Acupuncture for Joint Pain Associated With Aromatase Inhibition
Although aromatase inhibitors are highly effective as adjuvant therapy in metastatic breast cancer and for prevention of breast cancer, the side effects can be difficult to tolerate and often lead to discontinuation of therapy. A phase III randomized trial has found that acupuncture may relieve aromatase inhibitor–associated joint pain, possibly improving adherence to aromatase inhibitor treatment. In the study, acupuncture provided significantly greater pain relief compared with sham acupuncture as well as with a control group with no treatment.
For patients who are reluctant to take prescription medications to control pain and side effects, acupuncture provides a good option.— Dawn L. Hershman, MD
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“Endocrine therapy doesn’t work if you don’t take it. Noncompliance is a major problem with aromatase inhibitors. It is multifactorial, but one of the main reasons for discontinuing aromatase inhibitors is debilitating arthralgia and joint stiffness. We need strategies to control these side effects,” said lead investigator Dawn L. Hershman, MD, leader of the Breast Cancer Program at the Herbert Irving Comprehensive Cancer Center at -NewYork-Presbyterian/Columbia University Medical Center. Dr. Hershman presented the results of the SWOG 1200 study at the 2017 San Antonio Breast Cancer Symposium.1
Several studies have suggested acupuncture may be effective in alleviating aromatase inhibitor–induced arthralgias, but they were mainly small studies of short duration. In the randomized, blinded SWOG 1200 trial, Dr. Hershman and colleagues compared true acupuncture vs sham acupuncture vs wait-list controls (ie, no treatment) in women with early-stage, hormone receptor–positive cancer and aromatase inhibitor–induced joint pain.
Women in the active treatment arms were randomized 2:1:1 to receive either true acupuncture (based on traditional Chinese medicine point prescription to reduce pain and decrease stress, n = 110) or sham acupuncture (superficial insertion of narrow small needles into nonacupuncture pressure points, n = 59) for 35- to 40-minute sessions twice weekly for 6 weeks, followed by a maintenance intervention of 1 session per week for 6 more weeks. The control group comprised 57 patients who were wait-listed for acupuncture. All patients were followed for an additional 12 weeks after they stopped treatment.
Trial participants were on aromatase inhibitors for at least 30 days, with symptoms related to the initiation of aromatase inhibitors and a score of at least 3 on the Brief Pain Inventory Short Form, a self-administered, 14-item questionnaire with a pain scale scoring system from 0 (no pain) to 10 (worst pain). Patients were not allowed to receive opioids or corticosteroids or alternative physical therapy for treatment of joint pain within 28 days of entering the trial. Patients self-reported their level of pain on the Brief Pain Inventory before, during, and after acupuncture or no treatment. Both active treatment arms had similar baseline characteristics.
Managing Aromatase Inhibitor–Induced Joint Pain
- Acupuncture provided significant pain relief compared with sham acupuncture and no treatment in women with early hormone receptor–positive breast cancer and aromatase inhibitor–associated joint pain.
- This nonpharmacologic option has the potential to improve adherence to aromatase inhibitor therapy and perhaps outcomes.
At 6 weeks, acupuncture was significantly better in relieving pain compared with sham acupuncture (P < .01) and controls (P < .01). The percent of patients who achieved a clinically meaningful 2-point change on the Brief Pain Inventory for worst pain was 58% in the true acupuncture group vs 31% (P < .009) in the sham acupuncture group and 30% in the control group (P = .004).
Over 24 weeks (12 without treatment for both active treatment arms), patients treated with true acupuncture continued to have significantly improved pain control compared with the other two groups (P = .04 vs sham acupuncture and P < .0001 for controls).
True acupuncture was also significantly superior to sham acupuncture or no treatment for all secondary joint symptom endpoints, including Brief Pain Inventory average pain score, pain interference, pain severity, worse stiffness, scores on the Western Ontario and McMaster Universities Osteoarthritis Index, and a modified version of the Score for the Assessment and Quantification of Chronic Rheumatoid Affections of the Hands.
There were few side effects. One case each of grade 2 presyncope was reported in the true and sham acupuncture arms, and there was more grade 1 bruising in the acupuncture arm vs sham acupuncture: 47% vs 25%, respectively (P = .01).
Cost and Duration
“For patients who are reluctant to take prescription medications to control pain and side effects, acupuncture provides a good option. The cost of the 12-week, 18-intervention program was about $1,250 [$65 to $75 per session in New York]. Acupuncture is widely used, but the cost may be prohibitive for some patients. We feel this study provides sufficient evidence to support insurance coverage of acupuncture for aromatase inhibitor–induced arthralgia,” Dr. Hershman said.
However, Dr. Hershman added, it is not clear how long a person should stay on acupuncture. “Transitioning from twice a week to once-weekly acupuncture maintained the effect of the intervention. In this study, 12 weeks worked and provided persistent benefits,” she noted. ■
DISCLOSURE: Dr. Hershman reported no conflicts of interest.
1. Hershman DL, et al: 2017 San Antonio Breast Cancer Symposium. Abstract GS4-04. Presented December 7, 2017.
Kathryn Ruddy, MD
“This is a very exciting study. Acupuncture is another tool to address arthralgias associated with aromatase inhibitor therapy,” said Kathryn Ruddy, MD, of the Mayo Clinic, Rochester, Minnesota. “I don’t think every patient with joint pain will opt for this for a variety...