In recent years, the focus of prevention and control of early gastric cancer has shifted to the intervention and treatment of precancerous lesions, and the timely and effective control of precancerous lesions and primary prevention are important means and measures to prevent the development of gastric cancer [1, 2]. It is well known that gastric precancerous lesions (PLGC) mainly include chronic atrophic gastritis (CAG), intestinal epithelial metaplasia (IM) and heterogeneous hyperplasia (Dys) of gastric mucosa. Recently, many reports have shown that TCM has superior efficacy in the treatment of PLGC, but are the reported research results both good and bad? Can the efficacy advantages of TCM be widely recognized? Can it be widely applied in clinical areas other than TCM? Are there any “bottlenecks” and “confusions” in the clinical treatment of PLGC in TCM? And how to get rid of the “confusion”? It is necessary to reflect on and discuss the current situation of its treatment. 1. Modern medical research on PLGC is progressing rapidly, but has not yet shown any breakthrough. Modern medical research on PLGC focuses on the regulation of abnormal expression of cancer-related genes and proteins, such as gene knockout, sequence rearrangement and exogenous gene intervention, in order to change the biological pathogenesis of gastric cancer. Most studies have shown that abnormal expression of cancer-related genes such as P53, P16 gene, colorectal cancer deletion gene (DCC gene), fragile histidine triad gene (FHIT), Runt-related transcription factor 3 gene (RUNX3), tumor suppressor gene APC and oncogene c-met [3-5] are associated with the development of gastric cancer, but so far no gene has been seen that can specifically regulate the However, there is no specific drug that can specifically regulate the abnormal expression of related oncogenes. In addition, the exploration of serological biomarkers associated with the early diagnosis of gastric cancer has also attracted widespread interest, such as studies suggesting that serum pepsinogen I, serum pepsinogen II, anti-H. pylori IgG-type antibody, gastrin, gastric cancer monoclonal antibody MG7-Ag, growth hormone-releasing peptide (Ghrelin), IL-8, and other serological indicators are valuable for screening gastric mucosal atrophy and In clinical practice, many protein markers have also been gradually used for clinical detection, such as CA72, CA19, carcinoembryonic antigen (CEA), CA50 and CA125, cell adhesion molecules (CD44), vascular endothelial growth factor (VEGF), tyrosine kinases, epidermal kinases, and other protein markers. kinases), epidermal growth factor receptor (EGFR), erythropoietic leukemia virus homologous oncogene 2 (ERBB2), platelet-derived growth factor (PDGFR), etc. [11], are generally considered to be clinically relevant for the dynamic observation of the development of gastric precancerous lesions, but there are no biological indicators that can make a specific diagnosis of PLGC to date. It can be seen that the focus of modern basic medical research is on the intervention in the biological pathogenesis of PLGC and the exploration of biological markers that can detect the cancerous tendency of PLGC at an early stage. The principles of modern medical treatment for PLGC are “eradication of Hp bacterial infection, reinforcement of barrier function, promotion of epithelial growth, promotion of gastric peristalsis and reduction of intestinal fluid reflux” [12], with the main aim of eliminating pathogenic factors and relieving symptoms in order to control its pathological process and development. The Chinese Consensus Opinion on Chronic Gastritis states that some vitamins and selenium can reduce the risk of gastric cancer, that folic acid has a preventive effect on gastric cancer, and that tea polyphenols and allicin also have certain preventive effects on gastric cancer [13], probably by protecting DNA from oxidative damage and potential genetic mutations, etc. They play an anticancer role. A recent study found that retinoic acid, as an effective inhibitor of gastric mucosal cell proliferation in vitro, can induce gastric cancer cell differentiation and simultaneous induction of HL-60 cell differentiation and apoptosis, and vincristine and vincristine are new generation of vincristine compounds synthesized in China, and some studies have shown that the efficiency on human gastric mucosal heterotypic hyperplasia reaches 70%-89, 3% [11]. However, these studies and opinions have not yet been widely used in clinical practice, and evidence from multicenter, randomized, double-blind clinical trials is lacking [14]. As for the development of minimally invasive treatments such as endoscopic mucosal resection, mucosal dissection, high-frequency electrodesiccation therapy, argon knife therapy, laser therapy, and microwave therapy, they are suitable for those with severe heterogeneous hyperplasia or signs of mucosa that have become cancerous, and prevent the further development of carcinoma and early gastric cancer by removing PLGC tissue. It can be seen that the clinical research on PLGC in modern medicine focuses on early detection and early treatment, and although significant results have been achieved in symptomatological improvement, passive clinical interventions are still difficult to stop the process of PLGC fundamentally, thus gradually making some scholars feel “confused in diagnosis and treatment” [14]. It seems to be evident that modern medicine lacks specific treatment methods and drugs for PLGC, therefore, many scholars hope to seek some breakthroughs from the perspective of traditional Chinese medicine. 2. Traditional Chinese medicine has different views on the pathogenesis of PLGC and lacks a consensus theory of pathogenesis and legislative basis Traditional Chinese medicine’s understanding of the etiology of the disease is inseparable from Song Wuzhe’s “Three Causes of PLGC”. “fullness”, “gastric plumpness”, “deficiency plumpness”, “gastric pain”, “noisy”, etc., and based on the theory of etiology and pathogenesis of traditional Chinese medicine and their own experience, they The etiology and pathogenesis of PLGC have been summarized based on the traditional Chinese medical theory of etiology and pathogenesis and their respective experiences. Some have established a pathomechanical hypothesis based on the early, middle, and late stages of PLGC, which suggests that in the early stage of the disease, it is mostly due to blood stasis and heat toxicity; in the middle stage, it is mostly due to yin deficiency with heat; and in the late stage, it is mostly due to both qi and yin deficiency [15]. It has also been suggested that weakness of the spleen and stomach is the basis for the pathogenesis of precancerous lesions in the stomach, heat toxicity is the key link in the pathogenesis, and disharmony of the liver and stomach is the contributing factor [16]. Others have proposed that “turbidity” and “toxicity” cause the disease, suggesting that turbidity and toxicity affect the spleen and stomach qi flow, block the qi flow, injure yin with heat and toxicity, and stagnate the stomach ligaments with turbidity and toxicity [17]. However, more scholars believe that the disease is located in the spleen and stomach and is related to the liver, and that the pathogenesis is based on the deficiency of the spleen and stomach and the deficiency of both qi and yin, while the symptom refers to qi stagnation, blood stasis, heat toxicity, phlegm and dampness [18-21]. It seems to be evident from numerous research reports that the pathogenesis of PLGC is mostly associated with pathological factors such as spleen deficiency, qi stagnation, heat toxicity, blood stasis, dampness, and qi-yin injury. It is well known that the determination of disease treatment rules in Chinese medicine is theoretically based on the legislation of etiology and pathogenesis, but by virtue of empirical, subjective, and each holding its own views on the generalization of pathogenesis sometimes differ or even contradict and oppose each other epistemologically, such different pathogenetic views and the lack of consensus on the pathogenesis theory of disease evolution and development, thus inevitably lead to the pathogenesis, legislation, and treatment rules of PLGC “It is difficult to form a unified consensus within the profession. In 2009, the Chinese Society of Traditional Chinese Medicine, Splenic and Gastrointestinal Diseases Branch formulated the Consensus Opinion on the Traditional Chinese Medicine Treatment of Chronic Atrophic Gastritis [22], which, despite the generalization and unification of the TCM pathomechanism of CAG, which is one of PLGC, the individualized pathomechanism theory of CAG does not fully encompass and represent the pathogenesis of IM and Dys. Therefore, the author believes that combining the pathological process of PLGC atrophy → intestinalization → heterogeneous hyperplasia in modern medicine, clarifying the direction of the main axis of the evolution of TCM pathological mechanism, standardizing and forming a consensus pathomechanism theory, will be able to provide a framework knot and theoretical basis for the formulation of the general method of TCM treatment of PLGC. 3. There are many TCM treatment methods for PLGC, but lack of dominant treatment direction and primary and secondary structures of treatment methods Recently, many studies have reported that TCM treatment of PLGC has shown efficacy advantages [18-21], but due to different legislative bases and their respective clinical experience as well as the differences and similarities in the understanding of the treatment concept, it has led to the current situation of numerous clinical treatment methods and diffuse prescriptions. Looking at the literature in the past 5 years, among the treatments of PLGC, some advocate strengthening the spleen and benefiting the qi, some lead in draining the liver and qi, some emphasize clearing heat and detoxifying the toxin, some are good at activating blood circulation and resolving blood stasis, some focus on benefiting qi and nourishing yin, some advocate resolving dampness and draining turbidity, and there are also many concurrent treatments such as different or similar methods of harmonizing the stomach and lowering rebellion, cooling the blood and resolving blood stasis, benefiting the temperature and middle, strengthening the spleen and kidney, eliminating food and stomach, and promoting the lowering of dampness, etc.; there are also from the perspective of identifying the disease, targeting Hp bacterial There are more than 100 kinds of treatment methods from the perspective of disease identification, such as the combination of single herbs for Hp infection, inhibiting gastric mucosa atrophy, and preventing gastric mucosa intestinalization. Although the flexible treatment methods of TCM with different insights have broadened the therapeutic thinking of PLGC, such a variety and chaotic treatment methods lack the dominant direction of TCM treatment and inevitably lead to confusion and even questioning of the clinical treatment status. We believe that although there are many TCM evidence categories of diseases, the TCM evidence structure of a certain disease must have its main representation or there exists a primary and secondary evidence composition. For example, in 2009, the consensus opinion on the treatment of CAG in Chinese medicine formulated by the Chinese Society of Traditional Chinese Medicine (CSCM) Branch of Spleen and Gastrointestinal Diseases, there are consensus on the treatment of (1) six types of evidence-based treatment, (2) principles of adding and subtracting medication with the disease, (3) types and methods of using proprietary Chinese medicine, and (4) other therapies (acupuncture, diet, psychology) [22], but as mentioned earlier, whether this consensus opinion can include all pathological states of PLGC needs further study. Recently, during the implementation of the National 11th Five-Year Plan of Science and Technology Support Program “Optimization of Clinical Treatment Plan for Chronic Atrophic Gastritis”, the author summarized the literature of 8056 cases of CAG treated by TCM in China in the past 10 years and obtained The most basic treatment for CAG is the method of strengthening the spleen and benefiting the qi, accounting for 35-45% of the total treatment composition, followed by the method of draining the liver and harmonizing the stomach (22-24%) and the method of benefiting the qi and nourishing the yin (16-68%) [23], which seems to suggest that there are representative evidence and treatment methods for CAG in TCM, and the same should be true for PLGC. Therefore, the author believes that how to grasp the main pulse of TCM treatment of PLGC and how to select the advantageous treatments from many TCM treatments, so as to change the confusing situation of TCM treatment classification, firstly, the framework structure of the main treatment directions of PLGC should be constructed on the basis of the development and evolution of the TCM disease mechanism, and the main and secondary TCM treatments should be determined according to the advantages, which should be an important premise for determining the TCM treatment rules and treatments of PLGC. This should be an important prerequisite for determining the TCM treatment for PLGC. 4. The lack of “consensus” on the efficacy of TCM for PLGC has made it difficult for the treatment advantages to be widely accepted and promoted As the research reports and results on the clinical efficacy of TCM for PLGC are on the increase, the research on the inhibition of the process of gastric mucosal atrophy or the possible reversal of intestinalization and anisotropic hyperplasia has also achieved a lot of results. The results of the studies on the inhibition of gastric mucosal atrophy process or the possible reversal of intestinal and anisotropic hyperplasia have also been achieved. Recently, I searched the clinical literature of TCM for the treatment of PLGC in the past 10 years through online databases such as China Knowledge Network and Wikipedia Data, and there were 52 articles only for PLGC, and 735 articles for CAG (including 11 articles containing PLGC, 2 articles containing IM, and 6 articles containing Dys), 52 articles for IM and 36 articles for Dys, which seems to show the remarkable effectiveness of clinical research of TCM. This seems to show the remarkable effectiveness of clinical research in TCM. In the past 10 years, we searched the patents for the treatment of gastric precancerous lesions through the patent website of the State Intellectual Property Office, and found that there were 11 patents for PLGC alone, and more than 85 patents for CAG, 2 for IM, and 8 for Dys, which also showed the richness of the results obtained by Chinese medicine for PLGC. However, why are there no specific prescriptions for the treatment of PLGC pathology? Why have so many results not been translated and developed into specific drugs for the treatment of PLGC? We believe that the reasons may be related to the lack of universality of efficacy of individualized typical cases, the lack of reproducible evidence of clinical efficacy, the variety of prescriptions and medicines, the instability of medication and the irregularity of addition and subtraction with symptoms, etc.; at the same time, to a certain extent, it also indicates that there is a lack of “consensus” on the efficacy of TCM for PLGC, and even There are many controversies or questions. When we look at the clinical research literature of TCM and the results of invention authorization, most of them lack evidence of clinical multicenter randomized double-blind controlled studies, so it is difficult to obtain wide recognition of the efficacy. For example, “Gastric Fuchun” tablets developed and produced by Hu Qing Yu Tang in Hangzhou are increasingly used by Chinese and Western medicine clinicians in the treatment of CAG [24-25]; however, in recent years, there have been reports of better efficacy than the control group of “Gastric Fuchun” [26-28]. 28]; some people even concluded by Meta-analysis that “no definite conclusion can be drawn on the efficacy and safety of Gastrofuchun in the treatment of CAG” [29]. Recently, academician Wang Yongyan of the Chinese Academy of Traditional Chinese Medicine suggested that the core issue of “complexity intervention” in TCM is “consensus efficacy”, “What is consensus efficacy? That is, the efficacy that is recognized by Chinese medicine and Western medicine; the efficacy that is recognized by Chinese and foreigners is called consensus efficacy” [30]. Therefore, whether the efficacy of TCM for PLGC can be widely “agreed” at home and abroad is the key to whether the therapeutic advantages of TCM can be widely accepted and promoted. 5. Ideas and countermeasures to overcome the “confusion” in the treatment of PLGC in TCM As can be seen above, TCM lacks a unified understanding of the pathogenesis and pathogenesis of PLGC, and has not yet formed a theoretical overview of the pathogenesis along the main axis of disease development, and lacks a basic consensus on the pathogenesis and dialectical legislation of TCM, which inevitably leads to the diffusion of TCM treatment methods and prescriptions. In addition, the diversity of prescriptions and medicines, the instability of their use, and the irregularity of addition and subtraction with the disease do not reflect the reproducibility of the efficacy; furthermore, the lack of evidence of efficacy in randomized, double-blind controlled clinical studies makes it difficult for the efficacy of TCM to be widely accepted and applied. The above “confusion” in treatment has always affected the promotion and development of the advantages of TCM in PLGC. Recently, academician Wang Yongyan pointed out that the real demand for change in the direction of TCM discipline points to the direction of TCM discipline development, such as “continuously improving the evaluation method system of TCM efficacy in order to obtain consensus evidence-based evidence and thus improve the scientific and technical accessibility of TCM theories” and “establishing a standardized TCM industry standard”. “to establish standardized domestic and international prevailing standards in the TCM industry and to continuously improve international academic influence” [31]. It is also suggested that the efficacy of TCM for PLGC should be based on “consensus evidence” and “common standards at home and abroad” in order to be gradually accepted and promoted at home and abroad. How to make the advantages of TCM widely recognized, accepted and promoted at home and abroad, and how to overcome the “confusion” in the treatment of TCM, we believe that we can start from the following aspects: ① To summarize and condense the TCM pathomechanism theories in line with the evolution and development of PLGC, to establish the main pathological and evidential properties of TCM, and to construct the main types of TCM evidence of PLGC structure and primary and secondary classification. ② Determine the dominant direction of TCM treatment and the main priority of treatment methods, select representative prescriptions and medicines, and standardize the criteria of medication and structure of dosage. ③ Develop and standardize relatively unified TCM treatment PLGC program, the development of which should be based on the “combination of formula and evidence” and “combination of disease and evidence”, “combination of formula and evidence” that is The prescription of TCM is in accordance with the representative main evidence, and the combination of disease and evidence is that the structure of TCM evidence is in accordance with the main pathological processes of gastric mucosal atrophy, intestinalization and heterotypic hyperplasia, which is developed from the traditional evidence-based treatment to the combination of evidence and disease. The clinical study and the judgment of efficacy should be based on “consensus evidence-based”, and the study design should comply with DME principles (clinical research design, measurement, and evaluation) and GCP requirements (Good Clinical Practice,GCP). ⑤ Clarify the operable procedures that can be easily grasped by the general Chinese and Western medicine and digestive community, so that the clinical treatment pathway of PLGC in Chinese medicine can be clarified, standardized and standardized. (6) The “consensus on efficacy” and the linguistic explanation of its efficacy mechanism are in line with the “common standards at home and abroad”. If so, it is possible to make the TCM treatment plan and efficacy of PLGC widely recognized and accepted by the gastroenterology community, and the advantages of TCM in treating PLGC can be more widely used and promoted.