Acupuncture in cancer pain | Cam-Cancer

Acupuncture in cancer pain

Abstract and key points
  • Acupuncture entails needling of specific points on the body surface.
  • Some positive effects have been reported but the evidence on acupuncture in cancer pain is not conclusive.
  • Serious complications are probably rare.

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.

Several reviews of the evidence have been published but, 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 a high risk of bias.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 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]. November 25, 2017.

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 patients8,9.

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 practice1.

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-£501. 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?

Systematic reviews

Several systematic reviews of acupuncture in cancer pain have been published since 2012. Three focus specifically on acupuncture for cancer pain11,22,26, 3 on acupuncture for various symptoms including pain12,13,23 and 2 include acupuncture among various treatments for pain24,25 and are  summarised here:

A Cochrane review of acupuncture for cancer pain was originally published in 2011 and updated in 201510. Three RCTs were identified in 2011 and a further 3 RCTs (total 285 participants) in the update. 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. Of the remaining two studies, one compared acupuncture with medication for unspecified cancer and the other 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.

A systematic review and meta-analysis published subsequently (in 2017) focused on various types of cancer pain: malignancy-related, chemotherapy- or radiation therapy-induced, surgery-induced, and hormone therapy-induced pain22. 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]). Sub-group analysis suggested effects were limited to malignancy-related and surgery-induced pain [effect size (g) = -0.71, and -0.40; 95% CI = -0.94 to -0.48, and -0.69 to -0.10]. Effects in the other forms of pain were not found to be significant.  A larger number of RCTs were located than in the Cochrane review even though searches were to 2014 only as the searches included Chinese language databases. Several concerns, related to the included RCTs and to the systematic review and analysis process, suggest these results should be treated with caution.

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.

Five systematic reviews examined the evidence on acupuncture for a range of symptoms in cancer patients. The first, on palliative care in cancer patients, 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). Another review13 identified a total of 11 RCTs, including a trial in aromatase-inhibitor-associated joint pain which reported positive results as did a trial in chronic pain or dysfunction attributed to neck dissection. Both studies were, however, at high risk of bias and the overall conclusions of the review were that efficacy for cancer pain ‘remains undetermined’ because of the high risk of bias among studies. A more positive result was reported in another review assessing effects in a range of symptoms including 8 trials (591 participants) in pain:  ‘meta-analysis demonstrated that acupuncture produced small-to-large effects on adverse symptoms including pain…’20. A further review focused on a range of symptoms related to breast cancer and, based on a meta-analysis of 2 RCTs, suggested that acupoint stimulation is effective for general pain in this patient group (MD=-1.46, 95% CI=-2.38 to -0.53) but the narrative summary of 4 trials stated results were inconclusive21.

Randomised controlled trials

Two RCTs have been published subsequently: a trial in of acupressure in Iranian leukaemia patients, and a trial in breast cancer patients with symptom clusters that included pain.

An RCT of acupressure for cancer pain in hospitalised leukaemia patients was carried out in Iran. This found no significant differences between 12 acupressure sessions added to treatment and standard treatment alone23. A second small, randomised, pilot trial assessed the effects of ‘true’  versus sham acupressure for symptom clusters of pain, fatigue and sleep problems in patients with breast cancer24. 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.

Several trials have been published on the use of acupuncture after procedures undergone by cancer patients e.g. post-operatively or post-procedure. Trials have also been undertaken in treatment-related arthralgia and peripheral neuropathy but these are not discussed in this summary.

Collectively, while some positive results have been reported, the evidence to suggest that acupuncture is effective in reducing cancer pain is not conclusive.

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.

References
  1. BAcC (British Acupuncture Council) website. Ten Top Things to Know. Accessed 2nd November 2017.
  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. Paley CA, Johnson MI, Tashani OA, Bagnall AM. Acupuncture for cancer pain in adults. Cochrane Database Syst Rev. 2015 Oct 15;(10):CD007753.
  11. Choi TY, Lee MS, Kim TH, Zaslawski C, Ernst E. Acupuncture for the treatment of cancer pain: a systematic review of randomised clinical trials. Support Care Cancer 2012;20(6):1147-58.
  12. Lian WL, Pan MQ, Zhou DH, Zhang ZJ. Effectiveness of acupuncture for palliative care in cancer patients: a systematic review. Chin J Integr Med. 2014 20(2):136-47.
  13. Garcia MK, McQuade J, Haddad R, Patel S, Lee R, Yang P, Palmer JL, Cohen L. Systematic review of acupuncture in cancer care: a synthesis of the evidence. J Clin Oncol. 2013 31(7):952-60.
  14. White A, Hayhoe S, Ernst E. Survey of Adverse Events Following Acupuncture Acupunct Med. 1997; 15:67-70.
  15. 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.
  16. White A. A cumulative review of the range and incidence of significant adverse events associated with acupuncture. Acupunct Med. 2004; 22(3):122-123.
  17. Ernst E. Deaths after acupuncture: a systematic review. Int J Risk Safety 2010; 22(3):131-136.
  18. BMAS (British Medical Acupuncture Society). Code of Practice & Complaints Procedure. Version 9 December 2009. Accessed 2nd November 2017. 
  19. Lau CH, Wu X, Chung VC, Liu X, Hui EP, Cramer H, et al. Acupuncture and Related Therapies for Symptom Management in Palliative Cancer Care: Systematic Review and Meta-Analysis. Medicine (Baltimore). 2016;95(9):e2901.
  20. Tao WW, Jiang H, Tao XM, Jiang P, Sha LY, Sun XC. Effects of Acupuncture, Tuina, Tai Chi, Qigong, and Traditional Chinese Medicine Five-Element Music Therapy on Symptom Management and Quality of Life for Cancer Patients: A Meta-Analysis. Journal of pain and symptom management. 2016;51(4):728-47.
  21. Lee PL, Tam KW, Yeh ML, Wu WW. Acupoint stimulation, massage therapy and expressive writing for breast cancer: A systematic review and meta-analysis of randomized controlled trials. Complementary therapies in medicine. 2016;27:87-101.
  22. Chiu HY, Hsieh YJ, Tsai PS. Systematic review and meta-analysis of acupuncture to reduce cancer-related pain. European journal of cancer care. 2017;26(2).
  23. Sharif Nia H, Pahlevan Sharif S, Yaghoobzadeh A, Yeoh KK, Goudarzian AH, Soleimani MA, et al. Effect of acupressure on pain in Iranian leukemia patients: A randomized controlled trial study. Int J Nurs Pract. 2017;23(2).
  24. Yeh CH, Chien LC, Lin WC, Bovbjerg DH, van Londen GJ. Pilot Randomized Controlled Trial of Auricular Point Acupressure to Manage Symptom Clusters of Pain, Fatigue, and Disturbed Sleep in Breast Cancer Patients. Cancer nursing. 2016;39(5):402-10.

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