Concepts of Malignancy in Ayurveda
Prof. Muralidhar Sharma
Dr. Mrityunjay Dwivedi,
JR-3, Department of Shalya Tantra,
Faculty of Ayurveda,
Institute of Medical Sciences,
Banaras Hindu University, Varanasi
Based on the lecture available at–Concepts of malignancy in Ayurveda
Now I have tried to put up all that complexity of the assessment of the malignancy. And because the whole situation is complex, the clinical approach also is complex. To define that clinical approach would be in a very straightforward equation would be difficult. So what I have to say, I have tried to summarize my approach to the clinical practice. When I say this again, I stress upon that word that my approach to the clinical practice and it’s not that the same should be followed by everyone. And I’m not commenting upon many of those other, many of the other methods of approach to the malignancy. Many approach to the clinical approach of the malignancy based upon our basic guideline.
व्याधॆः तत्वपरिञ्नानम् वेदनायाश्च निग्रहः ।
एतत् वैद्यस्य वैद्यत्वं न वैद्यः प्रभुरायुषः ॥
I will be putting all the effort to know about the disease and at the same time trying to minimize the possibility of pain trying to minimize the trouble to the patient, the pain and other complications of the suffering of the patient could be minimized.
एतत् वैद्यस्य वैद्ययत्वं न वैद्यःप्रभुरायुष ll
Extending the life of the patient is not main target at all in the management of management, but at the same time being followed, the universal guidelines of the management, beneficence, non-maleficence, autonomy, justice and the fidelity. These are the basic issue of treating any of the disease which are considered to be the basis of medical practice and in case of malignant lesions, these are important. Considering Ayurvedic point of view the reason is we do not have any such a standard established method of curing a malignant lesion as such. So the treatment would be, from the point of view, of giving benefit to the patient at that moment considering all the possibilities. So, the important is, it’s not that whether the patient is cured of the disease or not. Life of the treatment also is important like life of the family of the patient if a person has to completely forgo all his properties to save the life of the old person of 90-plus age and with the cancer and extend life by around 2-3 years. These are All the questions are sensitive. So to highlight on that part, I have tried to summarize the data of my patients and I could have a standard data collection from somewhere in late 2000 and of course, I didn’t have a system.
So most of the data which I am presenting would be from 2006 from I have used the digital base for my clinical practice. So earlier data, of course I couldn’t present. So from that day onwards, maybe the total number of patients whom I have treated with the malignancy of different categories. New patients- 10,500 something like around 2.25 for a day. Statistically not that half or 1/4 of the patient comes in today and the follow up visits around 20,000 now. So my experience with dealing with the malignancy of different conditions would be of these categories among these variety of the patients terminally ill patients. Patients who are very ill and very severe conditions virtually. They are hopeless. Their number is quite sure. I usually use that word like may in our hospital my name is mentioned in the clinical register records as M(Yama) Sharma because the mortality figure of my patients is quite right because of these terminally ill patients. Then I say this, it’s not that the same pattern of distribution of patients will be true for all. It could be varying from physician to physician. So the guidelines can be modified according to the presence setup of the physician. This is what I have and dropouts from the current therapy. Some of the patients who are correct therapy and somehow they have droputs due to some reasons, either financial or other ways. And they try to find an alternative means and they come across and their memories around 475. Then patients who are undergoing therapy either chemo or radiation, They want to have a backup from my treatment that kind of patients that constitutes around another huge number. So, maximum number is terminally ill patients. Then another group of patients who are undergoing chemotherapy or radiation or whatever that current therapy. But at the same time, they need some backup. They need to have some relief about symptoms occurred during the management. Then there are certain of the patients who are diagnosed with malignancies, but not willing to go the current therapy. That’s another group of patients. Then a group of patients who come for a second opinion. They are diagnosed with malignancy. They are already prepared for the therapy with contemporary therapies. But before going for that they want to have an opinion like whether should I go there or not. And then of course a good number of patients who I diagnose around 921. And this is the spectrum of these patients whom I have, whom I see. So my approach to these patients will be a strategy approach. It’s not that I would be saying the same. For each of these patients, the main approach would be for a terminally ill patient, the approach would be somehow trying to prolong the life of the patient. It may be supportive treatment. It’s not that I can help. I suggest any specific line of treatment. It may be the approach would be, the expectation that would be lower. And somehow approach would be- like to improve the quality of life of the patient. Like, a patient who is bed ridden having lots of bed sores. Clean the bed sore. Somehow improve the general condition. If the patient is having severe Emaciation, try to improve the general condition with Rasayana chikitsa like Basti and so on. So that I cannot have a fixed standard medicine approach. All that approach would be depending upon the patient’s condition. Somehow relieve the patient’s distress. Symptoms would be reduced. That’s how they approach would be and that again, all that would be approach will be based upon the Dosha- dushya condition of the patient at that moment and then plan the management.
Whereas in the patients who have come up with a drop out of therapy dropout from therapy, I will be very cautious. It depends upon the possible outcome of the therapies. If the condition is somewhat better curable, has a better possible result, I insist on the patient to continue that therapy and only I would try to start with the Ayurvedic treatment rather I would always have a little bit such patients from dropping out of therapy unless it’s well known that therapy is useless. Our outcome is very poor. So the point is to give an advice to the patient. We should be aware of the possible outcome of the current treatment known and the possible available current treatment protocols also are necessary. So, from my point of view to be successful Ayurvedic practitioner, there should be awareness of the advantages and disadvantages of the current system.
Then a patient who is undergoing therapy and direct coming to us, the usual approach would be depending upon the clinical presentation and approach the Dhatwagni. So in all situations, one of the common prescription which I would give is Arogyavardhini and Kumariasava and it is a very common prescription and often a Kanchanar guggulu is also prescribed. The other medicines which I may give depending on the Dosha- dushya lakshana like a patient would have impaired appetite, then I will be adding Agnitundi like drugs. If the patient is very much emaciated, I would be adding Ashwagandha as such as a medicine so on and so for. So depending upon the patient’s presentation and Dosha –dushya lakshanas the treatment will be the medicines or maybe the Bastis also. I would prefer Niruha basti if the patient has more pain and Yapana basti if the patient is emaciated. So to define a single protocol would not be possible but my approach would be that approach based upon the Dosha conditions and one of the common approach would be to improve the Dhatvagni and one of the common prescription would be Arogyavardhani and Kumariasava. Then the patients who have been diagnosed as malignancies and not willing for therapy that again counseling with the judicious evaluation. Issue is simple, like if the outcome with the current therapy is really good and worth of it, I would insist on the patient to go for therapy then depending upon Ayurvedic therapy. If the outcome is extremely weak and the cost factor is so much that the patient’s family life, family would be destroyed, then I would just counsel the patient exactly the situation and then I may start with our treatment.
If a patient comes for the second opinion, this is really a challenging task and give a second opinion. We have to be very cautious. The currently available treatment and outcome has been on. So, we need to be updated So I try to keep myself updated with all the possible outcome of the cancer treatment now and possible extent, I’ll be giving an unbiased opinion in a fresh diagnosed case. Again, it would same though I diagnosed the case I leave an option to the patient with the same approach, like the judicious approach. So that’s about the general approach to the treatment of malignancy, in my practice. I don’t prescribe any specific treatment for the malignancy but maybe one of the rather certain of the drugs which I have treating initially in my clinical practice in 80s. I used to use bhallataka either bhallataka ksheerpaka or bhallataka leha. With the bhallataka of course there can be some significant changes in the outcome of the course of the disease. Some of the malignant conditions may have regressed slightly but it results in some complications later. Bone marrow depression would occur. So, I am not using bhallataka since last around 15 to 20 years. Similarly rasamanikya also was used earlier. But that also is not a very dependable drug. Certain changes are produced in leukemia like conditions but not a very sustained. Whereas currently meaning of the varieties of leukemia will have extremely good outcome. And compared to that, this would not be sufficient as such and hence, when I treat the patients, when I prescribe these medicines, I would be very careful and virtually I don’t suggest any specific treatment for malignancy. If there is anything it would be Kanchanar guggulu, Arogyavardhini and Kumaryasava, considering Kanchanar guggulu as a primary arbuda chikitsa. So whenever there is a mass Kanchanar guggulu definitely is indicated that. Arogyavardhini, Kumaryasava for dhatvagni could be one general line of treatment.
Surgery and Kanchanar guggulu
Then another sort of experience will be the surgery and Kanchanar guggulu. So most of the patients whom I have operated upon this is about the number of surgeries. Though, I have done surgeries in many varieties of the malignancies earlier, but their number is comparatively lesser, somewhat significant number is with the mastectomy and maybe the cancer prostate. in the cancer prostate conditions, he orchidectomy. these are the two significant number variety of the surgeries which I have done in my clinical practice and the number would be mastectomy. It’s in the earlier days, like 98 or earlier when I started my practice, number of patients whom I have operated more because at that time the insurance policies were not there as common as now. number of mastectomies has been reduced in the last few years. Last five years, it was very like mastectomy have been. So, these are word of data. In the presented situation because for the current schemes of these insurance, Most of the people they may prefer surgery to be done elsewhere. So most of these surgeries are something more than 10 years old surgeries. The important point is a patient, that I have operated in many clinical practice. Out of these 107 patients whom I have operated upon. I couldnot track upon what happened about five the patient .
Some of these patients after surgery to follow up like the radiation or chemotherapy if I give a choice to the patients if the patients prefer that okay, they may go there of course my responsibility removing the tumor, subjecting to histopathology and of course in those days it was only the histopathology, immunohistochemistry was not common at that time when I used to do the surgery. But recently immunohistochemistry where you have to tests and then may have HER2 tests also immunomediated tests which will be quite a fortune amount (14.00). But anyway, among the current investigation tools, it would be there and then the patient is given a choice. Now, those patients who do not come under this category, I have prescribed Kanchanara guggulu, Kumaryasava, Arogyavardhini Vati, so as the mainstay of the treatment for a long period with an idea of preventing the recurrence. The recurrence within a year, it’s around two patients; recurrence in between 1 to 5 years in 36 patients; recurrence after five years, six of the patients. 26 patients didn’t have a recurrence even after seven years. Of course to say that this is a very standard protocol treatment may be very confusing issue. But the point is of course the whole possibility of recurrence and then the incidents it has to be now viewed with the current subtypes like the HER-2 positive or negative. Also on ER/PR tests also is quite important where the prediction of the progress is possible. But most of these patients are prior to that period where the ER/PR tests were not possible. So to say that we have really produced the change is not very tenable. Like so it’s not very standard but Ayurvedic drugs like Kanchanara and Arogyavardhini, the data which is seen is comparable to data of that period in any other hospital set up with the chemotherapy are also. I think almost similar data could be produced. And one of the important reason the patients who may have operated with the carcinoma- breast, least grading was T2, N1. And because most of the patients who may have operated would be of late stages. Among the carcinoma prostate orchidectomy done around 12. Again the same issue. The survival period of above five years could be achieved in up to about four in patients, something around one third of the patients have survived. So the reason and the mainstay of treatment will be Kanchanara, Arogyavardhini and Kumaryasava along with some other modified changes as such. So that’s about our treatment as such.
- Area of strength
- Can add life to years though not years to life.
- Assess the Dosha dushya condition and manage.
- Niruha basti – pain management
- Arogyavardhini and Kumari asava – Dyspepsia
- Ashvagandharishta – Cachexia
- Mrityunjaya Rasa and Amritarishta – TNS pyrexia
Now the palliative care which I have said like patients who have come in terminally ill conditions and then there are no other options. This is the mainstay of my practice in malignant disorders and the whole approach would be I would say like I would be trying to add life to the years. Do not years to the life of the patient. I may not prolong the life of the patient but as long as the patient is living his condition could be somewhat improved and the approach to the management would be I will be assessing Dosha dushya condition and manage and that’s how I would be managing would be the same.
Pain management niruha basti is used, but the dyspepsia like symptoms, Arogyavardhini and Kumaryasava are occasionally agnitundi and for cachexia it is Ashwagandha. For tumor necrosis pyrexia Mrityunjaya Rasa and Amritarishta and for neurological lesions, Ekangaveera Rasa and Abhraka Bhasma and for Anemia, Punarnava Mandoora and Draksharishta. These are certainly examples of the prescription. So I can’t say like a single approach to the management
An adjuvant to the chemo or radiation
An adjuvant to the chemo or radiation, this is one of the important issues. Of course when I use the option of this treatment will have some ethical questions like whether it is justified or not. There will be some prejudice also whether it will be acceptable or not. So I would always try to avoid such situations where I will be giving my medicines as adjuvant, but in a few cases I have tried, but there are certain reports now, this is not from my experience. There are certain reports where people have tried and these reports are presented in standard journals like Indukant ghrita for immunomodulation and curcumin the extract of haridra has been studied.
These are all studied issues. So I have not tried. Just have referred to those issues. Now before the end of that I will try to share some of interesting certain clinical experience with one or two patients as such.
- Mrs XXX Nayak [72yrs] presented with signs of intestinal obstruction at KMC Manipal, as Jejunal tumour and recommended jejunostomy, maintained on continuous gastric drainage and parenteral maintenance was admitted on 6-7-2012.
- Parenteral management was contnued along with Dashamoola niruha basti and KanchanaraGuggulu and Arogyavardhini through Ryle’s tube intermittently.
- Switched to total oral feeding on 17-7-2012
- Laparotomy performed on 7-8-2012.
This is about a patient whom I have treated in 2000. patient was admitted on nine july 2012 patient was treated in KMC manipal and was diagnosed as a stromal tumor of the intestine. A huge mass was palpable and the patient’s condition was like that. The patient had an intestinal obstruction totally. And the patient has to be maintained on parental management. The only other option which is left over would be enterostomy where he had a bypass. The tumor has to be excised and then have a tube inserted through the tube patient has to be fed. The patient’s being a poor patient and as I told you this is say M Sharma policy that patients who had come to me when they say virtually no other option and they have spent a fortune at the time. When the patient came to me, the patient’s condition was very critical and she was discharged from the hospital. And before going home they came to our hospital and patient was admitted on nine July 2012 and the patient was maintained on the parenteral therapy only for initial few days and I have started Dashamula Niruha Basti. One of the important observations which I observed in that patient was when we palpated the tumor and I could feel the tumor mass easily over that time. If I had tiwsted the position of the humor the bowel movements would be possible. patient would pass the bowels. Then again after a few hours it gets re twisted and then again there would be an obstruction. So during my clinical examination every day, every time I used to keep that mass twisted so that the patients bowel movements improved and gradually we could reduce that parental administration and the patient was shifted to oral feedings around one week. By 17th patient could be maintained on oral feed. So obstruction could be partially releases by a manual twisting. So, I had some clue like this patient can be managed somehow surgically though not the enterostomy. The patient was a old, 70 years plus the old lady. So she was very resistant to that surgery. She would say that I would die than doing surgery. But somehow I insisted on her saying that it’s not the enterostomy done. I would just open and then too patients said, Okay, all right, I’m ready to die. But you should not get too.That’s the condition. Of course with the enterostomy also had a very unpleasant experience here. In the early days of my practice in 1986. I remember about that. I had done a gastrectomy in carcinoma esophagus, that the tumor cannot be removed otherwise. I had introduced a tube into the stomach and the patient was fed directly into the stomach through the tube. And then of course, I had used bhallataka during that period. I was using bhallataka on that patient and the patient had quickly improved remarkably.By about six months of surgery, patient and gained significant weight and patient was feeling well. Interestingly there are certain other messages and important issues didn’t follow up one of the days. The patient asked me like can I feed the tube with the sweet? From seeing the situation patient is not able to take anything orally . Patient is given the food through the directly into the stomach. patient has an urge for taking a sweet item specifically. At that time because of my youth. I was younger at that time if at all it would be today my approach many response would not have been the same. I made fun of that patient at that time. I regret for that kind of reaction. Now I made fun like how can you appreciate the taste by inserting in that led to the tube and that comment of mine produced a significant depression in the patient and the patient started developing a negative attitude the whole life and within three weeks the patient died And that was something like a very emotional issue for me also like a human being feeling like eating a specific sweet directly taking the specific sweet into the tube that you cannot appreciate the taste and naturally. That I always consider that as one of the major lessons we have learned in my practice and my approach of the patient also has changed. That was when I open it where I have to respect the sentiments of the patient at that time. Of course I repent upon all that. But from that day and I have decided like I would never do a bypass surgery, these tube feeding surgeries. That was the last time now with this patient also the same thing like I didn’t do that surgery. But I thought of doing laparotomy.
The mass size the CT scan make the size was quite huge. A large size of the mass you could see and it was palpable. During surgery, the mass is seen & I could just lift up the mass and it was around 6″ and 8″ in diameter. So what I did was something unusual. What I did was instead of removing the tumor, I made a small peritoneal pouch and kept that tumor in the peritoneal pouch so that the position was fixed. So that the patient’s bowel movements would be normal. I didn’t do anything to the tumor. I didn’t handle the tumor otherwise, because biopsy was done earlier diagnosis was known, so all that I did was only reinserted tumor into your peritoneal pouch. Something like a surgery which is usually done in case of volvulus surgeries, exteriorization and no textbook could say about that. But interestingly that patient had a good recovery and patients survived for around three years, Now during the postoperative period the patient was given only given Kanchanara guggulu, Arogyavardhini, Kumaryasava. Of course, in between, some supportive treatment with the blood transfusion. Patient survived for about three years. And she expired by around 2015 due to stoke. These three years, she had survived with all that normal life, visibly apparently normal life and she had maybe a marriage of her granddaughter and in that marriage of granddaughter, I was one of the major attractions. That’s the point like. So she had some meaningful quality of life. And in 2000 we had a conference in our institution malignancy and she was presented live in the conference too. And that interesting issue is She could survive such a long time with a normal life. And the whole cost of the treatment, average cost of the treatment prescribed is around rupees seven per day. Now the point is if the patient would have one for a standard medical treatment, otherwise the standard would be radical excision followed by imatinib. And the median survival period ss for the statistics is just 10 to 12 months after the surgery. So with the mine sort of surgical approach and our Ayurvedic treatment, the survival rate is more. And the current market at the cost of the treatment that Imatinib it is something like 3200 per pack of 10 tablets. So the cost of the treatment would be comparatively around 200 times more than the cost of treatment which I given. So the patient survived for three years and died after three years. And her post death ceremony the patient’s son had arranged two sweets . So there are two sweets. He could afford that. So now when I say all this, there is some emotional sentimental aspect of the treatment of the disease. This is not scientific. I’m not saying this as a scientific and this result, whatever we see it’s not exist in terms of the P value T value statistically. Instead it’s about the emotional value which we have to consider. So that’s one aspect. When I say this, it’s not that only one of these patients, we had a large number of such patients of that category. But something of that sort has occurred. And that emotional component is one of the important issues in that. Now above the same stromal tumor with the global incidents and statistics, the median survival period is around eight months and most of the patients have died with the stromal tumors and the medial humor survival period with the imatinib is 10-20 months. And compared to all that different statistics, the survival period has been better with our treatment and we could change that and before ending, another emotional issue an emotional presentation about the case.
This is another case which I have treated in 2015, a 20 years old patient had a huge tumor of the brain and it was diagnosed as anaplastic astrocytoma from humor and WHO grade 3. And he had undergone all the treatment elsewhere. And the outcome was very poor. Patient was expected to survive for about one month and the patient was very emaciated, had a persistent status epilepticus like conditions and the patient had a bed sore. Patient’s mother who was around 50 years was taking care of that patient. And in that stage patient came to our hospital and the size of the tumor quite huge, almost occupying half of the cerebral hemisphere. And the outcome was very poor. And the only mother is somehow at least one day my son should I didn’t recognize me and call me Amma and that’s my target. I don’t expect patient to survive.
Of course, we tried all that. There is no standard protocol of treatment. We did all the dressing of the bedsores. He had almost 30 bedsores over the body. And I used to spend more than one hour every day for doing the dressing. I did the dressing, give basties and everything like there is no standard protocol of treatment. Every day the treatment would change. His electrolyte imbalances were managed. Somehow we could achieve situation where the patient becomes semi-conscious and the patient could be able to identify his mother and call her as Amama. And that day patient’s mother approached me and said “Fine Sir! Now he may die she has said, I am satisfied that he has attained that level”. Of course within two or three weeks of that, he developed some more complications and died. So I’m not saying that the patient is cured. When I quote these two cases as such, it’s not about saying that Ayurvedic treatment can cure and I never claimed that I have cured many malignancy, but my experience with malignant patients is definitely as I’d rather have a definite role and in the management of the established diseases, particularly very complicated cases. But the point, very important point which the people have not, policymakers have not identified and which we should highlight would be the preventive value of the Ayurvedic treatment and elaborate study needs to be done and the importance of that should be convey to the society for the sake of the humanity. To conclude, the carry home points are the information about tumors in Ayurveda has not received the global attention recognition. Prevention of the disease by following the guidelines of healthy living, it needs to be highlighted and it requires a focused attention and they represent our area of strength is prevention and palliative care. Then I don’t say that curative treatment of a comparable nature to what we have in the contemporary system might not be possible as such. This is to come through with this.