Reconsidering Traditional Chinese Medicine in Cancer Therapy

Every year, the World Health Organization (WHO) updates its International Classification of Diseases (ICD), a publication and open-access resource for medicine that classifies and monitors causes of disease, injury, and death (International Classification of Diseases, n.d.). This is an incredibly valuable resource for physicians, healthcare providers, and even citizens across the world and is the global standard for diagnostic classification of health conditions, methods of treating the disease, and serves as the primary basis for studying causes of morbidity and mortality.

The International Statistical Institute adopted the first international version of the ICD in 1893, and upon the founding of the World Health Organization in 1948, the WHO has since assumed responsibility for designing and revising the ICD constantly so that it can best serve the world population’s health needs (International Classification of Diseases | Britannica, n.d.). In fact, even dating back to 1898, the American Public Health Association recommended that the ICD be updated and revised at least once a decade due to how diverse healthcare is on the global spectrum and how quickly medicine and healthcare can evolve spatially and temporally (Cyranoski, 2018).

Thus, it is interesting that, until 2019, there had been no official recognition of traditional medicine (TM) in any version of the ICD (Cyranoski, 2018). Traditional medicine, in contrast with scientific medicine, is broadly defined as any health practices that incorporate plant- or animal-based medicines, spiritual therapies, or other indigenous beliefs and aim to promote wellbeing or prevent, diagnose, or treat illnesses (Fokunang et al., 2011). Regardless of whether one believes the efficacy of traditional medicine, it is clearly a central component of global health care and is in high demand— TM is used in almost every country in the world, and in some African and Asian nations, almost 80 percent of the population utilizes TM as their main source of health care (Oyebode et al., 2016). Given the importance and ubiquity of traditional medicine, it is shocking how little presence it has had in the ICD.

The WHO has previously described traditional medicine outside of the ICD. For instance, in 2001, the WHO published a four-year strategy describing concrete plans of action to incorporate traditional medicine into modern medical care (World Health Organization, 2013). The addition of traditional medicine into the ICD, however, was unprecedented— for the first time in its distinguished global medical compendium, the World Health Organization was endorsing traditional medicine as a credible form of patient care. The recognition has huge implications, as medical practitioners now have official guidelines that explain how to utilize traditional medicine in their clinical care.

While some supporters of traditional medicine celebrate this progress and newfound openness to non-scientific medicine, others (myself included) question why it took this long for this to happen. Traditional medicine has been accessible for thousands of years— dating back to the ancient Sumerian and Egyptian civilizations— and as described earlier, the ICD has been available to use since 1893 (Ebers’ Papyrus, n.d.). Therefore, the active act to even include traditional medicine in the ICD for such a long period of time indicates that the WHO simply did not believe in its use and effectiveness.

The decades-long delay of the WHO integrating traditional medicine into the ICD is not an isolated event— it is reflective of a generations-long divide between scientific medicine and traditional medicine. In fact, when the WHO announced the inclusion of traditional medicine in the ICD, there was an uproar in many sectors of the scientific community, with some anonymous scientists writing, “To include TCM in the ICD is an egregious lapse in evidence-based thinking and practice. Data supporting the effectiveness of most traditional remedies are scant” (Editors, 2019). 

One particular form of traditional medicine that is of importance in the United States in the field of traditional medicine is traditional Chinese medicine (TCM). According to the 2020 United States Census, Asian Americans and Pacific Islanders (AAPIs) constitute over 24 million or 7.2% of the total population, and they are the most rapidly-growing minority group in the nation (U.S. Census Bureau, 2020). Among this group, Chinese-Americans comprise the largest subset of AAPIs (24%) and have had one of the longest histories of immigration to the U.S. compared to other groups, beginning in 1848 but with multiple large waves in the past century (U.S. Census Bureau, 2020). As a result of this mass immigration, over 50 percent of the Chinese-American population in the United States consists of foreign-born individuals who have not fully assimilated into Western culture yet. Consequently, many of these millions of individuals utilize traditional Chinese medicine, so understanding the cultural factors behind the health of this group and attempting to understand TCM is crucial.

Traditional Chinese medicine (TCM) has had a long and rich history, spanning over multiple millennia and continents. TCM refers to a plethora of medical frameworks, philosophical modalities, and treatment protocols, a majority of which have evolved over the centuries. TCM includes but is not limited to Chinese herbal medicine, massage therapy, and acupuncture, all of which are present not only in China and East Asia but also much of the United States and Western civilization (Traditional Chinese Medicine - a Brief History | Village Remedies, n.d.).

TCM is said to have originated during the Shang Dynasty, which was the 14th–11th centuries BCE (Traditional Chinese Medicine - a Brief History | Village Remedies, n.d.). Upon inspection of oracle bones dating back to that time, there were inscriptions of several illnesses that affected the Shang royal family, such as toothaches, eye disorders, and more (Chinese Medicine during the Shang Dynasty (1766-1122 BCE), n.d.). When analyzing the texts further, citizens of the time often believed these illnesses to be curses sent by ancestors. Moreover, research from historian and biochemist Joseph Needham found bone needles in ancient Shang dynasty tombs, leading many to hypothesize that acupuncture may have been present during that era (Chinese Medicine during the Shang Dynasty (1766-1122 BCE), n.d.).

Over the centuries and multiple dynastic cycles, TCM evolved to become a more standardized philosophical way of thinking about the human body and disease. Summarized in the hallmark works of Chinese medical literature The Inner Canon of the Yellow Emperor (黃帝內經) and The Treatise on Cold Damage Diseases (傷寒論), the doctrines of Chinese medicine are rooted in bodily functions— such as breathing, digestion, and temperature maintenance— rather than any particular organs or anatomical structures. One of its fundamental tenets states that the the human body contains a “vital energy” (氣 or qi), which circulates through channels known as meridians, which are connected to multiple parts of the body (Chinese Medicine during the Shang Dynasty (1766-1122 BCE), n.d.). Some Chinese philosophers have gone as far to claim that qi is the force that actually makes up and holds together everything in the observable universe, but with regards to TCM, qi can be understood as the energy flowing through one’s body.

Chinese characters are typically comprised of a finite number of parts known as radicals, which when assembled together in unique combinations and orders form new words, and oftentimes, analyzing these radicals will provide insight into the meaning and origins of the character of interest. When breaking down the character for qi, we see that 氣 consists of two radicals: 气 (vapor, steam) and 米 (uncooked rice) (Chinese Medicine during the Shang Dynasty (1766-1122 BCE), n.d.). This likely indicates that qi (氣), which represents the energy of the human body, is something material yet simultaneously immaterial, physically existing while also being spiritual in nature. Others, such as author and practitioner of Chinese medicine Giovanni Maciocia, have also argued that this may imply that the essence of the human body has the potential to be subtle like steam (Maciocia, 2020), or it can be dense and unpleasant such as uncooked rice. According to researchers of TCM, qi manifests as illness when qi becomes stagnant and pathologically dense, creating tumors and lumps throughout the affected areas in the body (Guan & He, 2014).

Because of the stark contrast of this philosophy as opposed to the ideologies in the modern United States and much of Western society, the treatments developed via TCM also differ from modern Western treatments. Most of these medicines include Chinese herbs, animal products, and mineral products, which in combination with certain eating habits and lifestyle habits are said to counteract qi deficiency and stagnation (Chinese Medicine during the Shang Dynasty (1766-1122 BCE), n.d.). While TCM and the concept of qi has been primarily founded upon observation and modeling, modern scientific medicine has been founded upon experimental research— that is, creating hypotheses based on observable phenomena and conducting experiments to identify which parts of the hypotheses are incorrect. Because of this additional step necessary in modern scientific medicine, traditional Chinese medicine and scientific medicine are fundamentally different in how they view the human body and disease, and thus they sometimes are seen as incompatible with one another.

Though it has existed for millennia, TCM only made its way to the United States within the past couple of centuries because immigration from China to the US began only in the mid-1800s (Liu, 2019). However, because TCM was so deeply-rooted in Chinese culture for so long, Chinese immigrants from as early as the California Gold Rush started opening herbal shops and providing TCM-based care. At the beginning, there was general enthusiasm for TCM; in fact, for most of the late 19th century and early 20th century in the United States, more white patients than Chinese patients frequented the offices and shops of established Chinese herbal doctors, which several historians attribute to Western medicine failing to treat patients’ illnesses and diseases during this time (Liu, 2019).

Though it has not been explicitly proven, some historians speculate that the early success of TCM-based businesses threatened Western medicine physicians. It is unlikely to be a coincidence that after multiple decades of offering traditional Chinese medicine to American society without any issues, the Chinese herbal doctors were suddenly no longer allowed to practice as medical doctors starting in the early 1900s due to a new policy from the California State Board of Medical Examiners (Liu, 2019). As a result, Chinese herbal doctors were able to continue their businesses but only as merchants rather than medical providers. However, just a couple decades later, in 1950, the United States officially passed the Trading with Enemy Economy Act, which prohibited any further imports of Chinese herbal medicine into the United States, effectively ceasing TCM in the country (50 Usc Ch. 53: Trading with the Enemy, n.d.).

Since then, traditional Chinese medicine has still been viewed negatively by many in the United States, though the reasons are no longer based on jealousy or fear but rather doubt and skepticism. For instance, a 2007 editorial described TCM as “fraught with pseudoscience” (“Hard to Swallow,” 2007). Similarly, placebo-controlled studies from the 21st century have found that Chinese herbal therapy lacks effectiveness and is of poor quality (Shang et al., 2007). Critics also assert that there is no physiological evidence of qi, and that any cases in which Chinese herbal treatments have worked are primarily anecdotal, and the cases where they have worked in randomized controlled clinical trials are scarce (Singh & Ernst, 2008).

United States and Western physicians often demand clinical proof of a drug’s efficacy in order to approve it. This is the role of the Food and Drug Administration (FDA), which serves to protect the public health of United States citizens by ensuring the safety and efficacy of medicines, foods, and other biological products. Therefore, one would expect that if the only issue that United States citizens had with traditional Chinese medicine was its efficacy, then as long as any TCM herb or compound could pass through clinical trials and FDA screening, then it would be acceptable for it to be approved.

However, it turns out that until the year 2004, the Food and Drug Administration did not even have a protocol for checking and approving multi-ingredient botanical drugs (Belli, 2020). Of course, there is no way of proving with certainty that this was due to prejudice against TCM, but the fact that there was not a process in place, streamlined or not, to approve a botanical drug indicates that the FDA did not consider them to be drugs ever since its founding in 1906.

A significant part of the effort to bring TCM to U.S. clinical trials and FDA approval was spearheaded by Yale professor Ying-Chi Cheng, who, for decades, has worked on designing botanical drugs commonly found in herbs used in TCM that would improve the efficacy of modern cancer treatments (Belli, 2020). Beginning in the early 2000s, Cheng and his colleagues conducted early-stage clinical trials of a traditional Chinese botanical drug known as YIV-906 (formerly PHY906), which serves to treat certain symptoms of cancer and alleviates the side effects produced by chemotherapy treatment (Belli, 2020).

In 2021, after decades of work, Cheng and his colleagues successfully launched an international clinical trial for YIV-906, which was the first international clinical trial for any botanical drug used in traditional Chinese medicine (Belli, 2020). Cheng and his colleagues found that YIV-906, inspired by traditional Chinese herbal formulation and historically used to treat diarrhea, nausea and vomiting, reduced the side effects of chemotherapy in mice and therefore has the potential to be used in combination with chemotherapy and radiation therapy to prolong survival and improve quality of life for cancer patients (Cheng, 2007). Mechanistically, YIV-906 works by inducing autophagy and apoptosis in cancer cells, a controlled form of cell death that cancer cells normally turn off in order to survive, via modulating the ERK1/2 proteins, which normally indirectly control apoptosis (Liu et al., 2019).

Similar to traditional Chinese medicine, YIV-906 aims to improve the quality of life of patients and is used in combination with other forms of treatment. On top of that, it is also a multi-targeted drug as it is made through the combination of multiple herbal ingredients commonly used in TCM. As Cheng described in an interview with the Yale Cancer Center, “Why four herbs and not one herb [in this drug]? That I have already told you; at least four ingredients are needed to be biologically active. If you analyze each herb, you find there are hundreds of compounds. Many of those compounds relate to each other so metabolically they may all come right into the few species and have many interactions” (Cheng, 2007).

This new type of cancer therapy— the use of a traditional Chinese herb— sheds light on the fact that there is some inherent validity behind traditional Chinese medicines. The mere fact that we currently do not understand how all TCM treatments work at the molecular level does not mean that they are not effective; in fact, because civilizations of people across centuries have found use in these herbs, we should consider these TCM drugs more carefully as potential therapeutics for modern medicine.

Although YIV-906 is the first TCM drug gaining worldwide popularity, its story sheds light on more than just its effectiveness as a drug. First, the connection between TCM and cancer is not new. As described previously, believers of TCM propose that when qi becomes stagnant and pathologically dense, this creates tumors around the body, possibly manifesting as what most people consider cancer (Guan & He, 2014). There is potential validity that what United States scientists see as apoptosis inhibition could be equivalent to what traditional Chinese medicine practitioners view as de-densification of qi. That is, just because one explanation is shown to be correct does not mean that another one is necessarily invalid— there may be multiple models of explaining a common phenomenon.

In fact, a meta-analysis in 2015 by Jie Liu and colleagues from the China Academy of Chinese Medical Sciences in Beijing exemplified the efficacy of traditional Chinese medicine in cancer treatment (Fig. 3). This figure describes how TCM can have various effects on different stages of cancer, and how TCM has the primary effect of enhancing the quality of life of patients. Specifically, it is described that radiation therapy and chemotherapy can damage the blood and the qi (Liu et al., 2015), thereby disrupting the function of the six bowels and five viscera, so complementing these therapies with TCM can help "tonify qi," reducing these harmful side effects.

Of course, it is important to realize that the tumors and lumps described by the traditional Chinese medicine practitioners might not necessarily be cancer, as there are non-cancerous benign tumors. The modern Chinese word for cancer, ai zheng (癌症) has actually itself changed over the centuries (“癌,” 2022). Originally, ái (癌) was not used to refer to cancer but rather yán (岩), which directly translated to “cliff” or “stone.” This makes sense because cancer tumors often take the shape of firm, solid lumps. However, the term was changed to ái (癌) in December 1962 because there was confusion between 癌 (yán, “cancer”) and 炎 (yán, “inflammation”), both common medical terms (“癌,” 2022).

There were terms said to be described explicitly in the aforementioned fundamental doctrinal source of TCM, The Inner Canon of the Yellow Emperor (黃帝內經), that classified multiple types of tumors. Though there were no associated images, the work described the chronic tumor (xī liú, 昔瘤), intestinal tumor (筋瘤, jīn liú), sinew tumor, esophageal tumor (yē ɡé, 噎嗝), and rock tumor (jī jù, 积聚) (Xiao, 2018). Interestingly, in contrast with how qi and most of TCM is centered on functional parts of the body as opposed to organs and locations, it seems as though some of these tumors are described by their corresponding body part, such as intestinal, esophageal, and sinew (tendons and ligaments). Regardless, on top of this, there is even evidence that ancient traditional Chinese medical doctor Hua Tuo from the Han Dynasty (5-220AD) conducted surgery to remove tumors (Xiao, 2018). The fact that TCM recognizes tumors as part of their ideology provides evidence to the fact that ancient Chinese physicians viewed cancer in a similar way as Western medicine— a foreign substance harming the body that needs to be removed. This adds credence to the idea that traditional Chinese medicines may be effective in treating cancer after all.

Moreover, on a philosophical level, the multi pronged approach exhibited by YIV-906 is reflective of the holistic wellbeing approach offered through traditional Chinese medicine. In Western scientific medicine, cancer treatment has evolved to become multi-pronged. While individual therapies (even targeted therapies) can be effective, tumors can develop resistance to these treatments over time. Therefore, in recent decades, physicians in Western civilization have attempted to improve the efficacy of each of these targeted drugs by administering multiple treatments in parallel, rather than individual drugs separately, an increasingly popular technique known as multi-targeted therapy (Li et al., 2014). This allows for the effects of the drugs in combination to be more effective than any individual drug. In a similar fashion, many Chinese herbalists practicing traditional Chinese medicine combine various herbs, roots, and extracts into a tea extraction in order to make use of the health-promoting chemical components within them together (Kuriyama, 1999). The TCM model of the body is not necessarily concerned directly with anatomical structures but instead on the body's functions such as breathing, blood flow, and temperature, due to the fact that the body's vital energy, or qi, circulates through channels connected to a particular bodily function (Kuriyama, 1999). Though there is no significant scientific basis underlying TCM, the interconnectedness of the human body under this model indicates that it is crucial to care for all parts of the body from multiple aspects, a theme that is also becoming increasingly common in Western medicine today as it transitions to a more holistic approach.

In a similar sense, physicians are shifting towards the view that treating multiple aspects of an illness is more effective than just focusing on a single physiological component. Companies are showing an increased focus on mental health and wellbeing, and there has been a movement for medicalization of many mental illnesses formerly not thought to be sicknesses. Moreover, scientists are not only attempting to eradicate diseases, but they are working to create ways to make the patient experience as comfortable as possible during the process— for example, by providing medications to reduce the side effects of chemotherapy. This novel Western approach of targeted and multi-targeted therapy draws parallels to traditional Chinese medicine. Similar to how modern scientists developed therapies with a focus on decreasing side effects, traditional Chinese medicine also aims for an overall improvement in quality of life (Kuriyama, 1999). That is, in Western medicine, there has been an increasing emphasis on caring for the patient rather than trying to simply eliminate the disease— if the latter were the priority, then chemotherapy and radiotherapy would have been satisfactory, and there would have been little incentive to develop targeted therapies to minimize side effects. Attention is paid not only to the disease but also to a holistic wellbeing of the body, which parallels the health and healing practices encompassed by TCM. In short, the success of YIV-906 shows that traditional Chinese medicine and scientific Western medicine are more similar than many think.

If I were to summarize the arguments of opponents of TCM in the United States, they generally boil down to one of two arguments. In order from most extreme to most moderate, people argue that 1) TCM is grounded in pseudoscience and therefore does not work, or 2) we do not understand the biochemical mechanisms by which TCM works (e.g. which cellular target receptors these medicines bind to), so they are unsafe.

With regards to the first argument, this is generally true, as shown by previous research studies, but that does not mean that we should rule out all forms of TCM, especially before experimenting with them in the lab or in clinical trials if deemed safe. As was seen in the case of YIV-906, certain traditional Chinese medicines do work, and disallowing the use of all of them might run the risk of causing more harm than good.

With regards to the second argument, though it is true that the mechanisms underlying most traditional Chinese medicines are unknown, that again does not mean that they don’t work. Again, in the case of YIV-906, it had not been known for centuries how this drug functioned on a chemical level, but by treating patients with this drug, people knew that it did work. Simply put, we don’t need to know how something works in order to know that it works. It is true that not knowing all the details runs the risk of causing irreparable side effects, but to play devil’s advocate, almost all US states mandate national board certification for those who practice herbal TCM, but most states allow acupuncture (which also falls under the TCM umbrella) to be practiced even without extensive formal training (Van Hal et al., 2022). The science behind acupuncture is also not well-solidified (Lu & Lu, 2013), so if TCM is argued to be too unsafe, then so should acupuncture and similar practices. The fact that acupuncture is generally accepted in the United States while most herbs are not means that society is not inherently doubtful about the lack of understanding of TCM. Perhaps society has become accustomed to dismissing ideas from other cultures, which would indicate a larger problem.

In short, TCM occupies a very important place in health care in the United States and worldwide. Society should work to view TCM more favorably, but more importantly, the US government should take steps towards establishing the necessary support to promote the possible role of TCM in primary health care, both financial support and institutional support. Cancer is a disease that kills over half a million people nationwide each year, and the fact that TCM can be used in that fight brings hope and promise. By integrating TCM into the United States healthcare system— or at the very least being open to other forms of medicine that have been well-established in other cultures— both Western and Eastern disciplines can complement one another to benefit the lives of millions. Simply dismissing it would be a tragic mistake.