Acupuncture (PDQ®)–Health Professional Version
Cancer-related fatigue
Fatigue is a common symptom in patients with cancer and a frequent side effect of chemotherapy and radiation therapy. No effective treatment exists. Several RCTs have been conducted to study the effect of acupuncture in reducing cancer-related fatigue (refer to Table 6).
One pilot RCT enrolled 47 cancer patients experiencing moderate to severe cancer fatigue and randomly assigned them to one of three groups: acupuncture (N = 15), acupressure (N = 16), or SA (N = 16). Patients in the acupuncture group received six 20-minute acupuncture sessions during a 2-week period; patients in the two acupressure groups were taught to massage RA versus SA points daily for 2 weeks.[75] The Multidimensional Fatigue Inventory was used to assess their responses at baseline, and at week 2 and week 4 follow-up. At the end of week 2, general fatigue, physical fatigue, activity, and motivation significantly improved in the acupuncture and acupressure groups when compared with baseline. At the end of week 2, fatigue level improved by 36% in the acupuncture group, 19% in the acupressure group and 0.6% in the control group. Moreover, the improvement was maintained at the week 4 follow-up. Acupuncture was found to be a more effective method than acupressure or SA. The authors concluded that acupuncture showed a greater potential for managing cancer-related fatigue; further testing in a multicenter RCT with larger sample sizes is warranted.[75] A small randomized study of 28 patients with non-small cell lung cancer reported decreased fatigue and improved QOL with RA compared with SA. The effect was sustained during the 6-week observation period.[76]
A follow-up RCT (N = 302) by the same group of investigators was published in 2013; among the 246 evaluable patients, acupuncture significantly reduced cancer-related fatigue, anxiety, and depression, and improved QOL when compared with usual care.[77] The investigators again randomly assigned 197 patients to receive 4 weeks of therapist-delivered acupuncture (N = 65), self-acupuncture (N = 67), or no acupuncture (N = 65) to determine the effect of maintenance therapy for cancer-related fatigue, and found that there was no difference between the therapist-delivered acupuncture and self-acupuncture; there was a nonsignificant trend in improving fatigue when comparing the acupuncture groups with the no-acupuncture group (P = .07).[78]
Conversely, two RCTs showed no significant difference between RA and SA in reducing cancer-related fatigue (refer to Table 6).[79,80] One study reported in 2009 that among the 27 patients receiving daily radiation therapy, both weekly RA and SA treatment improved fatigue, fatigue distress, QOL, and depression from baseline to 10 weeks, but the differences between the two interventions were not significant.[79] In 2013, another study reported the results of an RCT of RA compared with SA involving 101 patients with postchemotherapy chronic fatigue; among the 74 evaluable patients, both groups had a one-point decrease in Brief Fatigue Inventory score; however, there was no statistically significant difference between the groups. This study was limited by the large number of patients (27) lost to follow up.[80]
The effect of acupuncture on cancer-related fatigue was also studied as one of the secondary end points in acupuncture for the AIMSS study published in 2014.[81] When compared with WLCs, EA significantly improved fatigue, anxiety, and depression, although SA did not improve fatigue or anxiety but did improve depression.[81] In this study, the investigators did not compare EA with SA directly because the study was not powered to detect a difference between EA and SA, especially for secondary end points. Lastly, an Australian pilot study (N = 30) showed that when compared with controls, acupuncture significantly reduced fatigue and improved well-being in breast cancer patients with posttreatment fatigue.[82]
These results showed that acupuncture significantly improved fatigue when compared with usual care alone, although whether it is significantly better than SA will warrant further study.
A 2016 pilot RCT of 78 cancer survivors with cancer-related fatigue showed that infrared laser acupuncture point stimulation was safe in cancer patients and that patients who received infrared laser acupuncture point stimulation on ST36, CV4, and CV6 acupoints 3 times per week for 4 weeks had less fatigue than those who received sham treatment at the end of treatment (3.01 vs. 4.40; P = .002), and the effect lasted to week 8.[83] In addition, a 2016 large RCT of 288 breast cancer survivors with persistent fatigue (NCT01281904) showed that two types of acupressure (relaxing and stimulating) significantly reduced cancer fatigue.[84] Post hoc analysis revealed that acupressure was associated with reduced anxiety, pain, and depressive symptoms when compare with usual care.[85]
Xerostomia
A number of clinical studies have investigated the effect of acupuncture for the treatment and prevention of xerostomia in nasopharyngeal carcinoma and head and neck cancerpatients.
Acupuncture was associated with a decrease in the onset of symptoms and an increased saliva flow in two randomized studies that compared acupuncture with standard care for preventing xerostomia in patients undergoing radiation therapy.[88,89]
Compared with standard care, acupuncture significantly improved xerostomia symptoms in patients who experienced the condition following radiation therapy.[21,90]
Two RCTs, one for prevention, and one for treatment of radiation-induced xerostomia revealed increases in salivary flow rates following RA and SA (superficial needling 1 or 2 cm away from acupuncture points), although differences between groups were not significant.[91,92] It also reported improvements in QOL after acupuncture treatment, but there were no significant differences between the groups.[92]
In 2012, one group published two studies on the effect of acupuncture for preventing xerostomia. The first was a pilot study (N = 23); when compared with SA, RA significantly reduced xerostomia questionnaire scores from week 3 through the 1-month follow-up after radiation therapy. However, they did not find significant difference in salivary flow rates between the groups.[93] The other study (N = 86) showed that when compared with standard care acupuncture significantly lowered the xerostomia questionnaire scores in weeks 3 to 6 during 6 weeks of chemoradiation therapy. In addition, greater saliva flow was noticed in the acupuncture group than in the control group at weeks 7 and 11 and at the 6-month follow-up.[88]
Another study examined long-term effects of acupuncture on xerostomia.[94] Patients who received RA were followed for 6 months and up to 3 years. Compared with baseline, significant differences in salivary flow rates were seen in patients 6 months after acupuncture treatment. At 3 years, patients who received additional acupuncture exhibited greater saliva flow rates than patients who did not continue acupuncture treatment.
Two ongoing phase III clinical trials are evaluating the effect of acupuncture for treatment (NCT01141231 and NCT01266044) of xerostomia in head and neck cancer patients. Information about ongoing clinical trials is available from the NCI website.
The findings from these studies are summarized in Table 7 below.
Chemotherapy-induced peripheral neuropathy
Chemotherapy-induced peripheral neuropathy (CIPN), a common side effect of several chemotherapeutic agents, includes a variety of symptoms, such as paresthesia, pain, and muscle weakness.[95] CIPN can be serious enough to limit or delay the dose of administered chemotherapy and may warrant discontinuation of treatment. Long-term CIPN often produces substantive functional decline and diminished QOL.[96,97] For patients with persistent CIPN, treatment has been limited to symptom management with narcotics, antidepressants, and antiepileptics.[96] Studies suggest that analgesic regimens typically produce only modest relief of pain and are commonly associated with side effects such as dizziness, sedation, dry mouth, and constipation.[96]
CIPN from platinum-containing agents or taxanes
There have been several studies investigating the use of acupuncture treatment to alleviate CIPN. Two small nonplacebo-controlled studies (N = 5 [98] and N = 6 [99]) have shown preliminary evidence that MA can improve CIPN symptoms. A three-arm RCT (N = 90) that examined the use of auricular acupuncture to treat chronic peripheral or central neuropathic pain in cancer patients after treatment found a significant reduction in pain at 2 months compared with sham-controlled patients.[13] Another RCT that randomly assigned patients to either EA (N = 14), hydroelectric baths (N = 14), high-dose B vitamins (N = 15), or placebo (N = 17) reported no significant change in pain when treatments were compared with placebo.[100]
At least one research group has investigated if acupuncture could prevent the progression of CIPN in patients actively undergoing chemotherapy. In a phase IIA trial of acupuncture to prevent progression of CIPN severity from weekly paclitaxel in breast cancer patients, 26 of 27 patients did not experience a progression from grade II to grade III neuropathy, yielding a significantly lower progression than expected from historical controls, meeting the prespecified endpoint for the study warranting further investigation.[101]
CIPN from bortezomib or thalidomide
Studies evaluating the effects of acupuncture on bortezomib and/or thalidomide -induced peripheral neuropathy have also shown promising results. Two studies of patients with multiple myeloma (N = 27 [102] and N = 19, electroacupuncture [103]) concluded that acupuncture was safe and effective in treating CIPN after 10 weeks and 9 weeks of treatment, respectively. Another larger study (N = 104) randomly assigned patients to receive either methylcobalamin or acupuncture and methylcobalamin. This study reported a greater reduction in CIPN pain and improvement in daily functioning in the acupuncture group.[104]
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