Acupuncture for treatment-induced leukopenia

The notion that acupuncture might normalise pathologically low leukocyte counts in cancer patients emerged from several  case series (e.g Wei 1998, Huang1993) and poorly-controlled studies (e.g Chen 1991). Subsequently, several controlled clinical trials were published and summarised in one systematic review (Lu 2007).

Systematic reviews of acupuncture (including 11 trials assessing leukocyte counts) as well as two additional trials are available. Two reviews of moxibustion, one thereof a Cochrane review (n=25) are available. Seventeen studies in a more recent  systematic review  of both acupuncture and moxibustion are also available.

Acupuncture

An overview of systematic reviews of acupuncture for palliative care in cancer included two systematic reviews (Wu 2015). The first review included 11 controlled clinical trials published up to 2004, in which patients were randomised to receive either acupuncture or usual care only (Lu 2007). Their quality was rated by the review authors to be poor. Patients were treated once a day for 21 days on average. Only 7 trials published leukocyte counts; a meta-analysis across these studies showed a significant increase of leukocyte counts of 1,221 WBC/microliter (WMD 1.22; 95%CI 0.64 to 1.81) in the acupuncture compared to the control groups. The authors of the review concluded that the poor quality of the primary studies and publication bias might have generated a false positive overall impression.

The second review included two trials in breast cancer patients published up to 2008 (Chao 2009). Only one study was controlled but both trials involved injection of a drug at acupuncture points, thus confounding any effects of needling. The methodological quality of both studies was rated as poor.

Since the publication of these reviews, two trials have been published in journals indexed in English language databases.

A pilot RCT compared acupuncture with sham-acupuncture in 21 patients with chemotherapy-induced leukopenia (Lu 2009). The authors reported clinically relevant trends towards normalisation of the leukopenia; however, due to the fact that this was merely a small pilot, no conclusions regarding effectiveness can be drawn from this study.

A research team randomised 86 patients with chemotherapy-induced leukopenia into receiving granulocyte colony-stimulating factor with or without acupuncture (Han 2010). After 10, 17 and 24 days, the leukocyte counts were higher in the group receiving acupuncture. Apparently, there were no inter-group differences at the end of the follow-up period at 45 days. The study was published in Chinese, and only an English abstract is available which omits important details; interpretation of its results is therefore problematic.

A systematic review on acupuncture-moxibustion therapy (AMT) for leukopenia was published in 2020 (Jin 2020). Nine databases (English and Chinese) were searched up to September 2020 for trials of either acupuncture or moxibustion compared with conventional leukocyte-enhancing drugs (e.g., leucogen tablets, berbamine hydrochloride tablets, and rhG-CSF injection) or no treatment. A total of 17 studies (1206 patients) were included.  All the included studies were conducted in China and published from 2010 to 2019 (it is unclear why studies prior to 2010 were not included). The authors reported that 12 of the 17 trials were of acupuncture therapy and 5 of moxibustion but the table of studies indicate that 12 were of moxibustion.  Several of the trials were unpublished dissertations and Chinese herbs were used as control interventions in two trials. Three of the studies were included in the Cochrane review of moxibustion (discussed below). 

The general quality of all the trials was rated as moderate as relevant information was often missing or incomplete. Based on Cochrane risk of bias assessments it appears that the risk of bias was unclear due to lack of details on allocation concealment and blinding. Heterogeneity of the results was substantial (I² = 92%) possibly due to the different test and control interventions but this was not adequately investigated. Thus, there are concerns about methods and reporting of this systematic review and the trials on which conclusions were based. Results showing that AMT was more effective than conventional treatment in improving leukocyte counts (MD 1.10; 95% CI, 0.67–1.53; P < 0.00001) and the claim that AMT is a safe and effective alternative for the patients with leukopenia must be viewed with caution.

Moxibustion

Moxibustion which is often considered part of acupuncture therapy has also been assessed. A 2018 Cochrane review of 25 heterogeneous RCTs report small single studies showing various beneficial effects of moxibustion including increasing blood cell counts (Zhang 2018). Poor reporting and high risk of bias affected confidence in this evidence. Similar results were reported in a previous systematic review which included 6 RCTs with a total of 681 patients (Choi 2015). All the studies had a high risk of bias and evidence was judged to be low level on the superiority of moxibustion over drug therapies in the treatment of chemotherapy-induced leukopenia.

A more recent systematic review which included trials of moxibustion is described above (Jin 2020).

Transcutaneous electrical acupuncture stimulation

A research team carried out a 3-arm RCT to assess the effects of transcutaneous electrical acupoint stimulation (TEAS) on bone marrow suppression (Hou 2017). A total of 191 chemotherapy naive non-small cell lung cancer patients participated. They were allocated to routine nursing care (control group), oral administration of prophylactic agents (medication group) or TEAS at set acupoints. White blood cell counts were significantly higher in the TEAS group compared with the control group on days 8 and 14. While the authors suggested this was a positive result, no such significant results were seen at other time points (days 11, 21, 28).

References