Abstract Surgery, chemotherapy and radiotherapy havebeen the mainstay of colorectal cancer treatment. There ishowever current intense research on traditional Chinesemedicine (TCM) as novel or additional treatment meth-ods for colorectal cancer. This article reviews the currentuse of TCM in colorectal cancer so as to increase theawareness of colorectal surgeons. The pathogenesis ofcolorectal cancer according to TCM is discussed. TCMhas been used successfully during the perioperative peri-od to relieve intestinal obstruction, reduce postoperativeileus and reduce urinary retention after rectal surgery.Good results have been reported in the treatment of thecomplications of chemotherapy and radiation enterocoli-tis. Favourable results have also been shown in the use of

TCM either alone or in combination with chemotherapyto treat advanced colorectal cancer. Molecular studieshave shown some TCM compounds to reduce tumour cellproliferation and induce apoptosis. Although the reportedresults of TCM have been exciting thus far, problems oflack of consensus on treatment regimes and questions onthe reliability, validity and applicability of publishedstudies prevent its widespread use. There is now anurgent need for colorectal surgeons to work with TCMphysicians in the continuing research on this 6000-year-old art so as to realize its full potential for our patients.

Key words Traditional medicine · Chinese medicine ·Colorectal cancer

Introduction

Surgery, chemotherapy and radiotherapy had been themainstay of treatment of colorectal cancer in traditionalwestern medicine [1]. More recently, there had beenincreased research into molecular medicine,immunotherapy as well as various forms of gene therapy.Traditional Chinese medicine (TCM), however, had beenused to treat colorectal cancer over the last 6000 years orso with some degree of success. The time is thereforeright for us to revisit and explore the possibility of learn-ing from TCM. TCM may offer novel or exciting addi-tional treatment methods for colorectal cancer. It is nowan area of enthusiastic study in China and elsewhere inthe West. In this modern age of medical advancement wecannot, as colorectal cancer surgeons, pass off TCMtreatments as myths without first acquiring a properunderstanding or study of them. An attempt should bemade to understand the basics of TCM and the principles

Tech Coloproctol (2008) 12:1–6DOI 10.1007/s10151-008-0392-z

R E V I E W

The role of traditional Chinese medicine in colorectal cancertreatment

K.Y. Tan • C.B. Liu • A.H. Chen • Y.J. Ding • H.Y. Jin • F. Seow-Choen

Received: 9 October 2007 / Accepted: 28 December 2007

K.Y. TanDepartment of SurgeryColorectal ServiceAlexandra Hospital, Singapore

C.B. Liu · A.H. Chen Department of Colorectal SurgerySecond Affiliated HospitalZhejiang Wenzhou Medical CollegeWenzhou, PR China

Y.J. Ding · H.Y. JinNanjing Colorectal TCM HospitalNanjing, PR China

F. Seow-Choen (�)Seow-Choen Colorectal Centre3 Mt Elizabeth Medical Centre 09-10Singapore 228510e-mail: seowchoen@colorectalcentre.com

behind it. This article explores the current use of TCM incolorectal cancer. Perhaps we can see better, then, theadvantages of combining western and eastern medicinesin this field.

Pathogenesis of colorectal cancer according to TCM

According to TCM, colorectal cancer belongs to a groupof diseases caused by an accumulation of toxins [2].There is an imbalance in the body with inadequate ‘qi’and excess toxic fluids and ‘heat’ in the body. The com-bination of these effects is further aggravated by a weakspleen and kidneys allowing the flow of toxins into theintestines where they accumulate. A deficiency of ‘qi’ isthought to be the major driving force resulting in colorec-tal cancer. As such some herbs are making progress asmain remedies; these herbs are mainly used to promotecirculation, eliminate blood stasis, clear toxins and heat,invigorate the spleen and kidneys and most importantlyreplenish ‘qi’.

Concepts of ‘Qi’

Ancient Chinese philosophy holds that ‘qi’ is the mostbasic substance constituting the world [2]. Accordingly,TCM also believes that ‘qi’ is the most fundamental sub-stance in the construction of the human body and in themaintenance of its life activities. ‘Qi’ of the human bodytakes 2 forms. The first is coagulated ‘qi’ which is mani-fested as various structural components of the body, suchas viscera, body figure, sense organs, blood and body flu-ids; the second is diffused ‘qi’ which is manifested as theenergy and life force that flows in the body, but takes nocertain form. It flows within a fixed network of twelveinvisible pathways or meridians in the body. This is themost important concept of Chinese medicine. ‘Qi’ has thefunction of promoting the growth and development of thebody and the distribution and discharge of blood andbody fluids. ‘Qi’ also has the functions of warming,defense and homeostasis in the human body.

Wellness is achieved when opposite and complemen-tary forces, called Yin (feminine - cool, moist, nutritive,quiet) and Yang (masculine - warm, dry, energetic,active), are in balance and promote the unobstructedflow of ‘qi’. An imbalance of ‘qi’, Yin and Yang arebelieved to result in sickness. All treatments aim to bal-ance a person’s ‘qi’. Several methods are used to pro-mote, maintain and restore ‘qi’, including herbal reme-dies for nourishment, acupuncture, moxibustion (heattherapy), diet, massage, meditation and exercises suchas qigong and tai chi.

Treatment of intestinal obstruction

TCM distinguishes malignant bowel obstruction frombenign bowel obstruction. In malignant obstruction, notonly is there mechanical obstruction of the bowel, thereis impediment of the flow of ‘qi’, blood stasis and accu-mulation of toxins. It is thought that these issues havesevere impact on surgical outcome and need to beresolved to achieve uncomplicated surgery.

Peng [3] treated 45 patients with acute bowel obstruc-tion with a concoction comprising: Aurantii immaturusfruit (immature bitter orange), Magnoliae officinalis bark(officinal magnolia bark), fried Raphani seed (radishseed), Codonopsis root (tangshen root), Rhei root andrhizome (rhubarb), Paeoniae rubra root (red peony root),mirabilitum (mirabilite) and Patriniae herb (whiteflowerpatrinia herb). Of the 45 patients, 35 experienced reliefof the obstruction before surgery and subsequentlyunderwent surgery with no complications. The obstruc-tion was not resolved in the remaining 10 who underwentemergency surgery.

Zhou [4] treated 30 patients with acute colonicobstruction using rhubarb root and rhizome, mirabilite,immature bitter orange, officinal magnolia bark, Chineseangelica root, red peony root and Aucklandiae root (cos-tushoot). Obstruction was alleviated in 14 patients, whounderwent complication-free curative surgery with goodsurvival on follow-up. Of the remaining 16 who under-went emergency surgery, 6 underwent curative surgerywhile the remaining 10 underwent non-curative surgery.None had major surgical complications. These herbshave been thought to be able to reduce inflammation andimprove circulation to the bowel wall, and thus to have aprotective effect on bowel anastomosis.

Reduction of post-surgical ileus

While post-surgical ileus after colorectal surgery is treat-ed with nutrition and supportive treatment in westerncentres, TCM offers an extra dimension with a combina-tion of acupuncture and herbal enemas. Acupuncture wasused in combination with rhubarb root and rhizome andmirabilite enemas [5]. Whether these enemas had anyside effects in these post-surgical patients, however, wasnot reported.

Urinary retention after rectal cancer surgery

Urinary retention following rectal surgery had beenreduced with the widespread use of sharp total mesorec-tal excision compared to blunt rectal avulsion, but the

2 Tech Coloproctol (2008) 12:1–6

problem remains in some patients. In TCM, acupuncturehad been used to treat urinary retention effectively afterrectal surgery. The basis for this treatment is to improvethe flow of blood and ‘qi’, regulate water flow and invig-orate the bladder. Acupuncture after recto-anal surgeryhad been used with an efficacy reported as high as 94%[6]. However at the moment there is still no standard pro-tocol, inadequate data from different centres and minimalbasic research.

Treatment of complications of chemotherapy

Many patients with colorectal cancer require adjuvantchemotherapy after surgery. With advances in the field ofoncology, toxicity and side effects have been significant-ly reduced but remain a problem. Gastrointestinal dis-comfort and bone marrow depression are among the maincomplications during therapy. Patients with severe com-plications may have difficulty in completing the treat-ment cycle, leading to suboptimal results.

The use of TCM to invigorate the spleen, replenish‘qi’, improve immunological function and regulate theflow of ‘qi’ and blood has been found to improve patients’tolerance to chemotherapy. Mao and Huang [7] treated 46patients during chemotherapy with Liujunzi soup, whichconsists of tangshen root, membranous milkvetch root,largehead atractylodes rhizome, Indian buead, pinelliatuber, Chinese angelica, tangerine peel, platycodon root,barbed skullcap herb and Paridis rhizome (Yunnanmanyleaf Paris rhizome). Compared with 33 patients whounderwent chemotherapy alone, the TCM group had asignificantly lower rate of nausea and vomiting, occurringin 26% of patients compared with 45% in the controlgroup. Patients in the treatment group also had bettersleep and appetite compared to the control group.

Jing and Zhang [8] conducted a small randomizedstudy on 30 patients undergoing chemotherapy for mid-dle and terminal stage colorectal cancer. The experimen-tal group received Da An Wan, which consists of large-head atractylodes rhizome, Crataegi fruit (hawthornfruit), tangerine peel, radish seed, Forsythiae fruit (weep-ing forsythiae capsule) and other ingredients. Da An Wanwas found to significantly reduce gastrointestinal dis-comfort such as nausea and vomiting.

Zhang [9] described 47 patients undergoingchemotherapy with a basic remedy (Fuzhengpeiben)which improved immunologic function. Ingredientsincluded membranous milkvetch root, largehead atracty-lodes rhizome, Diosscoreae (common yam rhizome),tangshen root, Chinese angelica, Paeoniae alba root(white peony root), tangerine peel, tangshen root, Coicisseed (coix seed), Bambusae shavings (bamboo shavings)

and costushoot root. All patients treated had normalappetite without any complaints of fatigue; 30 of thesepatients (63.8%) had normal white cell counts, hemoglo-bin and platelets and only 10 (21.5%) had mild symp-toms. Total efficacy was 85.1%.

Zhang and Fei [10] tried herbs including tangshenroot, membranous milkvetch root, largehead atractylodesrhizome, Cuscutae seed (south dodder seed), tangerinepeel, fried Ozyzae germinatus (rice grain sprout), friedHordei germinatus (malt), Psoraleae fruit (malayteascrufpea fruit), Corni fruit (common macrocarpium fruit),red peony root and Glycyrrhizae root (liquoric root) in 24patients. These herbs were prescribed preoperatively topatients with colon cancer who were subsequently toundergo chemotherapy. There were significant improve-ments in fatigue (76.9%), appetite (75%), nausea andvomiting (55.6%) and defecation dysfunction (66.7%).

Wang and Guan [11] observed 56 patients undergoingchemotherapy after surgery (10 colorectal cancer cases).They prescribed Chinese angelica, largehead atractylodesrhizome, tangshen root, tangerine peel, membranousmilkvetch root, pinellia tuber, Gypsym fibrosum (gyp-sym), Amomi fruit (villous amomum fruit), bamboo shav-ings, Hedyotidis diffusae herb (spreading hedyotis herb),and Agrimoniae herb (hairyvein agrimonia herb). Only17% experienced nausea.

Therefore, some clinical studies suggest that herbsare useful for treating complications of chemotherapy.However, the underlying pharmacology of these herbs isstill not clear and the prescriptions are variable. Thus, aconsensus is required regarding these aspects and there isa real need for more organized research.

Treatment of radiation enterocolitis

Radiation enterocolitis may result in problematic symp-toms in patients undergoing pelvic radiation. The use ofsteroids in western medicine has only met withmediocre results. TCM enemas have been reported to beuseful in treating this problem. Ding et al. [12] treatedpatients with acute radiation colitis with membranousmilkvetch root, largehead atractylodes rhizome, tang-shen root, and Coptidis rhizome (golden thread) andother ingredients. A good response was found in 93.8%of patients. The same authors had previously investigat-ed the effects of these drugs on the mucosa of irradiatedrat bowels [13]. They found that there was a significantincrease in the number and height of villi in the mucosaof the irradiated bowels after treatment with TCM, sug-gesting that it promotes regeneration. Also, TCM wasfound to depress nitric oxide levels at the mucosa result-ing in less inflammation.

3Tech Coloproctol (2008) 12:1–6

Treatment of advanced colorectal cancer

Patients in this category currently continue to have a poorprognosis, with a 5-year survival of less than 10%. Thisis improving with the development of targetedchemotherapeutic agents. However, the cost of theseagents limits their availability to many patients. The sideeffects of standard palliative chemotherapy and radio-therapy also remain a problem.

There have been reports of combination chemothera-py and TCM achieving good results. Hu and Jie [14]reported the use of TCM in combination with chemother-apy (FOLFOX: oxaliplatin, leucovorin, 5-fluorouracil)and radiotherapy in 28 patients with advanced colorectalcancer. They prescribed a soup consisting of tangshenroot, largehead atractylodes rhizome, Indian buead,Chinese angelica, Chuanxiong rhizome (Szechuan lovagerhizome), liquoric root, and fresh and processedRehmanniae root (rehmannia root). They further addedhawthorn fruit, fried rice-grain sprout and fried malt forpatients with nausea. This combination effectivelyreduced symptoms in 39.3% of patients and enhanced thequality of life in 42.9% of patients. Stabilization of dis-ease was achieved in 78.6% of patients.

Zhang and Yang [15] combined chemotherapy of cis-platin and 5-fluorouracil with an enema consisting ofbarbed skullcap herb, raw coix seed, spreading hedyotisherb and Curcumae rhizome (zedoary). They found thatit was effective in 42.8% of 28 patients.

Wang [16] used Jianpixieshijiedu soup consisting ofginseng root, largehead atractylodes rhizome, Indianbuead, coix seed, barbed skullcap herb, liquoric root andSmilacis glabrae rhizome (glabrous greenbrier rhizome)6 days before infusional chemotherapy. He found thisformula effective in providing short-term benefit in 83%of the patients.

Cha [17] used Qingchangjiedu soup to treat 24patients with advanced colorectal cancer. The prescrip-tion included Sophorae flavescentis root (lightyellowsophora root), Pteridis multifidae herb (Chinese brakeherb), Euphobiae humufusae herb (humifuse euphorbiaherb), spreading hedyotis herb, Vitis adstrictae root(romanet grape root), coix seed and common peony root.The survival rates were: 62.5% at 1 year, 25.0% at 2years and 12.4% at 3 years.

Chen [18] reported excellent survival results of 100%at 1 year, 66.7% at 3 years and 38.9% at 5 years in 18patients with advanced colorectal cancer. He prescribedPulsatillae root (Chinese pulsatilla root), Portulacaeherb (parslane herb), spreading hedyotis herb, Iphigeniaeindicae (Indian iphigenia bulb), Phellodendri bark (amurcorktree bark), Chinese angelica, common peony root,and fried bitter orange. For patients with purulent and

blood-stained diarrhea, he added Cyrtomii rhizome (cyr-tomium rhizome), Cacumen platycladi (Chinese arbovi-tae twig), and raw Sanguisorbae root (garden burnetroot). He also added Prunellae (common selfheal fruit-spike), Sargassum (seaweed) and Thallus laminariae(kelp) for patients with lymphatic metastasis. He treated‘qi’ deficiency and anaemia with the standard tangshenroot and membranous milkvetch root. He also used anenema consisting of spreading hedyotis herb, Bruceae(java brucea fruit), whiteflower patrinia herb, glabrousgreenbrier rhizome, Draconis (dragon’s blood resin) andGleditsiae (Chinese honey locust spine).

There are therefore favourable results with TCMalone or in combination with western chemotherapy inthe treatment of advanced colorectal cancer. However,the treatment regimens vary widely.

Molecular basis of TCM

There is currently intense research in China with regardsto the use of various herbs and remedies for colorectalcancer. Some of these studies investigated the molecularbasis of these herbs in colorectal cancer. There is emerg-ing evidence that the modes of action include: inducingcancer cell apoptosis, promoting immunologic responseto cancer cells and regulating or inhibiting oncogeneexpression. Ye et al. [19] found tea polyphenol extractedfrom tea leaf to inhibit colorectal cancer cell proliferationand to decrease microsatellite instability. The action was,however, not found to be through the regulation of thehMLH1 and hMSH2 genes, suggesting another pathwayof action on microsatellite instability in these cells. Zuo etal. [20] found that an extract of the herb Rabdosiarubescens has an inhibiting effect on tumour cell prolifer-ation. It was found that oridonin, purified from Rabdosiarubescens, induces apoptosis in cancer cells. More thanone hundred herbs, including Andrographis (commonandrographis herb), Scutellariae root (baical skullcaproot), barbed skullcap herb, spreading hedyotis herb andlargehead atractylodes rhizome, have been found to haveeffects on colorectal cancer. With further studies, somemedicine from TCM may become novel western medicinefor use in colorectal cancer therapeutics.

Discussion

This article aims to increase the awareness of the use ofTCM in colorectal cancer amongst ‘western” colorectalspecialists. The uses and variations in TCM treatments areinnumerable and an exhaustive description is not withinthe scope of this article since TCM is an evolution of thou-

4 Tech Coloproctol (2008) 12:1–6

sands of years of practical experience. TCM use is unfor-tunately still currently not adequately documented or pub-lished in western medical literature. Many TCM physi-cians furthermore consider their management methods afamily secret and hence many do not publish their results.

It seems, then, that TCM, although initially an artpassed down from teacher to student behind closeddoors, is now slowly becoming a science with more sci-entific research. It is encouraging to see more and morearticles on TCM and its use in colorectal cancer in the lit-erature. An understanding of this literature by practition-ers of western medicine, however, remains a hurdle as itrequires one to have a good grasp of both the Chineseand English languages. Even then, some published stud-ies on TCM and its use in colorectal cancer are question-able regarding their reliability, validity and applicability.

The problem with the available information is thatwhile the basic premise for treatment of the variousaspects of colorectal cancer is similar, it is evident thatthere is a wide variation in prescription even for the samecondition. Each prescription contains numerous herbsand ingredients with indefinite permutations. It is notknown whether each ingredient plays a vital role or canbe omitted with no difference in result. Whether thesepublished concoctions represent what the majority ofTCM physicians use remains a question. The rationalebehind the use of the ingredients is sometimes abstractand physicians may differ in their opinions on theirusage. In order to make these studies more reliable, thereis an urgent need for consensus meetings among TCMphysicians so that concepts and treatment regimes can bemore standardized. Secondly, there is a pressing need formore western trained doctors to investigate these thera-pies more thoroughly so that truth will come out.

Most of the known reports of success are unfortunate-ly based on case studies conducted on small numbers ofpatients. Whilst there had been some attempts to makecomparative studies, these numbers are small. Reportingof results also lack uniformity, casting doubts on thevalidity of these results. It is however encouraging thatmore and more of these studies are being performed.Emphasis however should be on improving study designto make these studies more credible. It is in this area thatit is particularly helpful for physicians trained in TCM towork with physicians of western medicine whose prac-tice had become more evidence-based especially over thelast few years.

The integration and application of TCM methods topatients with colorectal cancer remain a challenge. Moreefficacy studies on TCM are required before widespreadapplication is possible and TCM still has to gain its placeas an acceptable practice. It is vital that side effects andcomplications do not go unreported. TCM however

remains an entity that a large number of people in theworld increasingly turn to. It therefore behooves us toinvestigate this traditional phenomenon as practitionersin colorectal surgery.

Perhaps the most exciting aspects of TCM are in theareas where western medicine has continued to haveinadequate solutions. The use of TCM in the reduction ofside effects and improvement of the outcome of standardtreatment and surgery should be areas of further research.TCM represents a ray of hope for patients who sufferfrom advanced disease and many patients have alreadytaken to it with anecdotal good results. The emphasis ofthe Chinese on molecular research is absolutely correctas it is only through basic research that light can be caston how these agents work. It is only then that TCM cantruly be integrated into current treatment practices.

References

1. Tjandra JJ, Kilkenny JW, Buie WD et al (2005) The StandardsPractice Task Force; The American Society of Colon and RectalSurgeons. Practice parameters for the management of rectal can-cer (revised). Dis Colon Rectum 48:411–423

2. Huang Di Nei Ching (The Canon of Internal Medicine)3. Peng B (2003) Chinese medicine treatment as intervention for

acute cancerous colon obstruction. Beijing Zhongyi 22:254. Zhou YL (2004) Colon cancer and acute intestinal obstruction.

Treatment of 30 patients with Chinese medicine. Fujian Med J26:158

5. Chuang QH (1998) Chinese medicine treatment of post-operativeileus. J Practical Traditional Chinese Med 14:29

6. Dong WH, Zhan LY, Chen F (2003) The aetiology and manage-ment of acute urinary retention after rectal surgery. XiandaiZhong Xi Yi Jiehe Zhazhi 12:2082–2083

7. Mao XL, Huang M (2005) Clinical trial of the use of TCM toreduce side-effects of post-operative chemotherapy in colon can-cer patients. Shandong Zhongyixue Daxuexuebao 29:128–129

8. Jing J, Zhang MZ (2005) Clinical trial on Da An Wan reducingpost colonic surgery chemotherapy nausea and vomiting.Zhongguo Zhongyiyao Newsletter 9:823–824

9. Zhang WY (2004) TCM (fuzhengpeiben method) aids chemothe-rapy in 47 patients. Zhongyiyao Lingchuang Zhazhi 16:117–118

10. Zhang LH, Fei GD (2001) Clinical study on fuzhengpeiben usedpreoperatively in 24 patients. Anhui Zhongyi Clin J 13:95–96

11. Wang ZH, Guan WJ (2004) Clinical results of using TCM in trea-ting chemotherapy related nausea. Shiyongquanke Yixue 2:254

12. Ding XF, Li DX, Zhao L (2004) Clinical study of TCM on thetreatment and prevention of radiation related bowel injury.Zhonghua Fangse Yixueyifanghu Zhazhi 24:49–51

13. Ding XF, Li DX, Zhao L (2003) Rat study on the mucosa andnitric oxide levels of irradiated bowel after treatment with TCM.Zhongguo Xiandai Yixue Zhazhi 13:42–44

14. Hu AM, Jie FY (2006) Results of combining TCM with chemothe-rapy in advanced colorectal cancer. Shiyongaizhen Zhazhi 21:74

15. Zhang Y, Yang Y (2003) Combination of chemotherapy and TCMenema in the treatment of advanced colorectal cancer. HubeiZhongyi Zhazhi 25:34

16. Wang ZX (2001) Results of using jianpixieshijiedu soup before thecommencement of infusional chemotherapy. Beijing Zhongyi 20:36

17. Cha XL (1997) The use of qingchangjiedu soup in the treatment of24 patients with advanced colorectal cancer. Jiangsu Zhongyi 18:20

5Tech Coloproctol (2008) 12:1–6

18. Chen PF (1995) TCM in the management of 18 patients withadvanced colorectal cancer. Jiangxi Zhong Yi 16:12

19. Ye J, Jiang H, Zhou JW et al (2002) Tea polyphenol inhibits colo-rectal cancer and reduces microsatellite instability. HuaxueyiWeizhuanxue Zhazhi 19:190–192

20. Zuo HJ, Li D, Zheng W et al (2005) The chemical composition ofRabdosia rubescens and its effect on tumours. ShenyangYikedaxue Xuebao 22:258–261

Invited comment

This is an interesting article since it begins to inform thewestern reader of traditional Chinese medicine (TCM)applied to colorectal cancer. It is important to keep anopen mind since TCM has been applied to patients for avery long time and therefore must have been valued bythose receiving it. Professor Seow-Choen is an acknowl-edged world authority in colorectal surgery and hasachieved this through conventional western practice towhich he has made important contributions.

To deal with a system which has developed largelywithout objective clinical testing is difficult. His articlegives the reader an overall view of the variety of treat-ments available. To the westerner it is obvious that thereis a cultural scientific gulf between the two systems. Oneof the difficulties is that throughout history there has beenno easy means of communication. Western doctors haveno possibility to understand the Chinese literature. Thewriting cannot be read and Chinese journals are thereforeinaccessible. We are therefore not in a position to under-stand the Chinese concept of the pathogenesis of colorec-tal cancer which is completely outside the mainstream ofwestern science. It is important here to realise that ration-al scientific progress in the West has been based on thescientific method which originated in the seventeenthcentury in Europe. This approach by experiment based onhypothesis has resulted in the technology from which theworld today benefits. Western science has pursued theunderstanding of natural phenomena largely included inthe discipline of physics. Physics is the basis of all scien-tific advances including medical discovery.

The western reader is therefore taken aback by a sys-tem which does not follow this line. To him or her ‘qi’ isakin to the four elements of ancient Greek philosophy.The natural question from the westerner would be how is‘qi’ defined. Can it be measured? How was the divisionbetween coagulated ‘qi’ and defuse ‘qi’ ratified? Theoverall sentiment is one of scepticism.

Professor Seow-Choen quotes studies of TCM appliedto conditions including obstruction, postoperative ileus andurinary retention. While it is quite possible that the concoc-tions will contain active pharmacological substances, thestudies beg the question of their identity as well as proof of

their effectiveness by formal controlled clinical trial. Thesame can be said for the treatment of complications ofchemotherapy and radiotherapy, the latter having so fardefeated western medical (as opposed to surgical) treat-ment. When it comes to the treatment of advanced colorec-tal cancer there is an even greater need for controlled clin-ical trials using adequate numbers of patients. The reader isleft in the difficult position of being sceptical without beingable to assess the various published articles. Again it maybe that herbs can cause apoptosis but we need greater detailof the methodology of the quoted studies, particularly theirdesign and the status of controls.

Professor Seow-Choen is a realist and in the discus-sion he acknowledges the difficulty of access by western-ers to Chinese articles and also the lack of uniformity ofthe herbal regimes prescribed. In commenting on thisarticle, I very much agree with him that western practi-tioners should take TCM seriously but in reality this willonly be possible if the work by Chinese doctors is acces-sible, that is to say published in a language that can beunderstood. Thus if there are positive effects as judgedby molecular research, these should be communicated sothat the results can be assessed using rational criteriathrough the objective interpretation of appropriately con-structed investigation.

R.J. Nicholls London, UK

Authors’ reply

We thank Professor Nicholls for his very thoughtful andmeaningful comments. In truth, he is the one who hasbrought English coloproctology into Europe and the restof the world by his very characteristic charismatic andecumenical thoughts with which he has influenced andwon over the western world. His world-renowned inter-est in cultures and languages beyond English had madehim a true ambassador to influence coloproctology inthe right direction. We had written this manuscript in thehope that it will serve as a springboard for others to con-sider investigating the phenomenon of TCM coloproc-tology. We are honored therefore to have ProfessorNicholls look at this paper and accept his commentswhich we hope will now serve to fuse western and east-ern coloproctology and bring us into the next age of newbeginnings.

K.Y. Tan, C.B. Liu, A.H. Chen,Y.J. Ding, H.Y. Jin, F. Seow-Choen

Alexandra HospitalSingapore

6 Tech Coloproctol (2008) 12:1–6