Managing cancer symptoms with acupuncture

Nausea and vomiting
There is sound evidence that acupuncture may be at least as effective as, if not more effective than, metoclopramide for postoperative nausea and vomiting.1,2

Acupuncture has also been evaluated for chemotherapy-induced nausea and vomiting and for patients with intractable symptoms. A systematic review3 of its use in chemotherapy-induced nausea and vomiting looked at 11 trials using different types of acupuncture and found an overall improvement in acute vomiting during chemotherapy, especially with the use of electroacupuncture. It found no significant difference compared to controls in the incidence of nausea or delayed symptoms after chemotherapy. It was suggested that the lack of uniform methodology hampered more definite conclusions and further studies are indicated.

One large multicentre trial4 reported a reduction in chemotherapy-induced nausea in patients wearing acupressure wrist bands on the day of treatment, although this may be related to expectation of effect.

More recently, researchers5 used manual acupuncture delivered two or three times a week in 15 patients receiving palliative chemotherapy, many of whom were nauseous before treatment, and measured scores for nausea, pain and constipation. They found a significant reduction in nausea at the end of the treatment period, which was sustained for three days after chemotherapy. There also seemed to be an effect on anticipatory nausea in many patients.

The need to give frequent treatments for sustained effect and the easier availability of antiemetics means that we often underuse this helpful adjuvant to drug treatment. Nonetheless, for those patients with intractable symptoms or intolerance to antiemetics, a trial of acupuncture or acupressure wrist bands should be considered.

Vasomotor symptoms
The effectiveness of acupuncture for vasomotor symptoms associated with the menopause6 is well documented. However, patients with breast or prostate cancer may experience similar symptoms as a consequence of chemotherapy or hormone manipulation and for many, these symptoms are intractable.

In one study, tamoxifen was found to cause vasomotor symptoms in up to 62% of breast cancer patients; for many, the symptoms were severe and debilitating, and resulted in discontinuation of the drug in 10%  of patients.7 Similarly, men with prostate cancer may experience hot flushes associated with antiandrogen treatments.8 If severe, these symptoms can disturb sleep and reduce quality of life.9 Acupuncture in breast cancer patients taking tamoxifen10 has been found to reduce the hot flushes, but only in the short term. As a consequence, researchers11 have piloted different methods of acupuncture at an oncology clinic, with a view to achieving longer-term benefit for patients.

Audit of their results showed that 79% of patients had a 50%  or greater reduction in hot flushes and that a sustained benefit could be achieved by teaching patients to carry out self-acupuncture using semipermanent needles or weekly conventional needling  removing the need for frequent hospital outpatient visits.

Initially, semipermanent needles were used, but the audit showed a 9% incidence of minor side-effects, usually local irritation, so weekly self-acupuncture is preferred. The mode of action is unclear, but it is suggested that acupuncture works by reducing calcitonin gene related peptide, which is released during a hot flush and may have a negative feedback effect on the hypothalamus, influencing temperature control.

Many patients may derive sustained benefit from acupuncture, although a recent trial in breast cancer patients found improvement in symptoms with true and sham acupuncture,12 suggesting that clarification is needed regarding its best use.

Acupuncture has been shown to improve dyspnoea in patients with COPD13 and more recently in those with cancer-related breathlessness.14 In this latter pilot study, 70% of patients reported benefit and there were significant improvements in breathlessness and anxiety up to six hours after acupuncture.

These effects were maintained by the use of indwelling semipermanent needles (studs) inserted into sternal acupuncture points (Figure 2--not shown), which could be rubbed when the patient had a breathless episode. A later placebo-controlled trial in 47 patients15 using needling followed by twice-daily stimulation of a semipermanent stud for the following seven days found improvements in both groups, but no significant difference between them.

As with all acupuncture trials, there is uncertainty over what is a true placebo and both trials suggest that further studies on a larger number of patients would help to clarify if acupuncture could be beneficial in the management of this symptom.

This difficult symptom can have a significant impact on quality of life and is the subject of much research. An initial study16 in 47 patients who had post-chemotherapy fatigue compared the use of acupuncture and acupressure with sham acupressure and found a significant improvement in general fatigue, physical fatigue, activity and motivation in all groups, which was sustained to a lesser degree two weeks after treatment.

This improvement was 36%  in the acupuncture group compared to 19%  in the acupressure group and 0.6%  in the sham group, indicating the need for further studies.

More than 70% of patients with advanced cancer experience xerostomia and it can have a significant effect on patients' quality of life. Where possible, treatment of the underlying cause should be commenced, but for many patients, such as those with radiation-induced xerostomia, treatment can only be symptomatic.

There has been increasing interest in the use of acupuncture for radiation-induced xerostomia following studies confirming a statistically significant increase in both resting and stimulated salivary flow,17 which has been found to be prolonged for up to six months.18 Most patients require 10-12 treatments, so a pilocarpine test can be used as a prognostic indicator of effect from acupuncture,19 enabling treatment to be targeted on those who are most likely to derive benefit.

A controlled study comparing real to sham acupuncture showed significant improvements in subjective and objective measures compared to sham treatment,20 strengthening the evidence to support its use in radiation-induced xerostomia.

Its use in hospice inpatients with xerostomia from multiple causes found a subjective alleviation of patient-rated discomfort caused by dry mouth, but an insignificant increase in the amount of saliva produced.21 Although this study was small, the patients reported a benefit and it was well tolerated, despite the frailty of the patients who participated in it.

Much of the evidence to support the use of acupuncture in cancer patients is still emerging. As with most studies in this patient group, recruitment and retention of trial patients, together with the inherent difficulties of developing double blind placebo-controlled trials in acupuncture, can make it difficult to prove a clear benefit. There is, however, sufficient evidence to suggest the need for further studies to show how acupuncture may be used most effectively for symptom management in cancer patients.

Dr Melanie Jefferson is consultant in palliative care at the Cardiff and Vale NHS Trust. Competing interests: None declared.

1. Non-pharmacological techniques prevent postoperative nausea and vomiting (accessed 25 August 2009).
2. Lee A, Fan LTY. Stimulation of the wrist acupuncture point P6 for preventing postoperative nausea and vomiting. Cochrane Database Syst Rev 2008, Issue 4. Art No:CD003281. DOI:10.1002/14651858.CD003281.pub3
3. Ezzo J, Richardson MA, Vickers A et al. Acupuncture-point stimulation for chemotherapy-induced nausea or vomiting. Cochrane Database Syst Rev 2006, Issue 2. Art No:CD002285. DOI:10.1002/14651858.CD002285.pub2
4. Roscoe JA, Morrow GR, Hickok JT et al. TENS wrist band device at PC performs less well for the relief of chemotherapy-induced nausea and vomiting. (n = 739). Acup Med 2004;22:48-57.
5. Nystrom E, Ridderstrom G, Leffler A. Manual acupuncture as an adjunctive treatment of nausea in patients with cancer in palliative care - a prospective, observational pilot study. Acup Med 2008;26:27-32.
6. Seidl MM, Stewart DE. Alternative treatments for menopausal symptoms. Systematic review of scientific and lay literature. Can Fam Physician 1998;44:1299-308.
7. Love RR, Cameron L, Connell BL et al. Symptoms associated with tamoxifen treatment in postmenopausal women. Arch Intern Med 1991;151:1842-7.
8. Karling P, Hammar M, Varenhorst E. Prevalence and duration of hot flushes after surgical or medical castration in men with prostate cancer. J Urol 1994;152:1170-3.
9. Watson M, Haviland JS, Greer S et al. Influence of psychological response on survival in breast cancer:a population-based cohort study. Lancet 1999;354:1331-6.
10. Cummins SM, Brunt AM. Does acupuncture influence the vasomotor symptoms experienced by breast cancer patients taking tamoxifen? Acupunct Med 2000;18:28.
11. Filshie J, Boloton T, Browne D et al. Acupuncture and self acupuncture for long term treatment of vasomotor symptoms in cancer patients - audit and treatment algorithm. Acup Med 2005;23:171-80.
12. Deng G, Vickers A, Yeung S et al. Randomized controlled trial of acupuncture for the treatment of hot flushes in breast cancer patients. J Clin Oncol 2007;25:5584-90.
13. Jobst K, Chen JH, McPherson K et al. Controlled trial of acupuncture for disabling breathlessness. Lancet 1986;20:1416-18.
14. Filshie J, Penn K, Ashley S et al. Acupuncture for the relief of cancer-related breathlessness. Pall Med 1996;10:145-50.
15. Vickers AJ, Feinstein MB, Deng GE et al. Acupuncture for dyspnoea in advanced cancer:a randomised placebo-controlled pilot trial. BMC Palliat Care 2005;4:5.
16. Molassiotis A, Sylt P, Diggins H. The management of cancer-related fatigue after chemotherapy with acupuncture and acupressure:a randomised controlled trial. Complement Ther Med 2007;15:238-46.
17. Braga FP, Sugaya NN, Hirota SK et al. The effect of acupuncture on salivary flow rate in patients with radiation-induced xerostomia. Minerva Stomatol 2008;57:343-8.
18. Wong RK, Jones GW, Sagar SM et al. A phase 1-2 study in the use of acupuncture-like transcutaneous nerve stimulation in the treatment of radiation-induced xerostomia in head and neck cancer patients treated with radical radiotherapy. Int J Radiat Oncol Biol Phys 2003;57:472-80.
19. Blom M, Kopp S, Lundeberg T. Prognostic value of the pilocarpine test to identify patients who may obtain long term relief from xerostomia by acupuncture treatment. Arch Otolaryngol Head Neck Surg 1999;125:561-6.
20. Cho JH, Chung WK, Kang W et al. Manual acupuncture improved quality of life in cancer patients with radiation-induced xerostomia. J Altern Complement Med 2008;14:523-6.
21. Meidell L, Rasmussen BH. Acupuncture as an optional treatment for hospice patients with xerostomia: an intervention study. Int J Palliat Nurs 2009;15:12-20.

This article originally appeared in MIMS: Oncology and Palliative Care, September 2009.

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