Pain due to cancer is one of the most important topics in the field of pain research. Pain caused by cancer may occur in many different parts of the body. It is often seen in patients suffering from cancer in its medium and later stages. More than 80% of patients with late-stage cancer may suffer from pain.
In Western medicine, it is believed that the growing of cancer or its métastasés may invade or press on nerves, vessels, bones and adjacent tissues. The fast-growing cancer cells cause pressure on the nerves. The tumour growth may also severely compress or stretch normal tissue, which by itself causes pain. These conditions may lead to poor blood supply, infection or necrosis, also causing pain.
The TCM viewpoint is that pain due to cancer is usually the result of invasion of the channels by the cancer toxin or blockage of the circulation of Qi and Blood in the channels and internal organs, because of tissue damage. In the development of cancer, TCM stresses the importance of interior imbalance, such as disorders of the Zang-Fu organs, Yin and Yang, Qi and Blood with accumulation of Phlegm, Damp, stagnant Blood, and so on. In short, cancer results from a mixture of Deficiency and Excess.
There are many publications, both ancient and recent, on TCM in the field of cancer, covering the aetiology, pathology, differentiation, treatment and prognosis of cancer. Many ancient descriptions of its aetiology, pathology and treatment are still very helpful and effective in modern clinical practice.
The ancient TCM literature on cancer (e.g. Qi Kun 1665, new edition 1997) covered many different kinds of cancers, including that of the tongue, the stomach, the oesophagus, the large intestine, the liver, the uterus and the bladder. In antiquity, TCM practitioners described cancer as diseases characterised by masses found on the skin or in the body, which are unsmooth on the surface, as hard as stones and rocks and cause severe pain (e.g. Ren Zhai Zhi Zhi 1982). The word ‘cancer’ dates back to the time when the Chinese characters were first formed, which strongly implies that even at that time cancers and pain due to cancer were one of the biggest pathogenic causes in daily life and endangered many people.
Over the past few decades, prevention and treatment of cancer and pain due to cancer have become one of the most important subjects in medical treatment. In TCM, comprehensive theories about cancer and pain due to cancer have been elaborated, departments of cancer research and treatment have been set up in many universities and hospitals, and many scientific reports and topics have been published (e.g. Lei Yongzhong 1982, Liu Jiaxiang 1981). Great progress has been made in this field—in China, research has been carried out not only on the effects of herbal medicine, but also on those of acupuncture, Qigong, diet, massage, lasers, injections and infusions. For instance, some reports on acupuncture treatment for different kinds of cancers mention the points ST-36, SP-6, GB-34, LR-13 and LR-14 as being effective for treating severe pain due to Liver cancer. Some practitioners use electroacupuncture, which can produce heat in order to kill cancer cells, to treat many kinds of cancer on the superficial part of the human body with satisfying results.
According to TCM, pain caused by cancer reflects the many pathological changes in channels, internal organs, Qi and Blood and the clinical manifestations vary with the different kinds of cancer. When the cancer occurs in the brain then headache, dizziness and vomiting are among the symptoms. Patients suffering from oesophagus cancer often have chest pain and difficulty in swallowing and vomiting. Patients with Stomach cancer often have stomach pain, nausea and a hard mass in the upper abdomen. Cancer in the Large Intestine may cause abdominal pain, constipation or diarrhoea with blood. Patients suffering from cancer in the Bladder may have bloody urine and lumbago. Patients with Lung cancer often have upper back pain, chest pain and sputum with blood.
Although pain due to cancer varies in nature—for instance, it can be stabbing, distending, a swollen feeling, a colic pain, pain with a feeling of contraction or pressure, there are common characteristics:
1. Ionghistory of pain
2. rapid aggravation of the pain
3. rapid deterioration of the general physical condition
4. the pain appears at a place near to the tumour area
5. there are hard masses on the skin or in the abdomen, which are palpable
6. cancers in deep parts of the body, such as brain or chest, can be detected by modem medical techniques.
Aetiology and pathology
There are many causes of cancer pain. Here only the major causes are discussed, which include invasion of pathogenic factors, disorders of diet and emotions, weakness of constitution, stagnation of Liver-Qi, stagnation of Blood, accumulation of Toxic Fire, accumulation of Damp-Phlegm, and deficiency of Qi and Blood, and Yin and Yang.
Invasion of External pathogenic factors
Persistence of any External pathogenic factors may cause blockage of the channels in the body, which leads to stagnation of Qi and Blood or disorders of the internal Zang-Fu organs. In the Ling Shu, it was pointed out that invasion and accumulation of Wind in the body might cause blockage of the channels (Ling Shu, 1963, p. 145). The same topic also mentioned that cancer could be triggered by Cold. Of course, due to limitation of understanding of the aetiology and pathology two thousand years ago, the Classics could not discover all the causes for cancer. However, in the topic Zhu Bing Yuan Hou Lun—general treatise on the causes and symptoms of diseases (611, new edition 1955), the author Chao Yuanfang detailed some causative factors, and pointed out that the major causes of the pain associated with cancer were disharmony between Yin and Yang, and weakness and Cold of the internal Zang-Fu organs leading to invasion of External Wind (p. 105). From this description, it can be seen clearly that invasion of Wind and Cold were considered to be causative factors.
However, invasion and accumulation of these External pathogenic factors are only triggering factors; Interior disorders are the key causes. In the Ling Shu, it also states that cancers of the Large Intestine are due to accumulation of some Toxin in the Intestine first, which subsequently predisposes the person to invasion of External factors (Ling Shu, 1963, p. 89). Thus the primary cause is disease of the Intestines and the Stomach, and cancer occurs secondarily. Moreover, accumulation of Cold in the Spleen and Stomach with invasion and accumulation of External factors may cause stagnation, thus the cancer is stimulated. In the topic Jing Yue Quan Shu—Complete works of Zhang Jingyue (1624, new edition 1991) it was stated that invasion of External Wind and Cold may mix with the Phlegm and stagnant food in the Spleen and Stomach, leading to formation of cancers in the Stomach and the Intestines (p. 479).
Disorder of emotions
TCM also stresses the role of the emotions in the development of cancer. For instance, the Neijing stated that sudden and strong grief may cause dysphasia, which is actually a preliminary form of oesophageal cancer. Again, in the case of breast cancer, Dr Chen Shigong described in his topic Wai Ke Zheng Zong—Orthodox manual of external diseases (1617, new edition 1997) that excessive grief and depression may cause impairment of the Liver, excessive meditation may damage the Spleen, and too much thinking may disturb the Heart, and these pathogenic factors may result in weakening of the circulation in the channels leading to the formation of nodules, and so breast cancer follows (p. 435). It is very clearly stated in TCM theory that disorder of the seven emotions may cause disturbance of the interior organs, bringing about invasion of external pathogenic factors based on weakness of the organs. Also, emotional disorders could also directly cause slowing down of the circulation of the Qi and Blood in the channels and the internal Zang-Fu organs, thus cancer occurs.
Disorder of diet
Unhealthy diets may cause impairment of the Spleen and Stomach, leading to weakening of their functions of transportation and transformation, thus the production of Qi and Blood is damaged and deficiency of Qi and Blood follows. External invasion may easily take place under such conditions. Moreover, weakness of the Spleen and Stomach may cause retention of food and water, leading to formation of Damp-Phlegm, which in its turn could block the circulation of Qi and Blood. A mixture of Phlegm and stagnant Qi and Blood may slow down the circulation in the channels and weaken the functioning of the Zang-Fu organs, which makes the formation of cancer more likely.
Unhealthy diet includes overeating of fatty and greasy food, and of milky products, sweet foods, highly flavoured food, too pungent food, as well as drinking too much alcohol, leading to the formation of Damp-Heat. Overeating of cold food and raw food may also cause damage of Spleen-Yang, resulting in the formation of Cold-Damp.
Also included is the intake of Toxic food, including contaminated food and unhygienic food, which causes formation of Toxin in the body, leading to stagnation of Qi and Blood, dysfunction of the Zang-Fu organs and blockage of the channels, thus predisposing to cancer development.
Stagnation of Qi and Blood
Stagnation of Qi and Blood is the result of pathogenic changes; however, when it develops it becomes a pathogenic factor in itself. Most of the pain due to cancer, especially at a later stage, is caused by this kind of pathogenic factor. When stagnation of Blood develops, besides causing pain it may further block the channels, and disturb the physiological functions of the Internal Zang-Fu organs and the nourishing function of the Blood, resulting in emaciation, dry skin and hair, tiredness, bleeding, formation of masses, damage of veins, purplish tongue, and a thready and unsmooth pulse.
Generally speaking, stagnation of Qi and Blood may be caused by:
• too-strong emotion and prolonged emotion
• invasion of External pathogenic factors
• deficiency of Qi and Yang
• deficiency of Yin
• accumulation of Heat
• accumulation of Damp-Phlegm
• physical trauma
• inappropriate operations
• interior bleeding
• inappropriate injection, infusion or vaccination
• inappropriate intake or prolonged intake of some medications
• insufficient physical activity.
So when there is a Stagnation of Qi and Blood, except for treating the pain, it is necessary to search for its cause and to try to get rid of it.
Weakness of constitution
Old age, constitutional weakness, prolonged sickness, and weakness of the Spleen and Kidney may cause disorders of Yin and Yang, dysfunction of the Zang-Fu organs and slowing down of the circulation of Qi and Blood. This situation creates an opportunity for the invasion of External pathogenic factors and uprising of internal pathogenic factors, such as Phlegm, Damp, toxin, Fire and so on, leading to formation of cancer blocking the Zang-Fu organs and channels, so pain develops. Formation of cancer in the body may also further consume Qi, Blood, Yin and Yang, resulting in weakening of the Defensive Qi and aggravating the stagnation of Qi and Blood and the accumulation of Damp-Phlegm. In some cases, inheritance of some pathogenic factors also plays a very important role in the occurrence of cancer.
Unhealthy lifestyle
Smoking, drinking too much alcohol and taking drugs may cause dysfunction of the internal Zang-Fu organs, leading to the stagnation of Qi and Blood, and accumulation of Damp-Phlegm, so cancer may develop and pain follows.
Hyperactivity of Toxic Fire
Toxin may invade the body from outside; however, it may also be formed internally because of dysfunction of the Zang-Fu organs. For instance, persisting stagnation of Qi and Blood and accumulation of stagnant Damp-Phlegm may cause formation of Toxin in the body. If this process continues over a long period, the result would be generation of Toxic Fire. Hyperactivity of Toxic Fire burns the Zang-Fu organs, muscles and other body tissues, thus high fever, severe pain, bleeding, erosions and ulceration follow.
In summary, the causative factors for cancer are actually a mixture of several kinds of pathogenic factors, including invasion of External factors, disordered emotions, unhealthy diets and lifestyle and a weak constitution.
Diagnosis
Pain due to cancer usually occurs in the later stage of the disease. Whether the pain is due to cancer or to other causes may be easily differentiated by modem technology, such as X-ray, computed tomography (CD scan, echo, blood test, marrow puncture, etc. However, by means of a differentiation of the symptoms and signs, TCM may also predict whether the pain is due to cancer or to another cause. The key points are as follows.
1. Cancer may occur at any age; however, most diseased people are middle-aged or elderly, owing to weakness of the Defensive Qi and a lowered resistance.
2. Most of the patients suffer from prolonged emotional disorders, especially too-intensive emotions, which may lead to impairment of mentality, stagnation of Qi and Blood, and blockage of the channels.
3. Bad dietary habits, including smoking too much, drinking too much alcohol, overeating of highly flavoured food and deep-fried food, and eating contaminated food, resulting in injury of the Spleen and Stomach with formation of Damp-Phlegm in the body.
4. Symptoms include prolonged high- or low-grade fever, fixed pain, no clear origin of bleeding, and progressive emaciation.
5. A hardening mass forms that grows progressively.
Treatment based on differentiation
Differentiation
Differentiation of location
When pain due to cancer occurs, it is very necessary to differentiate its location in order to discover which organ (or organs) is affected. Palpation of the painful areas and the course of the channels and differentiation of the clinical symptoms and signs may give a clear suggestion. For instance, in case of chest pain due to lung cancer, there would be cough, shortness of breath and expectoration of phlegm mixed with blood clots or pure haemoptysis; there could be tenderness at BL-13 Feishu, LU-I Zhongfu and LU-5 Chize. If pain is caused by oesophageal cancer or stomach cancer, there would be painful swallowing, inability to swallow, vomiting after eating, and haematemesis, and tenderness in the epigastric region (e.g. at ST-34 Liangqiu and ST-42 Chongyang).
Differentiation of Excess and Deficiency
Pain due to cancer differs according to whether it is caused by Excess or Deficiency.
— A distending pain, stabbing pain, colic pain, sharp pain, contracting pain or constant pain are usually due to Excess.
— A slight pain, intermittent pain or empty pain are usually caused by Deficiency.
— More often the pain caused by cancer is Excessive pain.
Differentiation of Yin and Yang
— The Yin type of cancer has the following characteristics: slight pain due to cancer on the surface of the body, a lack of itching, a diffuse swelling without clear delimitation, local hardening, erosion, necrosis, and a purplish colour to the tumour or a lack of colour change in the area. Accompanying symptoms can include an aversion to cold, cold hands and feet, a lack of thirst, tiredness, a pale complexion, listlessness, low voice, shortness of breath, palpitations, a pale tongue and a thready and weak pulse.
— The Yang type of cancer has the following characteristics: severe pain due to cancer on the surface of the body, redness, swelling, heat, a foul smell, erosion and necrosis with yellowing oozing. These symptoms are accompanied by fever, restlessness, a bitter taste in the mouth, thirst, constipation and a red tongue.
Differentiation of tongue and pulse
Differentiation of the tongue and pulse characteristics is a very important step in making an accurate diagnosis and in distinguishing between Excess and Deficiency.
— A pale tongue, swollen tongue, or small tongue, tooth marks, a wet tongue coating and a peeled coating indicate Deficiency syndrome.
— A red tongue, purplish tongue, or even black tongue and a greasy coating indicate Excess.
— A big pulse, wiry pulse, slippery pulse, forceful pulse, tight pulse and choppy pulse indicate Excess.
— A thready pulse, weak pulse, slow pulse, deep pulse, intermittent pulse and floating pulse indicate Deficiency.
Treatment
STAGNATION OF LIVER-QI
Symptoms and signs
Local distension and pain, formation of masses that are soft in nature, hypochondriac pain and distension, aggravation of the pain by emotional upset, much stress, depression, headache, irritability, nervousness, a thin and white tongue coating, or a thin and yellow coating, and a wiry and tight pulse.
Principle of treatment
Smooth the Liver and circulate the Liver-Qi, harmonise the collateral and sedate the pain.
HERBAL TREATMENT
Prescription
XIAO YAO SAN
Free and Relaxed Powder
Chai Hu Radix Bupleuri 10 g
Dang Gui Radix Angelicae Sinensis 10 g
Bai Shao Radix Paeoniae Alba 20 g
Bai Zhu Rhizoma Atractylodis Macrocephalae 10 g
Fu Ling Poria 15 g
Gan Cao Radix Glycyrrhizae 5 g
Bo He Herba Menthae 3 g
Sheng Jiang RIiizoma Zingiberis Recens 5 g
Explanations
• Chai Hu and Bo He regulate and promote the Liver-Qi circulation and remove Qi stagnation in the Liver.
• Bai Shao and Dang Gui nourish the Blood and strengthen the Liver. These two herbs can also relieve pain directly.
• Bai Zhu, Fu Ling and Sheng Jiang tonify the Spleen and Stomach.
• Gan Cao harmonises the actions of the other herbs.
Modifications
I. If there is low abdominal pain, add Wu Yao Radix Linderae 5 g and Ju He Semen Citri Reticulatae 10 g to regulate the Qi circulation and relieve the pain.
2. If there is sharp pain, add Yan Hu Suo Rhizoma Corydalis 15 g and Mo Yao Resma Myrrhae 10 g to relieve the pain.
3. If there is irritability and nervousness, add Yu Jin Radix Curcumae 10 g and Chuan Xiong Radix Ligustici Chuanxiong 10 g to regulate the circulation of Qi and Blood and smooth the Liver.
4. If there is a poor appetite, add Shan Zha Fructus Crataegi 20 g and Mai Ya Fructus Hordei Germinatus 20 g to promote the circulation of Qi and improve the appetite.
5. If there is fullness in the stomach, add Zhi Shi Fructus Aurantii Immaturus 10 g and E Zhu Rhizoma Zedoariac 10 g to promote the circulation of Qi and Blood and relieve the fullness.
6. If there is constipation, add Da Huang Radix et Rhizoma Rhei 6 g and Mang Xiao Natrii Sulfas 15 g to promote defecation and remove the stagnation of Qi and Blood.
Patent remedies
Xiao Yao Wan Free and Relaxed Pill
Shu Gan Wan Soothe Liver Pill
ACUPUNCTURE TREATMENT
LR-3 Taichong, LR-5 Ligou, LR-14 Qimen, PC-6
Neiguan, CV-17 Tanzhong and GB-20 Fengchi.
Reducing method is used on these points.
Explanations
• The Liver is in charge of promoting free flow of Qi in the body. If there is prolonged persistence of emotional disturbance the Liver is impaired, so stagnation of Liver-Qi occurs. In fact, stagnation of Liver-Qi may cause stagnation of Qi in the other Zang-Fu organs, such as the Lung, Stomach and Large Intestine. The key treatment therefore is to promote the circulation of Liver-Qi.
• LR-3, the Source point of the Liver channel, and LR-14, the Front Collecting point of the Liver, regulate the Liver, smooth the Liver and promote the free flow of Liver-Qi.
• LR-5, the Connecting point of the Liver channel, harmonises the collateral and sedates pain.
• PC-6, the Connecting point of the Pericardium channel and the point connecting to the Yin Linking Vessel, and CV-17, the Gathering point for the Qi, harmonise the Qi circulation, relax the chest, soothe the emotions, and relieve the blockage in the chest.
• GB-20 calms the Mind and the Liver and sedates headache.
