Description
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.
Efficacy
According to the most reliable evidence, no firm conclusions about the effectiveness of acupuncture for controlling cancer pain could be drawn.
Recent systematic reviews have been more positive reporting benefit to patients from adding acupuncture to conventional treatment.
Most trials included in reviews have generated positive results, but the trials had methodological limitations and were associated with an unclear or high risk of bias or were heterogeneous.
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. More recent trials are published in Chinese and have not been assessed in full but appear to be at unclear or high risk of bias.
Safety
Mild adverse effects can be expected in about 10% of all cases and serious complications, such as pneumothorax and hepatitis, seem to be 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).
Systematic reviews of the evidence on cancer pain include a Cochrane review published in 2015 and at least 11 other systematic reviews since that date. The scope of the acupuncture intervention and type of pain varied across the reviews. Some reviews also included study designs in addition to RCTs. Therefore, it is difficult to compare results. The systematic reviews are described in table 1. Collectively, the evidence on reducing cancer-related pain is not conclusive.
The Society for Integrative Oncology (SIO) has produced evidence-based guidelines on use of integrative therapies during and after breast cancer treatment (Greenlee 2017). These have been endorsed by the American Society of Clinical Oncology (Lyman 2018). 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.
Description of included studies
Acupuncture
A Cochrane review of acupuncture for cancer pain was updated in 2015 (Paley 2015) and confirmed as stable in 2020. A 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.
Reviews published subsequently have had a different focus or scope from the Cochrane review. This is reflected in number of RCTs included in each review which ranges from 1 to 41. There is also little overlap in the trials included in the various reviews. Five reviews included studies of a wider range of pain experienced by cancer patients (i.e. not only pain directly related to cancer but also pain related to treatments or surgery) (Hu 2016; Chiu 2017; Behzadmir 2020; He 2020; Dai 2021). Four reviews include acupressure as well as acupuncture (Behzadmir 2020; He 2020; Lau 2016; Yang 2020) while one covers various therapies (Dai 2021). Two reviews focus on pain as an adverse effect of cancer treatment (Pan 2018; Liu 2021) while three focus on pain in cancer palliative care (Dai 2021; Lau 2016; Yang 2021).
Those that are most up-to-date based on when searches for trials were carried out are the reviews by Dai (2021), Dong (2021), Yang (2020) and Yang (2021). All four reviews included trials published in English or Chinese and are described below:
Dai’s review (2021) covered various types of pain in cancer patients receiving palliative care. It also covered various acupuncture and related treatments (e.g. TENS) and studies other than RCTs. The 41 RCTs that were included tested the effects of combination treatment against analgesics alone. Only 2 RCTs had been included in the Cochrane review. Combined acupuncture and analgesics resulted in greater reduction in pain scores than analgesics alone (weighted mean difference [WMD]: 1.33 [0.85–1.82], p<0.001). The quality of the evidence was, however, rated as low.
The review by Dong (2021) focused on wrist acupuncture. Of the 8 RCTs, only 1 had been included in the Cochrane review . Acupuncture combined with analgesics was found to be more effective than analgesic alone (RR for pain relief = 1.31, 95% CI: 1.15-1.49, p<0.01]. No trials were blinded and the risk of bias was judged high.
Yang’s review (2020) focused on auricular therapy using acupuncture or acupressure. Two of the 9 RCTS had been included in the Cochrane review. The authors reported that auricular therapy combined with drug therapy was more effective than drug therapy alone based on effective rate for pain relief (RR = 1.40; 95% CI 1.22, 1.60; 4 studies). They also reported reduced adverse effects (RR = 0.46; 95% CI 0.37, 0.58) and a difference between acupuncture and sham (SMD = -1.45; 95% CI -2.80, -0.09; 2 studies). The majority of studies were at unclear risk of bias.
Yang’s review (2021) covered pain in palliative cancer patients but only 1 of the 5 included studies was an RCT and the reliability of the conclusions indicating an effect is not clear.
Of the remaining 7 reviews, two focus specifically on pain caused by cancer treatments (Liu 2021; Pan 2018). A review focused on breast cancer hormone therapy-related side effects did not find any effect on pain based on four small trials (Pan 2018). Lui’s 2021 review did find a beneficial effect on arthralgia caused by aromatase inhibitors based on 7 RCTs (mean difference in pain severity −1.57, 95% CI [−2.46, −0.68]). Four of the studies were judged at high risk of bias on one of the criteria.
Group acupuncture
A non-inferiority trial compared group acupuncture whereby patients are treated in a group setting for single conditions using standardised or semi-standardised protocols (Berkovitz 2008) with individual acupuncture for cancer pain (Reed et al. 2020). Seventy-four participants were randomly allocated to twelve treatments. Randomisation and allocation concealment are not described and blinding was not possible.
The primary outcome was pain (interference and severity) as measured by the BPI-SF. Overall attrition was 30.7% and significantly more participants receiving individual acupuncture (80%) completed both pre-assessment and post-assessment than those in the group acupuncture (58%). Both arms showed statistically significant improvements across all symptoms before and after the intervention.
Group acupuncture was found to be noninferior to individual acupuncture for treating cancer pain and was superior in many health outcomes including cost. Further confirmation of these findings are needed.
Acupressure
No systematic reviews were located that focused specifically on acupressure.
Several trials were included in systematic reviews described above. Behzadmir’s review (2020) included one trial (Zick 2018, described below). He’s review (2020) included two trials of acupressure. These were published in Chinese so few details are readily available but both appear to be open-label trials comparing of acupressure with analgesic versus analgesic alone in bone pain (n=60) and malignant neuropathic pain (n=46) respectively. Both reported positive results but were at high risk of bias.
A third trial in He’s review, combined acupressure with acupuncture so the effects of acupressure alone could not be determined. Yang’s review (2020) included a trial of auricular therapy (n=42) using press needles combined with analgesic versus analgesic alone. Positive results were again reported but risk of bias was judged unclear.
Three further RCTs focusing on acupressure were located: a trial of acupressure in Iranian leukaemia patients (Sharif 2017), a trial in breast cancer patients with symptom clusters that included pain (Yeh 2016), and an assessment of self-acupressure in cancer survivors (Zick 2018). Two further open-label studies were included in a systematic review described under Acupuncture above (He et al 2020) .
The RCT of acupressure for cancer pain in 100 hospitalised leukaemia patients found no significant differences between 12 acupressure sessions added to treatment and standard treatment alone (Sharif 2017). A second small, pilot RCT (n=31) assessed the effects of ‘true’ versus sham acupressure for symptom clusters of pain, fatigue and sleep problems in patients with breast cancer (Yeh 2016). 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 weeks (Zick 2018). 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.
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.
Behzadmehr R, Dastyar N, Moghadam MP, Abavisani M, Moradi M. Effect of complementary and alternative medicine interventions on cancer related pain among breast cancer patients: A systematic review. Complementary therapies in medicine. 2020;49:102318.
Berkovitz S, Cummings M, Perrin C, Ito R. High volume acupuncture clinic (HVAC) for chronic knee pain--audit of a possible model for delivery of acupuncture in the National Health Service. Acupunct Med. 2008 Mar;26(1):46-50.
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).
Dai L, Liu Y, Ji G, Xu Y. Acupuncture and derived therapies for pain in palliative cancer management: systematic review and meta-analysis based on single-arm and controlled trials. Journal of Palliative Medicine. 2021 Jul 1;24(7):1078-99.
Dong B, Lin L, Chen Q, Qi Y, Wang F, Qian K, et al. Wrist-ankle acupuncture has a positive effect on cancer pain: a meta-analysis. BMC complementary medicine and therapies. 2021;21(1):24
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 May 6;67(3):194-232.
He Y, Guo X, May BH, Zhang AL, Liu Y, Lu C, et al. Clinical Evidence for Association of Acupuncture and Acupressure With Improved Cancer Pain: A Systematic Review and Meta-Analysis. JAMA oncology. 2020;6(2):271-8.
Hu C, Zhang H, Wu W, Yu W, Li Y, Bai J, Luo B, Li S. Acupuncture for Pain Management in Cancer: A Systematic Review and Meta-Analysis. Evid Based Complement Alternat Med. 2016;2016:1720239. doi: 10.1155/2016/1720239.
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.
Liu X, Lu J, Wang G, Chen X, Xv H, Huang J, Xue M, Tang J. Acupuncture for Arthralgia Induced by Aromatase Inhibitors in Patients with Breast Cancer: A Systematic Review and Meta-analysis. Integr Cancer Ther. 2021 Jan-Dec;20:1534735420980811.
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 Sep 1;36(25):2647-2655. doi: 10.1200/JCO.2018.79.2721.
Paley CA, Johnson MI, Tashani OA, Bagnall AM. Acupuncture for cancer pain in adults. Cochrane Database Syst Rev. 2015 Oct 15;(10):CD007753.
Pan Y, Yang K, Shi X, Liang H, Shen X, Wang R, Ma L, Cui Q, Yu R, Dong Y. Clinical Benefits of Acupuncture for the Reduction of Hormone Therapy-Related Side Effects in Breast Cancer Patients: A Systematic Review. Integr Cancer Ther. 2018 Sep;17(3):602-618. doi: 10.1177/1534735418786801.
Reed EN, Landmann J, Oberoi D, Piedalue KA, Faris P, Carlson LE. Group versus Individual Acupuncture (AP) for Cancer Pain: a Randomized Noninferiority Trial. Evidence-based complementary and alternative medicine. 2020;2020
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).
Yang J, Wahner-Roedler DL, Zhou X, Johnson LA, Do A, Pachman DR, et al. Acupuncture for palliative cancer pain management: systematic review. BMJ supportive & palliative care. 2021.
Yang Y, Wen J, Hong J. The Effects of Auricular Therapy for Cancer Pain: A Systematic Review and Meta-Analysis. Evidence-based complementary and alternative medicine : eCAM. 2020;2020:1618767
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.
Zick SM, Sen A, Hassett AL, Schrepf A, Wyatt GK, Murphy SL, et al. Impact of Self-Acupressure on Co-Occurring Symptoms in Cancer Survivors. JNCI cancer spectrum. 2018;2(4):pky064.
Citation
Pilkington K, Ernst E, CAM-Cancer Collaboration. Acupuncture in cancer pain [online document], Sep 7, 2021.
Document history
Latest update: September 2021
Next update due: September 2024
