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

Acupuncture for chemotherapy-associated nausea and vomiting

Abstract and key points
  • The Pericardium 6 (P6) point is stimulated either with an acupuncture needle (acupuncture), or by a wristband or finger pressure (acupressure).
  • Acupuncture and acupressure of P6 were shown to reduce some aspects of chemotherapy-associated nausea and vomiting when given in conjunction with standard antiemetic treatments. More recent trials have produced mixed results so that overall effectiveness is currently unclear.-
  • Trials of other points are too limited to draw any conclusions on effectiveness.
  • Serious complications of acupuncture exist but are probably very rare.

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 narrative review 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.

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 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]. April 27, 2016.

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), andpungere,‘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

Two systematic reviews published in 200510 and 200911 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 patients11. 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 endpoint. Subsequently, the Cochrane review has been withdrawn from the Cochrane database as the authors were unable to complete updating in the required timescale.

Five further systematic reviews have been published since 2013. The first of these focused on acupuncture as an adjunct therapy in lung cancer patients12. 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 review, in which searches were conducted up to the end of 2011, found 11 RCTs13. 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.

Of the remaining three reviews, 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 studies15. 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)16. No between-group comparison was reported which does not allow conclusions to be drawn, particularly as significant methodological flaws were identified.

Clinical trials

Subsequent to these reviews, 8 RCTs have been published. For details please see Table 2.

Three trials investigated the effects of acupressure. Two trials of acupressure at P6 using a wrist band reported no difference between this and a ‘placebo band’17-19. One of these reported the effect of acupoint stimulation on chemotherapy-induced nausea and vomiting in 120 patients with breast, gynecological or lung cancer17. The authors reported that “real acupressure application is not an effective approach in decreasing the experience, occurrence, and problem of nausea-vomiting-retching” but there were several limitations in the reporting of the trials. The other trial involved a large sample of 500 patients and was rigorously reported18,19.  A third acupressure trial reported synergistic effects of P6 acupressure with nurse-provided counselling20.

The remaining 4 trials include one in which wrist-ankle acupuncture combined with ginger moxibustion was compared with tropisetron hydrochloride and dexamethasone in gynaecological cancer patients21. The acupuncture combination was reported to be more effective than conventional anti-emetic therapy but the trial was not blinded and so patient expectation may have influenced the result. A trial 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 missing22. No difference in effect was also observed in a trial of acustimulation at the K1 acupoint compared with electrostimulation at a placebo point23.

The final trial compared the effects of needleless transcutaneous electroacupuncture at Neiguan (PC6) and Jianshi (PC5) against electroacupuncture at non-acupoints24. Stimulation at the acupoints was reported to improve emesis and reduces nausea in the delayed phase of chemotherapy but equivalent additive effects were not recorded in the acute phase.

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 needling25,26. In addition, in rare cases complications due to tissue trauma, pneumothorax, cardiac tamponade or infection are on record27. 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 reports28.

Contraindications

Professional bodies for acupuncture vary somewhat in defining contraindications, particularly in relation to pregnancy1,29. 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 epilepsy29.

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. Available online. Accessed 17th April 2015.
  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. InIn: 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. 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.
  11. 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.
  12. 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.
  13. 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.
  14. Cheon S, Zhang X, Lee IS, Cho SH, Chae Y, Lee H. harmacopuncture for cancer care: a systematic review. Evid Based Complement Alternat Med 2014;2014:804746.
  15. 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.
  16. 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.
  17. 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.
  18. 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.
  19. 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.
  20. 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.
  21. 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.
  22. 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.
  23. 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.
  24. 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.
  25. White A, Hayhoe S, Ernst E. Survey of Adverse Events Following Acupuncture Acupunct Med 1997;15:67-70.
  26. 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.
  27. White A. A cumulative review of the range and incidence of significant adverse events associated with acupuncture. Acupunct Med 2004;22:122-123.
  28. Ernst E. Deaths after acupuncture: a systematic review. Int J Risk Safety 2010;22:131-136.
  29. BMAS (British Medical Acupuncture Society). Code of Practice & Complaints Procedure. Version 9 December 2009. Available online. Accessed 21st July 2015.

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