both the color and luster of a patients face.  In our experience:

• A gray, lusterless facial color is often associated with chemotherapy and/or progression of disease.  If the gray has a dark tone, it usually indicates that Kidney Qi is in decline or that Blood Stagnation is severe, or both. 
• A red color often appears in the face and/or targeted tissue when radiation is administered.  Look for 5 palm heat redness for yin-type or toxic-heat patterns.  
• A pale complexion can indicate many things, but it is seen with patients going through chemotherapy, patients with anemia due to blood loss after surgery or from a bleed, or from general disease progression. 
• A pasty-white complexion may equate to disharmony or stagnation of the lymph.
• Yellow sclera or skin tone may indicate jaundice. 

Observation of Tongue

       When looking at the tongue of a breast cancer patient, the breast area is in between the tip of the tongue and the middle of the tongue.  The sides of the tongue correspond to the Liver and Uterus.  These are the areas that may show first signs of changes in the body.  In clinical practice, here are some common observations:

• Redness:  Toxic Heat, sometimes in the form of cancer-promoting hormones or side effects of treatment
• Purple:  stagnation of blood (tumor)
• Blue:  blood stasis with cold
• Black spots:  fixed and sometimes raised black spots can signify recurrence or metastasis
• Red spots:  Toxic Heat
• Coat:  appearance of a coat can indicate the depth of disease, toxin build-up, and candida overgrowth from eradication of GI flora due to chemotherapy, often associated with dampness.  If the tongue coat quickly peels this can mean that the cancer is spreading.

For photos of tongues of breast cancer patients, please see Appendix 2.


Diagnosis from a Chinese Medical Perspective Continued

Palpation 
  
       It is important to monitor changes in the patient's pulse.  Note any significant changes in all pulse areas, including general Qi/Yang and Yin/Blood pulses, in addition to individual organ pulses.

Pulse changes that we have commonly seen in clinic include:
• Wiry pulses becoming more tight and forceful as stagnation increases.
• Slippery or soft pulses becoming more deficient as pathogen strength increases while Wei qi and Yang qi decrease.
• Superficial pulses in particular organs that may be seeing an increase in pathogenic factors.  This may appear as an external pernicious factor pulse, when in fact the fight going on is between the Wei qi and a latent pathogen.

Abdominal and Channel Palpation
       Abdominal palpation can be a great guide for an acupuncturist.  Note tender and full areas of the abdomen, and note abdominal channels that feel full and stagnant, especially considering all of these channels go through the chest and breast as well.  Treat those channels and then feel the abdomen again.  Has it resolved?

       Do the same for channels of the arms, legs, back and head as well when given the chance. 

     When palpating a patient's legs, keep in mind that women who have taken Tamoxifen are at greater risk of blood clots.  In fact, many conventional treatments for cancer increase the risk for DVT (deep vein thrombosis), a scenario we witnessed at the clinic and thus should always be on the forefront of your mind.  Needling an area with a suspected DVT is forbidden.  Refer to an MD or urgent care for further evaluation before treating if you see redness or feel warmth and/or swelling in a leg.

Listening
       Always note any labored breathing, wheezing, or shortness of breath.  Note if the patient's voice begins to become weak or is hoarse. 

Smelling
       Note if a patient's breath takes on a sour or bitter scent.  Anything new of different requires attention and can be used to gauge if patterns are shifting.  Has the patient's breath gone from a sour scent to a more sweet one?

       Odors are mostly associated with damp-type tumors.  In the extreme form, these tumors have opened up to the outside of the body, most commonly in the breast or chest area for breast cancer patients.  These tumors have holes that open up from the inside out, and leak some form of exudate.  The exudate can range in color and thickness, and following what we know about these principles, thicker exudate is associated with a more intense damp environment in the body and a darker color exudate is associated with more heat.  Odor is also a diagnostic tool when treating these tumors.  The more rancid, rotten, or fetid an odor, the more damp and/or heat present in the body.
 
       Once a tumor infiltrates the surface of the body and opens up to the outside of the body, there is a strong likelihood the tumor is associated with metastasis.  This is a combination of extreme inflammation and infection.  Antibiotics and steroids are often prescribed to address the side effects of these tumors.
 
       Chinese herbs and distal acupuncture can be used for infection and inflammation, and a referral to their oncologist mandatory.

Asking
       Ask both open-ended and guided questions in order to bring up anything new that a patient may be experiencing.  Many patients may find new symptoms insignificant that are very important clinically, like a change in bowel habits.  Use your knowledge and sound judgment to know when to further investigate and refer to their MD.

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Using Chinese Herbal Medicine as an Adjunct to Conventional Therapy

      
Before discussing the ways Chinese medicine can help support a patient before and after surgery, chemotherapy, and radiation, a short discussion on the delivery of herbal medicine is warranted.

     

    The delivery form of herbs must be carefully considered by the acupuncturist keeping in mind that the ultimate goal is compliance.  We know that herbal medicines take a while to accrue in the body, and consistent and habitual consumption is how we can make a difference.  The type of herbal medicine is hotly debated in TCM, and we hope to shed light on why and perhaps give some new perspective.

     Some practitioners believe that using herbs in tincture form adds heat to the body, which is very undesirable in the already Yin deficient cancer patient.  However, we have found that using herbs in tincture form is helpful when the transformation and transportive functions of the Spleen and Stomach are injured, which occurs during or following chemotherapy.  These extracts bypass the GI tract and are delivered to the bloodstream so they do not require a digestive fire to break down, which is absent in many chronic cancer patients.  Furthermore, many oncologists are more apt to approve medicinals in an alcohol extract than a raw herb format for worry of contaminants in raw herbs.  Chinese medical practitioners may have been instructed to not use alcohol extracts due to the heat component of alcohol.  However, when added to hot water most of the alcohol content is dissipated, which is why this is an acceptable method for recovering alcoholics. 

       Capsules, tablets, or teapills require a a digestive fire that is often not in tact.  Not only is their Kidney, Spleen and Stomach fire to too low, they are often on a heavy pharmaceutical regimen and are hesitant to take more pills.  It is not uncommon for a cancer patient to take an upwards of twenty pills a day, especially since many chemotherapy drugs and hormone therapy drugs are now oral.  Some patients simply can not bear the thought of taking one more pill per day, and a TCM pill regimen is often at least 12 pills per day (often in the range of 24).

       Raw herbs decocted in a tea is one standard of treatment in China, but nausea and lethargy often prevent the patients from cooking and drinking the formula.  (In China many herbs are given intravenously - wouldn't that be amazing if we could do that here!)  Powdered herbs are often a good in-between solution, although they often present with the same patient compliance issues as raw herbs.  Patients quite simply get sick of preparing them and also complain about the taste.

       As you can see, there is not an easy answer that fits every scenario.  It is important to be flexible and wherever possible, be able to offer all delivery methods to find one that is agreeable to your patient and your patient's oncologist.  This will ensure long-term herb compliance.

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Surgery

       Before the patient is on chemotherapy or other medications specific for their cancer, the post-operative period is an excellent time to use herbs and acupuncture to help the body recover and fortify them for whatever lies ahead.  However, some patients receive chemotherapy for several weeks before surgery in an attempt to shrink the tumor, which is a very important consideration when you are designing your own formula. 


       The type of surgery itself should be considered.  There will be significantly less trauma from a sentinel node biopsy than a radical mastectomy and this should weigh in when prescribing herbs.  Age and constitutional diagnosis of the patient should also be considered - is the woman in her 40‘s or 80‘s?  The goals of treatment should reflect the individual but should address the principles of supplementing Qi, nourishing Blood, fortifying the Spleen, and boosting the Kidneys (2).  Herbs like Huang Qi, Tai Zi Shen, Dang Gui, Huang Jin, Ji Xue Teng, Chi Shao, Bai Zhu, Fu Ling, Chen Pi, Dan Shen, and Yin Yang Huo are some good choices (2).  Tai Lahans adds qi-level heat clearing herbs like Xia Ku Cao and Jin Yin Hua (which both go to the chest), plus some herbs with anti-neoplastic properties including Shan Ci Gu, Bai Hua She She Cao, and Gua Lou Shi, which help to stop the spread of cancer cells (1).

       Useful classical formulas include Ba Zhen Tang, Shi Quan Ba Zhen Tang, or Gui Pi Tang, and depending on the presentation can be given before the surgery to boost qi and blood.  If you are looking for a prepared formula, Imperial Tonic by Evergreen is for Qi, Blood, Yin and Yang deficiencies, and is a variation of the classic formulas above.  Any of these formulas are suitable for a woman in her 6th, 7th, or 8th decade before or after surgery.  Absent from these formulas are heat-clearing or anti-neoplastic herbs, which may be added according to the practitioner's discretion.

       The formula Resilience by K’An in the Sage Solutions line is a blend of four mushrooms (Ling Zhi, Bai Mu Er, Zhu Ling, Maitake) and Huang Qi.  This formula builds white blood cells (fortifies Wei Qi), tonifies Qi, nurtures blood, and replenishes essence. 

       Many acupuncturists use the homeopathic Arnica Montana, which is safe and has good patient compliance.

Radiation

       Radiation can be considered an external pernicious evil of both heat and dryness.  Radiation causes a drying up of normal bodily fluids and quite simply burns the Yin.  It can cause dryness, redness, burning, irritation, pain, and swelling of the skin where the radiation was delivered.  


Internal therapy
       Side effects are mostly contained to the area being treated, but may include Yin deficiency, Qi deficiency, Blood stasis and scarring, and local Yin deficiency like red and blistered, painful skin.  Systemic lubricating and cooling herbs can be beneficial as well as herbs that clear heat and remove toxins.  These include anything that matches the pattern being presented.  Some useful herbs are:  Bei Sha Shen, Mai Men Dong, Tian Hua Fen, Sheng Di Huang, Shi Hu, Jin Yin Hua, Huang Qi, Zhi Zi, Ban Zhi Lian, Chi Shao, Ji Xue Teng, Chen Pi, Gou Qi Zi, Nu Zhen Zi, Pu Gong Ying, Dan Shen, Tai Zi Shen, Fu Ling, Zhu Ling, Tain Dong, Mu Dan Pi, Ling Zhi, Bei She Shen, Shan Yao, and Zhi Mu, amongst others.

       Some beneficial patent formulas include Resilience by Sage Solutions and C/R (Chemotherapy/Radiation) Support by Evergreen.


External therapy

       Topically, Ching Wan Hung, or Ten Thousand Brights cream is helpful in preventing blistering and painful burning.  Spring Wind herbals Burn Cream may also be used to preventing blisters and reducing pain (1).

Chemotherapy

       Chemotherapy acts like a Fire Poison.  In the acute phase it kills all fast growing cells and erodes the mucosal lining of the GI tract, causing the transportive and transformative functions of the Spleen to be eradicated.  This is why chemo causes GI symptoms such as nausea, vomiting, bowel irregularities, lowered immune system, etc.  After several weeks to months of chemotherapy a Spleen and Kidney Yang deficiency presentation develops, characterized by loose stools, cold body temperature, lowered immunity, anemia, etc.


       Herbal treatments should be directed at restoring Blood and Yin, warming, and promoting the proper flow of Qi and Blood.  In other words, treatment should be aimed to offset the damage created by chemotherapy.

       The formula Shi Quan Da Bu Tang is one main formula used to off-set chemotherapy-induced toxicities during treatment.  The formula is widely known for correcting deficiencies of Qi and Blood with Yang deficiency.  The formula contains immunostimulant, hematopoietic, anti-neoplastic, anti-tumor, and anti-metastatic properties (9). 



       The second formula often used to off-set chemo and radiation-induced toxicities is Bu Zhong Yi Qi Tang.  It’s main actions are to augment Middle Jiao Qi and raise Yang Qi in the event of prolapse.  Many patients on chemotherapy will have loose stools or diarrhea during the course of their treatment.  Without a functioning intestinal system, proper transformation and transportation of food can not happen.  This creates a deficient state where Yang is unable to hold.  The formula should not be given to patients with deficient or excess heat, as the formula is warming in nature.  The formula contains immunostimulant, anti-cancer, and radio-protective properties (10).


       There are several good patent formulas that can be added to the above formulas or given separately to a patient during and after chemotherapy.  Resilience by Sage Solutions, Chemo-Support in the Giovanni Maciocia line Three Treasures, and C/R Support by Evergreen can be used to bolster the patients immune system both during chemotherapy treatment and after. 

       In extremely debilitated patients, we have used Cordyceps, available in many forms by many companies. Cordyceps tonifies Kidney Yang and Essence and is a very safe herb that can be taken over time.

       Please refer to Integrating Conventional and Chinese Medicine in Cancer Care by Tai Lahans for specific herbal formulas to use during specific chemotherapy regimens, like AC or CMF. 

        Weeks to years after a patient completes their chemotherapy without any herbal or dietary therapy to counteract the damage, they often present with Stomach Yin deficiency and systemic Yin Deficiency.  Patients will complain of insomnia, dry mouth, dry cough, chronic sinusitis, and a whole series of Yin deficient systems from afternoon fevers to Yin sores.  Although the presentation is that of systemic Yin deficiency, often they will continue to have loose stools.  This is not so much because they are still cold, it has more to do with the chemotherapy causing opportunistic infection such as candida which will cause them to have bloating, loose stools, or diarrhea.  The tongue coat of a post-chemo patient can therefore be thick and greasy due to candida overgrowth.  The Chinese medical diagnosis would be Yin Deficiency, Liver Blood Deficiency and Spleen Qi deficiency with dampness/damp-heat.  Any herbal formulas that combat candida are helpful, plus probiotic therapy.



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Hormone Therapy

       Pre-menopausal patients with estrogen-receptor (ER+) positive cancers are given the selective estrogen receptor modulator (SERM) Tamoxifen, which prevents estrogen from binding to receptor sites on breast cells.  This makes the woman go into menopause, replete with all the menopausal signs and symptoms.  Post-menopausal women with ER+ cancers are given aromatase inhibitors like Arimidex or Femara.  Some women are given drugs like Lupron, a LHRH analog, which will stop ovarian manufacture of estrogen and will put someone into complete chemical menopause, with all the tell-tale signs and symptoms. 


       For women experiencing chemical menopause, using classical formulas that treat menopausal symptoms in patent form can be effective.  Two Immortals, Liu Wei Di Huang Wan and Zhi Bai Di Huang Wan are among some you might choose for starters.  In pre-menopausal women Liu Wei Di Huang Wan has been shown to lower estrogen levels, but in post-menopausal women it has been shown to raise them slightly, so the pre- or post-menopausal status should be considered when offering this formula (1).  Depending on the pattern, Yi Guan Jian (Linking Decoction) can also be effective.  As with all TCM diagnostics, treat the pattern that is being presented.

     Standard Process has a product called Vitanox that contains several ingredients including Rosemary, which researchers believe stimulates the liver enzymes which inactivate estrogen hormones.
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Acupuncture Guidelines

       In China, treating cancer is accomplished through herbal medicine.  However, acupuncture can be also be used to treat the symptoms of the cancer like pain and/or the help alleviate the side effects of treatment like nausea or constipation. 


       It is generally considered forbidden to needle on or near a tumor site.  This includes the tumor area, including the body part that may have been resected.  This is due to the idea that needling brings Qi and Blood to the area, which could potentially “feed” the tumor. 

       However, the ultimate goal of treatment must always be foremost when treating a breast cancer patient.  If the practitioner is treating a Stage 4 cancer patient whose chief complaint is pain, the benefits of pain reduction have to outweigh the speculation that acupuncture may increase tumorgenesis, in our opinion.  Furthermore, by the time there is metastasis, the cancer is well-established in the patient’s blood and lymphatic system, and therefore the speculation of spreading the cancer via acupuncture becomes moot.  Making the patient comfortable takes priority.

Needle method
       Herbal medicine generally treats a deficiency, when there is a need to add to something that is lacking.  Acupuncture generally treats excess, when there is a need to drain something, like excess heat.  In the case of cancer, it is a deficiency that has created the tumor.  In light of this, acupuncture should be employed in a very gentle manner.

       Most cancer patients who have been through conventional treatment will have received multiple IV therapies and injections, as well as repeated blood draws.  They may have developed a negative association with needles.   An even, pain-free needle technique using small gauge needles is appropriate.  Needle manipulation can be draining even if it is intended for tonification.  Although many patients may present with replete symptoms like pain, especially in the case of cancer metastasis, at root remember they are all deficient.  For patients too weak or blood deficient to needle, moxa is nourishing and effective, as are ear seeds used on the ear or body.

Less is More
       The old acupuncture adage that “one needle cures 1000 diseases” is a good mantra when using acupuncture on someone with breast cancer.  Cancer patients, especially those in later stages, seem to respond to significantly less than someone without cancer.  A one or two needle treatment that would normally not elicit results may have a profound effect on your cancer patient, like using bilateral LI4 resulting in a bowel movement for significant opiate-induced constipation.

Positioning
       Only the breast cancer patients who were very robust, acutely diagnosed, or in remission were put in the prone position to be able to get to the back Shu points.  Most of the time a breast cancer patient was treated in the supine position or in the lateral recumbent position, with the affected breast on top. 

A Note about Lymphedema
       Lymphedema of the arm on the side the radiation therapy is a common complication of radiation therapy and surgery.  Many patients have been told by their oncologists to not allow needling on the affected arm because the condition causes them to be more susceptible to infection.  In the instructor’s opinion, it is the stagnant lymph in the arm that makes it susceptible to infection.  Stagnant lymph blocks all the important channels that relate significantly to the chest and breasts, like the Pericardium and Lung.   Lymphatic massage is effective at moving stagnant lymph, yet is discouraged by many oncologists because of the notion that massage, like acupuncture, will promote lymph mobilization which will promote cancer cell mobilization.  That being said, in the clinic there were several cases where the doctors and the patients themselves requested acupuncture for stubborn and uncomfortable lymphedema.  (In some cases, the effected side was three times the size of the other arm).  Acupuncture was performed along with electrical stimulation.  The results were to be expected, the lymphedema was significantly reduced and would remain reduced for a period of roughly 24-72 hours after the treatment.  There were never any complications with frequent acupuncture to reduce lymphedema, and both the patients and the doctors were pleased with the results.  

Where to Needle
       Generally speaking, the points on the hands to elbows and feet knees are used the most.  These points are accessible and do not require disrobing. 

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Acupuncture Protocols

5 Shu Points

       The 5 shu points are where the qi gathers and plunges deeper into the body.  The shu-stream points on Yin channels are the main points for tonifying and harmonizing their organs.  Deadman et al says these points should be considered the single most important point of their respective channel (11).  Lung 9, Spleen 3, Heart 7, Kidney 3, Liver 3, are all incredibly useful points with a wide range of use.  The jing well points can be used for bone metastasis. The he sea points have a strong action on the stomach and intestines, and can be used for stomach or abdominal distention, diarrhea or constipation, all either symptoms of the disease and/or disease treatment.    

Auricular
       Auricular acupuncture is a staple at the clinic, as many of the patients are "hooked up" to IV’s (of natural therapy) for many hours, often at a very slow rate because intravenous B vitamins can be nauseating.  Giving patients ear acupuncture during the hours of IV reduced their anxiety, nausea, and pain.

       An auricular point protocol can be derived in many fashions.  You can use auricular for acute distress (nausea, etc.) or in lieu of a body treatment by choosing corresponding body points on th ear.

For example, a breast cancer protocol could consist of a combination of some of these points:

• Mammary glands (2 needles)
• Shenmen
• Liver
• Kidney yin
• Hormone
• Spleen

• Stomach

       Since auricular acupuncture uses the microcosm to treat the macrocosm, the sky is the limit with this system and it can be very effective and minimalist.

Points for Pain
       Tumors, when pushing upon adjacent tissues, can create pain.  Certain distal needling methods, like Dr. Tan’s balance system, can reduce systemic inflammation.  If pain management and palliation is your patient’s primary objective, needling closer to the painful area (often a place where there is bone metastasis) can bring about relief (bone metastasis pain is often reported as “burning”).  LI 4, the source point of Large Intestine channel, has a powerful antispasmodic action.  When combined with LIV 3, it can stop pain and calm the mind (11).  P6 moves Qi in the chest, and can be used to treat pain due to stagnation of qi or blood.  This point is great after surgery. 

Electroacupuncture (EA)
        Many patients develop tolerance to opiate-derived pain killers and sensitivities to NSAID’s.  In severe cases of intractable pain, like in a Stage IV cancer patient with metastasis, electrical stimulation can be employed as a pain reducing method.  The pain reducing affects of EA have been well documented.  Although the outcomes are better when using EA close to the painful site, we have used distal channel points with success accumulation points, for example.  For a patient with metastasis to the pelvic area with colon involvement on the Stomach channel with pain, you could connect ST 25 with ST 40, and ST 37 with LI 11, and P6 to ST44, bilaterally.  For severe pain, a higher-frequency and higher-intensity pulse seems to work better, while a lower-frequency and lower-intensity pulse works for less intense pain.

       Some researchers have advised against using any sort of electrical stimulation with cancer patients probably because of one study that was done using brain stimulation that increased metastatic activity.  On the other hand, a team of researchers at the University of Minnesota did an experiment with rats to see whether or not gender affects the degree of pain experienced with osteosarcoma tumors given electroacupuncture as a treatment for pain.  As to be expected, they found that both groups experienced a reduction of osteosarcoma pain on the days they were given electroacupuncture.  Furthermore, they found that giving electroacupuncture early to a rat with osteosarcoma also had an inhibitory effect on tumor growth (13).  In this study, the timing of the acupuncture treatment seems to be key.  Obviously these somewhat contradictory findings prove how much more is needed to understand EA in regards to tumorgenesis.  We hope more studies will prove the latter and we can begin to use EA with utmost regularity and confidence.

       Both manual acupuncture and electroacupuncture have been employed for the prevention and treatment of chemotherapy and radiation-induced side effects.  Specifically for countering lowered white blood cell counts, tissue repair in preventing necrosis, fibrosis in salivary glands or mucus membranes, and for improving circulation and reducing edema (12).

       In summary, if pain management and management of side effects of chemo and radiation is your goal, EA is a great tool.
 
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Acupuncture Protocols Continued

Points for Nausea
       P6 subdues rebellious Stomach Qi and can be used in most patterns where there is epigastric pain, acid reflux, hiccups or belching.  It is generally believed that for acute or excess conditions, P6 can induce vomiting.  Because the nausea a cancer patient experiences is more along the lines of a low-level, constant nausea due to medications, P6 is a good point.  Kidney 6, used for morning sickness in pregnant women, can also be effective for nausea in hormone-driven breast cancers.


Points for Anxiety and Depression
       P6 can be used in anxiety caused by any heart patterns.  It also calms the mind from irritability by its relationship to the Liver via the Jueyin channel.  Du 20 is a powerful point for lifting somebody’s spirit after diagnosis of breast cancer, or during the throes of conventional treatment.  Ear Shenmen shows great clinical success in the IV room, where apprehensive patients are able to close their eyes and breathe deeper after several minutes of retaining this needle.

Points for Constipation
       Constipation in a breast cancer patient is an example of the great paradox of cancer.  At root the disease one of severe deficiency, but manifests with replete symptoms like pain and severe constipation. The question is, do you treat a Yin deficient patient with strong Qi moving, excess-draining points?  This can only be answered by the practitioner using strong pulse and tongue diagnosis, a good interview, and an understanding of the both the cancer and the treatment stage the patient is in.  Is the constipation due to opiates for pain or severe Yin deficiency?  The big points for constipation - LI 4, SJ 5, SJ 6, ST 37, ST 25, can be used depending on the robustness of the patient and the severity of the constipation.  On these patients, even needling bilateral ST 25, Ren 6 and Ren 10 is indicated.  If the constipation is due to severe Yin and Blood deficiency, Kidney 6 or 7, Liver 3 or Spleen 6 can be used.  Depending on the sensitivity of the patient, massage techniques can be employed on the abdomen, low back, or legs instead of needling. 

Points for Peripheral Neuropathy
       The extra points Ba Xie (eight pathogenic factors) and Ba Feng (eight winds), in the web margins of the hands and toes to be very helpful in treatment chemo-therapy induced peripheral neuropathy.  This is due to the fact that they eliminate wind and relax the tendons.  In Master Tung’s system, the point combination 3 Emperors can also be useful for this condition for somebody whose feet are too sensitive to be needled.

       In addition, any points that tonify Liver Blood and calm Liver Wind are also helpful in treating peripheral neuropathy.  The homeopathic remedy Zincum Metallicum can be a useful adjunctive therapy.

Points for Hot Flashes in Anti-Estrogen Cancer Therapy
        A Korean study used the points: Du 20, Yin Tang, HT 8, Kid 10 and Liv 2 to address hot flashes induced by tamoxifen or anastrozole.  Treatment was 3 times a week for 4 weeks (12 treatments total) and a reduction in hot flashes occured in all women lasting for a month after the treatment ended.1


8 Extraordinary Vessels
       Considering the fact that the extraordinary vessels all derive from the kidneys, they are a good base point to construct an acupuncture point protocol.  The Du vessel can strengthen Kidney Yang.  The Ren vessel is the sea of Yin and exerts influence on all the Yin channels of the body.  The Chong channel connects the Kidneys and the Stomach, and is a very useful base point in dealing with the Liver Qi Stasis with Spleen Deficiency and Rebellious Stomach Qi pattern.  Its network branches out in many small capillary-like vessels that circulate defensive qi over the abdomen and chest.  This vessel is often used for hormonal-related conditions due to its role in regulating menstruation, so an argument can be made that it can be useful for ER/PR driven cancers.  It is also used to move qi and blood and remove obstructions.

       Because the Chong channel can be used in cases of weak constitution with digestive symptoms such as poor appetite, abdominal distention, and poor assimilation of food, it can also be helpful for a chemotherapy-induced Spleen Qi deficiency.  From a TCM standpoint, the opening point of the Chong channel is P6, helpful in alleviating nausea.

       The Chong channel also exerts an influence on the Heart and can be used to move the blood of the Heart in case of stuffiness and/or chest palpitations whether due to obstruction or emotional pain (13).  Many breast cancer patients complain of a chest constriction or tightness, whether emotionally derived or as a physical symptom, as in a skin irritation as a side effect of radiation therapy.

Dr. Tan’s System/Master Tung’s Points
       Dr. Tan's balance method can be utilized for systemic inflammation and allow the practitioner to address the painful part of the body without using local needling.  Similarly Master Tung’s points treat a myriad of pain and deficient disorders by using point combinations not taught in traditional acupuncture curriculums.  We have found both methods to be effective for different patients, and recommend using either one.  For a crash course in either system, you can observe at a community acupuncture clinic in your area.  These efficient practitioners tend to be quite adept at both systems as they require minimal disrobing and produce great results.

Miriam Lee’s Great 10 Points
       We often use this point combination for its simple elegance and practicality with breast cancer patients:  St 36, LI 4, LI 11, Lu 7, Sp 6.

Moxa
       Using moxa is a very nourishing treatment and can be used when the patient is deemed too weak for acupuncture needles.  Moxa is pure Yang and is moving, so is helpful in places where Qi is stuck.  It is also a very nourishing treatment, and can be used almost indiscriminately on ST 36.

1.  Jeong, Young Ju, Young Sun Park, Hyo Jung Kwon, Im Hee Shin, Jin Gu Bong, and Sung Hwan Park. "Acupuncture for the Treatment of Hot Flashes in Patients with Breast Cancer Receiving Antiestrogen Therapy: A Pilot Study in Korean Women." The Journal of Alternative and Complementary Medicine (2013).

Acupuncture Protocols Continued

Points Specific for Breast Cancer

       There does exist published traditional Chinese medical literature at least as early as the 1970’s for the specific indication of breast cancer.  The following is courtesy of Michael Broffman of the Pine Street Clinic, who translated the text Acupuncture Specialty Points.

Point A
Location:  Below the angle of the mandible, 0.8 inches medial.
Technique:  Bilateral;  0.3-0.5 inches perpendicular.
Indications:  Cancer of the throat, nasopharynx, breast, esophagus, colon, uterus, stomach, lung, liver.

Point B
Location:  On the little finger, at the ulnar end of the 1st phalangeal crease.
Technique:  With the finger flexed, needle until a yellow discharge appears.  For males, needle the left hand and for females, needle the right hand.  Needle bilaterally.
The patient should not wash hands after needling.
Indications:  Tumors.

Point C
Location:  1.0 inch directly below the nipple
Technique:  Moxa stick for 5-10 minutes or 3-7 moxa cones bilaterally
Indications:  Stomachache, flank pain, swollen breast, oligogalactia, breast cancer, chronic cough, dry retching, regurgitation, amenorrhea

Point D
Location:  0.5 in. below Kidney 2
Technique:  Needle subcutaneously across the sole of the foot.  Sensation of numbness and tightness should be generated to the toe.  For tumors of the head and neck, needle obliquely and anteriorly.  For tumors of the lower body, needle obliquely and posteriorly.
Indications:  Cancers of the throat, nasopharynx, esophagus, stomach, breast, liver, uterus, colon or lung.

Point E
Location:  Locate the navicular tuberosity on the medial side of the foot (at the junction of the talus and navicular bones).  From this point, draw a line down and across the sole of the foot, at a right angle to the midline of the sole.  This point is located one finger-width from the medial edge of the sole on the line drawn.  Needle bilaterally.
Technique:  Needle 0.3-0.5 inches.  Sensations of numbness and soreness should be generated to the toe.  3-7 moxa cones.
Indications: Cancer of the liver, mammary gland, and nasopharynx.


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Breast Cancer Metastasis

       Breast cancer cells that break away from the primary tumor in the breast most often end up in the lung, liver, bone, lymph nodes, or brain via the bloodstream or lymphatic system.  Qi movement is a mechanism for metastasis, so strongly moving the qi using acupuncture on a cancer patient is contraindicated.  However, proper qi flow is also a function of health - stagnant qi being a sign of disharmony- so moving the qi in cases of stagnation is appropriate.

       The most thorough, insightful article we have read regarding a systematic approach to adjunctive treatment using Chinese herbs with two common breast cancer chemotherapy regimens is in the book Botanical Medicine in Clinical Practice, chapter 38, "Magic Fusion:  The Meaning of Integration in Medicine."  The authors use the TNM staging system (See Breast Cancer Part 1 for details on this system) to correlate with Chinese medical patterns, and then give herbal formulas for each pattern and for each phase of chemotherapy.  This system, in clinical trials conducted at their clinic, almost doubled the 5 year survival rate.  Armed with this chapter alone, the TCM practitioner would be well suited to structure a metastasis treatment plan using Chinese herbs.  To read this chapter, the authors have generously offered it to Grasshopper students.  Please contact Michael McCulloch at mm@pinestreetfoundation.org directly for access.


Prevention & Preventing Recurrence
    
       After treatment and diagnostic testing to rule out any visible tumors in the breast or anywhere else in the body, a patient is considered in remission. Once a person is treated for cancer, there is a likelihood of recurrence within the first 2 years. Patients then have follow up blood work taken every 6-12 months to monitor progress.  However, no further care is recommended to keep cancer from recurring.  This time period is critical, and effective treatment can go a long way in removing any lingering cancer cells and restoring the proper body physiology after such damaging treatments have been performed.  This is one area that Chinese medical practitioners can significantly contribute to the cancer world. 


       Preventing cancer recurrence is about changing the bodies’ environment so that cancer no longer grows and thrives.  The monitoring of likely metastatic sites is a strength of Chinese medicine.  Breast cancer is the most likely to metastasize to the lungs, lymph nodes, bone, liver and brain, and so careful monitoring of these organ and organ systems by four pillars of diagnosis (observation, palpation, listening, smelling, asking) is necessary.


       As acupuncturists, we are often the only health practitioners seeing these patients on a regular basis.  We must find a balance between urgency and calm when referring cancer patients to seek further medical care. We must be aware and compassionate about the fear that goes along with this fact.  Do they worry about bone metastasis anytime they have joint pain?  Do they wonder if they have lung metastasis every time they cough?  As their health care practitioners who must monitor these symptoms and differentiate when to treat a wind-heat invasion versus when to refer to a medical doctor for further evaluation.


Here are some points to consider:

• If this is the first time you are seeing this patient, then you have no comparison of tongue, pulse, and other Chinese medical diagnostics.  This is why personal and family medical history are so important.

• Are you treating the symptom in a way that you normally would see results, but seeing little or no change, or even worsening of the symptom?

• Are there significant tongue anomalies or pulse readings that would alert you to severity of disease? 

• Clinically, those patients who address their diet, emotions, and spiritual awareness have a strong and more successful journey toward health.  Patients must be an active participant in their own treatment. 

       Many of our breast cancer patients come to see their dis-ease as a blessing.  With the diagnosis alone, some were able to get out of negative marriages, quit the job they hated, and change their lifestyle in a way that they had no impetus for doing so before.  Even in the throes of treatment, many reported feeling a sense of relief and health and a lightness in their spirit was observed.  By removing the obstacles of healing they made room for healing to take place.


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Dietary therapy

“The prime cause of cancer is the replacement of the respiration of oxygen in normal body cells by a fermentation of sugar.” 

- Otto Warburg, twice winner of Nobel Peace Prize in Medicine.

       Proper diet as a preventative tool and a therapeutic tool for cancer merits its own course.  We simply can not cover this topic completely as a subsection to this one.  Instead, we have chosen to address several key topics, drilled into us by our naturopathic and nutrition-trained colleagues at the clinic.  These concepts tend to relate quite well to our TCM training, in particular the three main themes of sugar, sodium, and proper cellular oxygenation are key nutritional components to health.

       Healthy digestion is enzymatic, not fermentative.  As we know in Chinese Medical dietary therapy, sugar is moistening and promotes damp and phlegm accumulation in the body.  It is imperative during any acute treatment of cancer that patients are on a low sugar regimen.  This means absolutely no added sugars, and natural sugar should be limited to whole grains, vegetables, and low sugar fruits.  Even after active treatment of cancer has commenced, this low sugar diet must be continued. Cancer cells have fifteen times more receptor sites for glucose than healthy cells (14).

       Excess sodium is another damp and phlegm creating substance, so it is important for cancer patients to follow a low sodium diet.  An ideal diet for any person, and especially a cancer patient, should consist of all fresh foods.  By taking processed foods completely out of their diets, patients will greatly reduce sodium intake.  Biologically, high sodium intake leeches potassium from cells, effectively creating intracellular edema.  This edema interrupts essential cellular processes, including proper electrical balance, enzyme formation, and cellular oxidation.  Healthy cellular replication relies on all of these factors.

       Cellular edema is described as damp in Chinese medicine.  Drinking water alone will not replenish cells after increased sodium intake.  You must put that water back into your body along with vital minerals, including potassium.  We recommend that patients “eat their water” in the form of fresh fruits and vegetables in order to reach optimal cell health.

       Oxygenation of cells also helps to dry these damp conditions and promote the flow of Qi. Cancerous cells live anaerobically and so hyperbaric oxygen chambers are used in alternative cancer treatment to "suffocate" the cancer cells.  Along with moderate amounts of physical movement and breathing exercises, it is necessary to eat foods rich in chlorophyll and germanium.  A list of these foods from Paul Pitchford’s Healing With Whole Foods include shiitake, reishi, and champignon mushrooms, ginseng, aloe vera juice, chlorella rich micro-algae, and barley.  Generally eating fresh, lightly-cooked or raw vegetables and fruits increases cellular oxygenation as well (15).

       Cruciferous vegetables (broccoli, kale, Brussels sprouts, cabbage, cauliflower, bok choy, etc.) have been proven in numerous studies to convert the “bad” estrogen into the “good” estrogen and are very important as a preventative tool for all women, not just those with a heightened risk for breast cancer.  A "quick and dirty" way for your patients to comply with eating this type of veggie is to take a supplement.  We recommend a whole food alternative, like Standard Process’ Cruciferous Complete, which was shown in one study done by the Metametrix Institute to reduce breast cancer risk.
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Exercise and Breath
    
       Not all exercise is created equal.  Exercise like tai chi, qi gong, and yoga differ from other aerobic exercise like running.  While practicing the former, the parasympathetic nervous system dominates.  In the latter, the sympathetic nervous system dominates.  Although a highly aerobic activity like running has plenty of health benefits including maintaining cardiovascular health, from a holistic standpoint, exercises like tai chi or yoga are more sustainable.


       The correlation between breath and qi gong or yoga is key, as most Westerners breathe shallowly without the full use of their respiratory organs.  This is a bad habit that doesn't allow for the full oxygenation of our blood or organs.  In fact, instruction on diaphragmatic breathing is a part of our patient's healthy living curriculum, as correct breathing can not be overstated for its health benefits as it relates to preventative medicine.

       Another valuable, less-talked about aspect of practices such as yoga, tai chi, or qi gong, are its benefits on the lymphatic system.  The lymphatic system does not have its own pump like the cardiovascular system, and relies on muscle contraction to push the lymph fluid through the vessels.  The twisting and stretching of yoga for example, releases stagnant lymph in key areas  like the chest and armpit.  The head forward/shoulders forward posture, also called double-crossed syndrome, is a posture that is endemic in our culture.  This posture, probably from working on the computer, creates sluggish lymph in the chest and armpits from shortened pectoral muscles.  Yoga and other exercises that stretch out the shortened pectoralis muscles improving lymph flow is vital.  Even walking on the beach, with arms swinging, and the head looking around, is an exercise that will move lymph.  Exercise as a preventative tool for cancer must be included into a healthy lifestyle plan.

Improving Sleep
       People with cancer frequently have a triad symptomology of pain, fatigue, and sleep disturbances.  There is evidence that these symptoms can all be improved by guided imagery/hypnosis and cognitive-behavioral therapy and coping-skills training, relaxation training, meditation training, and music (7).  In addition, helping your patients to establish sleep rituals like going to bed at the same time, waking up at the same time, avoiding stimulation in bed like watching TV, eating too late, exercising past 4 pm, and keeping their room cool, dark, and quiet can help significantly. 

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Practitioner Role
    
Moving Your Patients Towards Empowerment      
       Many patients feel victimized when learning of a breast cancer diagnosis.  There is often blame, either turned inwards or outwards.  Often this is a natural part of the acceptance process.  However, after the initial shock of diagnosis, encouraging your patients to let go of the victim status and move into a more empowered position of taking control of their life and health is imperative.  A victim lets the treatments happen to them and takes a passive role in getting better.  Somebody who accepts and owns the cancer, yet does not blame it on themselves or others, is in a better position to manage the cancer and move forward.  Ownership of the disease can also lead to empowerment in action.  What environmental injustices occurred that contributed to this disease that could create an impetus to seek change?  Do they use "pink-washed" beauty products that contain parabens? (17).  Was there significant water or air pollution in their area?  Have they unknowingly been eating canned foods with Bis-phenol A leaching into their food?  If so, can you encourage them to become politically involved and help facilitate the healing of the greater good? (Please see Appendix 4 for a list of patient resources).

       Patient empowerment is key in both survival and prevention of recurrence.  In Western medicine, we hear the term "remission" used often.  To a cancer patient, this is good news!  Patients, and their families, associate this term with being cancer-free.  The definition of remission is not "cancer free" but a state of absence of disease activity in patients with a chronic illness, with the possibility of return of disease activity.  In Western medicine, when a breast cancer patient is set free with a diagnosis of remission, besides the typical 5 year prescription for Tamoxifen, they are given no other medical advice on how to keep cancer at bay in the body.  This is when patient empowerment becomes important again.  They must try to turn any feelings of pity, fear, or anger into strength, determination, and enlightenment.  Once integrative therapies have been completed, and cancer addressed, the work has really just begun.  It will now be a lifetime of choices surrounding diet, environment, management of stress, healthy sleep patterns, presence of joy, and a strong spiritual practice.  This takes a great deal of time both in educating themselves about these matters, and implementing them into their lives.  Anything that you can do to help guide them in these matters will undoubtedly help the success of your practice.

Reminding Your Patients of their Wholeness
       In the Western medical system, the breast cancer patient can feel very demoralized.  They often sit for long periods of time in waiting rooms with other patients who are undergoing chemotherapy, and may receive their IV chemo in a communal room with other patients in all stages of the disease.  Make your office a place where they are reminded not of their sickness, but of their wholeness.  What positive aspects of their lives can they bring to their journey of health and wellness?  Were their breasts ever used for nurturing life by nursing their children?  What beautiful aspects of their beings can they focus on to get them through this time?  As practitioners, never forget to remind them of the perfect human beings they already are.
      
       We noticed many patients at the clinic, especially the Stage 3 and 4 ones, were quite deficient in human touch.  Perhaps their partner was absent, or even with the presense of a partner, the intimacy was long gone.  Foot rubs, gentle shoulder rubs, scalp rubs, hugs, and hand-holding were all practiced freely and often by us.  Be generous with the power of your healing touch. 

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Conclusion

       As TCM practitioners, we must educate and lead by example a lifestyle of cancer prevention.  A 2008 study led by Dean Ornish, Professor of Medicine at the UCSF, found that men were able to alter the expression of prostate cancer-relevant genes with lifestyle changes such as exercising 30 minutes per day, doing yoga or meditating one hour per day, and eating a diet high in vegetables and fruit.  The genes that were affected by these lifestyle changes were the oncogenes that also promote breast cancer.  This research proves that although our DNA is fixed, we have the capacity to turn genes on and off by our lifestyle choices (17)! 

       DNA has always been likened to jing, our ancestral qi, in Chinese medical theory.  Jing can be influenced by such practices as Qi Gong and by herbs such as ginseng, but it was believed that DNA was something you could not influence.  Ornish's study proves otherwise, that DNA is a lot more like jing than we thought.  The practitioner of TCM is in the unique position to play a large role in preventative care by using this knowledge in prescribing exercises, nutritional regimens, or immune-building, anti-inflammatory herbal medicines and acupuncture that treat constitutional deficiencies to help prevent cancer from arising.

Congratulations!  You have completed the course.  For California state or NCCAOM continuing education credit you may take the quiz, by clicking the "Go to Quiz" button on the top right corner of your screen.


A special thanks to Michael Broffman, L.Ac. from the Pine Street Clinic in San Anselmo, California who contributed his thoughtful comments and suggestions to better this course.  Throughout the years I have emailed Michael and although busy and only a distant acquaintance, he has always offered his time and expertise by unselfishly providing me with articles and giving me access to his translations of Chinese medical textbooks.  The work being done at the Pine Street Clinic, notably training canines to detect the presence of cancer by using breath samples, makes me very proud share with them the title "L.Ac." They are truly innovators, thinking outside the box in terms of early cancer screening.  Please see Appendix 4 for information on how to receive their free newsletter, Avenues, which offers cutting-edge research on cancer, cancer prevention, and other health topics.

Thank you to Giovanni Maciocia for his review and commentary on the breast cancer tongue case studies listed in the Appendix 2 of this course.

Thank you to the staff of Issels Medical Center and to Dr. Issels himself for keeping the acupuncture program alive.  Most importantly, thanks to the patients whose courage and candor give inspiration to us all.


Appendix 1:  Base Herbal Formulas

The following formulas are adapted from Li Peiwen's Management of Cancer with Chinese Medicine.

1.  Pattern
:  Phlegm-Damp due to Spleen/Stomach Deficiency

Base Herbal Formula:  Xiang Sha Liu Jun Zi Tang with modifications
Dang Shen  15g
Bai Zhu 
9g
Fu Ling
  9g
Chen Pi
  9g
Mu Xiang
  6g
Sha Ren
  3g
Yi Yi Ren
  30g
Mu Li
  15g
Xia Ku Cao  
15g
Shan Ci Gu
  15g
Gua Lou
  30g
Fa Ban Xia
  9g
Chaun Bei Mu  
9g
Ji Nei Jin
  12g

2.  Pattern:
  Disharmony of Chong and Ren
Base Herbal Formula:
  Liu Wei Di Huang Wan with modifications
Xian Mao  15g
Yin Yang Huo 
9g
Xiang Fu 
9g
Yu Jin 
9g
Dang Gui 
9g
Bai Shao 
9g
Chai Hu 
6g
Sheng Di Huang 
15g
Shu Di Huang 
15g
Nu Zhen Zi 
15g
Gou Qi Zi 
15g
Shan Yao 
20g
Ju Hua 
3g
Gua Lou 
20g
Hai Zao 
15g

Shan Ci Gu 
15g
Qing Pi  9g

3.  Pattern:  Accumulation of Stasis and Toxins
Base Herbal Formula:  Tao Hong Si Wu tang and Jin Yin Huan Gan Cao Tang with modifications
Tao Ren  9g
Hong Hua  9g
Chi Shao  12g
Dan Shen  20g
Jin Yin Hua  15g
Pu Gong Ying  20g
Chong Lou  15g
Ye Ju Hua  6g
E Zhu  9g
Shan Ci Gu  15g
Ku Shen  15g
Huang Qi  30g
Yan Hu Suo  9g
Bai Ying  20g
Ban Zhi Lian  30g
San Qi Fen  3g (infused in the prepared decoction)

4.  Pattern:  Liver Depression and Qi Stagnation
Base Herbal Formula:  Xiao Yao San with modifications
Cu Chao Chai Hu 9g (stir fried with vinegar)
Dang Gui  12g
Bai Shao  10g
Xian Gu  9g
Yu Jin  9g
Qing Pi  9g
Chen Pi  9g
Chaun Lian Zi  9g
Ju Ye  9g
Huang Qi  9g
Xia Ku Cao  15g
Pi Gong Ying 20g
Gua Lou  30g
Xie Bai  9g
Shan Ci Gu  15g
Yi Yi Ren  30g
Bai Zhu  9g
Chong Lou  15g

5.  Pattern:  Deficiency of Qi and Blood
Base Herbal Formula:  Yi Qi Yang Rong Tang with Shi Quan Da Bu Tang with modifications
Dang Shen  20g
Tai Zi Shen  20g
Xi Yang Shen  3g
Bai Zhu  9g
Fu Ling  9g
Dang Gui  9g
Huang Qi  40g
Huang Jin  20g
Dan Shen  20g
Chi Shao  15g
Ji Xue Teng  15g
Xiang Fu  9g
Ban Zhi Lian  20g
Pu Gong Ying  20g
Bai Hua She She Cao  30g
Long Kui  20g

The following formula is taken from Tai Lahan's Integrating Conventional and Chinese Medicine in Cancer Care

Pattern
:  Liver Qi Stagnation with Spleen Deficiency leading to Rebellious Stomach Qi
Base Herbal Formula
Hu Lu Ba 10g
Bai Zhi 8g
San Leng 10g
Chuang Xiong 10g
Mo Yao 10g
Zao Jiao Ci 10g
Jie Geng 10g
Gui Ban 10g
Gua Lou Shi 15 g
Dang Gui 12 g
Quan Xie 10g
Wu Gong 3g
Mai Ya 20 g
Bai Zhu 10 g



Appendix 2:  Breast Cancer Tongues

1.  “Jane”

Commentary:  This was an unusual case as the patient had Inflammatory Breast Cancer yet had refused all biomedical treatment and had never had chemotherapy or other conventional therapies.  She presented with significant lymphedema in the left arm - it was about three times the size of the right arm.  Her chest and lower neck area was reddish purple and knotty-looking, almost like an old tree.  The most significant thing I remember besides the severe lymphadema was not the texture of the skin but dark reddish-purple color of blood stagnation.

Her naturopathic doctors were giving her intense treatments for the cancer, so we started working on the lymphadema.  Obviously no needles were placed on her left arm.

TCM Diagnosis:  Accumulation of Stasis and Toxins

Pulse
:  Thready


Tongue:  Very reddish-purple tongue body, especially on the sides which correspond to either the Liver or Uterus on a woman.  There are red points on the side of the tongue (Liver/Uterus) which also indicate toxic heat.  Toxic heat indicates that cancer is spreading fast.  The coating is thick yellow, and sticky.

Acupuncture
Kid 7, Sp 9, St 36, Kid 10, Sp 10
R arm: SJ 6, LI 7, SJ 2, St 43, Ht 3

Herbal medicine:  
K'An herbals Water’s Way


Tongue 1

Appendix 2:  Breast Cancer Tongues

2.  “Mary”
Commentary:  Mary previously had hormone-driven breast cancer, and her doctor (not her oncologist) gave her hormone replacement therapy (HRT),  presumably for peri-menopausal complaints.  The cancer spread like wildfire.  Her chief complaints were ascities causing pain in the groin, flanks, and epigastrum.  She had nausea due to bile/acid reflux.  She had an infection of her mastiod process.  She also had tapeworms which she passed in her stool.

TCM Diagnosis:  Liver Qi Stagnation with Spleen Deficiency leading to rebellious Stomach Qi with Dampness

Pulse:  Her pulse was generally thin, rapid, tight, and deficient.

Tongue:  In the first tongue photo, her tongue is a bluish-purple, meaning blood stasis with cold.  Note the patch on the top right with no coating, the beginning of Stomach Yin deficiency.  The sides are pale and swollen.  The tongue coat is greasy, yellow, and rootless.  About two weeks later the second photo was taken.  As her disease progressed, the anterior 2/3 of her tongue coat peeled, revealing fissures in the tongue body.  When a coat quickly peels, it is a sign that cancer is spreading.  The tongue coat in the second photo is now showing more heat signs as it is reddish-purple.  The coat is thick, green, and rootless, indicating dampness.  The peeled coat indicates Stomach Yin deficiency.  Of particular interest is the tip of the tongue which is swollen and slightly curled up.  This indicates damp phlegm in the lungs.


Acupuncture:
This patient was treated with acupuncture 5 times

1.  St 43*, Kid 10, Liv 8, Kid 7, SJ 6
2.  SJ 17, Sp , St 43, St 36, Li 4, Ren 22
3.  St 43, Sp 4, Liv 3, Ren 22, Li4, St 37
4.  St 44, St 43, Sp 4, St 36, Li 4
5.  St 37, Li 5, St 41, Li 4

*Clinically we found St 43 useful for distention and fullness in the epigastrum and hypochondrium.

Photo 1:

Tongue 2




























Photo 2:
Tongue 3

Appendix 2 - Breast Cancer Tongues

3.  “Joan”

Commentary:  37 year old female with metastasis to skull and lumbar spine.  Notable in her case was chronic indigestion and constipation.  Her stool was loose now only due to past chemo and current meds.  Past treatment included chemo, radiation & mastectomy.  Currently on Predinisone to control pain (inflammation) caused by skull metastasis.

TCM Diagnosis:  Deficiency of Qi and Blood w/concurrent blood stagnation

Pulse:  Slippery


Tongue:  Joan has a bluish-purple tongue body that is slightly swollen.  The tongue coat is sticky and yellow.  Notable on her tongue is that the Lung area is swollen and the breast area of the tongue (on both sides behind the tip) is purple.  She does have a shallow heart crack with a red tip.


Photo 1:

Tongue 4


















Photo 2:

Tongue 5

Appendix 2 - Breast Cancer Tongues

“Krista”

Commentary:  Krista had three primary cancers - breast, thyroid, and lung.
Past treatment included a left mastectomy and a complete hysterectomy.  She suffered from frequent bladder infections prior to the diagnosis with lung cancer, demonstrating the Kidney/UB and the Lung relationship in TCM.  She used an oxygen tank due to diminished lung capacity.  Due to the metastasis to the colon, she had 12 inches of her colon resected.

Her chief complaint was pain around T5 due to bone metastasis.

This patient was very fragile and weak, and only auricular acupuncture points were used to reduce pain, improve lung function, and calm Shen.

TCM Diagnosis:  Phlegm-Damp due to Spleen/Stomach Deficiency
 
Pulse:  Slippery, full.  Chi position:  deep, weak

Tongue:  This tongue is purple and swollen.  The tongue coat is rootless, and gets thicker and darker in the posterior portion of the tongue.  The black patch at the posterior 1/3 of the tongue indicates severe heat.  The deep center crack is a stomach crack which indicates, in her case, phelgm heat.  The purple color on the sides and the center is in the stomach area.  This tongue indicates that bloos stasis is very pronounced.

Photo 1
Tongue 6

Appendix 2 - Breast Cancer Tongues

“Roseanne”

Commentary:  Roseanne had a breast carcinoma below her left clavicle that was visible and about the size of 1/3 of a golf ball protruding.  The tumor was pressing on her brachial plexus causing severe nerve pain around the tumor and going down her left arm.  She had left arm lymphedema and a history of cervical cancer.

TCM Diagnosis:  Phlegm-Damp due to Spleen/Stomach Deficiency

Pulse:  Tight


Tongue
:  Roseanne's tongue was purple, especially on the sides, which means stagnation of blood in the liver or uterus.  Her tongue was also slightly swollen, and according to Giovanni this indicates phlegm as opposed to a qi deficiency, which we agree with in this case.  Her tongue coat was thick, yellow, sticky and had root, indicating that although she had significant damp heat and blood stasis in the stomach and intestines, her stomach qi was still fighting the cancer. 


Photo 1:
Tongue 6


Appendix 3 - Case Study Breast Cancer Metastasis
 
History:  67 year-old female with a history of metastatic breast cancer presented with shingles occurring near T7, with blisters and pain radiating out laterally to the left.  After successful treatment of the shingles with plum-blossom and herbal therapy, it recurred two weeks later.  Also presenting at that time was a sciatic-type pain on the left side.  Right breast carcinoma diagnosed 3 ½ years prior, axillary recurrence 1 ½ years prior. 

Pulse: Initially the pulses were submerged and rolling.  With the second outbreak of shingles, the pulses became increasingly thready and weak. 

Tongue: Initially the tongue was pale pink with a red rim, and a slight white coat.  With the second recurrence of shingles, the tongue body was still pink, but the sides were becoming dark purple/red.  Most notably, a small black dot appeared on the patient's left side of her tongue.

The patient’s facial color became grey over the weeks that I was seeing her, and she was experiencing dips in her energy level.  The pain around her ribcage was becoming more sharp with greater intensity.


Treatment:  With the second outbreak of shingles, hip and leg pain, and changes in tongue, pulse and facial color, I recommended that she follow-up with her oncologist to have some diagnostic testing.  She refused. 

Within one month, she was experiencing night sweats, insomnia, and shortness of breath.  Each week that she came in during this time, I urged her to go to her oncologist, and she finally consented.

Findings:  The patient had bone, liver, and lung metastasis.  The shingles were breaking out on the area of her spine and ribcage where the lesions were the most severe.  Her hip and leg pain were associated with lesions in the pelvic and thigh bones.

Discussion:  Shingles outbreaks occur when our immune function is low.  In her case, her immune system was compromised by her body's struggle to manage the cancer.  Another likely scenario is the new lesions corresponded to the spinal root segments where herpes zoster lay dormant, and the activity caused by tumorgenesis fostered the shingles outbreak.  The small black dot that appeared in the left side of the tongue, the area associated with the liver, was a tell-tale sign that a disease process was underway in the liver or liver channel.  The pain around the ribcage is indicative of bone or lung metastasis, and given her history, was a red flag. 
Adding to the fact that the second recurrence of breast cancer was just 1.5 years prior to all of this, a new breast cancer metastasis was the most likely scenario.   

The patient understandably was in denial and even with some firm, gentle pressure to see her oncologist by me, she ultimately needed to accept and make the decision to see her MD for herself.

Appendix 4 - Patient and Practitioner Resources

Websites
Pine Street Foundation:  http://pinestreetfoundation.org/

Cosmetic Database, through the Environmental Working Group:  http://www.ewg.org/skindeep/

Environmental Working Group:  http://www.ewg.org


Safe Cosmetics:  http://safecosmetics.org/

Cancer Care:  http://www.cancercare.org/


Cancer Support Community:  http://www.cancersupportcommunity.org/


Livestrong, Get Cancer Help:  http://www.livestrong.org/

Steve Dunn's Cancer Guide:  http://cancerguide.org/

Dr. Mercola:  http://www.mercola.com

Dr. Bernie Siegel:  http://berniesiegelmd.com/

Weston Price Foundation:  http://www.westonaprice.org/

Cancer Staging Charts, American Joint Committee on Cancer:  http://www.cancerstaging.org/staging/index.html

Breast Cancer Fund:  http://www.breastcancerfund.org

Social Media
LinkedIn:  Chinese Medicine Cancer Support Group (must be a LinkedIn member to join)



Movies
Cut, Poison, Burn:  http://cutpoisonburn.com/

Newsletters
Avenues, published by the Pine Street Foundation @ http://pinestreetfoundation.org/

Books
Magic Fusion:  the Meaning of Integration in Medicine.  Botanical Medicine in Clinical Practice by Broffman, M.  McCulloch, et al.

Integrating Conventional and Chinese Medicine in Cancer Care by Tai Lahans

Management of Cancer with Chinese Medicine by Li Peiwen

Green This:  Volume 1 Greening Your Cleaning by Dierdre Imus

Organic Housekeeping
by Ellen Sandbeck

Beauty to Die For by Judith Vance


Alternative Cancer Clinics
Dr. Burzinsky:  http://www.burzynskiclinic.com/

Issels Medical Center:  http://www.issels.com/


Gerson Clinic:  http://gerson.org/gerpress/


Pine Street Clinic:  http://pinestreetclinic.com/

Cornerstone Cancer Clinic:  http://cornerstonecancerclinic.com/html/tai.shtml




References

1.  Lahans, T.  (2007).  Integrating Conventional and Chinese Medicine in Cancer Care.  Philadelphia:  Elsevier Ltd.

2.  Cal. Health & Saf. Code [ss] 109300-109355. (http://www.leginfo.ca.gov/cgi-bin/displaycode?section=hsc&group=109001-110000&file=109300-109395)

3.  Open Secrets.org, “Lobbying:  Top Industries,” available online at http://www.opensecrets.org/lobby/top.php?indexType=i (last visited March 7, 2012)

4.  National Cancer Institute, “Cancer Prevalance and Cost of Care Projections,” available at http://costprojections.cancer.gov/annual.costs.html (last visited February 5, 2012).

5.  Peiwen, Li.  (2003).  Management of Cancer with Chinese Medicine.  United Kingdom:  Donica Publishing Ltd.

6.  Friedman, S.  (2006). Medical QiGong Exercise Prescriptions.  U.S.:  Xlibris Corporation. 

7.  McCulloch, M. & Ferguson, T.  “Sleep:  An Evolutional Imperative. Are We Getting Enough?” Avenues.  Autumn/Winter 2010.

8.  Broffman, M.  McCulloch, et al.  (2008). Magic Fusion:  the Meaning of Integration in Medicine.  Botanical Medicine in Clinical Practice.  R.R.W.V.R. Preedy.  Wallingford, CABI:  366-376.)

9.  Chen, J.  “Treatment of Chemotherapy- and Radiation-Induced Toxicities.”  Acupuncture Today February 2008, Vol. 09, Issue 02.

10.  Chen, J.  “Treatment of Chemotherapy- and Radiation-Induced Toxicities-Part 2”  Acupuncture Today March 2008, Vol. 09, Issue 03

11.  Deadman et al.  (2001).  A Manual of Acupuncture.  Vista:  Eastland Press.

12.  Mayor, D.  (2007).  ElectroAcupuncture.  Philadelphia:  Elsevier Ltd.

13.  Al-Gizawiy, Mona, M., “Effects of electroacupuncture in a mouse model of experimentally-induced osteosarcoma,” December 2009, available online at http://purl.umn.edu/58046 (last visited March 7, 2012).

14.  Issels, J.  (1999)  Cancer A Second Opinion.  Garden City Park:  Square One Publishers.

15.  Pitchford, P.  (1993).  Healing with Whole Foods.  Berkeley:  North Atlantic Books.

16.  Organic Consumers Association, "Unrecognized Cancer and Hormonal Risks of Avon Products," available online at http://www.organicconsumers.org/articles/article_19335.cfm, last visited April 19, 2012.

17.  Dean Ornish, et al. "Changes in prostate gene expression in men undergoing an intensive nutrition and lifestyle intervention," June 16, 2008, available online at http://pnas.org/content/105/24/8369.full.pdf+html?sid=b9a5803d-db40-4256-9be7-7ec01c1f1c40 (last visited May 9, 2011).
 

 
 
 
 
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