Since the National Institutes of Health Consensus Statement in 1997 concluded that the evidence to date suggests acupuncture is effective in the treatment of chemotherapy-induced nausea and vomiting,¹ numerous additional indications for its use in relieving symptoms related to cancer or its treatment have been confirmed. There are data to support the use of acupuncture for relief of hot flashes related to hormonal manipulation in women with breast cancer,² as well as in men on androgen-deprivation therapy.³ The musculoskeletal symptoms related to aromatase inhibitor therapy have also been found to improve with acupuncture in a sham-controlled trial.⁴

Recently, radiation-induced xerostomia in the treatment of head and neck cancer has also been ameliorated by the intervention.⁵ The National Comprehensive Cancer Network Adult Cancer Pain Guideline recommends acupuncture or acupressure as a useful integrative intervention to be considered.⁶ Many patients receive acupuncture in an attempt to decrease chemotherapy-associated peripheral neuropathy, with some evidence of success in clinical trials.

Now, the troublesome problem of lymphedema secondary to axillary lymph node dissection in women with breast cancer also appears to be responsive to acupuncture, on the basis of this well-conducted pilot from the Integrative Medicine Service at Memorial Sloan-Kettering Cancer Center.

Former Taboos Dispelled

One of the underlying features that make this report exciting is that lymphedematous limbs were previously considered to be off limits for acupuncture needle insertion, given a fear of the risk of infection or other potential complications. Although prior retrospective analyses questioned the need for this concern by showing no evidence of ill effects, this prospective trial reports no infections among the 34 women who were analyzed. Despite some reports of mild local bruising or pain and tingling, the investigators found no serious adverse events or exacerbations of the lymphedema in 255 treatment sessions with 6 months of follow-up.

Similarly, the fear of doing acupuncture in patients with cancer who have low platelet counts had already been put to rest by a study from the Integrative Medicine group in the Division of Pediatric Oncology at Columbia University Medical Center when they reported no bleeding episodes in 32 patients being needled with mild to severe therapy-related thrombocytopenia.⁷ So, as more data accumulate, some of the former taboos against the procedure are being dispelled.

The Original Personalized Medicine

Acupuncture is just one intervention used in the practice of traditional Chinese medicine, which usually also involves nutrition, movement, and herbal therapies. Traditional Chinese medicine practitioners use a whole different system to diagnose from the one we learn in Western medical practice. Treatment is usually individualized for each patient based on the traditional Chinese medicine diagnosis—think of it as the original personalized medicine.

This study, like virtually all studies in the Western literature, utilized a fixed set of acupuncture treatment points for all patients, regardless of their underlying traditional Chinese medicine diagnosis—hence, a deviation from the norm of practice and one that would, if anything, likely bias against the intervention. Just as an oncologist would not treat all women with breast cancer with docetaxel and trastuzumab (Herceptin) without more information about the particular patient’s pathology, a traditional Chinese medicine practitioner would not treat all women with treatment-related lymphedema with the same acupoints.

The young, thin, anxious woman with triple-negative breast cancer and lymphedema may warrant different acupuncture points than an overweight, postmenopausal, depressed, estrogen-receptor–positive counterpart in the eyes of the traditional Chinese medicine practitioner. However, to make the results more interpretable within the context of our Western scientific paradigms, only acupuncture is studied rather than the whole system of traditional Chinese medicine, and standardized acupuncture points for all study participants are the norm.

Two Concerns

The investigators conclude that “although these results await confirmation in a randomized trial, acupuncture can be considered for women with no other options for sustained arm circumference reduction.” This summary statement presents two concerns.

First, the choice of an appropriate control intervention in acupuncture studies is very difficult. Inserting needles into what are not considered to be “true” acupuncture points could possibly exert similar effects to those obtained using the traditional sites. Inserting specialized needles that do not puncture but are still along the active meridian and, in fact, sitting on a known acupuncture point may in and of itself cause a similar effect, since we know that burning the perennial plant mugwort over acupoints (moxibustion) and applying manual pressure (acupressure) are therapeutic. So, deciding what constitutes a valid control for active acupuncture in the follow-on randomized trial could be a challenge.

Second, the authors strongly signal that acupuncture helped a significant proportion of their participants with few minor complaints and no serious adverse effects. Why, then, would one suggest limiting this benign and seemingly effective intervention only to women with no other options? Could this perhaps be one of the initial interventions one might consider? If it works for established lymphedema, could there be a role for prophylactic acupuncture to prevent lymphedema in patients at risk?

Many integrative oncologists generally manage all patients receiving active conventional cancer treatment interventions with a collaborating traditional Chinese medicine practitioner in hopes of minimizing side effects and optimizing clinical outcomes. Fortunately, it appears as if the science is catching up! ■

Dr. Abrams is Chief, Hematology-Oncology, San Francisco General Hospital; Integrative Oncology, UCSF Osher Center for Integrative Medicine; Professor of Clinical Medicine, University of California, San Francisco.

Disclosure: Dr. Abrams reported no potential conflicts of interest.

Reference

1. Acupuncture. NIH Consensus Statement 15(5):1-34, November 3-5, 1997.

2. Walker EM, Rodriguez AI, Kohn B, et al: Acupuncture versus venlafaxine for the management of vasomotor symptoms in patients with hormone receptor-positive breast cancer: A randomized controlled trial. J Clin Oncol 28:634-640, 2010.

3. Beer TM, Benavides M, Emmons SL, et al: Acupuncture for hot flashes in patients with prostate cancer. Urology 76:1182-1188, 2010.

4. Crew KD, Capodice JL, Greenlee H, et al: Randomized, blinded, sham-controlled trial of acupuncture for the management of aromatase inhibitor-associated joint symptoms in women with early-stage breast cancer. J Clin Oncol 28:1154-1160, 2010.

5. Simcock R, Fallowfield L, Monson K, et al: ARIX: A randomised trial of acupuncture v oral care sessions in patients with chronic xerostomia following treatment of head and neck cancer. Ann Oncol 24:776-783, 2013.

6. National Comprehensive Cancer Network: NCCN Clinical Practice Guidelines in Oncology: Adult cancer pain. Version 2.2013. Available at www.nccn.org. Accessed July 18, 2013.

7. Ladas EJ, Rooney D, Taromina K, et al: The safety of acupuncture in children and adolescents with cancer therapy-related thrombocytopenia. Support Care Cancer 18:1487-1490, 2010.