Guidance significance of TCM balance theory in the prevention and treatment of geriatric tumors Elderly patients are a high incidence group of malignant tumors. With the advent of global aging society, the number of elderly tumor patients has increased significantly. Due to the reduced physiological function and other comorbidities of elderly patients, many clinical trials have not included this population, and therefore oncology clinicians lack appropriate guidelines to make treatment decisions for elderly tumor patients. In this paper, we describe the significance of the TCM theory of balance on the pathogenesis, treatment, prevention and rehabilitation of elderly tumor patients according to their characteristics. Under the guidance of TCM balance theory, the formulation of combined Chinese and Western medicine guidelines for the treatment of geriatric tumors in accordance with Chinese national conditions is of great clinical significance for the prevention and treatment of geriatric tumors. Elderly patients are a high incidence group of malignant tumors. With the advent of global aging society, the number of elderly tumor patients has increased dramatically. A survey in the United States shows that tumors are the leading cause of death among people aged 60-79 years, more than 50% of tumor patients are older than 65 years, and more than 70% of tumor-related deaths occur above the age of 65 years, and it is expected that more than 70% of patients with initial cancer diagnosis in the United States will be older than 65 years in 2030 [1]. Due to the reduced physiological function and other comorbidities of elderly patients, many clinical trials have not included this population, and therefore oncology clinicians lack appropriate guidelines to make treatment decisions for elderly oncology patients. In this paper, we describe the significance of the theory of balance in Chinese medicine in the prevention and treatment of elderly tumors according to the characteristics of elderly tumor patients. I. Significance of Chinese medicine balance theory in the development of geriatric tumors Chinese medicine theory believes that the balance of yin and yang is the key to health. As stated in “Suwen’s Treatise on Anger and the General Sky”, “When yin and yang are balanced and secret, the spirit is cured; when yin and yang are separated from the decision, the essence is extinguished.” The balance of yin and yang is specifically expressed as the coordination and balance of the functions of various systems (including organs, meridians, essence and spirit, etc.) centered on the five organs. If the balance is maintained, the internal environment of the organism remains relatively stable (internal homeostasis), and it will be in a healthy state. On the contrary, if the balance is out of balance and the internal environment of the body is disturbed, pathological changes will occur, leading to disease and even death. Age factor has an important significance in the development of tumor, the older the age, the higher the incidence rate. For example, in “Surgery Qixuan” on cancer development, it is pointed out that “cancer develops above forty years old, blood deficiency and qi failure, thick taste is too much, one or two out of ten”. Zhang Jingyue pointed out that “this disease is rarely seen in adolescents, but is more common in middle-aged people who have lost their lives”, indicating the significance of the age factor. Yu Rencun proposed the “internal deficiency theory” in the etiology of tumor [2], pointing out that internal deficiency is the fundamental cause of tumor development. The so-called “internal deficiency” refers to the imbalance of qi, blood, yin and yang of the internal organs. The function of the internal organs of the elderly is gradually declining, which shows that both yin and yang are insufficient, but the relative balance between them is maintained, which we can call a state of sub-healthy equilibrium. This equilibrium is a fragile balance that can easily be disrupted by other factors and the duration of the imbalance is relatively longer than that of non-elderly patients. This explains why the elderly are less resistant to disease and are more susceptible to disease and difficult to recover from it. The occurrence, development and metastasis of tumor are caused by many imbalances, such as imbalance between oncogenes and oncogenes, imbalance between proliferation and differentiation, imbalance between proliferation and apoptosis, imbalance between body resistance and tumor aggressiveness. If the imbalance exists for a long time and accumulates over time, it will lead to tumor development. Take oncogene and oncogene as an example, they are one yin and one yang, opposing each other, restraining each other, interdependent, and maintaining dynamic balance. With the occurrence of multiple genetic mutations, this balance is disrupted and normal cells evolve into malignant tumor cells. Studies have shown that the evolution of normal cells into malignant cells is usually accompanied by the accumulation of multiple point mutations and deletion mutations of genes (oncogenes and oncogenes). Alterations in the expression of many genes (metastasis suppressor genes, adhesion molecule receptor genes) also occur during the subsequent development, leading to further infiltration and metastasis after the appearance of visible tumors. It can be seen that the occurrence and development of tumor is an accumulative process of multiple genetic alterations, i.e., an alteration in the balance between oncogenes and oncogenes. From the perspective of Chinese medicine, it means that the imbalance between yin and yang has not been corrected for a long time. This is also the reason for the higher incidence of tumors in the elderly. According to the balance theory of Chinese medicine, the purpose of treatment is to regulate yin and yang and bring them back to balance. Regardless of the treatment of any disease, a comprehensive analysis should be made of the age, geography, age of the patient, physical constitution, the balance of yin and yang of the internal organs, and the contrast between the forces of evil and positive to formulate appropriate treatment measures. For example, as stated in Suwen Yin and Yang Yingxiang Daxue: “Be careful to observe where the yin and yang are and regulate them for a period of pacification”, it is pointed out that the general principle of treating diseases is to restore the balance of yin and yang in the human body. Another example is Article 58 of the “Treatise on Typhoid”, which says: “In all diseases, if sweating, if vomiting, if giving, if losing blood, if losing fluids, and if Yin and Yang are in harmony with each other, they will heal themselves. The key to treatment is how to grasp the relationship between attacking evil and supporting righteousness, not to be too conservative, nor to overdo it. Especially for elderly tumor patients, it is unwise to maintain the relative balance between yin and yang and between positive and evil through reasonable treatment, i.e., “yin and yang are in harmony” and “to be peaceful” as mentioned above. The goal of elderly tumor treatment is to maintain the balance between yin and yang and between positive and evil. According to the theory of Chinese medicine, the physiological condition and the surplus and deficit of qi and blood of human body are different at different ages, and their pathological reflections are also different, therefore, the therapeutic medicine should also be different. Therefore, the treatment should also be different. The elderly people have reduced vitality, and their qi and blood are in deficiency, so they have more deficiency or mixed deficiency and reality. For example, the treatise on plague? The treatise on the different treatment of the young and the old says: “Where the elderly are, exploitation is most contraindicated. If you throw in Cheng Qi, you can take one for ten; if you use Ginseng, ten does not offset one. Covering the elderly Rongwei withered, a few micro-energy is easy to deplete and difficult to restore.” As Zhang Jingyue of the Ming Dynasty said, “If the urgency is in the heart, can be quickly attacked; if the accumulation of gradually, the vital energy day deficiency, the more attacked the more deficient, not die in deficiency but in attack”, and pointed out that “the importance of the life, do not care about the disease. To correctly grasp the relationship between supporting the righteousness and eliminating the evil, we should be guided by the doctrine of balance in TCM, and assess the aggressiveness of the tumor, i.e. the strength of the evil, based on the patient’s symptoms, physical signs, biological characteristics of the tumor, tumor staging, grading, immunohistochemistry and genetic test results, etc.; then combine the four diagnostic data of TCM and laboratory test results to identify the yin and yang of the internal organs and assess the strength of the righteousness. The strength of the positive qi was then assessed by combining the four diagnostic data and laboratory test results of TCM to identify the strength and weakness of the yin and yang of the internal organs. Based on the results of the evaluation of both positive and negative aspects, a comprehensive treatment strategy combining Chinese medicine and Western medicine, disease identification and evidence identification, and the combination of supporting the positive and eliminating the negative is formulated in order to achieve a balance of effectiveness and safety. The NCCN guidelines for the treatment of geriatric oncology recommend the use of the Com-prehensive Geriatric Assessment (CGA) system. Based on the screening and CGA system, elderly patients are classified into high, intermediate and low risk groups. For the high and intermediate risk groups, the degree of functional dependence and concurrent diseases are further assessed, while for the low risk patients, only symptom control or palliative care is required. Patients were divided into functionally independent group, moderately impaired function group, and major function impairment and/or with comorbid diseases according to the functional assessment of patients in the medium and high risk groups. Patients who were functionally independent and without serious co-morbidities could receive most normal treatment without regard to age and only symptom control or supportive treatment if there were contraindications; for patients with moderate functional impairment, whether or not they had co-morbidities, they were prone to treatment complications, and individualized treatment should be considered for this group, with special consideration of their treatment dose, and only symptom control or supportive treatment should still be considered if there were contraindications In patients with major functional impairment and/or comorbidities, only supportive therapy should be considered, regardless of the presence or absence of serious co-morbidities. This assessment system is different from the Karnofsky Physical Status (KPS) score and the Eastern Cooperative Oncology Group (ECOG) score, which are more general and do not systematically assess and grade organ function. In contrast, the CGA assessment system includes several aspects of functional status, comorbidities, compound medication, socioeconomic status, geriatric syndrome and nutritional status. The Comprehensive Geriatric Assessment (CGA) system can be applied in the clinical setting to classify patients into treatable, adjustable treatable and supportive groups [1]. This assessment system is in line with the individualized treatment concept of TCM, which provides clinical guidelines to better grasp the relationship between supporting the righteous and eliminating the evil and to develop appropriate treatment plans. It is of great clinical significance if the content of TCM is combined with this system to develop a combined Chinese and Western medicine guideline for the treatment of geriatric tumors that is more in line with the national conditions of China. For elderly tumor patients, improving the quality of life is one of the most important treatment objectives. Individualized multidisciplinary treatment using Chinese and Western medicine can complement each other’s strengths and give full play to their respective advantages, and find a balance between effectiveness and safety in order to achieve the best treatment effect. Long-term clinical practice research shows that traditional Chinese medicine is really effective in the treatment of tumors, especially in the treatment of elderly tumors, and has certain advantages. Because of its less toxic side effects, Chinese medicine is not restricted by age, general condition of patients, disease stage, concomitant diseases and other factors, it can be widely used in clinical practice, especially for patients with poor general condition and advanced tumors of advanced age. Chinese medicine is good at supporting the righteousness and strengthening the fundamentals, through regulating the patient’s yin and yang and the imbalance of internal organs, adjusting the internal environment of the patient’s body and establishing a new state of equilibrium, so that the patient’s general condition, digestive system, blood system and immune system can be protected to a certain extent, and the purpose of long-term survival with tumor can be achieved. A large number of clinical research data show that TCM has its unique efficacy and role in the whole process of comprehensive cancer treatment, especially in improving symptoms, improving the quality of survival and prolonging the survival period. According to our experience, even if the patient has cancer tumor in his body, if the patient has good mental and physical strength, stable weight, good appetite and appetite, normal stool and good sleep, it means that the patient’s body is in a stable state of relative balance between evil and positive, then we should try to maintain this balance and not to break it easily, so that we can prolong the survival time with tumor and maintain a better quality of life. In this regard, we have many experiences, such as a 72-year-old patient with pancreatic cancer, who was confirmed to have hypofractionated adenocarcinoma of the cardia and liver metastasis by abdominal dissection, which could not be removed and closed the abdomen. Another 80-year-old patient with hepatocellular carcinoma, AFP>8000, had one interventional treatment, but the AFP remained high, and then took Chinese herbal medicine maintenance treatment for three years to survive with cancer. Similar cases are not uncommon in clinical practice. Therefore, the evaluation of cancer efficacy should not be evaluated simply from the aspect of tumor shrinkage, but from the balance view of TCM, the overall efficacy level of treatment should be evaluated. The role of TCM treatment in the comprehensive treatment of elderly tumors is mainly reflected in the following aspects: 1. Treatment of low-risk tumors: low-grade malignant tumors are less invasive and have slower proliferation rate, while the immune function of the body is not seriously damaged, and the balance between good and evil is in a relative state, so the efficiency of radiotherapy is low and often cannot obtain satisfactory curative effect, but will injure the human body due to its toxic side effects. The efficiency of radiotherapy is low and often cannot achieve satisfactory results. The strategy of Western medical treatment for these patients is to observe and wait, or use symptomatic treatment, which is slightly negative. The application of Chinese medicine treatment, which combines the treatment of supporting the positive and eliminating the evil, can correct the imbalance and keep the disease in a stable state for a long time. 2.Treatment of residual tumor: After radiotherapy and chemotherapy, the tumor shrinks but does not disappear completely, because radiotherapy and chemotherapy have a certain dose limit, if continue to administer radiotherapy and chemotherapy, it may lead to the collapse of immune function and destroy the balance between good and evil, which will adversely affect the patient’s condition and quality of life. In this case, Chinese medicine maintenance therapy is used to give drugs to support the positive and dispel the evil, so that the balance between the positive and the evil is in a relative state, in order to obtain long-term survival with tumor. 3.For patients who are old, weak, and with major organ dysfunction such as liver and kidney, it is difficult to bear surgery, radiotherapy, chemotherapy and some biological treatments that can cause high fever, so it is a better choice to use Chinese medicine treatment with less toxic side effects. 4. As postoperative treatment for tumors with low risk of recurrence and metastasis: for low-risk tumors, radiotherapy is generally not advocated after surgery, because it cannot benefit patients’ survival, but on the contrary, it can cause damage to the organism and affect the quality of survival. Instead, Chinese medicine treatment can be used to adjust the internal environment of the body, balance yin and yang, and support positive energy to achieve the purpose of preventing recurrence and metastasis. 5. Combine with western medicine therapy to correct the state of medical imbalance: For elderly tumor patients with good physical condition, they can refer to the treatment plan of non-elderly patients for treatment. The traditional treatment methods of tumor are surgery, radiotherapy and chemotherapy, which can kill the tumor and hurt the body’s vital energy at the same time, for example, surgery can damage qi and consume blood, and make the organs and meridians dysfunction; radiotherapy can cause skin and mucous membrane ulcers, radioactive pneumonia, pulmonary fibrosis, radioactive enteritis, myocardial damage, increase the occurrence of heart attack and cardiovascular disease, etc.; chemotherapy can cause immune function to decrease, and bone marrow hematopoietic function to decrease. Chemotherapy can lead to a decline in immune function, bone marrow hematopoietic dysfunction, nausea, vomiting and hair loss, and other adverse effects. The result of treatment often does not restore the body to a “balanced state”, but sometimes aggravates the “imbalance” of the body. At this time, the combination of Chinese medicine treatment can prevent or correct the imbalance of the body. The division of labor between Chinese and Western medicine cancer treatment can effectively kill the tumor and maintain the balance of the internal environment of the body. 3. Balance theory and prevention of tumor in old age According to the combined view of Chinese and Western medicine, the occurrence and development of tumor is related to both internal and external factors. External carcinogenic factors are the conditions for the development of tumor, while the imbalance of the internal environment is the key. As mentioned above, the function of internal organs of the elderly is gradually declining, which shows that both yin and yang are insufficient, and the body is in a fragile state of equilibrium. Tumor will occur. Based on the above relationship between the theory of balance in Chinese medicine and the development of tumors in the elderly, the following prevention principles are proposed from both internal and external causes: (1) Eliminate or avoid the long-term effects of external carcinogenic factors on human body. For example, smoking, alcohol consumption, ionizing radiation, chemical carcinogens, bad dietary habits, etc. (2) To adjust the internal environment of the body and enhance the body’s ability to fight cancer, from the viewpoint of “internal deficiency”, enhancing the body’s anti-cancer function is one of the important measures to prevent cancer. It is one of the important measures to enhance the anti-cancer function of the body from the viewpoint of “internal deficiency”. Insist on physical exercise to enhance physical fitness; regulate emotion and avoid mental stimulation and trauma. (3) Timely detection and correction of the imbalance of the body’s internal environment. Actively treat chronic diseases and precancerous lesions that may become cancerous, such as mucosal leukoplakia, hyperplastic mastopathy, heavy hyperplasia of esophageal mucosal epithelium, gastric ulcer in the elderly, atrophic gastritis, intestinal polyp-like adenoma, chronic hepatitis, etc. In this regard, herbal medicine has certain effect to prevent and reduce the incidence of cancer. For example, augmentin blocking therapy can reduce the risk of carcinogenesis of esophageal and cardia cancer in people with severe hyperplasia grade 1 [4]; gastric fuchsin has good therapeutic effect on moderate and severe heterogeneous hyperplasia of gastric mucosa, which can promote the reversal of diseased gastric mucosa and reduce the risk of carcinogenesis, and can be used in the treatment of precancerous lesions of gastric cancer [5]. As the occurrence of tumor is the result of the long-term existence of imbalance and accumulation over time. Sometimes it can be up to 5~20 years. Therefore, for the prevention of tumors in the elderly, we should start with regulating yin and yang, strengthening the spleen and benefiting the qi, and tonifying the kidneys and consolidating the essence from the middle age. Many elderly people show depression, loneliness, indifference or anxiety in their daily life. Long-term emotional and mental disorders will affect the function of internal organs and lead to the imbalance of internal environment, which will eventually cause tumor. Once they have tumor, their emotions will be more volatile, psychologically disturbed, depressed so as to lose appetite, sleep disturbance, fear psychology makes them nervous, afraid and anxious, thinking of life and death problems, family problems, life problems, treatment problems and economic problems. There are also a few patients who are anxious and desperate because of old age and refuse treatment, thus accelerating the deterioration of their disease. Therefore, in the prevention and treatment of tumor, we must pay great attention to and understand the psychological state and emotional changes of patients, and both medical and nursing staff and family members should do a good job in psychotherapy. If elderly tumor patients can scientifically combine psychotherapy and drug treatment without psychological and medical stimulation and interference, they can prolong their survival period and improve their survival rate with the active combination of Chinese and Western medicine. Enhancing the feelings between doctors and patients, eliminating patients’ mental pressure and fear, fully mobilizing patients’ subjective initiative, establishing confidence in overcoming cancer, and cooperating closely with medical and nursing care, often receive good results. In addition, psychological counseling, lectures, talks and “talk therapy”, qigong, games, music, etc. are all good methods. In conclusion, if we pay attention to the physical and mental balance of patients and psychotherapy, it will play a positive role in the comprehensive treatment of tumor. In conclusion, the doctrine of balance in Chinese medicine has an important significance in the development, treatment, prevention and rehabilitation of tumors in the elderly. Under the guidance of the TCM theory of balance, it is of great clinical significance to develop a combined Chinese and Western medicine treatment guideline for geriatric tumors, which is in line with the national conditions of China, for the prevention and treatment of geriatric tumors.