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