Acupuncture in cancer pain | Cam-Cancer

Acupuncture in cancer pain

Abstract and key points

Acupuncture usually entails needling specific points of the body surface. According to traditional Chinese medicine (TCM) philosophy, illness is caused by imbalances of energies or a disruption to the flow of energy in the body and acupuncture is seen as a treatment that corrects these problems. Many practitioners advocate its use for a wide range of conditions and symptoms.

Four systematic reviews of the evidence on cancer pain have been published as have five reviews assessing effects on various cancer-related symptoms including pain. Collectively, the evidence to suggest that acupuncture is effective in reducing cancer-related pain is not conclusive. According to the most reliable evidence, a Cochrane systematic review from 2015, no firm conclusions about the effectiveness of acupuncture for controlling cancer pain could be drawn. Most trials generated positive results, but the trials had methodological limitations and were associated with an unclear or high risk of bias.

For acupressure, the results from three randomized trials are mixed although there is some limited evidence for self-acupressure to help manage symptom clusters including pain in the short-term.

Mild adverse effects can be expected in about 10% of all cases and serious complications, such as pneumothorax and hepatitis, seem to be rare.

Document history

Most recently updated in September 2019 by Karen Pilkington
Revised and updated in November 2017 by Karen Pilkington.
Revised and updated in August 2015 by Karen Pilkington.
Revised and updated in June 2012 by Edzard Ernst.
First published in March 2011, authored by Edzard Ernst.

Citation

Karen Pilkington, Edzard Ernst, CAM-Cancer Consortium. Acupuncture in cancer pain [online document]. September, 2019.

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’) flows1. 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 philosophy4. 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 ago5. 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 diagnosis5. 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 19714. 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/alleged indications

According to TCM concepts, acupuncture is a therapy for most symptoms and diseases. Modern Western concepts are centred around conditions likely to be influenced through effects on neurotransmitters, such as musculoskeletal pain and nausea and vomiting3,7.

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 obtained6. Neurophysiological theories to explain acupuncture’s modes of action in pain have been developed, e.g. gate-control mechanism, and effects on neurotransmitters like endorphins7.

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 patients8,9Acupuncture has been shown to be the therapy most frequently provided by integrative oncology centres across Europe, being provided by 55% of 47 centres28.

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 practice1.

For information on other countries: Read about the regulation, supervision and reimbursement of acupuncture at NAFKAMs website CAM Regulation.

Cost and expenditures

In many European countries, the cost of acupuncture ranges between EUR 35 and 95 for the first session (60-90 mins) and EUR 35-75 for ordinary appointments of 30-60 mins. In the UK, for example, average costs are £50-£70 for the first session, and £35-£50 for sessions between 30-60 minutes.1 One series of treatments would normally comprise 5-20 sessions. Please see our CAM Regulation article on acupuncture for coverage of cost by public health insurers across Europe. 

Does it work?

Summary

Several systematic reviews of acupuncture in cancer pain have been published since 2012.  Four reviews focus specifically on acupuncture for cancer pain10,11,20,23 and 5 reviews assess the evidence on acupuncture for various symptoms including pain12,13,19,24,25. Two RCTs were published after these systematic reviews; one large RCT in breast cancer patients with aromatase inhibitor‐related joint pain and a pilot study of acupuncture for self-administered acupuncture for breakthrough pain.

No systematic reviews but three RCTs focusing on acupressure were located including an assessment of self-acupressure in cancer survivors.

  • Collectively, the evidence to suggest that acupuncture is effective in reducing cancer-related pain is not conclusive. According to the most reliable evidence, a Cochrane systematic review from 2015, no firm conclusions about the effectiveness of acupuncture for controlling cancer pain could be drawn. Most trials generated positive results, but the trials had methodological limitations and were associated with an unclear or high risk of bias.
  • For acupressure, the results are mixed although there is some limited evidence for self-acupressure to help manage symptom clusters including pain in the short-term.

Acupuncture

Systematic reviews

A 2012 systematic review included 15 RCTs with a total of 1,157 participants11. Most used TCM-based acupuncture. Two used non-penetrating sham acupuncture as the control and 12 compared acupuncture against conventional medication while one compared acupuncture with chemotherapy or radiotherapy. Interventions and types of cancer varied. Few details of the methods were reported leading to the trials being assessed as at high risk of bias. Most trials reported positive results including better effects with a combination of acupuncture and medication compared with medication alone but the quality and quantity of evidence was too low for this to be confirmed.

A Cochrane review of acupuncture for cancer pain was originally published in 2011 and updated in 201510A total of 5 RCTs including 285 participants were identified. One study included people with chronic peripheral or central neuropathic pain related to cancer. Auricular acupuncture was compared with auricular acupuncture at 'placebo' points and with non-invasive vaccaria ear seeds (Semen vaccariae) attached at 'placebo' points. Participants in the true acupuncture group reported lower pain scores at two months than those in the other groups. The study was assessed as high quality but there was a question over whether blinding was maintained, which may have biased the results. One trial compared acupuncture with medication for unspecified cancer and another trial compared acupuncture with medication and with point-injection for stomach carcinoma. Both reported positive results favouring acupuncture but the reliability of the results is uncertain due to methodological limitations, small sample sizes, poor reporting and inadequate analysis. The two further RCTs included when the review was updated in 2015 compared electroacupuncture with sham acupuncture in pancreatic cancer pain and gynaecological cancer-related pain respectively. One reported positive results but blinding was unclear while the second did not find a difference but may not have been of sufficient size to do so. Meta-analysis was not carried out due to variations in the methodologies, cancer populations and techniques used and, overall, there was insufficient evidence for firm conclusions.

The Cochrane review was, however, limited to pain directly related to cancer and did not include pain from pre‐existing pathologies or treatments. A subsequent review included any type of pain in cancer patients and, consequently, included a much larger number of trials (20 RCTs with 1,639 participants)23. Acupuncture alone was not found to be superior to conventional drug therapy. A combination of acupuncture plus drug therapy was reported to be better than drug therapy alone but there was a high risk of bias in the original studies suggesting these conclusions are interpreted with caution.

A systematic review and meta-analysis published in 2017 also focused on various types of cancer pain: malignancy-related, chemotherapy- or radiation therapy-induced, surgery-induced, and hormone therapy-induced pain20. Twenty-nine RCTs were located and included in the meta-analysis. The overall effect of acupuncture on cancer-related pain was shown to be beneficial (-0.45 [95% confidence interval (CI) -0.63 to -0.26]) but sub-group analysis suggested effects were limited to malignancy-related and surgery-induced pain. A larger number of RCTs were located than in the Cochrane review as the searches included Chinese language databases but none of the RCTs were at low risk of bias on all elements. Multiple comparisons from individual trials were also used in calculating meta-analyses but appropriate adjustments to overall numbers compared were not carried out. These concerns suggests that these results should be treated with caution.

Five systematic reviews examined the evidence on acupuncture for a range of symptoms in cancer patients including cancer-related pain. One review13 identified a total of 11 RCTs, including a trial in aromatase-inhibitor-associated joint pain and a trial in chronic pain or dysfunction attributed to neck dissection both of which reported positive results. Both studies were, however, at high risk of bias and the overall conclusions of the review were that efficacy for cancer pain ‘remains undetermined’. Two reviews focused on palliative care in cancer patients: one concluded that the effectiveness of acupuncture is promising for cancer pain12. A more recent review on the same topic carried out a meta-analysis of 2 trials19. This showed a beneficial effect of acupuncture and related therapies compared with conventional treatment for pain in patients with liver or gastric cancer (2 studies, n = 175, pooled weighted mean difference: -0.76, 95% confidence interval: -0.14 to -0.39).  A review of pharmacopuncture in cancer patients revealed that although positive results were reported, there was a high risk of bias in all 8 trials in cancer pain24. The most recent review focused on breast cancer treatment-related side effects and did not find any effect on pain based on four small trials25.

The Society for Integrative Oncology (SIO) has produced evidence-based guidelines on use of integrative therapies during and after breast cancer treatment30. These have been endorsed by the American Society of Clinical Oncology31. The SIO guidelines are based on a systematic review of RCTs published up to 2015 and state that, although the 5 trials located had small sample sizes and mixed findings, acupuncture can be considered for pain associated with aromatase inhibitor associated musculoskeletal symptoms. 

Randomised controlled trials (published since the most recent systematic review)

A large multicentre RCT involved 226 breast cancer patients with aromatase inhibitor‐related joint pain32. The patients were randomised to receive true acupuncture, sham acupuncture or to join a waitlist control group for 6 weeks. The mean pain score decreased most in the true acupuncture group (2.05 points compared with 1.07 points in the sham acupuncture group and 0.99 points in the waitlist control group). The adjusted difference for true acupuncture vs sham acupuncture was 0.92 points (95% CI, 0.20‐1.65; P =0.01) and for true acupuncture vs waitlist control was 0.96 points (95% CI, 0.24‐1.67; P = 0.01). While this result is statistically significant, the clinical significance is uncertain. Patients in the true acupuncture group experienced more grade 1 bruising compared with patients in the sham acupuncture group (47% vs 25%; P = 0.01).

One further RCT (n=30) was a feasibility study of intradermal acupuncture self-administered when required for breakthrough pain27. Participants had advanced cancer with only palliative chemotherapy available. Several body acupuncture points were used and needling was compared with sham acupuncture at the same points. Twenty-seven of the 30 patients enrolled completed the trial. While the trial appeared to indicate feasibility and safety of the technique, further investigations are needed to confirm these preliminary results.

Acupressure

No systematic reviews but three RCTs focusing on acupressure were located: a trial of acupressure in Iranian leukaemia patients21 a trial in breast cancer patients with symptom clusters that included pain22 and an assessment of self-acupressure in cancer survivors26.

The RCT of acupressure for cancer pain in 100 hospitalised leukaemia patients in Iran found no significant differences between 12 acupressure sessions added to treatment and standard treatment alone21. A second small, randomised, pilot trial (n=31) assessed the effects of ‘true’ versus sham acupressure for symptom clusters of pain, fatigue and sleep problems in patients with breast cancer22. Between group differences were seen in pain and distress reflecting beneficial effects of acupressure at the end of the intervention but not at one month. One further RCT (n=288) involved daily self-administered acupressure using a ‘relaxing’ and a ‘stimulating’ protocol compared with usual care for 6 weeks26. The participants had stage 0 to III breast cancer and had completed primary treatment at least 12 months previously and were suffering from fatigue. Pain was measured using a visual analogue scale and the Brief Pain Inventory. Post-hoc analysis showed that relaxing acupressure was associated with greater reductions in pain severity, and stimulating acupressure was associated with greater reductions in pain interference after treatment. These effects were not maintained at 10 weeks.

Several trials have been published on the use of acupuncture after procedures undergone by cancer patients e.g. post-operatively or post-procedure.

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 needling14,15. In addition, in rare cases complications due to tissue trauma, pneumothorax, cardiac tamponade or infection are on record16. 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 reports17.

Contraindications

Professional bodies for acupuncture vary somewhat in defining contraindications, particularly in relation to pregnancy1,18. 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 epilepsy18.

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.

Recommendations from the US National Cancer Institute's Conference on Acupuncture for Symptom Management in Oncology in 2017 indicate that “oncology acupuncture” is a specialty area of practice. 29 Specific concerns include higher risks of infection and bleeding due to neutropenia and thrombocytopenia and possibility for hemodynamic instability due to dehydration and malnutrition. It was proposed that clinical practice guidelines are followed that take into account lab values such as absolute neutrophil and platelet counts.

References
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  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.
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