–Talking about the way of treatment selection for oncology clinicians Sun Lingyun, Yang Yufei Department of Oncology, Xiyuan Hospital, Chinese Academy of Traditional Chinese Medicine Yang Yufei Department of Oncology, Xiyuan Hospital, Chinese Academy of Traditional Chinese Medicine Early stage tumors have a high possibility of cure, relatively clear treatment options, or surgery, or radiotherapy, short treatment time and better prognosis. However, the current treatment profile of advanced stage tumors is still not optimistic, and patients and their families are under great pressure, and at the same time, it brings difficult challenges to clinical workers. However, patients have limited physical ability, energy, time and money, so they are often faced with decisions and trade-offs in clinical work. Although the final choice is in the hands of patients, as clinicians, when facing patients with advanced cancer, they should help them choose the treatment plan or recommendation that is most beneficial to their personal survival and interests under limited conditions, and at the same time meets their own and their family’s wishes. So how should we provide the best plan for advanced cancer patients from the perspective of comprehensive treatment and combining various practical factors in clinical practice? First of all, clinicians need to have a full understanding of the current treatment and cure rate of relevant advanced tumors. The rapid progress of modern medicine has made some advanced tumors curable or long-term survival with tumors, such as lymphoma, breast cancer, ovarian cancer, prostate cancer, multiple myeloma, and certain types of acute leukemia. At the same time, many tumors can be genotyped to find therapeutically effective targeted drugs, and survival time is greatly extended, such as lung adenocarcinoma and mesenchymal cell tumor. However, there are also liver cancer, pancreatic cancer, esophageal cancer, etc., for which clinical efficacy is not significantly improved, and the survival time can only be prolonged by a few months after exhausting various treatments in modern medicine. If clinicians can have a good understanding of these medical advances, they can make psychological expectations in advance when they receive patients with related advanced tumors. For advanced tumors with different treatment status, clinicians should not easily dash the hopes of patients with the above mentioned potentially curable tumors when delivering their conditions; for patients with tumors with poor current clinical outcomes, they should not set their treatment goals as too ideal and unrealistic. To make patients and their families clear, most advanced tumors have no possibility of cure, and the treatment goal is to prolong the survival period with tumor and improve the quality of life as much as possible, so as to cooperate with physicians for further treatment. Only the right one, not the expensive one – differentiate between Western medicine and Chinese medicine. The treatment of advanced tumors is progressing rapidly, especially in the field of targeted therapy, and there are many new clinical drugs. Take colorectal cancer as an example, from the data of clinical studies, the use of targeted drugs has significantly improved the survival time of patients with advanced disease. Although the corresponding treatment cost is very expensive, it has become the preferred choice of many patients, and they even feel secure with the use of targeted drugs. People traditionally believe that “good drugs” and “expensive drugs” must have good effect in treating diseases, which is certainly understandable, but is the most expensive the most suitable one? Take colorectal cancer as an example, at present, the population that can apply targeted drugs, that is, the population with the advantage of Western medicine, is K-ras, N-ras, B-raf gene wild type patients, which accounts for about 40-50% of advanced colorectal cancer patients. The latest foreign research shows that there are some patients with all-wild type in the current fund test who have poorer effect of targeted drug therapy, and it has been confirmed that there are previously undetected “ras new mutations” in this group of patients, so the proportion of the above-mentioned western medicine advantageous group is actually less than 40-50%. Thus, a large proportion of patients with advanced colorectal cancer are not in the advantageous group of Western medicine, and for them, the most expensive one is not the most suitable one, and it may have the opposite effect. We have cooperated with the Beijing Municipal Medical Insurance Department to conduct a study on the cost of colorectal cancer hospitalization, and the results show that among all types of hospitals, Chinese hospitals have the lowest medical costs for colorectal cancer treatment. From the situation of our department, compared to chemotherapy (around 200,000 per year) and targeted therapy (200,000-400,000 per year), the cost of pure TCM integrated treatment plan (6,000-100,000 per year) is significantly lower. This shows that the relatively low cost of treatment and the easy acceptance of patients’ financial situation is one of the advantages of TCM. Meanwhile, a large number of clinical studies have confirmed that TCM also plays a very important role in improving the symptoms, quality of life and prolonging the survival of patients with advanced tumors. The huge cost of advanced cancer treatment, the heavy burden of medical insurance and the heavy burden of social families are important causes of poverty, so is it the most suitable to choose the cheapest and effective TCM? Take colorectal cancer as an example, if the patient really belongs to the above-mentioned group of people who have the advantages of western medicine and the family’s economic condition allows, we believe that such patients should take targeted drugs and at the same time add Chinese medicine as a means of comprehensive treatment, that is, targeted + Chinese medicine is the optimal treatment direction, which can achieve the most ideal treatment effect. Therefore, clinicians must help patients to make rational choices on this issue, specifically to distinguish between Western medicine and Chinese medicine for patients with advanced tumors, so as to provide patients with the most suitable rather than the cheapest or most expensive treatment. After choosing the most suitable treatment direction according to whether patients with advanced tumor are in the advantageous group of Western medicine or Chinese medicine, we also need to help patients to make 1-3 years treatment planning with reference to patients’ and families’ wishes, economic status and social support. After choosing the most suitable treatment direction for patients with Western medicine/Chinese medicine advantage, we need to help patients to do 1-3 years treatment planning rationally with reference to patients’ and families’ wishes, economic status and social support. Our clinical experience is that the time period before the end of life for advanced tumor patients is often the most expensive time period for treatment, however, most patients overspend a lot of money in the early stage of treatment, so the financial burden is very high at the end of life, and they suffer from both spiritual and economic blows, which undoubtedly aggravates the pain of patients and their families. Therefore, we emphasize that patients with advanced cancer should plan carefully and carefully in terms of not only physical, psychological and time, but also in terms of treatment cost. How to help patients in treatment planning? First of all, advanced tumor patients should be further classified on the basis of TCM/Western medicine advantageous population. For advanced tumor patients who are old, have slow disease progression, many complications and no financial strength, they can choose simple TCM treatment, but they need to carefully evaluate whether they are TCM superior population. For young, fast developing advanced tumor patients with economic strength, pre-treatment evaluation is very important, such as genetic testing, which is of great significance to judge the prognosis of patients, and on this basis, combined Chinese and Western medicine treatment is carried out. Initial and repeat advanced tumor patients also need to be categorized. For the first diagnosis of advanced tumor patients, firstly, the clinical stage of patients should be confirmed by various examination means, especially for surgeons, they should avoid rushing to surgery without good preoperative staging, which makes the tragedy of switch operation for advanced patients staged, therefore, preoperative staging examination and internal medicine consultation are of great significance. In addition, special attention should be paid to the results of preoperative tumor marker measurement, in which abnormal indicators can be used as postoperative monitoring items. If preoperative tumor marker measurement is not done or the information is lost, there will be no “eyes” to monitor the disease after surgery, which to a certain extent makes the treatment blind and increases the treatment cost. Many people think that Chinese medicine is a whole body treatment, so it can be divided into different departments, and many Chinese medicine clinics often do not have any specialties. If they lack certain knowledge of tumor specialties, some TCM doctors may have some misunderstandings when taking tumor patients. For example, some tumor patients are also undergoing chemotherapy while taking traditional Chinese medicine. If the TCM doctor does not ask about the western medical treatment in detail or does not pay attention to the cooperation with western medical treatment, adding too much heat-clearing and detoxifying anti-tumor Chinese medicine in the soup, it is very likely to aggravate the discomfort of patients during chemotherapy and bring counterproductive effect to the treatment. For example, for endocrine-related tumors such as breast cancer and thyroid cancer, it is also very important to be advised and explained by the physician on the patient’s life and diet during the consultation process, and if it is ignored because of ignorance of this aspect, the therapeutic benefit to the patient will be limited. In addition, it is not the best choice for patients if they do not understand the latest advances in modern oncology medicine, if they are vague about the concepts of gene testing and targeted therapy, if they are unaware of the superiority of Western medicine in the face of the population or if they only prescribe prescriptions without knowing the advantages and disadvantages just because they want pure Chinese medicine treatment. Therefore, Chinese medicine doctors should pay enough attention to the treatment of western medicine when seeing tumor patients; besides Chinese medicine treatment, they should also emphasize the importance of tumor specialist consultation and standardized treatment to patients repeatedly, no matter how much the patients or their families believe in Chinese medicine, they should not be blindly confident as clinicians and should actively consult with tumor specialists to avoid delaying the disease. Many western medical practitioners believe that TCM is empirical medicine and lacks evidence, so they are not convinced of its clinical efficacy, and some doctors even refuse to treat tumor patients with TCM because of the liver and kidney toxicity of certain Chinese medicines. More often than not, patients are only advised to seek TCM treatment when they are completely helpless, and these concepts are misunderstood and biased. With the progress of modern medicine, oncologists at home and abroad are increasingly aware of the importance of tumor microenvironment in tumor occurrence, recurrence and metastasis, etc. Existing studies also show that TCM has positive effects in improving body immunity and regulating tumor microenvironment. The concept of TCM to treat tumors by regulating the body’s own balance is in line with the research progress of modern medicine, which is the embodiment of TCM worthy of further exploration, research and utilization. A large number of clinical studies have provided evidence-based medical evidence for the efficacy of TCM in treating tumors, and some of them have even been recognized in the international community. Therefore, we have reasons to believe that TCM can improve the symptoms of tumor patients, improve the quality of life and prolong the survival of tumor patients. In an international multicenter prospective cohort study, we have shown that TCM therapeutic tonics for more than 1 year can improve the recurrence and metastasis rate after radical surgery for stage II and III colorectal cancer. Therefore, it is important to add TCM treatment to the comprehensive treatment as early as possible, rather than waiting until Western medicine is at its wits’ end before allowing patients to seek TCM treatment, and the whole treatment and participation is needed. It is also important to emphasize that the core of TCM treatment is the diagnosis and treatment of tonics, which requires the TCM doctor to look, smell, ask questions, consult and treat with the four diagnoses, and the efficacy of which cannot be completely replaced by proprietary Chinese medicine. Some surveys have shown that most of the prescriptions of proprietary Chinese medicines are prescribed by western doctors, and the abuse, overuse, and non-correspondence to Chinese medical evidence often lead to the side effects of proprietary Chinese medicines. For advanced tumor patients, TCM can reduce toxicity and increase effectiveness during radiotherapy, and can help eliminate evil during non-radiotherapy, resist recurrence and metastasis, and prolong the survival period of advanced tumor patients with tumor. Therefore, the role of TCM in tumor treatment should not be neglected, and the correct choice will achieve twice the effect with half the effort. Sixth, comprehensive treatment, multidisciplinary cooperation Sun Yan academician in the interpretation of the concept of comprehensive treatment stressed the application of existing treatment means, not to exclude any effective methods, and to plan and rationalize the arrangement. Therefore, as a medical oncologist, we should strengthen the communication and cooperation among medical, surgical, radiotherapy, interventional and Chinese medicine departments in order to achieve the best therapeutic effect through integrated treatment. As the saying goes, there are priorities in hearing and specialties in the field. If comprehensive tumor treatment is a battleship fighting against cancer, then tumor clinicians in various specialties are an indispensable part of it, so it is more necessary to unite and cooperate with each other in order to achieve our common goal – to let tumor patients survive better. As an important part of comprehensive tumor treatment, we have pioneered the concept of integrated Chinese medicine treatment, and have continuously practiced and applied it in our clinical work to achieve satisfactory results. Under the guidance of the basic theory of TCM, the comprehensive treatment of TCM is based on the core of evidence-based treatment, the combination of evidence-based and disease-based treatment, the combination of traditional TCM concept and modern scientific technology, the planned and rational use of various different TCM treatment methods, and the maximization of the advantages of the overall treatment of TCM, striving to form the whole treatment of tumor. The oral administration of the tonic medicine is the main body of TCM comprehensive treatment, which should be used throughout the whole process of TCM treatment. Those who cannot eat normally can take the tonic medicine enema, and at the same time, 1-2 kinds of Chinese medicinal preparations for the treatment of tumor which can dispel evil or help righteousness are taken orally, or 1-2 kinds of Chinese medicinal preparations for the treatment of tumor which can help righteousness or dispel evil are injected intravenously. In addition, TCM tumor comprehensive treatment includes a series of non-pharmaceutical therapies such as TCM food therapy, TCM five elements music therapy, TCM foot bath, Qigong, acupuncture, TCM physical therapy, TCM external application and TCM psychological intervention, which have been widely recognized and praised by tumor patients during years of clinical application. We have also been trying to explore the chronic disease management mode applicable to tumor patients under current medical conditions. Integrated Chinese medicine treatment can influence the lifestyle and physical and mental status of tumor patients to a greater extent. Patients can learn to carry out tumor prevention and health care through daily diet, foot bath, music, qigong and other easy-to-use methods during treatment, which enhances the long-term therapeutic effect and is conducive to patients’ self-rehabilitation and disease management, in line with the concept of tumor prevention and treatment advocated by WHO. In conclusion, the most suitable program for advanced tumor patients is never single and isolated, but should be diversified and integrated. Therefore, it is important for multidisciplinary clinicians to actively cooperate and strive to improve the integrated treatment program of Chinese and Western medicine.