Written by Karen Pilkington, Edzard Ernst and the CAM-Cancer Consortium.
Updated July 16, 2015

Acupuncture for treatment-induced leukopenia

Abstract and key points

  • Acupuncture usually entails the needling of specific points located on the body surface.
  • The effectiveness of acupuncture for cancer treatment-induced leukopenia is uncertain.
  • Serious complications of acupuncture exist but are probably very rare.

Acupuncture typically entails needling specific points of the body surface. According to Traditional Chinese Medicine (TCM) philosophy, illness is caused by imbalances of energies in the body and acupuncture is a treatment that re-balances energies. Therefore, it is claimed by TCM-practitioners to be helpful in most human condition. By contrast, most Western acupuncturists follow the principles of conventional medicine and would employ acupuncture only for specific conditions. Yet both types of practitioners might advocate acupuncture for a wide range of conditions and symptoms. Treatment-induced leukopenia (reduced number of white blood cells) is one condition for which acupuncture treatment has been suggested. The evidence for the effectiveness of acupuncture for this indication is, however, very limited. The existing studies are mostly published in Chinese and thus difficult to access; more importantly, they are all of poor methodological quality.

Mild adverse effects, e.g. pain or bleeding at the site of acupuncture can be expected in about 10% of all cases, and serious complications, such as pneumothorax and hepatitis, seem to be very rare.

Read about the regulation, supervision and reimbursement of acupuncture at NAFKAMs website CAM Regulation.

What is it?

Scientific name/Description

Acupuncture refers to the insertion of fine needles at specific points (acupuncture points or acupoints) on the body for the prevention or treatment of disease or the maintenance of health. The term ‘acupuncture’ is derived from Latin and means ‘piercing with a sharp instrument’. from Latinacus,‘needle’ (noun), and pungere,‘to prick or puncture’ (verb).

Ingredients/Components

Acupuncture is usually performed with fine, solid needles but many variations exist. ‘Acupoints’ might, for instance, be stimulated by electrical currents with or without needles (electro-acupuncture), by pressure (acupressure involving use of ‘press’ needles, studs or manual pressure), by heat (moxibustion) or laser light (laser-acupuncture). Techniques that do not involve the insertion of needles are not always classed as acupuncture.

Acupuncture is often part of a complex intervention that includes use of herbal mixtures, moxibustion (burning of herbs), and dietary and lifestyle advice.

Application and dosage

Acupuncture is applied to the body surface including the ears and scalp. The dosage (number of points stimulated, depth of needle insertion, duration of stimulation and frequency and duration of treatment sessions) depends on the condition treated. Sometimes only one acupoint is stimulated; more commonly several needles are applied. A specific area of the body (for example, ear-acupuncture) may be treated but, more commonly, several areas are needled. Needles are usually removed after a 30 minute treatment session but press needles and studs may be left for several days or, in some cases, weeks. Needles may be stimulated by manual manipulation or left unstimulated. Treatments may be repeated at regular intervals, for example once or twice weekly, or treatment can comprise of a single session.

The placement of needles is determined by the condition being treated and, to some extent, by the type of acupuncture being applied. In traditional Chinese or East Asian forms of acupuncture, acupoints are considered to be located along channels or ‘meridians’ through which a vital force or energy (‘Qi’) flows.1 Diagnosis is carried out using a number of methods including peripheral pulses, the appearance of the tongue, speech, history and overall impressions of the patient. The ‘symptom pattern’ and underlying ‘imbalances’ guide selection of points. In ‘Western medical’ acupuncture, points are selected according to contemporary neurophysiology and are considered to be sites where external stimuli result in a greater sensory stimulus,  so-called ‘trigger points’.2,3

History/providers

The history of acupuncture can be traced to ancient China and its Taoist philosophy.4 It has been practised in China for more than 2000 years and in other East Asian countries including Japan, Korea and Vietnam, for between 1000 to 2000 years arriving in Europe several hundred years ago.5 In traditional Chinese medicine (TCM), the life energy ‘Qi’ flowing through the body in meridians and the balance of ‘yin’ and ‘yang’ are thought to determine human health. Illness is seen as an imbalance of these energies and acupuncture is perceived to be one method for re-balancing the imbalance. Traditionally, acupuncture was not used primarily for specific problems such as pain control but to treat a wide range of symptoms or problems based on the pattern of diagnosis.5 Yet, in recent years, pain-control seems to have become its main purpose in many clinical settings.

Acupuncture became particularly popular outside Asia after the US president Richard Nixon visited China in 1971.4 Acupuncture treatments were originally provided by traditional acupuncturists but as interest in the technique extended, health professionals adopted and adapted the techniques, using acupuncture alongside conventional treatment.

Claims of efficacy

In TCM, acupuncture is considered to be a therapy for most human illnesses. In Western medical acupuncture, the main focus of claims of efficacy is on treatment of musculoskeletal pain and nausea and vomiting.3

Mechanisms of action

Considerable research effort has been focused on finding physiological or histological evidence of the existence of concepts postulated within TCM acupuncture such as Qi, meridians and specific acupuncture points but conclusive proof has not been obtained.6 Neurophysiological theories to explain acupuncture’s modes of action in pain have been developed, e.g. gate-control mechanism, and effects on neurotransmitters like endorphins.7

Alleged indications

According to TCM concepts, acupuncture is a therapy for most symptoms and diseases. Modern concepts are centred around the management of pain and conditions likely to be influenced through effects on neurotransmitters.7

Prevalence of use

In many countries, acupuncture is now one of the most popular forms of CAM. Most modern pain clinics and many oncology centres across the world routinely offer acupuncture as one of several therapeutic options. Exact prevalence figures vary from country to country and from setting to setting. A survey of cancer patients in Europe reported use of acupuncture by between 2 to 4% of patients before and after diagnosis but use varied by cancer type and acupuncture was used by up to 17% of gynaecological cancer patients.8,9

Legal issues

In most countries, acupuncture can be administered by both medically-trained and statutorily regulated health professionals (e.g. doctors, physiotherapists, nurses, midwives) and by non-medically-trained acupuncturists. The regulation of acupuncture varies from one country to another. In the UK, there is voluntary rather than statutory regulation and local authorities can regulate hygiene of acupuncture practice.1

Cost and expenditures

In the UK, average costs are £40-£70 for the first session, with ordinary appointments of between 30-60 minutes between £25-£50.1 One series of treatments would normally comprise 5-20 sessions. In Germany, costs of acupuncture for some conditions are covered by public health insurers.

Does it work?

The notion that acupuncture might normalise pathologically low leukocyte counts in cancer patients emerged from several Chinese case series (e.g. 10,11) and poorly-controlled studies (e.g. 12). Subsequently, several controlled clinical trials were published and summarised in one systematic review.13

Systematic reviews

This review covered the publication period from 1979 to 2004 and included 11 controlled clinical trials where patients had been randomised to receive either acupuncture or usual care only.13 All the studies came from China and had been published in non-Medline listed Chinese journals. Their quality was rated by the review authors to be poor. Patients were treated once a day for 21 days on average. Only 7 trials published leukocyte counts; a meta-analysis across these studies showed a significant increase of leukocyte counts of 1,221 WBC/muL in the acupuncture compared to the control groups. The authors of the review concluded that the poor quality of the primary studies and publication bias might have generated a false positive overall impression.

Randomised controlled trials

Since the publication of this review, two trials published in journals indexed in English language databases.

A randomised pilot RCT compared acupuncture with sham-acupuncture in 21 patients with chemotherapy-induced leukopenia.14 The authors reported clinically relevant trends towards normalisation of the leukopenia; however, due to the fact that this was merely a small pilot, no conclusions regarding effectiveness can be drawn from this study.

A Chinese team randomised 86 patients with chemotherapy-induced leukopenia into receiving granulocyte colony-stimulating factor with or without acupuncture.15 After 10, 17 and 24 days, the leukocyte counts were higher in the group receiving acupuncture. Apparently, there were no inter-group differences at the end of the follow-up period at 45 days. The study was published in Chinese, and only an English abstract is available which omits important details; interpretation of its results is therefore problematic.

Is it safe?

Adverse events

In about 8-10% of all patients, acupuncture causes mild, transient adverse effects such as pain, haematoma or bleeding at the site of needling.16,17 In addition, in rare cases complications due to tissue trauma, pneumothorax, cardiac tamponade or infection are on record.18 Risk of cross-infection of blood borne disease, particularly hepatitis B, is minimised by the use of sterile disposable needles, and immunisation of acupuncturists. Rare cases of fatalities after acupuncture treatment have been reported although causality was not confirmed in many of these reports.19

Contraindications

Professional bodies for acupuncture vary somewhat in defining contraindications, particularly in relation to pregnancy.1,20 Bleeding abnormalities and anticoagulant treatment, oedema, epilepsy, pregnancy and needle phobia are among those conditions that have been suggested as relative, or in some cases absolute, contra-indications. Some points are considered ‘forbidden’ or not to be used for acupuncture needling.

Interactions

None known, except for electro-acupuncture where the electrical current might interfere with pacemakers and is used with caution in epilepsy.20

Warnings

Strict asepsis and use of sterile disposable needles are mandatory to avoid infections. Some patients faint during acupuncture and should thus be treated lying down.

Citation

Karen Pilkington, Edzard Ernst, CAM-Cancer Consortium. Acupuncture for treatment-induced leukopenia [online document]. http://cam-cancer.org/The-Summaries/Mind-body-interventions/Acupuncture-for-treatment-induced-leukopenia. July 16, 2015.

Document history

Revised in July 2015 by Karen Pilkington.
Summary first published in April 2013, authored by Edzard Ernst.

References

  1. BAcC (British Acupuncture Council) website. Ten Top Things to Know. Available at: www.acupuncture.org.uk. Accessed 17th April 2015.
  2. Filshie, J., Cummings, M. Western medical acupuncture. In: Ernst, E., White, A.  (Eds). Acupuncture: A Scientific Appraisal. 1999. Butterworth-Heinemann, Oxford. pp 31-59.
  3. White A; Editorial Board of Acupuncture in Medicine. Western medical acupuncture: a definition. Acupunct Med. 2009 27(1):33-5.
  4. White A, Ernst E. Introduction. In: Ernst, E., White, A. (Eds). Acupuncture: A Scientific Appraisal. 1999. Butterworth-Heinemann, Oxford. pp1-10.
  5. Birch S, Kaptchuk T. History, nature and current practice of acupuncture: an East Asian perspective. In: Ernst, E., White, A.  (Eds). Acupuncture: A Scientific Appraisal. 1999. Butterworth-Heinemann, Oxford. pp 11-30.
  6. Ahn AC, Colbert AP, Anderson BJ, Martinsen OG, Hammerschlag R, Cina S, Wayne PM, Langevin HM. Electrical properties of acupuncture points and meridians: a systematic review. Bioelectromagnetics. 2008 29(4):245-56.
  7. Zhao ZQ. Neural mechanism underlying acupuncture analgesia. Prog Neurobiol 2008; 84(4):355-375.
  8. Molassiotis A, Browall M, Milovics L, Panteli V, Patiraki E, Fernandez-Ortega P. Complementary and alternative medicine use in patients with gynecological cancers in Europe. Int J Gynecol Cancer. 2006 16 Suppl 1:219-24.
  9. Molassiotis A, Fernadez-Ortega P, Pud D, Ozden G, Scott JA, Panteli V, Margulies A, Browall M, Magri M, Selvekerova S, Madsen E, Milovics L, Bruyns I, Gudmundsdottir G, Hummerston S, Ahmad AM, Platin N, Kearney N, Patiraki E. Use of complementary and alternative medicine in cancer patients: a European survey. Ann Oncol. 2005 16(4):655-63.
  10. Wei Z. Clinical observation on therapeutic effect of acupuncture at zusanli for leukopenia. J Tradit Chin Med 1998; 18: 94-5.
  11. Huang X, Chen H, Guo X et al. Treatment with cone moxibustion of chemotherapeutic leukocytopenia in 114 cases. J Tradit Chin Med 1993; 13: 266-7.
  12. Chen HL, Huang XM. Treatment of chemotherapy-induced leukocytopenia with acupuncture and moxibustion. [in Chinese]. Zhong Xi Yi Jie He Za Zhi 1991; 11: 350-2.
  13. Lu W, Hu D, Dean-Clower E et al. Acupuncture for chemotherapy-induced leukopenia: exploratory meta-analysis of randomized controlled trials. J Soc Integr Oncol 2007; 5: 1-10.
  14. 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: 745-53.
  15. Han YF, Gong Z, Huang LQ et al. Clinical study on acupuncture for leukopenia induced by chemotherapy. [in Chinese]. Zhongguo Zhen Jiu 2010; 30: 802-5.
  16. White A, Hayhoe S, Ernst E. Survey of Adverse Events Following Acupuncture Acupunct Med. 1997; 15:67-70.
  17. Witt CM, Pach D, Brinkhaus B, Wruck K, Tag B, Mank S, Willich SN. Safety of acupuncture: results of a prospective observational study with 229,230 patients and introduction of a medical information and consent form. Forsch Komplementmed. 2009 Apr;16(2):91-7. doi: 10.1159/000209315. Epub 2009 Apr 9.
  18. White A. A cumulative review of the range and incidence of significant adverse events associated with acupuncture. Acupunct Med. 2004; 22(3):122-123.
  19. Ernst E. Deaths after acupuncture: a systematic review. Int J Risk Safety 2010; 22(3):131-136.
  20. BMAS (British Medical Acupuncture Society). Code of Practice & Complaints Procedure. Version 9 December 2009. Available at: http://www.medical-acupuncture.co.uk/LinkClick.aspx?fileticket=HTz5FvjFjfA%3d&tabid=64. Accessed 21st July 2015.