Acupuncture in Cancer Care

Acupuncture is a therapeutic modality in Traditional Chinese Medicine (TCM), developed over the millennia. Treatment involves the placement of needles at selected points on the body, followed by manipulation with physical forces, heat, or, in modern times, electrical stimuli. According to TCM theory, vital energy ("Chi" or "Qi" in Chinese) flows throughout the body along channels called meridians (Figure 1). It was believed that the interruption or obstruction of the body's energy makes one vulnerable to illness. Insertion of needles at specific points along the meridian is thought to regulate the energy flow, which produces a therapeutic benefit.

The concepts of "Qi" and meridians are inconsistent with our current understanding of human anatomy and physiology. However, research supports the clinical effects of acupuncture. Recent neuroscience research suggests that it appears to work by modulating the nervous system. Therefore, "Qi" and meridians may be viewed as metaphors to explain the clinical responses observed by TCM practitioners during acupuncture.[1]

During a treatment, the therapist first interviews the patient, then performs an examination according to TCM teachings, with special focus on the qualities of the pulse and appearance of the tongue, and arrives at a TCM diagnosis. The diagnosis typically is a description of a disease pattern rather than a pathological opinion. Based on the diagnosis, acupuncture points are selected.

FIGURE 1

Human body meridians used in acupuncture. Figure reproduced from Wikimedia Commons, with permission from author “KVDP.”

These points on the body are located and the skin is cleaned. Then the needle, in its guide tube, is placed at each identified point. A gentle tap applied to the top of the needle helps it to penetrate the skin. The guide tube is subsequently removed, and the needle is advanced to the desired depth via a gentle twisting and pushing movement. The practitioner may decide to apply heat or electrical stimuli to the needle. Heat is traditionally provided by TCM practitioners through moxibustion, a burning mound of the chrysanthemum species Artemisia vulgaris, or in modern times, by a heat lamp. As of the latter part of the 20th century, some acupuncturists attach a small electric pulse-generating device to each needle to increase stimulation of the acupuncture points. Such practice is called "electroacupuncture." Acupuncture needles are regulated as a medical device in the United States. They are filiform, sterile, single-use, and thin (28 to 40 gauge), about the width of a human hair. The needles are usually made of stainless steel and are individually packaged in a guide tube (see Figure 2).

How Is It Currently Used?

FIGURE 2

An assortment of acupuncture needles. Figure courtesy of Gary Deng, MD, PhD.

Historically, acupuncture was used to prevent and treat many ailments. Its efficacy has been evaluated with rigorous scientific research methodology only in the last few decades, when acupuncture's physiologic effects, possible mechanisms of action, and clinical efficacy for specific indications have been documented. It has been shown to be efficacious in randomized controlled clinical trials for pain, nausea and vomiting, and other symptoms.[2–5] Acupuncture is perhaps the most accepted TCM modality in Western countries, due in large part to this growing body of research. Acupuncture can induce objective, measurable neurophysiologic changes in animals and humans.

During the last decade, acupuncture has become increasingly integrated into mainstream cancer care in the US. Most major comprehensive cancer centers and many community hospitals have an integrative medicine component that includes acupuncture treatment as a supportive care modality. Acupuncture is not used as a treatment for disease. Accredited acupuncturists who often are physicians provide acupuncture. Some patients seek care from acupuncture practitioners who are in the community and not affiliated with major medical institutions.

What Is the Evidence for Use of Acupuncture in Cancer Care?

There is no evidence that acupuncture has direct effects against cancer, and it should not be used in efforts to treat disease. However, clinical research shows that acupuncture can reduce many important physical and emotional symptoms commonly experienced by cancer patients, thereby improving patients' quality of life.

Pain

Pain is the most common and best-studied indication for acupuncture. Strong evidence in support of acupuncture as a supportive treatment comes from studies of headache, lower back pain, and arthritic pain.[4,6–8] Acupuncture appears to be effective against cancer-related pain, although the evidence is less strong.[9–11] A randomized placebo-controlled trial tested auricular (outer ear) acupuncture for patients experiencing pain despite stable medication. Small acupuncture needles were implanted at selected points on the ears for 1 month. Pain intensity decreased by 36% at 2 months from baseline in the treatment group, a statistically significant difference compared with two control groups in the study, for whom little pain reduction was seen. Skin penetration per se showed no significant analgesic effect. These results are interesting because most of the study patients had neuropathic pain, which rarely responds to conventional treatment.[12]

Other painful conditions in cancer patients have been studied. For example, breast cancer patients taking aromatase inhibitors often experience joint pain. A randomized controlled trial evaluated auricular and full-body acupuncture treatment for aromatase-inhibitor-induced arthralgia in breast cancer patients. Fifty-one postmenopausal women were randomized to receive true or sham acupuncture twice weekly for 6 weeks. The worst pain scores, pain severity, and pain-related functional interference were significantly reduced by actual versus sham acupuncture treatment.

CINV

Chemotherapy-induced nausea and vomiting (CINV) is another well-studied indication for acupuncture.[4,13,14] In one investigation, 104 breast cancer patients receiving highly emetogenic chemotherapy were randomized to receive electroacupuncture at the PC6 and ST36 acupuncture points (located on the forearm and the leg, respectively) once daily for 5 days, minimal needling at nonacupuncture points, or pharmacotherapy alone. All patients received the same triple pharmacological agents for emesis management: intravenous prochlorperazine, lorazepam, and diphenhydramine hydrochloride. Electroacupuncture significantly reduced the number of episodes of total emesis (median from 15 to 5; mean from 13.4 to 6.3 episodes) when compared with pharmacotherapy only. During the follow-up period days 6 to 14, when groups were no longer receiving acupuncture therapy, the difference in emesis episodes essentially disappeared. The effects of acupuncture do not seem to be due entirely to attention, clinician-patient interaction, or placebo. In this study, nausea was not included as an outcome measure.[15] In another study, the combination of acupuncture and 5HT3 receptor antagonists, agents commonly used for standard prevention of nausea and vomiting, yielded mixed results.[16,17]

Several systematic reviews strongly recommend acupuncture for acute CINV.[13,18,19] Diverse acupuncture regimens were employed in the trials included in those reviews, ranging from once daily on the day of and the day after chemotherapy, to electrical stimulation every 2 hours for 5 days. Most of the studies were conducted in patients receiving highly emetogenic chemotherapy.

Acupuncture for management of CINV is covered by some insurance plans. The general consensus suggests that electroacupuncture is more effective than manual acupuncture, which in turn is more effective than acupressure (nerve stimulation without needles, with very light touch or deeper pressure of the fingers over pressure points).[19] Regarding management of delayed CINV, however, more studies on EA, acupuncture, and acupressure are required.

Recently published clinical trials also show that acupuncture is effective in the pediatric oncology setting.[20,21] Acupressure wristbands, which are to be placed on top the PC-6 acupuncture point, are commercially available. In a randomized controlled trial of 739 patients, applying pressure to this point (acupressure) on the day of chemotherapy significantly reduced nausea in patients wearing wristbands, compared with no-band controls. No significant differences were found in terms of an effect of the wristbands on delayed CINV.[22]

Hot Flashes

Breast or prostate cancer patients under treatment with hormonal therapy may develop severe hot flashes that can interfere with daily activities. The standard treatment for hot flashes, estrogen or androgen supplementation, is contraindicated in patients with cancer, however. Several uncontrolled studies suggest that acupuncture may reduce hot flashes in patients with breast or prostate cancer.[23–25] Controlled studies of acupuncture in this setting show mixed results.[26,27]

Xerostomia

Radiation therapy to the head and neck can damage the salivary glands, and many head and neck cancer patients consequently develop persistent dry mouth (xerostomia). Acupuncture has been shown to reduce this symptom. In a randomized controlled trial of patients with head and neck cancer who experienced pain and dysfunction following neck dissection, 58 patients received either weekly acupuncture for 4 weeks or usual care (eg, physical therapy, analgesia, and/or anti-inflammatory drugs). Acupuncture greatly improved reported xerostomia, pain, and function of neck and shoulder muscles. The benefit is even greater in patients with more severe dry mouth.[28] The possible neuronal matrix involved was explored in a mechanistic study that used functional magnetic resonance imaging (fMRI). In this randomized controlled trial, acupuncture was associated with bilateral activation of the insula and adjacent operculum, changes not seen with the sham acupuncture point. Moreover, the true acupuncture induced greater saliva production than did sham acupuncture.[29] Although more definitive studies are needed, it may be argued that a trial course of acupuncture treatment (once or twice a week for 4 weeks) is worthwhile in patients with severe dry mouth that fails to respond to other treatment.[30] If no clinical improvement is seen after 4 weeks, then it is unlikely that acupuncture will help that particular patient.

What Are the Potential Risks?

Acupuncture is generally safe when it is performed by qualified practitioners. The patient usually feels a light needle pricking and later a heavy or sore sensation at the site. If a sharp pain is felt, the needle is not placed in the correct position. After 30–60 minutes, the needles are removed. Usually there is no visible sign of skin penetration or loss of blood at the site after the treatment.

A prospective survey of Japanese acupuncture practitioners recorded only 94 minor adverse events, the most common being forgotten needles and faintness, but no serious adverse events across 65,000 treatments.[31] A study of Swedish physiotherapists practicing acupuncture prospectively recorded side effects during more than 9,000 episodes of care. Although minor bleeding or hematoma was reported following nearly one in five treatments, fatigue, sweating, and other minor adverse effects were rare and there were no serious complications.[32] In a study of more than 760,000 treatments in 97,733 patients receiving acupuncture in Germany, only six cases of potentially serious adverse events were reported. They included exacerbation of depression, hypertensive crisis, vasovagal reaction, asthma attack, and pneumothorax. The most common nonserious adverse events included local bleeding and needle pain.[33]

Patients should be advised to receive acupuncture treatment from practitioners who are professionally trained, properly credentialed, and experienced in treating cancer patients. The practitioners should exercise clean needle techniques, universal precautions, and special safety precautions for patients undergoing cancer treatment.

Guidelines, Precautions, and Professional Requirements

In cancer patients, special safety precautions related to acupuncture are required. Cancer patients undergoing active treatment may be prone to infection or bleeding. Cancer or cancer treatment may have distorted anatomical structures, which makes needling certain points not advisable. Acupuncture should not be performed on patients with recent stem cell or organ transplantation, absolute neutrophil count less than 500/µL, platelets less than 20,000/µL, INR greater than 4.0, or new-onset cardiac arrhythmia. It also should not be done at the site of primary or metastatic neoplasm; or when the patient has a medical device/prosthesis, open wound, active infection, or fistula; or has recently undergone treatment with radiotherapy.

Availability of acupuncture therapy and the degree of its integration into mainstream healthcare varies by geographic location, institution type, and the demographics of the patient population. Laws regulating the practice of acupuncture vary across states. In most states, acupuncture falls within the scope of practice for conventionally trained physicians. Some states require additional training in acupuncture, which varies from 100–300 hours. Others do not require such training.

Most states grant licenses or certifications to individuals who are not graduates of conventional medical schools, but who have successfully completed training in a qualified education program in acupuncture and traditional Oriental medicine. Such acupuncture schools exist in the US and abroad. The National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) is the national organization that validates entry-level competency in the practice of acupuncture and Oriental medicine through professional certification. In some states, acupuncture can also be provided by chiropractors, dentists, and podiatrists who may not have received additional acupuncture training.[34,35]

What's the Bottom-Line Message?

Acupuncture is a complementary medicine modality that can be usefully incorporated as a component of supportive oncology care. Although acupuncture does not treat cancer directly, it may reduce some common symptoms experienced by cancer patients. Current research supports its use in the reduction of pain and CINV. Other research suggests it may also reduce radiation-induced dry-mouth, although this indication requires further study.

Acupuncture is best provided as part of a multimodality treatment approach. It has a good safety record when given by qualified practitioners. Acupuncturists should exercise special safety precautions when treating cancer patients.

To view information about acupuncture from the National Institutes of Health's National Center for Complementary and Alternative Medicine (NCCAM), please visit: http://nccam.nih.gov/health/acupuncture/. Information about acupuncture is also available on Memorial Sloan-Kettering Cancer Center's website, "About Herbs, Botanicals & Other Products," at http://www.mskcc.org/mskcc/html/69111.cfm.

Financial Disclosure: The authors have no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.

References:

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