Acupuncture has been practiced for thousands of years in Eastern Asian cultures as a component of traditional Chinese medicine.1 In the United States, acupuncture became known to the public as a complementary and alternative medicine technique in the 1970s, but it took many years before it was recognized as a legitimate health practice. Events that moved the field of acupuncture forward were the reclassification of acupuncture needles as medical devices by the U.S. Food and Drug Administration in 19962 and the release of the National Institute of Health (NIH) consensus statement in 1997 declaring that sufficient evidence was available to support the usefulness of acupuncture as a therapeutic intervention.3
Acupuncture is increasingly integrated into conventional health practice. According to the most recent National Health Interview Survey (NHIS), the use of acupuncture among U.S. adults rose significantly from 2002 to 2012.4 NHIS data also suggested that individuals with cancer are more likely to have used a complementary and alternative medicine technique, such as acupuncture, than individuals without cancer.5 Acupuncture rates among patients with cancer are estimated to be as high as 17%, based on a review of studies published in English.6
Patients with cancer often experience multiple concurrent physical and emotional symptoms. Interventions are needed to manage these symptoms and to improve patients’ quality of life. This article provides an introduction to the use of acupuncture in cancer symptom management and its potential use as a treatment for symptom clusters.
Acupuncture Research
Research on the use of acupuncture to treat cancer-related symptoms is relatively new, and early studies suffered from a number of limitations, such as a small sample size; lack of a control group; and failure to report methodologic details, including the style of acupuncture (eg, traditional Chinese medicine, Korean), needling procedures, the frequency and duration of treatment, or the provider’s training.3,7,8 To date, the design of an appropriate placebo control group remains a challenge, as acupuncture providers cannot be blinded and sham procedures themselves may have a therapeutic effect.9,10 Sham needling involves placement of a sham needle, which does not pierce the skin, or placement of a penetrating needle at a site on the body that is an incorrect point or a nonacupuncture point.11
The placebo effect is well documented in medical and psychological research,12 and it is also a known factor affecting acupuncture clinical trials.13,14 For example, Bao et al found that patients with breast cancer treated with an aromatase inhibitor reported reductions in hot flashes after receiving either real or sham acupuncture treatment for 8 weeks.13 One possible explanation for the placebo effect is response expectancy, or the belief that an intervention will have the desired effect.
In a randomized controlled trial of women receiving electroacupuncture or sham acupuncture for treatment of aromatase inhibitor–related joint pain, Bauml and colleagues found that pain relief was moderated by response expectancy.15 Although pain relief between the two groups was similar, in the sham acupuncture group, only women who expected acupuncture to be effective reported clinically significant pain relief. Clinically significant pain relief experienced by women in the electroacupuncture group was unrelated to response expectancy.
Clinical trials are increasingly rigorous, and evidence has slowly accumulated to support the use of acupuncture for treatment of specific cancer-related symptoms such as pain,16,17 nausea,18 and hot flashes.19,20
Evidenced-Based Guidelines for Clinical Practice
Integrative medicine is a treatment approach that incorporates “nonmainstream” complementary health practices into conventional health care.21 In 2007, the Society for Integrative Oncology convened a group of experts in integrative medicine and oncology to review the evidence on integrative health techniques and to develop clinical guidelines for the use of these techniques in patients with cancer.22
The consensus for acupuncture was that it is safe for use in oncology when conducted by a trained provider. It can be recommended as a complementary treatment for radiation-induced xerostomia and inadequately controlled cancer-related symptoms, including pain, chemotherapy-induced neuropathy, postoperative nausea and vomiting, chemotherapy-related nausea and vomiting, severe hot flashes, dyspnea, and fatigue. The guidelines caution against the use of acupuncture in individuals with hematologic conditions (eg, neutropenia, thrombocytopenia), in tumor sites, or in limbs affected by lymphedema.
More recently, disease-specific guidelines for the use of acupuncture have been published for patients with lung cancer23 and patients with breast cancer.24 These guidelines are generally consistent with the original guidelines. To date, however, these guidelines provide recommendations for treatment of individual symptoms.
Cancer Symptom Clusters
Patients with cancer often experience multiple symptoms related to the disease process or its treatment. Findings from a review of 18 studies by Esther Kim indicated that fatigue, dry mouth, insomnia, drowsiness, mood disturbance, and pain were the most common symptoms experienced by patients with cancer during treatment.25 Further, more than five concurrent symptoms were experienced by 22% to 30% of the patients.
The concept of cancer symptom clusters, first introduced by Dodd et al in 2001,26 is defined as the co-occurrence of two or more related symptoms.27 Clusters may occur if symptoms share a similar etiology (eg, circadian-signaling inhibition resulting in sleep disruption, fatigue, and poor appetite28), if one symptom causes or worsens another symptom (eg, uncontrolled worrying leads to inability to sleep), or if the treatment of one symptom causes a new symptom (eg, opioid management of pain causes fatigue).29,30 Although there is no consensus as to which symptoms constitute a particular symptom cluster, several studies have identified similar co-occurring symptoms, such as pain/fatigue/sleep,31-33 depression/anxiety,33-35 nausea/vomiting,36,37 dyspnea/cough/fatigue,38 and weight/food intake.33,34
The presence of multiple concurrent symptoms may increase the symptom burden and may have a greater negative effect on functional status,39 psychological well-being,33,40 and quality of life40,41 than do individual symptoms.25
Acupuncture Treatment of Symptom Clusters
There are obvious benefits to treating cancer symptom clusters with a single intervention. This approach has the potential to reduce polypharmacy and drug interactions, decrease the risk of side effects, and reduce the cost of treatment to the patient.29,30,42 A critical understanding of the potential role of acupuncture under these circumstances is to understand that its effect may be general as well as specific.
For example, the Ming Men approach targets acupuncture points in the lower torso to strengthen Qi (“vital energy” in traditional Chinese medicine). Stimulation of these acupuncture points for fatigue in patients with breast cancer may also reduce distress from hot flashes. In traditional Chinese medicine, hot flashes may be described as “kidney water exhausted,”43 signifying a deficiency as the cause for hot flashes; for this diagnosis, there are many potentially logical acupuncture points and treatment regimens. Use of the Ming Men technique to treat hot flashes will also relax and energize patients because it engages acupuncture points associated with various traditional Chinese medicine organ systems, including the kidneys, lungs, and triple burner [the flow of energy through all 12 vital organs].
We have published objective responses in both hot flashes and sleep in patients with breast cancer.44 Unique to this study was the use of a cadre of community acupuncturists selecting acupuncture points they considered appropriate given each patient’s unique symptom constellation. Oddly to the Western-trained physician, of the 38 points used in the study, 70% of treatments involved the acupoint Lu (lung) unilaterally on the left. This properly points out the vast differences in perspective between traditional Chinese medicine practitioners and physicians—even physician acupuncturists. Those trained in traditional Chinese medicine are far more informed on the lore and artistic nature of the craft than those of us who are not, who tend to think practically in terms of points and effects.
Study Findings
Although no published studies have examined cancer symptom clusters as a primary outcome, studies have been conducted to evaluate the effect of acupuncture on multiple symptoms.25 For example, in 2013, Kasymjanova et al conducted an observational study of 33 patients with lung cancer who received at least four sessions of acupuncture for symptom control.45 Significant improvements were seen in pain, nausea, appetite, nervousness, and well-being.
In an observational study by Dean-Clower et al in 2010, 26 women with advanced gynecologic or breast cancer completed up to 8 weeks of acupuncture treatment.46 Among those who reported baseline symptoms, the severity of anxiety, depression, fatigue, and pain decreased over the course of the acupuncture treatment.
In 2014, Garcia and colleagues conducted a study in which patients with cancer patients who had uncontrolled pain participated in up to 10 sessions of acupuncture with or without electrical stimulation.47 Acupuncture points were selected by the provider based on patients’ pain location, pain type, other symptoms, and medical history. Patients completed measures assessing the severity of pain and other cancer-related symptoms as well as the extent to which these symptoms interfered with daily activities. In addition to significant reductions in pain, patients also reported improved overall quality of life and less symptom interference.
In a pragmatic controlled trial conducted in 2012, Molassiotis et al randomized patients with breast cancer to 6 weeks of acupuncture or usual care (ie, educational booklet on fatigue) for the treatment of cancer-related fatigue.48 The acupuncture intervention targeted three acupuncture points to treat fatigue, and providers choose two substitute points if the target points could not be accessed. In addition to improvement in the primary outcome of fatigue, women also reported improvement in physical and emotional well-being.
Closing Thoughts
Oncologists should be alert to the potential of acupuncture to relieve cancer-related symptom clusters. Acupuncture is safe for most patients, and growing evidence demonstrates its potential effectiveness as an adjunct intervention. Research into the role of response expectancy is ongoing and should inform the true role of “placebo” across all interventions, including radiotherapy and chemotherapy. Further integration of practitioners trained in traditional Chinese medicine into mainstream cancer care will open new doors to cross-cutting symptom management in our patients. ■
Disclosure: Drs. Thompson and Johnstone reported no potential conflicts of interest.
References
1. Lu DP, Lu GP: An historical review and perspective on the impact of acupuncture on U.S. medicine and society. Med Acupunct 25:311-316, 2013.
2. U.S. Food and Drug Administration: CFR - Code of Federal Regulations Title 21. Available at https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/cfrsearch.cfm. Accessed October 1, 2015.
3. NIH Consensus Conference: Acupuncture. JAMA 280:1518-1524, 1998.
4. Clarke TC, Black LI, Stussman BJ, et al: Trends in the use of complementary health approaches among adults: United States, 2002-2012. Natl Health Stat Report 79:1-16, 2015.
5. Anderson JG, Taylor AG: Use of complementary therapies by individuals with or at risk for cardiovascular disease: Results of the 2007 National Health Interview Survey. J Cardiovasc Nurs 27:96-102, 2012.
6. Carmady B, Smith CA: Use of Chinese medicine by cancer patients: A review of surveys. Chin Med 6:22, 2011.
7. Lian WL, Pan MQ, Zhou DH, et al: Effectiveness of acupuncture for palliative care in cancer patients: A systematic review. Chin J Integr Med 20:136-147, 2014.
8. MacPherson H, Thomas K, Walters S, et al: A prospective survey of adverse events and treatment reactions following 34,000 consultations with professional acupuncturists. Acupunct Med 19:93-102, 2001.
9. Haddad NE, Palesh O: Acupuncture in the treatment of cancer-related psychological symptoms. Integr Cancer Ther 13:371-385, 2014.
10. Moffet HH: Sham acupuncture may be as efficacious as true acupuncture: A systematic review of clincial trials. J Altern Complement Med 15:213-216, 2009.
11. Langevin HM, Wayne PM, MacPherson H, et al: Paradoxes in acupuncture research: Strategies for moving forward. Evid Based Complement Alternat Med 2011:180805, 2011.
12. Colagiuri B, Schenk LA, Kessler MD, et al: The placebo effect: From concepts to genes. Neuroscience 307:171-190, 2015.
13. Bao T, Cai L, Snyder C, et al: Patient-reported outcomes in women with breast cancer enrolled in a dual-center, double-blind, randomized controlled trial assessing the effect of acupuncture in reducing aromatase inhibitor-induced musculoskeletal symptoms. Cancer 120:381-389, 2014.
14. Rostock M, Jaroslawski K, Guethlin C, et al: Chemotherapy-induced peripheral neuropathy in cancer patients: A four-arm randomized trial on the effectiveness of electroacupuncture. Evid Based Complement Alternat Med 2013:349653, 2013.
15. Bauml J, Xie SX, Farrar JT, et al: Expectancy in real and sham electroacupuncture: Does believing make it so? J Natl Cancer Inst Monogr 2014:302-307, 2014.
16. Alimi D, Rubino C, Pichard-Léandri E, et al: Analgesic effect of auricular acupuncture for cancer pain: A randomized, blinded, controlled trial. J Clin Oncol 21:4120-4126, 2003.
17. Garcia MK, McQuade J, Lee R, et al: Acupuncture for symptom management in cancer care: An update. Curr Oncol Rep 16:418, 2014.
18. Ezzo JM, Richardson MA, Vickers A, et al: Acupuncture-point stimulation for chemotherapy-induced nausea or vomiting. Cochrane Database Syst Rev Apr 19(2):CD002285, 2006.
19. Frisk J, Spetz AC, Hjertberg H, et al: Two modes of acupuncture as a treatment for hot flushes in men with prostate cancer—A prospective multicenter study with long-term follow-up. Eur Urol 55:156-163, 2009.
20. 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.
21. National Center for Complementary and Integrative Health: What is complementary, alternative, or integrative health? Available at https://nccih.nih.gov/health/integrative-health. Accessed October 17, 2015.
22. Deng GE, Frenkel M, Cohen L, et al: Evidence-based clinical practice guidelines for integrative oncology: Ceomplementary therapies and botanicals. J Soc Integr Oncol 7:85-120, 2009.
23. Deng GE, Rausch SM, Jones LW, et al: Complementary therapies and integrative medicine in lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 143:e420S-e436S, 2013.
24. Greenlee H, Balneaves LG, Carlson LE, et al: Clinical practice guidelines on the use of integrative therapies as supportive care in patients treated for breast cancer. J Natl Cancer Inst Monogr 2014:346-358, 2014.
25. Esther Kim JE, Dodd MJ, Aouizerat BE, et al: A review of the prevalence and impact of multiple symptoms in oncology patients. J Pain Symptom Manag 37:715-736, 2009.
26. Dodd M, Janson S, Facione N, et al: Advancing the science of symptom management. J Adv Nurs 33:668-676, 2001.
27. Kim HJ, McGuire DB, Tulman L, et al: Symptom clusters: Concept analysis and clinical implications for cancer nursing. Cancer Nurs 28:270-282, 2005.
28. Rich TA: Analyzing the symptoms in cancer patients: Disrupted circadian signaling by the epidermal growth factor receptor. IEEE Eng Med Biol Mag 27:25-28, 2008.
29. Kwekkeboom KL, Cherwin CH, Lee JW, et al: Mind-body treatments for the pain-fatigue-sleep disturbance symptom cluster in persons with cancer. J Pain Symptom Manage 39:126-138, 2010.
30. Williams LA: Clinical management of symptom clusters. Semin Oncol Nurs 23:113-120, 2007.
31. Beck SL, Dudley WN, Barsevick A: Pain, sleep disturbance, and fatigue in patients with cancer: Using a mediation model to test a symptom cluster. Oncol Nurs Forum 32:542, 2005.
32. Hoffman AJ, Given BA, von Eye A, et al: Relationships among pain, fatigue, insomnia, and gender in persons with lung cancer. Oncol Nurs Forum 34:785-792, 2007.
33. Thomas BC, Waller A, Malhi RL, et al: A longitudinal analysis of symptom clusters in cancer patients and their sociodemographic predictors. J Pain Symptom Manage 47:566-578, 2014.
34. Breen SJ, Baravelli CM, Schofield PE, et al: Is symptom burden a predictor of anxiety and depression in patients with cancer about to commence chemotherapy? Med J Aust 190:S99-S104, 2009.
35. Chow E, Fan G, Hadi S, et al: Symptom clusters in cancer patients with bone metastases. Support Care Cancer 15:1035-1043, 2007.
36. Aktas A, Walsh D, Hu B: Cancer symptom clusters: An exploratory analysis of eight statistical techniques. J Pain Symptom Manage 48:1254-1266, 2014.
37. Walsh D, Rybicki L: Symptom clustering in advanced cancer. Support Care Cancer 14:831-836, 2006.
38. Cheville AL, Novotny PJ, Sloan JA, et al: Fatigue, dyspnea, and cough comprise a persistent symptom cluster up to five years after diagnosis with lung cancer. J Pain Symptom Manage 42:202-212, 2011.
39. Dodd MJ, Miaskowski C, Paul SM: Symptom clusters and their effect on the functional status of patients with cancer. Oncol Nurs Forum 28:465-470, 2001.
40. Portenoy RK, Thaler HT, Kornblith AB, et al: The Memorial Symptom Assessment Scale: An instrument for the evaluation of symptom prevalence, characteristics and distress. Eur J Cancer 30A:1326-1336, 1994.
41. Chang VT, Hwang SS, Feuerman M, et al: Symptom and quality of life survey of medical oncology patients at a veterans affairs medical center: A role for symptom assessment. Cancer 88:1175-1183, 2000.
42. Johnstone PA: Acupuncture as cancer symptom therapy: What a difference a decade makes. J Acupunct Meridian Stud 4:209-213, 2011.
43. Kaptchuk TJ: The Web That Has No Weaver: Understanding Chinese Medicine, 2nd ed. Chicago, IL, Contemporary Books, 2000.
44. Otte JL, Carpenter JS, Zhong X, et al: Feasibility study of acupuncture for reducing sleep disturbances and hot flashes in postmenopausal breast cancer survivors. Clin Nurse Spec 25:228-236, 2011.
45. Kasymjanova G, Grossman M, Tran T, et al: The potential role for acupuncture in treating symptoms in patients with lung cancer: An observational longitudinal study. Curr Oncol 20:152-157, 2013.
46. Dean-Clower E, Doherty-Gilman AM, Keshaviah A, et al: Acupuncture as palliative therapy for physical symptoms and quality of life for advanced cancer patients. Integr Cancer Ther 9:158-167, 2010.
47. Garcia MK, Driver L, Haddad R, et al: Acupuncture for treatment of uncontrolled pain in cancer patients: A pragmatic pilot study. Integr Cancer Ther 13:133-140, 2014.
48. Molassiotis A, Bardy J, Finnegan-John J, et al: Acupuncture for cancer-related fatigue in patients with breast cancer: A pragmatic randomized controlled trial. J Clin Oncol 30:4470-4476, 2012.
Dr. Thompson is Director of Integrative Medicine and Dr. Johnstone is a radiation oncologist at H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida.
GUEST EDITOR
Integrative Oncology is guest edited by Barrie R. Cassileth, MS, PhD, Former Chief of the Integrative Medicine Service and Former Laurance S. Rockefeller Chair in Integrative Medicine at Memorial Sloan Kettering Cancer Center, New York.
The Integrative Medicine Service at Memorial Sloan Kettering Cancer Center developed and maintains a free website—About Herbs (www.mskcc.org/aboutherbs)—that provides objective and unbiased information about herbs, vitamins, minerals, and other dietary supplements, and unproved anticancer treatments. Each of the close to 300 and growing number of entries offers health-care professional and patient versions, and entries are regularly updated with the latest research findings.
In addition, the About Herbs app, Memorial Sloan Kettering Cancer Center’s very first mobile application, can be downloaded at http://itunes.apple.com/us/app/about-herbs/id554267162?mt=8. The app is compatible with iPad, iPhone, and iPod Touch devices.
