Why take primary liver cancer as an example? Answer: 1.Important Treatment Success or Failure Human and Financial Survival 2.Necessary Attack Battle Decision-making 3.Success or Failure Case A Advanced Brain Cancer B Gynecological Cancer (Li Yuanyuan) During an ordinary routine checkup after giving birth, the obstetrician and gynecologist told my family grimly that I had gynecological cancer. Less than two months after my baby was born, I was admitted to the hospital again for surgery. After the surgery, there was the routine radiotherapy treatment. The process of chemotherapy was so long and accompanied by tremendous physical pain that the cure was still extremely painful. During the chemotherapy, the body reacted badly to the daily infusions. I kept vomiting, I was uncomfortable, my white blood cells dropped to the lowest point, and I was extremely weak. I had my family play VCDs for me after the infusion to distract my body from the pain while watching the film. When I couldn’t eat, I often encouraged myself to fight against the disease, to eat desperately, and to eat so that my body would get better to meet the next step of treatment. The doctor told me that so far, the main international treatment for this disease is still surgery plus radiotherapy. China’s cure rate for this disease is among the more advanced in the international arena. C. Strange phenomenon? How to make the right decision? Answer: To deal with the four relationships: Chinese medicine treatment and Western medicine treatment, treating the symptoms and treating the root, helping the righteous and attacking the evil, overall treatment and local treatment – How to deal with the relationship between Chinese medicine treatment and Western medicine treatment? Answer: To insist on the combination of Western medical treatment and Chinese medical treatment Why do we need to combine Chinese and Western medical treatment? Chinese medicine is the wisdom of the East and Western medicine is the wisdom of the West. Combining Chinese and Western medicine is the wisdom of all human beings to overcome the disease. After decades of arduous exploration, the treatment of liver cancer has now formed the principle of comprehensive treatment mainly based on surgery. More and more clinical practices have confirmed that the combination of Chinese and Western medicine is the best form of comprehensive treatment. (a) What is the main task of Western medicine in identifying the disease? The first main task of disease identification treatment is to clarify the diagnosis of primary liver cancer in modern medicine and to distinguish the different stages of the disease. In the past, Chinese medicine did not have the name of “liver cancer”, so the first main task of disease identification treatment is to clarify the diagnosis of primary liver cancer in modern medicine and to distinguish different stages of the disease through various modern medical testing methods and collective expert consultation. This is the prerequisite for combining Chinese and Western medicine in the treatment of liver cancer. The principle is to be active and cautious to prevent delay or rash misdiagnosis. Example: My friend’s father’s lung cancer, my colleague’s liver hemangioma. 2. Choose the main treatment according to the disease The second main task of identifying the disease is to choose the main treatment method according to the patient’s different diseases. With the rapid development of modern science and technology, in addition to surgical resection, new treatment techniques such as radiofrequency, freezing, microwave, laser, anhydrous alcohol intratumoral injection, radio-interventional hepatic artery embolization chemotherapy and X-knife have emerged one after another and have achieved certain efficacy in clinical application. However, each new technology has its own indications and limitations. At present, there are many inappropriate clinical indications, so that some patients miss the opportunity of reasonable surgical treatment or even cure, and some patients even cause irreversible consequences. What should patients do in the face of the dazzling treatment methods? The principle is to choose according to national authoritative norms. In 2000, the Chinese Society of Surgery adopted the Program for the Selection of Surgical Treatment for Primary Liver Cancer, which provides a basis for the selection of surgical indications or cases of common clinical surgical treatment methods. The protocol was revised again in 2004. It is worth recommending. In conclusion, before we carry out the combined treatment of Chinese and Western medicine for liver cancer, first of all, it is necessary to choose the main measures of treatment carefully under the premise of clear diagnosis and staging and according to the above-mentioned type of authoritative opinions, instead of choosing an inappropriate treatment at will or easily opposing patients with surgical indications to receive surgical treatment and changing to the treatment with Chinese medicine alone, otherwise, it can cause serious consequences. (2) What is the main task of TCM evidence-based treatment? 1.Adhere to the long-term concomitant treatment of Chinese medicine Why should we adhere to the long-term concomitant treatment of Chinese medicine? Almost all malignant tumors, including liver cancer, are stubborn and difficult to treat, and they are prone to recurrence. Why can TCM be a long-term treatment? There are two reasons (1) Firstly, TCM is applicable to all stages of liver cancer, including early, middle and late stages of the disease. Before and after surgery, when western doctors were arguing about the value of pre-surgical radiation intervention for huge liver cancer and post-surgical bailout chemotherapy, the role of TCM with surgery in improving surgical tolerance, reducing surgical mortality, accelerating physical recovery and reducing post-surgical recurrence and metastasis has been recognized by all parties. While Western doctors are having difficulties in treating hepatocellular carcinoma because of its insensitivity to radiotherapy and chemotherapy and its obvious side effects, the use of TCM can increase the effectiveness and reduce the toxicity and improve the patient’s compliance to radiotherapy and chemotherapy. For example, for postoperative recurrence of gastric cancer, TCM together with emerging local physiotherapy such as laser and radiofrequency can significantly reduce symptoms and improve quality of life, and some can even achieve curative effects similar to those of radical surgery. And when the patient enters the advanced stage which can no longer bear surgery and radiotherapy and chemotherapy, TCM can be used as the main treatment to alleviate the patient’s pain and prolong the survival time with the cooperation of Western allopathic treatment. (2) Secondly, TCM has no obvious toxic side effects, with mild onset and long-lasting effects, which is suitable for long-term use by liver cancer patients. In a word, Chinese medicine is the basic treatment for liver cancer, just like exercise for hypertension and diet control for diabetes, which must be adhered to for a long time. 2. Insist on the principle of combining diagnosis and treatment with Chinese medicine treatment (1) Diagnosis and treatment are the characteristics of Chinese medicine and the essence of Chinese medicine theory. If a bunch of Chinese medicines with anti-cancer effects are listed and mixed and decocted without distinguishing between cold and heat, warm and cool, or if a famous formula, secret formula, experimental formula or special proprietary Chinese medicine for cancer treatment is applied, one medicine will be invalidated in clinical practice. (2) On the premise of clear diagnosis and based on modern pharmacological research or experience of famous and veteran Chinese medicine practitioners in using drugs, TCM uses drugs with direct effect on liver cancer cells, such as turtle nail, Xia Gu Cao, August zha, Curcuma longa, Dong Ling Cao, etc., in order to enhance the effect of TCM against liver cancer. (3) How to implement the combination of Chinese and Western medicine The combination of Chinese and Western medicine complement each other’s strengths and divide the work. In the treatment of liver cancer, Chinese medicine and modern medicine have their respective strengths and weaknesses: Chinese medicine is good at helping the righteous, while western medicine is good at eliminating the evil; Chinese medicine is good at systemic conditioning, while western medicine is good at local treatment. Therefore, the combination of Chinese and Western medicine is not simply a pile of Chinese medicine and Western medicine treatment, but an organic combination. In the early stage, Western medicine is the mainstay, and can be surgically removed as soon as possible, supplemented by Chinese medicine; in the middle and late stage, Chinese medicine should be the mainstay, supplemented by Western medicine. Among them, the use of pure traditional Chinese medicine or interventional therapy combined with Chinese and Western medicine or tumor injection therapy should be the development direction of organic combination of Chinese and Western medicine in the treatment of liver cancer in the future. How to deal with the relationship between treating the symptoms and the root cause? Answer: The treatment of tumor should distinguish the symptoms and the root cause of the disease. 1. What is the meaning of “the root” of the disease? The “root” of the disease must be sought, the “root” has a dual meaning: one is the fundamental purpose of treatment. Secondly, it is the root of “symptoms” and “root”. Liver cancer is a serious and difficult disease. In most cases, patients have a history of chronic hepatitis and cirrhosis for many years, with multiple symptoms and huge local tumors in the liver, at this time, facing the patients, doctors must first solve the problem of clarifying the fundamental purpose of treatment. Is it “disease” or “person” oriented? 2. What is disease-oriented? If the treatment is disease-oriented, then regardless of the patient’s physical condition and liver function, surgery, chemotherapy and radiotherapy will be used together; or traditional Chinese medicine will attack the tumor with poison, activate blood circulation and break down blood stasis, clear heat and detoxify the tumor, soften and disperse the nodules, and “airplanes, tanks and cannons” will be bombarded indiscriminately, trying to destroy the tumor cells cleanly, completely and completely in a short period of time, which often results in more harm than good. The result is often more harm than good, making the body’s vitality lose a lot of energy, “killing 8,000 enemies, but losing 10,000”, “two door plates pressed straight hunchback, hunchback though go but life does not return”. If the tumor cells are not eliminated, the cancer will come back and metastasize, or the tumor will die with the person. 3.What is people-oriented? Why should be people-oriented? Human-centered is to clarify that the fundamental purpose of treatment is to prolong the survival time, reduce the pain and improve the quality of life, and on this basis, if the conditions allow, then strive for a cure. If we put people first, we will not treat people indiscriminately with the so-called “standard therapy” and “authoritative dose”. Rather, the treatment method and dosage will be carefully selected taking into account the patient’s physical condition, the strength of his or her vital energy, the patient’s tolerance to treatment, and the normalcy of his or her liver function. The relationship between “treating the disease” and “treating the person” should be handled appropriately. (2) Identify the symptoms and determine the priority of treatment. As the saying goes: treat the symptoms if it is urgent, and treat the root cause if it is slow 1. “It mainly indicates which are the essence of the disease, which are the external manifestations of the disease, which are the main contradictions of the disease, and which are the secondary contradictions of the disease. The so-called “symptoms” refer to the phenomena of the disease, while the “essence” refers to the nature of the disease. Only when the symptoms are clearly identified can we not be confused by the complex symptoms and can grasp the essence of the disease and provide the correct treatment. The disease is complex and often in the process of development and change, therefore, “symptoms” and “essence” are not unchanging, but a relative discriminative concept with various meanings. 2.How to distinguish the specimen for tumor patients? In terms of tumor and symptoms, tumor is the essence of the disease, and the various symptoms and urgent symptoms that occur in the process of tumor can sometimes threaten the life of patients. “These are the symptoms. When patients have general symptoms, focus on treating tumor as the “root”, i.e., slow is the cure for the root. When there are urgent symptoms such as bleeding, fever, infection and large amount of fluid in chest and abdomen, we should actively treat the “symptoms”, that is, treat the symptoms urgently. On the level of human immune function and tumor, tumor is the “symptom”, while low immune function, which is an important factor for the occurrence and development of tumor, is the “root”, therefore, after the tumor is removed, the focus should be on the treatment with Chinese medicine or biological agents to improve the immune system. Therefore, after the tumor is removed, the focus should be on the treatment with Chinese medicine or biological agents to improve the immunity of the body, which is the “root”. Therefore, when the tumor is removed, the focus should be on Chinese medicine or biologics to improve the immune system of the body. For patients with early recurrence after surgery, we should treat both the symptoms and the root cause, not only to improve the immunity of the body, but also to kill the tumor cells appropriately. In conclusion, we can only overcome tumor step by step by continuously identifying the symptoms and the root cause of liver cancer disease process, continuously seizing the main contradiction and solving the main contradiction. How to deal with the relationship between treatment to support the righteousness and treatment to attack the evil? As a common saying goes: support the righteousness and dispel the evil What is the righteousness? What is evil? In Chinese medicine, it refers to the normal function of the human body and its ability to maintain health, including the ability to self-regulate, the ability to adapt to the environment, the ability to resist evil and prevent disease, and the ability to recover and heal oneself. Evil: is the abbreviation of evil qi, as opposed to positive qi, in Chinese medicine refers to: general refers to various disease-causing factors. It includes all kinds of factors that exist in the external environment and within the human body that cause disease or damage the righteousness. These factors include the Six Perversions, Plague, Seven Affections, trauma, Phlegm and Blood stasis, etc. How do they relate to the onset of disease? Only when the body’s positive qi is not enough to resist the evil, or when the force of the evil attacking the body exceeds the resistance of the body’s positive qi, then the disease may develop, and the whole process of disease is the process of the struggle between positive and evil. (1) Attacking the evil and less injuring the righteousness is the inevitable trend in the development of liver cancer treatment (1) What is the role of the righteousness in Chinese medicine and the immune system in Western medicine in tumor? Liver cancer belongs to the category of “liver accumulation”, “dropsy”, “Y accumulation” and “gangrene” in Chinese medicine, which is a disease of deficiency and It is a disease of deficiency at the root and the symptoms at the end. According to Chinese medicine, the formation of tumor is the result of the deficiency of the body’s positive energy and then the entrapment of evil energy. Although the causes of tumor are very complicated, in general, they are internal and external, and the internal cause of deficiency of positive qi plays a leading role. “The internal cause of deficiency is the leading role. Emphasis is placed on prevention and treatment of tumors by improving the body’s own resistance. Modern medicine believes that the etiology of tumor is very complex, there are external environmental factors, including chemical, physical and biological factors, such as nitrosamines, hepatitis B virus; and also internal factors of the body, including genetic factors, hormone levels, age, gender, emotions, etc., especially gene mutation, oncogene expression and reduced immune function. Modern immunology proposes that the 3 major functions of the body’s immune system (immune defense, immune stabilization and immune surveillance) are of great importance in anti-tumor. From the above, it can be seen that the so-called positive energy in Chinese medicine coincides with the three functions of immune system in modern medicine, which are the most important forces in the body to fight against tumors. 2.What is the law of continuous progress of western medicine in treating liver cancer? The continuous progress of modern medicine in treating liver cancer is based on the rule that anti-tumor (i.e. attacking evil) should less damage the immune function of human body (i.e. less harming positive), i.e. attacking evil should less harm positive. For example, the transition of surgical resection of liver cancer from regular wide resection to irregular local resection and subhepatic segmental resection has not only simplified the surgery but also greatly reduced the mortality rate; the transition of chemotherapy for liver cancer from systemic chemotherapy to hepatic artery and hepatic artery superselective chemotherapy or embolization chemotherapy has reduced the side effects and improved the efficacy, while percutaneous anhydrous alcohol intrahepatic injection can be considered as the latest progress of chemotherapy, the efficacy of which is close to that of surgical resection for small liver cancer in 5 years. After 30 years of clinical practice, radiotherapy for hepatocellular carcinoma has undergone several changes such as whole liver irradiation → local irradiation → whole liver mobile strip irradiation → surgical accurately positioned local irradiation → super-segmented irradiation, etc. In addition to external irradiation, internal irradiation therapy has opened up a new way for radiotherapy, and with the continuous progress of radiotherapy technology, the efficacy of radiotherapy for hepatocellular carcinoma has been significantly improved, and the side effects have been significantly reduced. In addition, the newly developed guided therapy has been developed in recent years. In addition, the newly developed guided therapy and local minimally invasive therapy, such as laser, radio frequency and even local non-invasive therapy, have also been applied in recent years, which have precise efficacy and less side effects and can improve the immune function of the body. 3.What is the significance of mastering the law of continuous progress of modern medical treatment for liver cancer for treatment decision? Nowadays, the above treatment methods coexist in different hospitals and different departments of the same hospital, so we can choose the more advanced and technically mature treatment according to the principle of attacking evil and less harming righteousness. 4.What kind of rules should Chinese medicine practitioners follow when using drugs with obvious toxic side effects to treat diseases? Chinese medicine has a long-established view on the use of drugs with obvious toxic side effects in treating diseases. The Nei Jing states, “The big poison cures the disease ten to its six, the regular poison cures the disease ten to its seven, the small poison cures the disease ten to its eight …… without making it too much and hurting its righteousness.” In short, surgery, chemotherapy, radiotherapy, as well as Chinese medicine to clear heat and detoxification, blood circulation and blood stasis, to fight poison with poison Chinese medicine, all belong to the treatment methods and drugs to eliminate evil and hurt the right, and especially radiotherapy, chemotherapy hurt the right, the human immune system is destroyed, toxic side effects are serious. Only with the support of positive Chinese medicine and biological agents can we achieve a more desirable therapeutic effect, not overuse, abuse, overdose and overdose. (2) Continuous support is the fundamental to further improve the curative effect. 1. What are the difficulties in the treatment of liver cancer by western medicine? Although modern medicine has made continuous progress in the treatment of hepatocellular carcinoma, there are three main difficulties in treatment: Firstly, the problem of liver function damage, which is closely related to the mortality rate of surgery, complication rate and postoperative recurrence; secondly, the problem of high recurrence rate after surgery; thirdly, the problem of poor curative effect of most large and advanced hepatocellular carcinomas. 2. Why does it provide the best opportunity for the combination of Chinese and Western medicine? Because the anti-tumor effect of Chinese medicine has its own characteristics and certain advantages. Firstly, it can act directly on tumor cells through multi-link and multi-target. It includes tumor suppressing, tumor killing and anti-tumor metastasis effects. Secondly, it can also prevent tumors by improving the body’s immune function and preventing normal cell mutation. Thirdly, when used in combination with radiotherapy, chemotherapy and surgery, it has the effect of “reducing toxicity and increasing sensitivity”, which can not only improve the therapeutic effect, but also reduce the damage of radiotherapy, chemotherapy and surgery to the body, reduce their toxic side effects, prolong the survival time of tumor patients and improve their quality of life. 3.Why do you say that supporting the righteousness and cultivating the root is the basic rule of TCM in treating liver cancer and the root of improving the curative effect? To support the righteousness and cultivate the root is the basic rule of Chinese medicine in treating liver cancer and the root of improving the efficacy. Its most prominent function is to regulate the immune function of the body, especially the cellular immune function. After the formation of liver cancer, it continuously depletes the positive qi, and the deficiency caused by the disease over time further leads to the deficiency of positive qi, and whether the cancer foci can be controlled in the body and whether they can spread and metastasize depends on the result of the struggle between the evil qi and positive qi. Although attacking the evil (including surgery, radiotherapy, chemotherapy, Chinese medicine, etc.) is an important method to treat tumor and can restore the body to achieve the purpose of “the evil goes away and the righteousness is at peace”, attacking the evil may deepen the suppression of the immune function of the body, and if the righteousness is not protected in time, it will often make the righteousness fail and the evil flourish, and the evil will flourish and the righteousness will fail, thus contributing to the spread and development of liver cancer. Therefore, during the treatment process and post-treatment consolidation stage, attention must be paid to support and cultivate the essence to improve the immune function of patients and reduce the chance of tumor recurrence and spread. (3) The best combination of Chinese and Western medicine is the ladder to improve the efficacy. 1. Lessons from the treatment of tumors by Chinese and Western medicine in Zhongshan Hospital of Shanghai Medical University In the 1960s and 1970s, the treatment of liver cancer with Chinese herbal medicine was mainly mono-formulas, more often used were half a branch of lotus, white flowered snake tongue grass, lobelia, etc., and many other worm medicines were used to fight poison with poison. And Chinese medicine and Western medicine often have no connection. On the one hand, high doses of chemotherapy are used, and on the other hand, the above-mentioned drugs are applied in large quantities to clear heat and detoxify the toxin. 2, Shanghai Medical University Zhongshan Hospital experience of combining Chinese and Western medicine Failure is the mother of success, clinical treatment failure prompted them to summarize, they found that if Chinese and Western medicine combined properly, the bleeding rate is low, the survival rate is high, such as improper combination of bleeding rate is high, the survival rate is low. By proper, it means that when Western medicine is used for radiotherapy and chemotherapy, Chinese medicine should be used as a supplement; if chemotherapy and radiotherapy are used at the same time, Chinese medicine is used as an attacking agent, it is not proper. Further analysis shows that if chemotherapy is used in medium doses, it is best to combine TCM with tonic; if chemotherapy is used in small doses, it is better to combine TCM with both attacking and tonic. Fourth, how to deal with the relationship between overall treatment and local treatment? (1) Clarify the dialectical relationship between local lesions and the whole body 1. The holistic concept is one of the basic features of the theoretical system of Chinese medicine, which regards the internal organs and body surface as well as the tissues and organs of the human body as an organic whole, which are physiologically interrelated and pathologically interact with each other, and emphasizes the coordination and perfection of the internal body. This holistic concept can be used in the diagnosis and treatment of the disease, instead of focusing on the local lesions. 2.According to the theory of holistic concept, what is the discriminative relationship between localized lesions of liver cancer and systemic conditions? Liver cancer is a local manifestation of systemic disease, and the relationship between tumor and human body is a discriminative relationship of opposites and unity, in which shrinking cancer lesions can improve the systemic condition, while improving the systemic condition can improve the body’s anti-cancer ability and control the development of cancer lesions. The whole body condition is the main aspect of the conflict, which determines the quality and survival period of the patient and the prognosis of the patient, and is the “essence” of the disease. Of course, if the local cancer foci are huge and have direct or imminent serious complications, then the cancer foci, which is the “target”, will become the main aspect of the conflict if the systemic condition is not very serious, and it is necessary to “treat the target urgently” by reducing or removing the cancer foci first. If the systemic condition is not very serious, it will become the main aspect of the conflict. If the systemic condition is very poor, even though the cancer foci are huge, at this time, “treating the root” will be the main focus, and while “treating the root”, “treating the symptoms” will be taken into consideration. 3.Why do we say that tumor efficacy standards will affect the treatment of tumor by combining Chinese and Western medicine? At present, the WHO tumor efficacy criteria, such as complete remission (CR), partial remission (PR), stability (R) and deterioration (P), which are commonly used at home and abroad, are likely to mislead the treatment of liver cancer and make people only care about the local lesions but ignore the whole body. weight, hemoglobin and other 14 indexes, comprehensive score is recorded, and it is divided into 3 grades of good, moderate and poor according to the total score estimation. It solves the problem of overall efficacy evaluation of Chinese medicine treatment. It is a more comprehensive and realistic reflection of patients’ quality of life status. According to clinical practice, the assessment of patient survival based on it is far more accurate than WHO tumor efficacy index. Of course, the combination of these two factors with survival rate will provide a more comprehensive evaluation of the treatment effect of liver cancer. (2) There are many treatment options for focal lesions, so choose them carefully to minimize injuries 1. Patients and family members are dazzled by many treatment methods, and doctors of various specialties emphasize that their own treatment methods are the best, either because of their limited vision or because of economic interests. In our opinion, it should be considered from three aspects: efficiency (including quality of life index and survival rate), toxicity and side effects, and pain level. Surgery is the first choice because malignant tumor cells can produce some immunosuppressive factors, which can close the immune surveillance system and inhibit the immune rejection function, and the more tumor cells there are, the stronger this inhibitory effect will be. The more tumor cells there are, the stronger this inhibitory effect will be. At the same time, the efficiency and survival rate of surgery are the highest among all treatments. Therefore, those who can undergo surgery or stage II surgery must be treated surgically. Physical therapy such as radiofrequency, laser, cryotherapy, and Chinese medicine injection are the second choice. It is characterized by less damage, can be repeated, without the toxic side effects of radiotherapy and chemotherapy. The lesion treatment can also cause enhanced immune response. The third choice is hepatic artery chemoembolization, such as chemoembolization with pure herbal preparations, which can be used as a second choice for rich hemangioma. Systemic chemotherapy and radiotherapy for larger areas should be chosen with caution. The specific choice should be decided strictly according to the indications and indications of each treatment method. 3.What is the general selection standard of treatment? The standard is appropriate, appropriate amount, and less damage to the righteousness. (3) Survival with tumor – a new concept of “one country, two systems” in the treatment of advanced tumor by combining Chinese and Western medicine 1. Zhang Qingquan et al. optimized the comprehensive treatment for 35 cases of unresectable large hepatocellular carcinoma confirmed by dissection, and the 5-year survival rate was 52%, and the quality of life was improved. 2.Can elderly patients with advanced and dying tumors survive? The answer above is yes, then is it purely by chance or is it inevitable? With the continuous exploration of Chinese and Western medicine combined with tumor treatment, people found that the organism responsiveness of cancer patients is very important for tumor rehabilitation treatment. Effective treatment does not mean that the local tumor needs to be removed absolutely no matter what the condition is. We can understand the body reactivity as the positive energy in Chinese medicine, whose strength or weakness determines the growth of tumor and largely affects the stability and progress of the disease. Therefore, for patients with advanced liver cancer who have lost the chance of surgery, the most important thing at this time is to adopt the overall method of supporting and cultivating the righteousness for conditioning treatment. To support and enhance the positive energy, improve the general condition and enhance the immune function of the body, which is conducive to inhibiting the growth of tumor and the progress of the disease, so that some patients can survive with tumor for a long time and obtain a better quality of survival. In conclusion, survival with tumor suggests that we must get out of the misunderstanding of only seeing local lesions but not the overall positive energy, and always put the overall conditioning in the first place. The key to correct decision making is to deal with four kinds of relationships (1) insist on the combination of Western medical treatment and Chinese medical treatment (2) distinguish the symptoms from the root cause of the tumor, and seek the root cause of the disease (3) attack the evil to less damage the righteousness, and help the righteousness is the root (4) treat the local lesions smartly, and the overall conditioning is the first priority.