Description
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. Many providers advocate it for a wide range of conditions and symptoms, including cancer-related breathlessness. Two randomised controlled trials (RCT) of acupuncture, an RCT of acupressure and a small randomised pilot study of acupressure are available.
Efficacy
Four RCTs have not demonstrated a clear effect of acupuncture on breathlessness as results have been non-significant or the clinical significance is unclear.
One trial suggested possible beneficial effects of acupuncture in reducing morphine requirements and reducing anxiety related to breathlessness. These preliminary findings require further confirmation.
Safety
Mild adverse effects can be expected in about 10% of all cases, and serious complications, such as pneumothorax and hepatitis, seem to be very rare.
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 acus, ‘needle’ (noun), and pungere, ‘to prick or puncture’ (verb).
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.
Background and prevalence
The history of acupuncture can be traced to ancient China and its Taoist philosophy (White 1999). 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 (Birch 1999). 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 (Birch 1999). Yet, in recent years, pain-control seems to have become its main purpose in many clinical settings.
The history of acupuncture can be traced to ancient China and its Taoist philosophy (White 1999). 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 (Birch 1999). 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 (Birch 1999). Yet, in recent years, pain-control seems to have become its main purpose in many clinical settings. Most modern pain clinics and many oncology centres across the world routinely offer acupuncture as one of several therapeutic options. In integrative oncology centres across Europe, acupuncture was the therapy most frequently provided by being provided by 55% of 47 centres (Rossi 2015).
Application and providers
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 (BAcC 2019).
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’ (Filshie 1999, White 2009).
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 vomiting (White 2009, Zhao 2008).
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 (Ahn 2008). 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 (Zhao 2008).
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. Information on the regulation of acupuncture in European countries can be found on websites such as that of the European Traditional Chinese Medicine Association (ETCMA).
No systematic reviews have focused specifically on acupuncture for breathlessness due to cancer but either included breathlessness due to other disease states (van Trott 2020) or assessed acupuncture for breathlessness in cancer alongside other interventions (e.g. Dy 2020). Few trials have been carried out and the findings of systematic reviews are based on one or more of these trials. Two randomised controlled trials (RCT) of acupuncture (Minchom 2016, Vickers 2005), an RCT of acupressure (Dogan 2020) and a small randomised pilot study of acupressure (Strong 2016) are available.
Description of included RCTs of acupuncture
One RCT involved the treatment of 47 patients suffering from advanced breast or lung cancer and breathlessness (American Thoracic Society Breathlessness score 2 or higher) (Vickers 2005). They received a single session of real or sham acupuncture (needling at non-specific points) in addition to standard drug treatments. Semi-permanent studs were subsequently inserted for twice daily self-treatments. Follow-up was one week. Forty-five patients were followed up using a 0-10 breathless scale. The results show a slight but not statistically significant advantage in terms of symptomatic relief for the real acupuncture group. The authors concluded that the acupuncture technique used in this trial is unlikely to have effects on dyspnoea (breathlessness) 'importantly larger than placebo' for patients with advanced cancer. The methodology including allocation and blinding was rigorous.
In a subsequent RCT, acupuncture was compared with morphine and with acupuncture combined with morphine (Minchom 2016). The 173 patients treated were suffering from breathlessness associated with advanced non-small cell lung cancer and mesothelioma. Acupuncture treatment included semi-permanent intrastuds for massaging when symptomatic. Response was based on patients achieving >1.5 improvement in VAS dyspnoea at 4 h. This was achieved in 74%, 60% and 66% of patients treated with acupuncture, morphine and the combination respectively. No statistically significant difference in overall response was observed between the 3 groups. The groups were similar at baseline but the trial was slightly underpowered to detect a difference in effects. Details of the randomisation process are limited (e.g. who carried allocation out) and blinding was not feasible due to the type of interventions. Fewer patients, however, treated with acupuncture required at least one morphine dose (p<0.0001) and acupuncture was linked with less adverse effects than morphine. Acupuncture also had an anxiolytic effect in this situation as suggested in a subsequent conference abstract of this study (Minchom 2017)
Description of included RCTs of acupressure
Auricular acupressure involving application of Vaccaria segetalis (a small seed) to the ear, was assessed in a small 3-arm randomised pilot study (Strong 2016). Advanced lung cancer patients were randomised to standard care plus auricular acupressure at non-specific points, to acupressure at points considered specific to lung function plus standard care, or to standard care alone. The Cancer Dyspnea Scale and oxygen saturation were used to assess effects. Significant effects were reported but, as only 11 patients in total were involved and blinding could not be fully achieved, these results are preliminary and need further confirmation.
An RCT conducted in a university hospital in Turkey compared acupressure to usual care in 60 patients with advanced lung cancer (Dogan, 2020). Acupressure was applied twice daily for 4 weeks by patients after an initial instruction session. A statistically significant between group difference was reported in median breathlessness scores, both before a 6 minute walking test (p=0.004) and after a 6 minute walking test (p=0.018). It is unclear if the difference was clinically relevant. Trial methods were rigorous but acupressure was self-administered and blinding was not possible.
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 (Coyle 2014, White 1997, Witt 2009). Most commonly reported problems are local pain (3.3%), bruising (3.2%), minor bleeding (1.4%), and orthostatic problems (0.5%) (Melchart 2004). In addition, in rare cases complications due to tissue trauma, pneumothorax, cardiac tamponade or infection are on record (White 2004).
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 (Ernst 2010).
Safety incidents have been assessed that were linked to acupuncture treatments received in a healthcare setting (UK National Health Service) (Wheway 2012). The 325 incidents over a 3 year period included retained needles (31%), dizziness (30%), loss of consciousness/unresponsive (19%), falls (4%), bruising or soreness at needle site (2%), pneumothorax (1%) and other adverse reactions (12%). The majority (95%) of the incidents were categorised as low or no harm.
Contraindications
Professional bodies for acupuncture vary somewhat in defining contraindications, particularly in relation to pregnancy (BAcC 2019, BMAS 2019). 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 (Filshie 1999).
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 (Zia 2017). 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.
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BAcC (British Acupuncture Council) website: accessed 15th February 2021. Top 10 Things to Know is accessible via the homepage.
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.
BMAS (British Medical Acupuncture Society): Code of Practice, version 10 August 2018. Accessed 26th January 2021.
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Minchom A, Punwani R, Filshie J, Bhosle J, Nimako K, Myerson J, et al. A randomised study comparing the effectiveness of acupuncture or morphine versus the combination for the relief of dyspnoea in patients with advanced non-small cell lung cancer and mesothelioma. Eur J Cancer 2016; 61:102-10pp.
Minchom A, Punwani R, Filshie J, Bhosle J, Nimako K, Myerson J, et al. Anxiolytic effect of acupuncture in a phase II study of acupuncture and morphine for dyspnea in lung cancer and mesothelioma. Journal of thoracic oncology. 2017;12(1):S1415‐S6. (conference abstract)
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Strong RA, Georges JM, Connelly CD. Pilot Evaluation of Auricular Acupressure in End-Stage Lung Cancer Patients. Journal of palliative medicine. 2016;19(5):556-8.
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Citation
Pilkington K, Ernst E, CAM Cancer Collaboration. Acupuncture for breathlessness [online document], Feb 15, 2021
Document history
Latest update: February 2021
Next update due: February 2024
