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.

  • Stimulation of acupoints: 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 (n=3) 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 (n=11) published following the most recent review have reported mixed findings, particularly when testing is against a sham or placebo treatment.
  • Other forms of acupuncture: Three systematic reviews assessed  pharmacopuncture, self-acupressure and auricular therapy (ear acupuncture). None of these reviews provides rigorous evidence of an effect of acupuncture/acupressure. Similarly, RCTs (n=8) using points other than P6 have produced mixed results.
  • Moxibustion: Mixed results have also been reported by two systematic reviews
  • Acupuncture/acupressure in children: Few studies have been carried out in children and these are either of insufficient size or reported findings are conflicting.

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.

Citation

Karen Pilkington and the CAM Cancer Consortium. Acupuncture for chemotherapy-associated nausea and vomiting [online document]. March 9th, 2021.

Document history

Most recent update and revision in February 2021 by Karen Pilkington.
Fully revised and updated 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.

What is it?

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).

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.

Acupuncture became particularly popular outside Asia after the US president Richard Nixon visited China in 1971 (White 1999). 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.

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 patients (Molassiotis 2006, Molassiotis 2005). Acupuncture was the therapy most frequently provided by integrative oncology centres across Europe, 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  2021). 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). The P6 acupoint (Pericardium 6 or Neiguan) located on the inner arm near the wrist is frequently used in prevention of nausea and vomiting.

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 and cost

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 see the European Traditional Chinese Medicine Association (ETCMA) website.

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 the ETCMA website (as above) for coverage of cost by public health insurers across Europe. 

Does it work?

Eleven systematic reviews (table 1) and 22 randomized controlled trials (RCTs) (table 2) are included in this summary.

  • Stimulation of acupoints: 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 (n=11) published following the most recent review or excluded from reviews because of a limited focus have reported mixed findings, particularly when testing is against a sham or placebo treatment.
  • Other forms of acupuncture: Three systematic reviews assessed pharmacopuncture, self-acupressure and auricular therapy (ear acupuncture). None of these reviews provides rigorous evidence of an effect of acupuncture/acupressure. Similarly, RCTs (n=8) using points other than P6 have produced mixed results.
  • Moxibustion: Mixed results have also been reported by two systematic reviews.
  • Acupuncture/acupressure in children: Few studies have been carried out in children and these are either of insufficient size or reported findings are conflicting.

The American Society of Clinical Oncology (Lyman 2018) has endorsed evidence-based guidelines produced by the Society for Integrative Oncology (SIO) on the use of integrative therapies during and after breast cancer treatment (Greenlee 2017). 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.

Description of included studies

Acupoint stimulation (mainly P6)

Two older systematic reviews were identified that specifically addressed acupuncture and/or acupressure in chemotherapy-induced nausea and vomiting in adults. One was published in 2005 and as a Cochrane review in 2006 (Ezzo 2005; Ezzo 2006) and the other was published in 2009 (Chao 2009) . They both included 11 trials in their analyses; the 2006 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 patients (Chao 2009). Both reviews reported that stimulation of acupoints (mainly P6) reduced nausea and/or vomiting. The Cochrane 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.

Three further systematic reviews have been published since 2013. The first of these focused on acupuncture as an adjunct therapy in lung cancer patients (Chen 2013). 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 RCTs (Garcia 2014). 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.

The third systematic review assessed acupuncture for a range of treatment-related symptoms in women with breast cancer (Jang 2020). Only two studies on CINV were included: a randomised controlled pilot study of electroacupuncture carried out in Australia (Beith 2012) and a later study published in Chinese (He 2017). The mixed results of these trials meant that there was insufficient evidence to assess any benefit from acupuncture.

Three further trials tested acupuncture at the same point as above (P6) (Liu 2015, Rithirangsriroj  2015, Widgren 2017). Two of these compared acupuncture against conventional anti-emetic medication (Liu 2015, Rithirangsriroj 2015). 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 impact  (Rithirangsriroj 2015). 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 group (Widgren 2017). One trial attempted to confirm whether receiving acupuncture 30 minutes before chemotherapy was more effective than 30 minutes after chemotherapy (Cheng 2020). The trial involved 105 patients with lung cancer.  The P6 and ST36 (a point below the knee) acupoints were needled.  Both acupuncture regimens appeared better than control as did the pre versus post acupuncture but the reporting of methods and results was not completely clear.

Six further trials (7 reports) investigated the effects of acupressure at the P6 point (Genc 2013, Molassiotis 2013, Molassiotis 2014, Kaur 2015, Suh 2012, Avc 2016, Perkins 2020). Three trials of acupressure at P6 using a wrist band reported no difference between this and a ‘placebo band’ (Genc 2013, Molassiotis 2013, Molassiotis 2014, Perkins 2020). The first of these trials involved a large sample of 500 patients and was rigorously reported (Molassiotis 2013, Molassiotis 2014).  The second trial was  in 120 patients with breast, gynaecological or lung cancer (Genc 2013). 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. A similar result was found in a trial of an ‘active’ versus a ‘placebo’ band in 57 palliative care patients with advanced cancer (Perkins 2020). A fourth acupressure trial reported synergistic effects of P6 acupressure with nurse-provided counselling for breast cancer patients (Suh 2012). The fifth study reported positive effects of a wristband compared with finger pressure but suffered from a number of methodological problems (Avc 2016). The sixth study, carried out 40 patients in India, reported positive effects of self-applied acupressure after 24 hours but the control intervention is unclear (Kaur 2015).

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 determined (Cheon 2014). Two assessed specific forms of treatment; one focused on self-acupressure and only located 2 studies (Song 2015). Only one of 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) (Tan 2014). 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 points (Eghbali 2015, Kong 2018).

Acupuncture at several points was reported to be more effective than no acupuncture but key details of the study (n=56) were missing, it was not blinded and was self-assessed (Zhou 2017). Another trial conducted in China was a multicentre study involving 134 patients with advanced cancer (Li 2020).  Again, a range of points was used and sham acupoints used for comparison. No significant difference was seen in complete response rates although severity was reported to be less with true acupuncture. No difference in effect was also observed in a trial (n=103) of acustimulation at the K1 acupoint compared with electrostimulation at a placebo point (Shen 2015).

No significant difference was found between electroacupuncture and sham or placebo electroacupuncture in two trials (n=153, n=142) (McKeon 2015, Xie 2017). These findings are in contrast to those of a third trial (n=72) (Zhang 2014). 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 treatments (Fang 2012).

Moxibustion

The two most recent systematic reviews focus on moxibustion. The first, a Cochrane review, assessed moxibustion for various indications related to cancer treatment (Zhang 2018). Nine trials suggested evidence of beneficial effects when compared to sham (n=1) or used alongside conventional drug treatment (n=8). 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 treatment (Huang 2017). Risk of bias was again a concern but the reason for the difference in conclusions of the two reviews is unclear.

Acupuncture/acupressure in children with cancer

One review described as systematic included two RCTs, 1 of acupuncture and 1 of acupressure, in children (Momani 2017). No formal appraisal was carried out and no conclusions could be reached as the first trial only included 11 patients and the second found no difference between sham and true acupressure. Two subsequent RCTs, one of finger acupressure at true and sham points and the other using acupressure versus sham wrist bands, reported conflicting findings (Ghezelbash 2017; Dupuis 2018).

An RCT of laser acupuncture versus sham laser acupuncture was carried out in children and adolescents (Varajao 2018). Reduced nausea and vomiting episodes were reported but the trial was small (n= 18) and these findings have not been replicated in other studies.

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 needling (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 2021, BMAS 2021). 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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