Acupuncture in cancer pain management

Dr Jacqueline Filshie, consultant in anaesthesia and pain management at the Royal Marsden Hospital and past president of the British Medical Acupuncture Society, reported on the use of acupuncture in 193 cancer patients attending outpatient clinics over five years and observed that of 156 patients who went on to receive treatment, 56 per cent had a worthwhile improvement in their pain for more than seven days.1

A further 22 per cent had a short-term response but no lasting benefit and 22 per cent had no beneficial effect from the treatment. The patients fell into three almost-equal groups; those with cancer-related pain, those with treatment-related pain and those with unrelated causes for pain. Patients with treatment-related pain generally responded better than those with cancer-related pain. It was also noted that patients with malignant disease needed more frequent treatments compared to the general population to achieve a similar effect.

Another study,2 reporting the use of acupuncture in an oncology centre where more than half of the patients had been referred for pain management, found that 60 per cent of patients treated showed at least a 30 per cent improvement in symptoms. Whether or not they experienced any benefit, 86 per cent of the patients thought it was very important that acupuncture should continue to be provided.

A survey of patients attending another palliative care unit found that 80 per cent would have been interested in receiving acupuncture if it were made available.3 There are now guidelines (see Box 1) for practitioners that are specific for cancer patients and ensure clinicians follow best accepted practice.4

Pain management in cancer patients
Pain, one of the most common symptoms in cancer patients, becomes more prevalent with advancing disease.5 The development of the WHO analgesic ladder6 has done much to improve pain management and for many patients, the use of regular oral medication following this regimen is sufficient. However, many patients require other techniques, such as acupuncture, TENS or other complementary therapies, to supplement pharmacological treatments if they are to achieve acceptable pain relief with minimal side-effects.

A systematic review7 of acupuncture in cancer-related pain found only one randomised controlled trial (RCT) that showed significant pain relief, although a number of studies and increasing clinical experience suggest it may be an effective adjuvant treatment for appropriately assessed patients.

The only published RCT for cancer pain8 randomised a group of 90 patients to receive two treatments of either one of two different sorts of placebo treatment or conventional auricular acupuncture. Pain scores were assessed at two months and those receiving acupuncture had pain intensity reduced by 36 per cent compared to only 2 per cent of those receiving placebo. The development of increasingly sophisticated placebo acupuncture needles9 should enable more such studies to be performed, to strengthen the evidence base through RCTs.

As shown in Box 2 and noted in early studies, the types of pain treated can be divided into three main groups.

Pain due directly to the cancer
It has been observed that tumour-related pain was less likely to respond to acupuncture than other types of pain;1 however, it should be considered for those patients who do not respond to conventional analgesia or who wish to limit or are unable to increase their analgesia due to side-effects. Needling directly into the tumour, lymphoedematous limbs or areas with spinal instability are contraindications to treatment.4

Treatment of visceral pain, such as liver capsule pain, is likely to involve needling distal points on the body, possibly using traditional Chinese points, although this varies between practitioners and will involve up to six weekly or twice-weekly treatments to assess effect.

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