Acupuncture for chemotherapy-associated nausea and vomiting | Cam-Cancer

Acupuncture for chemotherapy-associated nausea and vomiting

Abstract and key points

Acupuncture or acupressure stimulation of the Pericardium 6 (P6) acupoint is a popular treatment for nausea and vomiting associated with chemotherapy. Traditional Chinese medicine (TCM) claims that chemotherapy-induced nausea and vomiting are due to the reversal of the gastrointestinal flow of "qi" (flow of energy). Stimulation of P6 is claimed to cause the qi to flow in the right (downward) direction. The antiemetic effect is likely mediated via the central opioid pathway.

Two systematic reviews, as well as one overview reported that stimulation of acupoints (mainly P6) reduced some aspects of nausea and/or vomiting associated with chemotherapy when given in conjunction with standard antiemetic treatments. Subsequent reviews have reported similar findings but the limitations in the design of these reviews and in that of the original trials prevents firm conclusions on effectiveness. Similarly, RCTs published following the most recent review have reported mixed findings, particularly when testing is against a sham or placebo treatment.

Three systematic reviews assessed other forms of acupuncture including pharmacopuncture, self-acupressure and auricular therapy (ear acupuncture). None of these reviews provides rigorous evidence of an effect of acupuncture/acupressure. Similarly, RCTs using points other than P6 have produced mixed results.

Mixed results have also been reported by two systematic reviews of moxibustion (a therapy often used as part of an acupuncture intervention).

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.

Document history

Most recent update and revision in July 2019 by Karen Pilkington. 
Fully revised and updated in March 2016 by Karen Pilkington. 
Fully revised and updated in August 2013 by Vinjar Fønnebø.
Fully revised and updated in February 2011 by Vinjar Fønnebø.
Fully revised and updated in June 2009 by Vinjar Fønnebø.
Summary first published in November 2005, authored by Vinjar Fønnebø.

Citation

Karen Pilkington, Vinjar Fønnebø, CAM-Cancer Consortium. Acupuncture for chemotherapy-associated nausea and vomiting [online document], http://cam-cancer.org/en/acupuncture-chemotherapy-associated-nausea-and-vomiting. July 10th, 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 was the therapy most frequently provided by integrative oncology centres across Europe, being provided by 55% of 47 centres10.

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. For regulation of acupuncture in European countries please visit the CAM Regulation website.

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. One series of treatments would normally comprise 5-20 sessions. Please see CAM Regulation for coverage of cost by public health insurers across Europe

Does it work?

Summary

Two systematic reviews, as well as one overview reported that stimulation of acupoints (mainly P6) reduced some aspects of nausea and/or vomiting associated with chemotherapy when given in conjunction with standard antiemetic treatments. Subsequent reviews have reported similar findings but the limitations in the design of these reviews and in that of the original trials prevents firm conclusions on effectiveness. Similarly, RCTs published following the most recent review have reported mixed findings, particularly when testing is against a sham or placebo treatment.

Three systematic reviews assessed other forms of acupuncture including pharmacopuncture, self-acupressure and auricular therapy (ear acupuncture). None of these reviews provides rigorous evidence of an effect of acupuncture/acupressure. Similarly, RCTs using points other than P6 have produced mixed results.

Mixed results have also been reported by two systematic reviews of moxibustion (a therapy often used as part of an acupuncture intervention).

The American Society of Clinical Oncology44 has endorsed evidence-based guidelines produced by the Society for Integrative Oncology (SIO) on the use of integrative therapies during and after breast cancer treatment45. The SIO guidelines are based on a systematic review of RCTs published up to 2015 and recommend acupressure and acupuncture for reducing chemotherapy-induced nausea and vomiting.

One overview summarised 6 systematic reviews, 4 of which are described below (Ezzo 200511 – cited as 2014; Chao 200912; Chen 201313; Cheon 201414), plus an older review covering a range of side effects and a review in Chinese15 Based on these, the authors claimed there is evidence for the therapeutic effects of acupuncture for the management of chemotherapy-induced nausea and vomiting.

Acupoint stimulation (mainly P6)

Two systematic reviews published in 200511 and 200912 specifically addressing acupuncture and/or acupressure in chemotherapy-induced nausea and vomiting in adults were identified. They both included 11 trials in their analyses; the 2005 review, a Cochrane review, had a total of 1247 patients in the 11 trials, while the 2009 review had 761 patients in their 11 included trials. The 2009 review had chemotherapy-induced nausea and vomiting as one of several therapy-related adverse events studied in breast cancer patients12. Both reviews reported that stimulation of acupoints (mainly P6) reduced nausea and/or vomiting. The Cochrane 2005 review reported that the effect was mainly seen on vomiting, while the second review included mainly trials where emesis reduction was the endpoint11.Subsequently, the Cochrane review has been withdrawn from the Cochrane database as the authors were unable to complete updating in the required timescale.

Two further systematic reviews have been published since 2013. The first of these focused on acupuncture as an adjunct therapy in lung cancer patients13. It appears that there were either 2 or 3 RCTs of acupuncture and 2 of acupressure in chemotherapy-associated nausea and vomiting included, all of which were published after the Cochrane review. It is difficult to interpret the results of this review as the trials reported in the tables and text do not match. Therefore, the conclusion that all forms of acupuncture treatment assessed significantly attenuated the grade of nausea and vomiting cannot be confirmed.

A second systematic review, in which searches were conducted up to the end of 2011, found 11 RCTs16. Four of these had been included in the 2005 Cochrane review and 7 had not (5 because they were published subsequently). Of the 11 RCTs, 8 were at high risk of bias, in 2 the extent of bias was unclear with 1 at low risk of bias. Positive results for acupuncture were reported; non-specific effects contributed to the effects although the specific effects were reported to be larger.

Three further trials tested acupuncture at the same point as above (P6)17-19. Two of these compared acupuncture against conventional anti-emetic medication17,18. Wrist-ankle acupuncture combined with ginger moxibustion was used in one trial in 60 gynaecological cancer patients. The acupuncture combination was reported to be more effective but the trial was not blinded and so patient expectation may have influenced the result. A trial (n=70) comparing acupuncture at P6 point with ondansetron also reported better effects of the acupuncture treatment but some details of the methods used in this trial are missing and again patient expectation may have had an impact18. When acupuncture was compared with sham, however, no effects were seen although this trial (n=68) may not have been sufficiently powered to detect a difference and more anti-emetic medication was required by the sham group19.

Four further trials (5 reports) investigated the effects of acupressure at the P6 point20-24. Two trials of acupressure at P6 using a wrist band reported no difference between this and a ‘placebo band’20-22. The first of these trials was in 120 patients with breast, gynecological or lung cancer20. No difference was found between a wristband and a ‘placebo band’ but details of the placebo band and of some of the methods were missing.. The other trial involved a large sample of 500 patients and was rigorously reported21,22.  A third acupressure trial reported synergistic effects of P6 acupressure with nurse-provided counselling for breast cancer patients23. The fourth study also reported positive effects of a wristband compared with finger pressure but suffered from a number of methodological problems24.

Other forms of acupuncture/acupoint stimulation at other points

Three systematic reviews are available. One focused on a treatment approach whereby medication is injected at acupuncture points and so the effects of acupuncture therapy alone cannot be determined14. Two assessed specific forms of treatment; one focused on self-acupressure and only located 2 studies25. Only one these was an RCT and, therefore, there was not a sufficient basis for firm conclusions on effectiveness. The final review focused on auricular therapy (ear acupuncture)26. No between-group comparison was reported which does not allow conclusions to be drawn, particularly as significant methodological flaws were identified.

Two further trials of auricular acupressure using auricular seeds reported conflicting results: one (n=48) positive results compared with no acupressure and the other (n=110) reporting no difference between specific and non-specific points27,28.

Acupuncture at several points was reported to be more effective than no acupuncture but key details on the study (n=56) were missing, it was not blinded and was self-assessed29.

No difference in effect was also observed in a trial (n=103) of acustimulation at the K1 acupoint compared with electrostimulation at a placebo point30.

No significant difference was found between electroacupuncture and sham or placebo electroacupuncture in two trials (n=153, n=142)31,32. These findings are in contrast to those of a third trial (n=72)33. Stimulation at the acupoints was reported to improve emesis and reduce nausea in the delayed phase of chemotherapy but equivalent additive effects were not recorded in the acute phase. One trial combined moxibustion with acupoint massage and reported better effects than with anti-emetic therapy but these results have not been confirmed by subsequent trials and the risk of bias would be high due to the obvious difference between the treatments34.

Moxibustion

The two most recent systematic reviews focus on moxibustion. The first, a Cochrane review, assessed moxibustion for various indications related to cancer treatment35. Nine trials suggested evidence of beneficial effects when compared to sham (1 trial) or used alongside conventional drug treatment (8 trials). High risk of bias, however, was identified in all these trials. The second review of moxibustion included more trials and found evidence of effects compared with no treatment but no effects when used with drug treatment36. Risk of bias was again a concern but the reason for the difference in conclusions of the two reviews is unclear.

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 needling37,38. Most commonly reported problems are local pain (3.3%), bruising (3.2%), minor bleeding (1.4%), and orthostatic problems (0.5%)39.   In addition, in rare cases complications due to tissue trauma, pneumothorax, cardiac tamponade or infection are on record40. 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 reports41.

Contraindications

Professional bodies for acupuncture vary somewhat in defining contraindications, particularly in relation to pregnancy1,42. 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 epilepsy2.

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 practice43. 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
  1. BAcC (British Acupuncture Council) website. Ten Top Things to Know. Available online. Accessed 10th July 2019.
  2. Filshie, J., Cummings, M. Western medical acupuncture. In: Ernst E, White A.  (Eds). Acupuncture: A Scientific Appraisal. 1999. Oxford: Butterworth-Heinemann, 1999. pp 31-59.
  3. White A, Editorial Board of Acupuncture in Medicine. Western medical acupuncture: a definition. Acupunct Med 2009;27:33-5.
  4. White A, Ernst E. Introduction. In: Ernst E, White, A. (Eds). Acupuncture: A Scientific Appraisal. Oxford: Butterworth-Heinemann, 1999. 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. Oxford: Butterworth-Heinemann, 1999. 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;29:245-56.
  7. Zhao ZQ. Neural mechanism underlying acupuncture analgesia. Prog Neurobiol 2008;84:355-375.
  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;16:655-63.
  10. Rossi E, Vita A, Baccetti S, Di Stefano M, Voller F, Zanobini A. Complementary and alternative medicine for cancer patients: results of the EPAAC survey on integrative oncology centres in Europe. Support Care Cancer. 2015 23(6):1795-806.
  11. Ezzo J, Vickers A, Richardson MA, Allen C, Dibble SL, Issell B et al. Acupuncture-point stimulation for chemotherapy-induced nausea and vomiting. J Clin Oncol 2005;23:7188-98.
  12. Chao LF, Zhang AL, Liu HE, Cheng HM et al. The efficacy of acupoint stimulation for the management of therapy related adverse events in patients with breast cancer: a systematic review. Breast Cancer Res Treat 2009;118:255-267.
  13. Chen HY, Li SG, Cho WC, Zhang ZJ. The role of acupoint stimulation as an adjunct therapy for lung cancer: a systematic review and meta-analysis. BMC Complement Altern Med;2013 13:362.
  14. Cheon S, Zhang X, Lee IS, Cho SH, Chae Y, Lee H. Pharmacopuncture for cancer care: a systematic review. Evid Based Complement Alternat Med 2014;2014:804746.
  15. Wu X, Chung VC, Hui EP, Ziea ET, Ng BF, Ho RS, et al. Effectiveness of acupuncture and related therapies for palliative care of cancer: overview of systematic reviews. Scientific reports. 2015;5:16776.
  16. Garcia MK, McQuade J, Lee R, Haddad R, Spano M, Cohen L. Acupuncture for symptom management in cancer care: an update. Curr Oncol Rep 2014;16:418.
  17. Liu Y, Sun QS, Dong HJ, Zhai DX, Zhang DY, Shen W, Bai LL, Yu J, Zhou LH, Yu CQ. Wrist-ankle acupuncture and ginger moxibustion for preventing gastrointestinal reactions to chemotherapy: A randomized controlled trial. Chin J Integr Med 2015;21:697-702.
  18. Rithirangsriroj K, Manchana T, Akkayagorn L. Efficacy of acupuncture in prevention of delayed chemotherapy induced nausea and vomiting in gynecologic cancer patients. Gynecol Oncol 2015;136:82-6.
  19. Widgren Y, Enblom A. Emesis in patients receiving acupuncture, sham acupuncture or standard care during chemo-radiation: A randomized controlled study. Complementary therapies in medicine. 2017;34:16-25.
  20. Genc A, Can G, Aydiner A. The efficiency of the acupressure in prevention of the chemotherapy-induced nausea and vomiting. Support Care Cancer 2013;21:253-61.
  21. Molassiotis A, Russel W, Hughes J, Breckons M, Lloyd-Williams M, Richardson J, Hulme C, Brearley S, Campbell M, Garrow A, Ryder W. The effectiveness and cost-effectiveness of acupressure for the control and management of chemotherapy-related acute and delayed nausea: Assessment of Nausea in Chemotherapy Research (ANCHoR), a randomised controlled trial. Health Technol Assess 2013;17: 1-114.
  22. Molassiotis A, Russel W, Hughes J, Breckons M, Lloyd-Williams M, Richardson J, Hulme C, Brearley S, Campbell M, Garrow A, Ryder W. The effectiveness of acupressure for the control and management of chemotherapy-related acute and delayed nausea: a randomized controlled trial. J Pain Symptom Manage 2014;47:12-25.
  23. Suh EE. The effects of P6 acupressure and nurse-provided counseling on chemotherapy-induced nausea and vomiting in patients with breast cancer. Oncol Nurs Forum 2012;39:E1-9.
  24. Avc HS, Ovayolu N, Ovayolu O. Effect of Acupressure on Nausea-Vomiting in Patients With Acute Myeloblastic Leukemia. Holistic nursing practice. 2016;30(5):257‐62.
  25. Song HJ, Seo HJ, Lee H, Son H, Choi SM, Lee S. Effect of self-acupressure for symptom management: a systematic review. Complement Ther Med 2015;23:68-78.
  26. Tan JY, Molassiotis A, Wang T, Suen LK. Current evidence on auricular therapy for chemotherapy-induced nausea and vomiting in cancer patients: a systematic review of randomized controlled trials. Evid Based Complement Alternat Med 2014;2014:430796.
  27. Eghbali M, Varee S, Yekaninejad MS, Jalalinia SF, Samimi MA, Saatchi K. Use of ear acupressure as a strategy to relieve nausea and vomiting caused by chemotherapy in patients with breast cancer. Avicenna journal of phytomedicine. 2015;5:32‐3.
  28. Kong C, Han M, Zhang C, Zhao Z, Fang F, Zhang Z, et al. Auricular point acupressure improved nausea, vomiting, diarrhea and nutritional status in gastric cancer patients receiving oral s-1 therapy. International journal of clinical and experimental medicine. 2018;11(9):9200-9209.
  29. Zhou J, Fang L, Wu WY, He F, Zhang XL, Zhou X, et al. The effect of acupuncture on chemotherapy-associated gastrointestinal symptoms in gastric cancer. Current oncology (Toronto, Ont). 2017;24(1):e1-e5.
  30. Shen Y, Liu L, Chiang JS, Meng Z, Garcia MK, Chen Z, Peng H, Bei W, Zhao Q, Spelman AR, Cohen L. Randomized, placebo-controlled trial of K1 acupoint acustimulation to prevent cisplatin-induced or oxaliplatin-induced nausea. Cancer 2015; 121: 84-92.
  31. McKeon C, Smith CA, Gibbons K, Hardy J. EA versus sham acupuncture and no acupuncture for the control of acute and delayed chemotherapy-induced nausea and vomiting: a pilot study. Acupuncture in medicine. 2015;33(4):277‐83.
  32. Xie J, Chen LH, Ning ZY, Zhang CY, Chen H, Chen Z, et al. Effect of transcutaneous electrical acupoint stimulation combined with palonosetron on chemotherapy-induced nausea and vomiting: a single-blind, randomized, controlled trial. Chinese journal of cancer. 2017;36(1):6.
  33. Zhang X, Jin HF, Fan YH, Lu B, Meng LN, Chen JD. Effects and mechanisms of transcutaneous electroacupuncture on chemotherapy-induced nausea and vomiting. Evid Based Complement Alternat Med 2014;2014:860631.
  34. Fang X, Wu H, Xu Y. Observation on curative effect of portable moxibustion combined with acupoint massage in the treatment and prevention of vomiting after chemotherapy for breast cancer. International journal of clinical acupuncture. 2012;21(4):150‐1.
  35. Zhang HW, Lin ZX, Cheung F, Cho WC, Tang JL. Moxibustion for alleviating side effects of chemotherapy or radiotherapy in people with cancer. The Cochrane database of systematic reviews. 2018;11:Cd010559
  36. Huang Z, Qin Z, Yao Q, Wang Y, Liu Z. Moxibustion for Chemotherapy-Induced Nausea and Vomiting: A Systematic Review and Meta-Analysis. Evid Based Complement Alternat Med. 2017;2017:9854893. doi: 10.1155/2017/9854893.
  37. White A, Hayhoe S, Ernst E. Survey of Adverse Events Following Acupuncture Acupunct Med 1997;15:67-70.
  38. 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;16:91-7.
  39. Melchart D, Weidenhammer W, Streng A., et al. Prospective investigation of adverse effects of acupuncture in 97 733 patients. Arch Intern Med. 2004;1641:104–105.
  40. White A. A cumulative review of the range and incidence of significant adverse events associated with acupuncture. Acupunct Med 2004;22:122-123.
  41. Ernst E. Deaths after acupuncture: a systematic review. Int J Risk Safety 2010;22:131-136.
  42. BMAS (British Medical Acupuncture Society). Code of Practice & Complaints Procedure. Version 9 December 2009. Available online. Accessed 10th July 2019.
  43. Zia FZ, Olaku O, Bao T, et al. The National Cancer Institute's Conference on Acupuncture for Symptom Management in Oncology: State of the Science, Evidence, and Research Gaps. J Natl Cancer Inst Monogr. 2017;2017(52).
  44. Lyman GH, Greenlee H, Bohlke K, Bao T, DeMichele AM, Deng GE, Fouladbakhsh JM, Gil B, Hershman DL, Mansfield S, Mussallem DM, Mustian KM, Price E, Rafte S, Cohen L. Integrative Therapies During and After Breast Cancer Treatment: ASCO Endorsement of the SIO Clinical Practice Guideline. J Clin Oncol. 2018;36(25):2647-2655.
  45. Greenlee H, DuPont-Reyes MJ, Balneaves LG, Carlson LE, Cohen MR, Deng G, Johnson JA, Mumber M, Seely D, Zick SM, Boyce LM, Tripathy D. Clinical practice guidelines on the evidence-based use of integrative therapies during and after breast cancer treatment. CA Cancer J Clin. 2017;67(3):194-232.

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