Acupuncture and Cancer

What is Acupuncture?

Acupuncture is an ancient healing technique that dates as far back as the Stone Age and originated in China. It was modernised during the Ming Dynasty (1368-1644) and travelled to Japan in the 6th century and to the West in the 1800s.

It involves the application of needles by a qualified practitioner into the superficial layer of the skin. This occurs at specific points over the body or ear (auricular acupuncture) and correspond to meridian lines. These points are responsive to stimulation and cause physiological reactions that may lead to the alleviation of symptoms and signs of disease.

How does it work?

The mechanism of action is demonstrated in human and animal studies to cause stimulation and response of the neuroendocrine system involving the central and peripheral nervous systems (Lu et al 2008). Functional MRI studies show changes in brain areas responsible for sensory detection (primary and secondary somatosensory cortex), attention (prefrontal cortex), emotion processing (insular cortex and amygdala), memory (hippocampus), endocrine function (hypothalamus) and cognition (anterior cingulate), in response to needle stimulation at a distance. This brain response is seen to differ according to the degree of sensations felt by the acupuncturist and felt by the patient. These changes suggest that not only is the acupuncture acting to cause physiological change to reduce the symptom but that it also acts on the personal experience of the symptom.

What is it used for in cancer?

Acupuncture is gaining popularity in treating the symptoms of cancer and the side effects of cancer treatment (Birch et al 2019). In 1997 the NIH approved its use for chemotherapy-induced nausea and vomiting and there is a growing body of evidence of effectiveness for cancer pain, aromatase inhibitor induced arthralgia, fatigue, anxiety and depression and sleep disturbance.

There are positive and results trending positive for chemotherapy-induced nausea and vomiting, post-operative nausea and vomiting, post-operative pain, cancer-related pain, arthralgia from aromatase-inhibitor, xerostomia, hot flushes, fatigue, depression and anxiety, sleep problems, chemotherapy induced peripheral neuropathy, hiccups, dyspnoea (shortness of breath) in palliative care, radiotherapy-induced nausea and vomiting, lymphoedema (swelling in arms and legs), leucopoenia (low blood white cell count), post-operative gastroparesis and quality of life in cancer patients.

At present in Australia, there are public health recommendations for its use in chemotherapy-induced nausea and vomiting, cancer pain, post-operative pain, post-operative nausea and vomiting, dyspnoea (shortness of breath) in palliative care, fatigue, hot flushes and sleep disturbance. There is also increasing evidence of effectiveness for xerostomia (dry mouth after radiotherapy for head and neck cancer) and arthralgia (joint and muscle pain associated with endocrine therapy for breast cancer).

What is the evidence?

1.       Acupuncture for Treatment-Induced Nausea and Vomiting

The strongest evidence to support the use of acupuncture in cancer care is in the treatment and prevention of both chemotherapy-related and radiotherapy-related nausea and vomiting (Birch et al 2019). However, a more thorough systematic review and meta-analysis is planned for 2020 (Ma et al 2020).

2.       Acupuncture for Cancer Pain

A Cochrane Systematic Review published in 2018 (Paley et al 2018) included 5 randomised controlled trials with a total of 285 participants. Due to significant heterogeneity between studies, a meta-analysis could not be performed. However, for the 5 trials, acupuncture was shown to be effective for pancreatic cancer pain, no difference over a sham control for ovarian cancer pain, superior to conventional medication for late-stage cancer pain, auricular over placebo for neuropathic cancer pain and no difference over conventional methods for stomach cancer. Although the results of individual studies were promising, the Cochrane conclusion was that there was still insufficient evidence to judge whether acupuncture is effective.

3.       Acupuncture for Hot Flushes and Menopause Symptoms in Breast Cancer

A systematic review and meta-analysis published in 2017 (Chien et al 2017) included 13 randomised controlled trials to total 844 patients with breast cancer, average age 58, using endocrine therapy. Although the results of individual studies for improving hot flush was promising, it found that overall in the meta-analysis when results of all patients were pooled, acupuncture did not have a statistically significant effect on hot flushes (p=0.34) but it did significantly ameliorate menopause symptoms including improving quality of life, sleep disturbance and mood (p=0.009). None of the studies reported on adverse events.

4.       Acupuncture for Xerostomia

A pilot study using functional MRI (Deng et al 2006) suggests a relationship between stimulating the acupuncture point at the base of the index finger that corresponds to the L1-L2 position and activation of the brain function area responsible for salivary production. This is promising. As yet, a systematic review published in 2018 (Assy et al 2018) and another in 2017 (Mercadante et al 2017) have not shown overall convincing evidence to support the use of acupuncture for xerostomia, however the results of individual trials for salivary flow production and subjective dry mouth feeling is trending positive. A further review is planned and underway (Ni et al 2019). Li et al 2015 provide guidelines for using acupuncture to treat xerostomia based on a literature review.

5.       Acupuncture for Leucopoenia

There is evidence to show that acupuncture causes statistically significant increases in G-CSF and WCC. In one trial (Zhao et al 1999) of 7 patients undergoing chemotherapy who received 9 daily treatments of acupuncture, there was a statistically significant increase in both G-CSF (p<0.001) and WCC (p<0.01). In another (Lu et al 2009) pilot study that was randomised and sham-controlled in patients receiving chemotherapy for ovarian cancer, the white cell count was higher in the group receiving acupuncture than in the control arm (p=0.046). The incidence of grade 2-4 leukopenia was less in the acupuncture arm than in the sham arm (30% versus 90%; p = 0.02). There were no statistically significant differences in plasma G-CSF between the two groups. The results warrant a larger trial.

6.       Acupuncture for Peripheral Neuropathy

A systematic review and metanalysis published in 2019 (Chien et al 2019) included 386 patients from 6 randomised controlled studies. Meta-analysis showed that acupuncture improved pain (p< 0.00001) and nerve symptoms (p<0.00001) but did not impact nerve conduction (p = 0.47).

Safety of Acupuncture

Acupuncture is safe to use when practiced by qualified practitioners. There are minimal adverse effects reported in studies, however acupuncture studies also have a paucity of reporting adverse effects.

Conclusion

The evidence is increasing for the use of acupuncture in cancer care. This is led by both patient demand, increasing clinical evidence and the integration of Eastern practices into Western medicine and its inclusion in treatment guidelines. There is evidence to support its use in cancer pain, treatment-related nausea and vomiting, arthralgia, xerostomia, peripheral neuropathy and leucopoenia.

Most importantly, is to initially consider conventional treatments under medical supervision, that have been proven to be effective, not delaying appropriate medical care and considering the addition of therapies such as acupuncture as a complement to care or when no other effective therapies are available. As with all treatments, seek advice from the treating medical team, an Integrative Consultant and a qualified Traditional Chinese Medicine Practitioner or Acupuncturist.

References

1. Lu W, Dean-Clower E, Doherty-Gilman A, Rosenthal DS. The value of acupuncture in cancer care. Hematol Oncol Clin North Am. 2008;22(4):631-viii. doi:10.1016/j.hoc.2008.04.005

2. Birch S, Lee MS, Alraek T, Kim TH. Evidence, safety and recommendations for when to use acupuncture for treating cancer related symptoms: a narrative review. Integr Med Res. 2019;8(3):160-166. doi:10.1016/j.imr.2019.05.002

3. Ma TT, Zhang T, Zhang GL, et al. Prevention of chemotherapy-induced nausea and vomiting with acupuncture: A protocol for systematic review and meta-analysis. Medicine (Baltimore). 2020;99(3):e18828. doi:10.1097/MD.0000000000018828

4. Paley CA, Johnson MI, Tashani OA, Bagnall AM. Acupuncture for cancer pain in adults. Cochrane Database Syst Rev. 2015;2015(10):CD007753. Published 2015 Oct 15. doi:10.1002/14651858.CD007753.pub3

5. Chien TJ, Hsu CH, Liu CY, Fang CJ. Effect of acupuncture on hot flush and menopause symptoms in breast cancer- A systematic review and meta-analysis. PLoS One. 2017;12(8):e0180918. Published 2017 Aug 22. doi:10.1371/journal.pone.0180918

6. Deng, GE. Randomized controlled study of fMRI changes associated with acupuncture at a point used to treat xerostomia versus sham acupuncture or gustatory stimulation. The Society for Integrative Oncology 3rd International Conference; Boston, Massachusetts. 2006

7. Assy Z, Brand HS. A systematic review of the effects of acupuncture on xerostomia and hyposalivation. BMC Complement Altern Med. 2018;18(1):57. Published 2018 Feb 13. doi:10.1186/s12906-018-2124-x

8. Mercadante V, Al Hamad A, Lodi G, Porter S, Fedele S. Interventions for the management of radiotherapy-induced xerostomia and hyposalivation: A systematic review and meta-analysis. Oral Oncol. 2017;66:64-74. doi:10.1016/j.oraloncology.2016.12.031

9. Ni X, Yu Y, Tian T, et al. Acupuncture for patients with cancer-induced xerostomia: a systematic review protocol. BMJ Open. 2019;9(12):e031892. Published 2019 Dec 16. doi:10.1136/bmjopen-2019-031892

10. Li LX, Tian G, He J. The standardization of acupuncture treatment for radiation-induced xerostomia: A literature review. Chin J Integr Med. 2016;22(7):549-554. doi:10.1007/s11655-015-2145-y

11. Zhao X, Wang H, Cao D, Li W, Tian K. Influence of acupuncture and moxibustion on serum CSF activity of patients with leukopenia caused by chemotherapy. Zhen Ci Yan Jiu 1999;(1):17–19.

12. Lu W, Matulonis UA, Doherty-Gilman A, et al. Acupuncture for chemotherapy-induced neutropenia in patients with gynecologic malignancies: a pilot randomized, sham-controlled clinical trial. J Altern Complement Med. 2009;15(7):745-753. doi:10.1089/acm.2008.0589

13. Chien TJ, Liu CY, Fang CJ, Kuo CY. The Efficacy of Acupuncture in Chemotherapy-Induced Peripheral Neuropathy: Systematic Review and Meta-Analysis. Integr Cancer Ther. 2019;18:1534735419886662. doi:10.1177/1534735419886662

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