Guest Editor’s Note: Nocturia, waking up from sleep more than once to urinate, is prevalent in survivors of prostate cancer and is associated with a diminished quality of life and a higher mortality than the general population. The evidence supporting current treatment options for nocturia is weak. In this installment of The ASCO Post’s Integrative Oncology series, Kevin Liou, MD, summarizes the findings from a published pilot clinical trial conducted by integrative medicine researchers at Memorial Sloan Kettering Cancer Center. The study aimed to investigate the effects of acupuncture, compared to usual care, for treatment of nocturia in survivors of prostate cancer.
Nocturia, or waking up from sleep to urinate followed by intention to sleep,1 affects two in three survivors of prostate cancer2 and is linked with high symptom burden,3-7 poor quality of life,8 and increased mortality.9,10 Medications for nocturia include desmopressin, alpha-blockers, anti-muscarinics such as oxybutynin and tolterodine, surgical procedures (eg, artificial urinary sphincter), and other nonpharmacological treatments (eg, pelvic floor exercises and posterior tibial nerve stimulation), but the evidence for these modalities is inconclusive for survivors of prostate cancer.11 Prostate cancer survivorship care guidelines from the American Cancer Society rate the evidence level for nocturia treatments as “0,” which is the lowest rating possible.12 Hence, there exists a critical need for better treatment options for this prevalent condition.
Acupuncture: One Approach to Treating Nocturia
Acupuncture is a therapeutic modality derived from traditional Chinese medicine that involves the insertion of thin, sterile, single-use, metallic needles into specific points on the body. Acupuncture has demonstrated growing evidence of possible benefits for subjective and objective urinary function relative to placebo controls; however, these studies were mostly conducted in populations without prostate cancer.13-16 Electrical stimulation of lumbosacral acupoints has been shown to modulate the pelvic, pudendal, and hypogastric nerves innervating the bladder and lower urinary tract.17,18 These findings provide biological plausibility for the observed effects of acupuncture on urinary function. As a nonpharmacological modality, acupuncture represents a promising option for an aging cancer survivor population with concerns about polypharmacy.19 To date, no rigorous trials have studied acupuncture for nocturia in prostate cancer survivors, highlighting an untapped scientific opportunity.
In this pilot trial, acupuncture produced a greater reduction in nocturia and clinically meaningful improvements in urinary function compared to usual care.— KEVIN T. LIOU, MD
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To explore whether acupuncture is a feasible intervention for nocturia in survivors of prostate cancer, integrative medicine researchers at Memorial Sloan Kettering Cancer Center, New York, conducted a pilot randomized controlled trial.20 Study participants were adults treated for prostate cancer and with no evidence of disease who reported clinically significant nocturia, defined as two or more episodes each night for the past month. A total of 60 participants were randomized in a 2:1 ratio to an acupuncture group that received 10 standardized weekly treatments, or to a usual-care waitlist control group. Nocturia episodes were assessed using the International Prostate Symptom Score (IPSS), a validated instrument that also provides a general measure of urinary function.21
The mean age of trial participants was 72.4 (standard deviation [SD] 7.0) years. Nearly one-fifth of participants identified as Black. One-half had stage II prostate cancer. Most participants received surgery (58%) and/or radiation (55%). Prior to acupuncture treatment, participants had a mean of 3.0 (SD 0.9) nocturia episodes per night.
Guest Editor
Jun J. Mao, MD, MSCE
Dr. Mao is the Laurance S. Rockefeller Chair in Integrative Medicine and Chief of Integrative Medicine Service at Memorial Sloan Kettering Cancer Center, New York.
At the end of the 10-week treatment period, acupuncture produced greater reduction in nocturia than usual care by 1.13 episodes (95% confidence interval [CI] -1.56 to -0.71, P < .0001). These effects persisted up to one-month posttreatment, with the acupuncture group reporting 0.85 fewer episodes (95% CI -1.27 to -0.42, P = .0001). Compared to usual care, acupuncture also produced a greater reduction in International Prostate Symptom Scores (IPSS) total scores at the end of the treatment period (difference = -3.76 points, 95% CI -6.07 to -1.44, P = .002) and at one-month posttreatment (difference = -3.39 points, 95% CI -5.70 to -1.09, P = .004). (IPSS total score reduction of 3 points is considered a clinically meaningful improvement.) The reduction in the IPSS total score at both timepoints was clinically meaningful.21 Adverse events in the acupuncture group were few and mild.
Clinical Implications and Future Directions
In this pilot trial, acupuncture produced a greater reduction in nocturia and clinically meaningful improvements in urinary function compared to usual care. The effects of acupuncture on nocturia were comparable or superior to other treatments, such as desmopressin, alpha-blockers, and anti-muscarinic medications.22 Although these preliminary findings still need to be confirmed in larger studies, prostate cancer survivors may consider acupuncture as a potential treatment option, particularly if other interventions have been tried without benefit. Notably, acupuncture appears to be safe with few side effects.22
Building on these findings, integrative medicine researchers are designing a larger clinical trial to determine the efficacy and mechanisms of acupuncture on nocturia in prostate cancer survivors. This future research has the potential to advance treatment for a distressing urinary symptom that affects thousands of prostate cancer survivors.
DISCLOSURE: Dr Liou reported grants from Chanel Endowment to Fund Survivorship Research, grants from the National Cancer Institute (NCI) (K08CA266927), and grants from NCI (P30CA008748) during the conduct of the study.
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Dr. Liou is an assistant attending physician, Integrative Medicine and Wellness Service, Department of Medicine at Memorial Sloan Kettering Cancer Center, New York.
