Last month, one of my late-stage cancer patients developed abnormal liver function. After hepatoprotective treatment proved ineffective, the Western medicine team inexplicably demanded that the patient stop taking Chinese herbal medicine. The patient asked for my opinion, and of course I agreed — after all, I had no say in the matter. But after stopping the herbs, the liver markers remained unchanged. So I proposed stopping the Western medications instead. The Western doctors, of course, refused — again, I had no say. But the patient was determined and requested the stop themselves. After discontinuing the Western drugs, the markers gradually improved and have now returned to near-normal levels.
That is the basic situation. As a Chinese medicine physician operating on the margins of the institutional healthcare system, that is about all I could do.
But the clinical reasoning behind this case reveals what I can only describe as the bandit logic of certain Western medicine practitioners.
This is a complex issue. Even setting drug factors aside, this patient already had extensive metastasis with multiple hepatic lesions. Abnormal liver function under such circumstances is entirely to be expected. There is no justification for reflexively blaming the herbal medicine.
The patient was receiving targeted therapy, and drug-induced liver injury is a well-known adverse effect. Liver function had been relatively normal for the prior two months, making the sudden abnormality this month highly likely related to the targeted drug. Why, then, were the Chinese herbs the first suspect?
Chinese herbal medicine is indeed a recognized cause of drug-induced liver injury (DILI). However, according to a 2022 report on DILI-related adverse drug reactions in mainland China published in Acta Pharmaceutica Sinica B (doi: 10.1016/j.apsb.2022.04.019):
In DILI-related ADR reports from 2012–2016, conventional chemical drugs accounted for 94.5%, Chinese herbal medicines for 4.5%, biological products for 0.8%, and others for 0.2%.
Chinese herbal medicine is not the primary cause of drug-induced liver injury in China. This patient had been taking herbs longer than the Western medications — there is absolutely no reason to suspect the herbs first.
This patient was already at Stage IV. The response rate of targeted therapy is, at best, around 30% — the benefit to the patient is modest at best. Moreover, many of the post-chemotherapy symptoms were being managed by the Chinese herbal treatment. What, then, was the rationale for insisting on continuing the Western drugs?
Furthermore, while the liver function abnormality was not catastrophic, it had persisted for some time without meaningful improvement. Although there is no universal standard for drug discontinuation, FDA clinical trial guidelines recommend stopping treatment when ALT exceeds 5× ULN for more than two weeks. What, then, was the justification for refusing to stop the Western medications?
The entire clinical reasoning of the Western medicine team in this case was driven by anecdotal experience — and the decision to stop the Chinese herbs was the most anecdotal of all. They didn’t even review my prescription. The least they could have done was check which specific herbs have documented hepatotoxic or nephrotoxic potential. After all, the patient was an inpatient — it’s not as if they were rushed in an outpatient setting. This condescending attitude and limited perspective made me deeply uncomfortable. Uncomfortable enough that I felt compelled to write about it.
If we are going to talk about reliance on experience, Western medicine has nothing on Chinese medicine. To the outside world, Chinese medicine is the epitome of “empirical medicine.” If you want to demand evidence-based practice, I have no objection. But in this case, not a single evidence-based decision was made throughout the entire course of treatment — it was purely subjective judgment. This case is a microcosm of the current medical environment.
中文原文 / Chinese Original
上个月，我有一个肿瘤晚期病人出现了肝功能异常，西医在保肝护肝治疗无效后无缘故要求停服中药，病人询问我的意见，我当然是同意了，毕竟咱在这方面没有话语权，但是停中药后指标仍然没有变化，于是我提出要求停西药，西医当然不同意，毕竟咱在这方面没有话语权，但是患者很给力，自己要求停了，停了之后指标逐渐好转，现已基本正常。
以上为基本情况，作为一个游离于体制内外的中医大夫，我能做的也就是这些。
但是这里面的诊疗思路彰显了某些西医的强盗逻辑。
首先是肝损伤的出现，这个问题比较复杂，把药物的因素排除在外，由于这个病人本身已经出现了广泛转移，肝内也有多个占位，出现肝功能异常是一个完全可以接受的情况，不一定非要把锅扣在草药头上。
第二，由于病人正在接受靶向治疗，出现肝损伤是比较常见的一个不良反应，并且之前两个月还是比较正常的，这个月突然出现的肝功能异常很有可能与药物有关，为什么要怀疑是中药导致的？
第三，中草药确实是一个比较重要的药物性肝损来源因素，根据《药学学报》2022年发布的中国大陆药物性肝损伤不良反应情况报告（Acta Pharmaceutica Sinica B 2022. https://doi.org/10.1016/j.apsb.2022.04.019）显示：
在2012~2016年DILI-related ADR报告中，化学药占94.5%，中草药占4.5%，生物药占0.8%，其他占0.2%。
中草药不是我国药物性肝损的主要原因，这位病人吃中药的时间比吃西药的时间长，完全没有理由首先怀疑是中药的问题。
第四，为什么不能停西药？这个病人已经处于Ⅳ期，靶向药的有效率最多也就是30%左右，对于病人的收益并不是很大，并且化疗后出现的很多症状都是靠中药缓解的，坚持服药的意义是什么？其次，虽然肝功能异常的程度并不是特别严重，但也已经持续了一段时间并且没有明显改善，纵然停药没有标准，但依据FDA临床试验指南，在ALT>5 ULN大于两周的情况下应该停药，不能停西药的理由究竟是什么？
所以，西医对这个情况的整个诊疗思路都是以经验为主，停服中药更是经验中的经验，他甚至没有查阅我的处方，好歹查一下哪些药有明确肝肾损伤依据吧？毕竟病人住着院呢，又不是门诊上没有时间，这种居高临下的态度和见识让我很不舒服，甚至不爽，以至于必须写点东西应付应付。
要是谈起经验来，西医比我们中医差远了，在外人眼里中医就是经验医学，你要讲证据我倒也没话可说，可是这个病历的诊疗全程没有使用证据，完全就是个人的主观判断，这是当前医疗环境的一个缩影。
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