With the progress of biological research and evidence-based medical research on breast cancer, the purely surgical treatment model of breast cancer has developed into a comprehensive treatment model including surgery, radiotherapy, chemotherapy, endocrine therapy, molecular targeted therapy, and Chinese medicine treatment, and the overall treatment level of breast cancer has improved rapidly. Most of the patients have recurrence and metastasis. In clinical practice, Chinese medicine is often used in the peri-operative, peri-chemotherapy and peri-radiotherapy stages of breast cancer, and it is difficult to evaluate the objective efficacy of Chinese medicine because the above treatments are used together with other methods. The therapeutic effects of TCM can be better reflected, i.e., reducing tumor recurrence and metastasis, improving quality of life, and treating related complications. In this paper, we review the TCM treatment for patients without tumor during the recovery period of breast cancer.
1.Characteristics of TCM —– Qi and Yin deficiency and dysregulation of the flush and the capillary are the main types of evidence
Liu Sheng et al. conducted a typing study on 407 postoperative breast cancer patients to explore the pattern of identification and found that the majority of patients had Qi and Yin deficiency, accounting for 94.35% in 384 cases, a minority of patients had Qi and Blood deficiency, accounting for 5.41% in 22 cases, 88.57% had Qi and Stomach disorders, 19.41% had Liver Qi disorders, and 313 cases had Qi and Yin deficiency with Qi and Stomach disorders. 76.90% of the cases [1]. Wu Xueqing et al. collected TCM symptoms from 108 postoperative breast cancer patients and found that there were 81 cases (75.00%) of Qi deficiency, 77 cases (71.30%) of Yin deficiency, 25 cases (23.15%) of Blood deficiency, 57 cases (52.78%) of Chong Ren imbalance, 37 cases (34.26%) of Liver Qi stagnation, 22 cases (20.37%) of Liver and Kidney Yin deficiency; 60 cases of both Qi and Yin deficiency. (55.56%), and 34 cases (31.48%) had Qi deficiency, Yin deficiency, and Qi-hypogastric disorders. Age, disease duration, estrogen and progesterone receptor expression, axillary lymph node metastasis and triamcinolone had no effect on the classification of the evidence. It is suggested that the clinical classification of postoperative breast cancer patients is complex, with Qi deficiency and Yin deficiency evidence or both being the most common; followed by Chong Ren dysregulation evidence or all three [2]. Zhou Jiaming et al. observed 117 patients who had undergone radiotherapy and chemotherapy after breast cancer surgery and classified them into liver-depression and qi stagnation, qi-blood weakness, fluid deficiency and internal heat and blood stasis according to TCM evidence, and many of them had several symptoms. Sun et al. counted more than 80 papers on breast cancer from all over the country mentioning evidence and symptoms, with a total of 1534 clinical cases. The frequency of distribution of postoperative breast cancer patients in clinical cases was Qi-Yin deficiency, Chong Ren dysregulation, Qi deficiency, Blood stasis and water stagnation, Liver depression, Phlegm stasis and toxic heat, Qi and Blood deficiency, Spleen deficiency, Phlegm and Dampness, and Spleen Qi weakness [4]. The meeting was held in Guangdong Provincial Hospital of Traditional Chinese Medicine, which unanimously affirmed the staging system of breast cancer into peri-operative, peri-chemotherapy, peri-radiotherapy and consolidation stages proposed by Professor Lin Yi of the Department of Breast Medicine of Guangdong Provincial Hospital of Traditional Chinese Medicine based on years of clinical practice. This theoretical system considers that the consolidation stage is mostly characterized by the evidence of two deficiencies of qi and blood (yin), two deficiencies of spleen and kidney, and the evidence of dysregulation of flushing and the absence of evidence of disease [5].
2. Dialectical treatment
2.1 The general principle is to support the righteousness and eliminate the evil, and adjust the functions of yin and yang, qi and blood, and viscera
Chinese medicine treatment in the rehabilitation period should be based on the overall approach, according to the different clinical symptoms, the main principle is to support the positive, and the secondary principle is to dispel the evil, so as to adjust the function of yin and yang, qi and blood, and internal organs of the patient’s body. According to the principle of “understanding the disease as the root, identifying the evidence as the use, combining the disease and evidence, and treating both the symptoms and the root cause”, we advocate the combination of supporting the positive and the evil according to the etiology and pathogenesis of the disease, as the saying goes, “Nourishing the positive will remove itself, eliminating the evil will help the tumor disappear”, and establishing different treatments by clearly identifying the strength and weakness of the positive and evil, the location and stage of the disease. Different treatment methods are established according to the strength and weakness of the positive and the evil, the location and the stage of the disease [6].
In the treatment of breast cancer, the main focus is on treating the root of the disease, and supporting the righteousness can dispel evil, suppress evil and prevent evil. The main method is to help the spleen and kidney. Zhu Huayu et al. used raw astragalus, atractylodes, poria and yam to benefit qi and nourish blood, strengthen the spleen and stomach; raw groundnut, smallpox powder and wolfberry to nourish yin and promote fluid; Xianmao, Xianling spleen, bone marrow and cuscuta to warm yang and tonify the kidney [7]. The mechanisms of their effects in the treatment of tumors are: inhibition of TS activity; activation of macrophage activity; promotion of interferon production; protection of bone marrow, adrenal cortex and liver function; synergistic effects with interleukin II; and the antioxidant and free radical trapping effects of some Fu Zheng herbs.
In addition, to help the righteous also not forget to dispel the evil, often on the basis of the identification of drugs to identify the disease, with the selection of drugs with anti-cancer activity, so as to improve the body’s ability to inhibit tumors, to achieve the purpose of anti-cancer and anti-cancer [7]. For example, curcuma longa, peach kernel, wang bu liu xing, wuling lily, tiger scepter, and earth turtle worm have the effects of directly killing tumor cells, improving blood rheology, lowering blood viscosity, inhibiting platelet activity, promoting fibrinolysis, anti-thrombosis, and eliminating microcirculatory disorders, thus exerting the effects of anti-metastasis, chemoradiotherapy potentiation, and immunomodulation. The heat-clearing and detoxifying herbal medicines such as white flowering snake’s tongue herb, half-branch lotus, fishy grass, fleabane, dandelion, dongling grass, golden buckwheat, etc., as well as soft and loose drugs such as mountain cichlid mushroom, raw oyster, sea clam shell, soapberry, seaweed, kombu, etc., have been found to have anti-tumor effects in experimental animals during clinical and experimental studies. When the patient’s physical condition allows, the combination of drugs such as whole scorpion and ground turtle worm, which have cytotoxic effects on cancer cells, and the method of fostering the righteousness in the treatment of breast cancer may have certain efficacy, but because their overuse may easily harm the righteousness, clinical use should be cautious [8].
2.2 Treatment after radiotherapy
According to Jia Xihua et al, chemotherapy can cause toxic evil to accumulate in the body and damage qi, blood, liver and kidney. Radiotherapy, on the other hand, is prone to depletion of fluids and internal heat manifestations of yin deficiency. Therefore, during radiation and chemotherapy, the patient should be identified as having deficiency of qi and yin, deficiency of liver and kidney, and weakness of spleen and stomach, and the treatment should be to benefit qi and nourish yin, tonify liver and kidney, and strengthen spleen and stomach. After radiotherapy, patients are mostly suffering from positive deficiency and evil attachment, so the treatment is based on supporting the positive and eliminating evil, benefiting the qi and strengthening the spleen, and dispelling turbidity and phlegm [9].
2.3 Treatment during endocrine therapy
Patients with hormone receptor positivity are routinely treated with endocrine therapy for at least 5 years, and patients often develop a series of symptoms of menopause-like syndrome, such as menstrual disorders, irritability, hot flashes and sweating, chest tightness and fatigue, and depression, which affect the quality of life. Chinese herbal medicine can be used to alleviate the symptoms caused by anti-estrogenic drugs by regulating the flushing of the blood and removing blood stasis. Wang Xiang applied Liu Wei Di Huang combined with Gan Mai Da Zao Tang plus flavor to treat menopause-like syndrome symptoms arising from endocrine treatment of breast cancer. After 2-3 courses of treatment in 42 cases, 22 cases were cured accounting for 52.4%, 8 cases improved accounting for 19%, and 6 cases improved accounting for 14.3% after 4 courses, with a total effective rate of 85.6% [10].
2.4, Chinese medicine treatment for hormone receptor negative patients
Most of the hormone receptor-negative patients with breast cancer are observed after surgery and radiotherapy, and most of them have few clinical symptoms, and some of them even have no evidence to identify. The objective of anti- recurrence and metastasis can be achieved by modulating the tumor and changing the basis of tumor production. Through clinical observation, they divided the patients into three types: liver qi stagnation type: qi stagnation type, postoperative or radiotherapy, or with breast hyperplasia, mood depression or impatience, irritability, emaciation, thin white moss, light and dark tongue, smooth pulse, treatment: dredge liver and qi, dissolve phlegm and disperse nodules. Treatment: Diversify liver and Qi, resolve phlegm and disperse nodules. If breast swelling is obvious, add Wang Bu Liuxing, Yuan Hu and Di Zhaosi, and for breast nodules, add Xia Ku Cao, Shan Ci Gu and Qi Ye Yi Zhi Hua. Stasis of blood and blood obstruction type: stasis of blood, postoperative scar formation or radiotherapy, localized hard skin or dark complexion, sometimes stinging pain, or with menstrual disorders, dark tongue or petechiae, stringent or astringent pulse, treatment: invigorate blood and resolve blood stasis, soften hardness and disperse nodules. Remedy: Peach-Hong Si-Wu Tang with added flavor. Dysregulation of the flush: Yin deficiency, mostly in post-menopausal elderly people, with soreness and weakness of the waist and knees, irritability of the five hearts, tiredness and fatigue, dry mouth and throat, little coating, thin pulse. The formula: Erxian Tang combined with Siwu Tang plus or minus [11].
According to Chinese medicine, there is a physiological relationship between the internal organs of the human body, which are mutually nourishing and restraining, and there is a pathological relationship between the internal organs, which are mutually influencing and mutually transmitting. A disease in one organ can affect the related organs. According to the tendency of disease and evil transmission, medicine is used to treat the disease and evil before it changes, so as to achieve the purpose of “firstly, to protect the place where the evil has not been received”, thus blocking the transmission pathway of the disease, preventing the metastasis of cancer, and making the disease develop towards healing. Liu et al. concluded that hormone receptor (-) breast cancer patients are the blind spot for endocrine therapy, and the majority of ER/PR (-) breast cancer patients have a worse prognosis than ER/PR (+) patients in clinical practice. Therefore, to address the characteristics of ER/PR(-) breast cancer patients who are prone to visceral metastasis, we should focus on treating the root cause of the disease, starting from the Chinese medicine principle of “all five organs are deficient, only the middle jiao is taken”, and treating with the method of strengthening the spleen and benefiting the qi to improve the immunity of the body may be useful in preventing recurrence and metastasis in this group of patients [8].
3.Specialized formula treatment
Party ginseng, Atractylodes macrocephala, Radix Astragali, Radix et Rhizoma Shouwu, Radix seaweed, Radix Xia Gu Cao, Radix et Rhizoma Half-blossoms, Radix deer pointer, Radix et Rhizoma alba, and Radix et Rhizoma Huang Yaozi were used as the main formula and were added and subtracted in combination with clinical follow up. 76 cases of postoperative breast cancer patients were treated with 2 years of continuous medication, resulting in 68 cases with actual follow up of 2-8 years, of which 3 cases had recurrence, 65 cases were in good health, and 28 cases returned to work [12]. Wu Zhongzheng et al. treated 50 patients with postoperative radiotherapy or chemotherapy for breast cancer with 12 g each of Chai Hu, Xiang Shen and Yu Jin, 15 g each of Shan Cixi mushroom, Cuscutae and Xian Ling spleen, and 30 g each of Vine’s root and Cat’s claw herb, forming a specific formula with the evidence, and the survival rates were 66% and 56% at 5 and 10 years, respectively, after more than 1 year of continuous medication [13]. Wang Yicheng et al. randomly divided 62 patients with postoperative radiotherapy and chemotherapy for breast cancer into 2 groups, and in one group, Chinese herbal medicines (13 flavors of Astragalus, Salvia, Fritillaria, etc.) were added. The results showed that the survival rate of the group with Chinese herbal medicine was 74.2% for more than 5 years, and the immune function of the patients was normal; the survival rate of the group without Chinese herbal medicine was 32.3% for more than 5 years, and the immune function of the patients was 50% normal. P<0.01 in the comparison between the two groups [14]. Chen Qianjun et al. selected 183 patients treated with chemotherapy after resection of invasive ductal carcinoma and divided them into 2 groups. The treatment group was treated with chemotherapy along with breast nourishment II (composed of raw Astragalus, Radix Codonopsis, Atractylodes, Poria, Nansha Ginseng, Fructus Lycii, Xianling spleen, Cistanches, Cornu Cervi Pantotrichum, Shijiazhuang and Beehive), while the control group was treated with chemotherapy alone. The recurrence and metastasis rates of both groups were followed up for 2 years after drug administration. The results showed that the 2-year recurrence and metastasis rate of patients with primary tumor diameter >5 cm, the 2-year recurrence and metastasis rate of patients with positive axillary lymph nodes ≥4 and the 2-year recurrence and metastasis rate of patients with stage III breast cancer were significantly lower in the treatment group than in the control group (P<0.005 for all). It is suggested that Breastin II helps to control the recurrence and metastasis rate in the high-risk group of recurrence and metastasis [15].
4. Problems and outlook
At present, there are more reports related to the application of herbal medicine for breast cancer with tumor or perioperative period, peri-chemotherapy period, and peri-radiation period, while few studies have been reported on the evaluation of the efficacy of the treatment in the recovery period by applying herbal medicine alone. The treatment during the rehabilitation period is another way to reflect the ancient idea of “treating the untreated disease”, specifically the prevention of recurrence and metastasis of breast cancer [16]. The objective efficacy of TCM can be better reflected in the treatment during the recovery period. Although TCM has its characteristics and advantages in preventing recurrence and metastasis, treating complications, improving quality of life, and compensating for the lack of medicine for patients with hormone receptor shadows, there are still controversies in the identification and typing of TCM in breast cancer recovery. There is a lack of standardized criteria for the evaluation of diagnosis and treatment and efficacy of breast cancer, a lack of quantitative indicators for diagnosis and classification, a small sample size in the literature, and a lack of follow-up on long-term efficacy. The lack of prospective, randomized, multicenter, standardized clinical studies with large samples makes it difficult for the efficacy to be widely recognized by the medical community.
In future studies, firstly, standardized research on the evidence pattern should be conducted, unified evidence pattern criteria should be formulated, epidemiological methods should be adopted, and objective, systematic, scientific and reproducible results should be obtained through large sample surveys and scientific statistics to guide the treatment of breast cancer. Secondly, we adopt evidence-based medicine to conduct randomized, multicenter, large-sample, standardized clinical studies with long-term follow-up to objectively evaluate the efficacy of TCM. The establishment of standardized treatment protocols of TCM during the recovery period of breast cancer and continuous optimization in practice may lead to breakthroughs in the prevention of recurrence and metastasis of breast cancer.