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Keywords: Chinese medicine, Chinese herbal medicine, digestive tract cancer, BaZhen Tang (Eight Pearls Decoction), HCPT combination chemotherapy

It is well known that chemotherapy for the treatment of cancer often causes digestive tract reactions, such as nausea and vomiting, as well as suppression of the bone marrow's production of new blood cells. For instance, with commonly used chemotherapy regimes, such as the HPF regimen described below, grade III-IV neutropenia may occur in more than 40% of patients and grade III-IV diarrhea may occur in more than 20% of patients. The incidence of such adverse reactions or side effects is directly proportional to dose intensity, and sometimes the severity of such side effects requires a decrease in the dose intensity of the chemotherapy. For instance, the incidence of bone marrow suppression and digestive tract reactions markedly increases when the use of lO-hydroxycamptothecin (HCPT) reaches 12-20mg/in2 per day. Bone marrow suppression is the most common and the most lethal dose-limiting side effect of chemotherapy. Unfortunately, reducing the dosage intensity of the chemotherapy may make it less effective in combating the cancer. Typically, the higher chemotherapy dose tolerated, the better the tumor response.

In the People's Republic of China, one way of mitigating the adverse reactions of chemotherapy is to combine its use with Chinese herbal medicine. Such a combined use of Chinese and Western medicines is referred to in China as "integrated Chinese-Western medicine (zhong xi yi jue he)" and tends to be the standard of care when it comes to the treatment of most types of malignancies. An example of this approach is an article titled, "The Treatment of 51 Cases of Digestive Tract Cancer with BaZhen Tang Jia Jian (Eight Pearls Decoction with Additions & Subtractions) Combined with an HPF Regimen." This article was authored by Kuang Jian-min of the Shandong Provincial Cancer Hospital in Jinan et at. and appeared on pages 720-72 1 of issue #12, 2002 of the Shan Dong Zhong Yi Za Zhi (Shandong Journal of Chinese Medicine). Because this article provides a glimpse of how Chinese and Western medicines are being used in tandem in China in the treatment of digestive tract cancers, a summary of its main clinical points is g iven below.

Cohort description

The 51 patients enrolled in this study were seen from July 2000 to July 2002 at the main author's hospital. Among them, there were 32 males and 19 females with an average age of 59 years. Their diagnosis of cancer had been confirmed by pathology and histology. Sixteen patients suffered from esophageal cancer, 20 suffered from stomach cancer, and 15 suffered from colon cancer. Prior to undergoing chemotherapy, these patients' routine blood analysis and liver function were normal. In terms of the side effects to chemotherapy experienced by this group, 17.6% had grade IV toxic-reactive leukopenia, 5.9% had diarrhea, and 5.9% had vomiting.

Treatment method

Treatment consisted of the oral administration of modified Ba Zhen Tang (Eight Pearls Decoction) as follows: Radix Astragali Membranacei (Huang Qi), 45g, Radix Codonopsitis Pilosulae (Dang Shen), 30g, Scierotium Poriae Cocos (Fit Ling), 30g. scorched Rhizoma Atractylodis Macrocephalae (Bai Zhu), 15g, Extremitas Radicis Angelicae Sinensis (Dang Gui Wei), 12g, cooked Radix Rehmanniae (Shu Di), 30g, Radix Rubrus Paeoniae Lactiflorae (Chi Shao), 15g, Radix Albus Paeoniae Lactiflorae (Bai Shao), 30g, Caulis Milletiae Seu Spatholobi (Ji Xue Teng), 30g, Fructus Ligustri Lucidi (Nu Zhen Zi), 30g, and Fructus Germinatus Oryzae Sativae (Gu Ya) and Fructus Germinatus Hordei Vulgaris (Mai Ya), 30g each. One packet of these medicinals was decocted in water and administered in two divided doses per day for a continuous 15 days.

At the same time, patients received an HPF regimen of chemotherapy. This consisted of 15mg of 10hydroxycamptothecin (the H in HPF) per day for days 1-5, 20mg of cisplatin (PDD, the P in HPF) per day for days 1-5, and 750mg of 5-fluorouracil (5-FU, the F in HPF) per day for days 1-5. All three of these chemotherapeutic agents were administered by intravenous drip. Up to 21 days equaled one round of treatment and six rounds of chemotherapy were given. During chemotherapy, 5-HT3 receptor agonists for chemotherapy-induced vomiting was permitted and granulocyte colony stimulating factor (G-CSF) was administered if white blood cells (WBCs) fell below 1.0 x [10.sup.9]/L.

Treatment outcomes

The average Karnovsky performance status (KPS) in the above 51 patients was 70 points before treatment. After treatment, the average KPS increased by 20 points. Karnovsky performance status is a standard way of measuring the ability of cancer patients to perform ordinary tasks. It is a method for assessing a patient's prognosis and to measure changes in function. This scale runs from 0-100 points. Routine peripheral blood examination showed a marked positive effect or change in 20 cases, some effect in 15 cases, stabilization in nine cases, and less than 0.1 x [10.sup.9]/L of WBCs in seven cases. Therefore, the total effectiveness rate in terms of effectiveness for WBC production was reported as 68.6%. In terms of digestive tract symptoms, 16 cases experienced a marked effect, 21 experienced some effect, seven were stabilized, five still had severe vomiting, and two still had severe diarrhea. Therefore, the total effectiveness rate for digestive tract symptoms was reported as 72.5%.

Discussion

In Chinese medicine, digestive tract side effects from chemotherapy are mainly due to damage of the spleen and stomach, the viscus and bowel which govern the digestive process. If the spleen is damaged, it fails to upbear the clear. In that case, undivided clear and turbid pour downward, causing diarrhea. If the stomach is damaged, its qi fails to descend properly. Instead, it counterfiows upward, causing nausea and vomiting. Further, the spleen and stomach together are the latter heaven root of qi and blood engenderment and transformation. Therefore, damage to the spleen and stomach may lead to nonproduction of the qi and blood. If there is qi vacuity, there is fatigue, lack of strength, and easy contraction of external evils (i.e., infection). If there is blood vacuity, there is pallor, dizziness, and hair loss. Further, since blood and essence share a common source, blood vacuity may lead to yin vacuity and yin may fail to control yang. In that case, there may be leukopenic fever.

Ba Zhen Tang (Eight Pearls Decoction) is originally from a book titled Zheng Ti Lei Yao (Catalogued Essentials for Correcting the Body) written by Bi Li-zhai and published in 1529. In its unmodified form, it is composed of two sets of four ingredients: 1) Si Jun Zi Tang (Four Gentlemen Decoction) to supplement the qi, and 2) Si Wit Tang (Four Materials Decoction) to nourish the blood. Si Jun Zi Tang consists of Radix Codonopsitis Pilosulae (Dang Shen), Rhizoma Atractylodis Macrocephalae (Bai Zhit), Sclerotium Poriae Cocos (Fit Ling), and Radix Glycyrrhizae (Gan Cao). These four medicinals supplement the spleen by fortifying the spleen. Si Wit Tang consists of: cooked Radix Rehmanniae (Skit Di), Radix Albus Paeoniae Lactiflorae (Bai Shao), Radix Angelicae Sinensis (Dang Gui), and Radix Ligustici Wallichii (Chuan Xiong). These four medicinals nourish the blood and emolliate the liver at the same time as quickening the blood and transforming stasis. In this particular version of this formula, Can Cao has been de leted and substituted with Huang Qi in order to more effectively supplement the qi. Dang Gui Wei is used instead of Dang Guiand Chi Shao is added to increase this formula's ability to quicken the blood and dispel stasis. According to the authors of this formula, Ji Xue Teng and Nit Zhen Zi have been added to further enrich yin and nourish the blood, while Git Ya and Mai Ya have been added to fortify the spleen and harmonize the stomach. Taken as whole, this modified version of Ba Zhen Tang supplements both the qi and yin. It supplements the qi without being drying, it nourishes the blood without being slimy, and it both hardens and softens at the same time. Therefore, it is the Chinese authors' opinion that this formula is suitable for the treatment of digestive tract cancers accompanied by nausea. It improves the bone marrow's hemopoietic function, decreases digestive tract side effects, and helps keep dose intensity stabile at a clinically effective level.