Chemotherapy-induced nausea and vomiting (CINV) is another well-studied indication for acupuncture.[4,13,14] In one investigation, 104 breast cancer patients receiving highly emetogenic chemotherapy were randomized to receive electroacupuncture at the PC6 and ST36 acupuncture points (located on the forearm and the leg, respectively) once daily for 5 days, minimal needling at nonacupuncture points, or pharmacotherapy alone. All patients received the same triple pharmacological agents for emesis management: intravenous prochlorperazine(Drug information on prochlorperazine), lorazepam(Drug information on lorazepam), and diphenhydramine(Drug information on diphenhydramine) hydrochloride. Electroacupuncture significantly reduced the number of episodes of total emesis (median from 15 to 5; mean from 13.4 to 6.3 episodes) when compared with pharmacotherapy only. During the follow-up period days 6 to 14, when groups were no longer receiving acupuncture therapy, the difference in emesis episodes essentially disappeared. The effects of acupuncture do not seem to be due entirely to attention, clinician-patient interaction, or placebo. In this study, nausea was not included as an outcome measure. In another study, the combination of acupuncture and 5HT3 receptor antagonists, agents commonly used for standard prevention of nausea and vomiting, yielded mixed results.[16,17]
Several systematic reviews strongly recommend acupuncture for acute CINV.[13,18,19] Diverse acupuncture regimens were employed in the trials included in those reviews, ranging from once daily on the day of and the day after chemotherapy, to electrical stimulation every 2 hours for 5 days. Most of the studies were conducted in patients receiving highly emetogenic chemotherapy.
Acupuncture for management of CINV is covered by some insurance plans. The general consensus suggests that electroacupuncture is more effective than manual acupuncture, which in turn is more effective than acupressure (nerve stimulation without needles, with very light touch or deeper pressure of the fingers over pressure points). Regarding management of delayed CINV, however, more studies on EA, acupuncture, and acupressure are required.
Recently published clinical trials also show that acupuncture is effective in the pediatric oncology setting.[20,21] Acupressure wristbands, which are to be placed on top the PC-6 acupuncture point, are commercially available. In a randomized controlled trial of 739 patients, applying pressure to this point (acupressure) on the day of chemotherapy significantly reduced nausea in patients wearing wristbands, compared with no-band controls. No significant differences were found in terms of an effect of the wristbands on delayed CINV.
Breast or prostate cancer patients under treatment with hormonal therapy may develop severe hot flashes that can interfere with daily activities. The standard treatment for hot flashes, estrogen or androgen supplementation, is contraindicated in patients with cancer, however. Several uncontrolled studies suggest that acupuncture may reduce hot flashes in patients with breast or prostate cancer.[23–25] Controlled studies of acupuncture in this setting show mixed results.[26,27]
Radiation therapy to the head and neck can damage the salivary glands, and many head and neck cancer patients consequently develop persistent dry mouth (xerostomia). Acupuncture has been shown to reduce this symptom. In a randomized controlled trial of patients with head and neck cancer who experienced pain and dysfunction following neck dissection, 58 patients received either weekly acupuncture for 4 weeks or usual care (eg, physical therapy, analgesia, and/or anti-inflammatory drugs). Acupuncture greatly improved reported xerostomia, pain, and function of neck and shoulder muscles. The benefit is even greater in patients with more severe dry mouth. The possible neuronal matrix involved was explored in a mechanistic study that used functional magnetic resonance imaging (fMRI). In this randomized controlled trial, acupuncture was associated with bilateral activation of the insula and adjacent operculum, changes not seen with the sham acupuncture point. Moreover, the true acupuncture induced greater saliva production than did sham acupuncture. Although more definitive studies are needed, it may be argued that a trial course of acupuncture treatment (once or twice a week for 4 weeks) is worthwhile in patients with severe dry mouth that fails to respond to other treatment. If no clinical improvement is seen after 4 weeks, then it is unlikely that acupuncture will help that particular patient.
What Are the Potential Risks?
Acupuncture is generally safe when it is performed by qualified practitioners. The patient usually feels a light needle pricking and later a heavy or sore sensation at the site. If a sharp pain is felt, the needle is not placed in the correct position. After 30–60 minutes, the needles are removed. Usually there is no visible sign of skin penetration or loss of blood at the site after the treatment.
A prospective survey of Japanese acupuncture practitioners recorded only 94 minor adverse events, the most common being forgotten needles and faintness, but no serious adverse events across 65,000 treatments. A study of Swedish physiotherapists practicing acupuncture prospectively recorded side effects during more than 9,000 episodes of care. Although minor bleeding or hematoma was reported following nearly one in five treatments, fatigue, sweating, and other minor adverse effects were rare and there were no serious complications. In a study of more than 760,000 treatments in 97,733 patients receiving acupuncture in Germany, only six cases of potentially serious adverse events were reported. They included exacerbation of depression, hypertensive crisis, vasovagal reaction, asthma attack, and pneumothorax. The most common nonserious adverse events included local bleeding and needle pain.
Patients should be advised to receive acupuncture treatment from practitioners who are professionally trained, properly credentialed, and experienced in treating cancer patients. The practitioners should exercise clean needle techniques, universal precautions, and special safety precautions for patients undergoing cancer treatment.
Guidelines, Precautions, and Professional Requirements
In cancer patients, special safety precautions related to acupuncture are required. Cancer patients undergoing active treatment may be prone to infection or bleeding. Cancer or cancer treatment may have distorted anatomical structures, which makes needling certain points not advisable. Acupuncture should not be performed on patients with recent stem cell or organ transplantation, absolute neutrophil count less than 500/µL, platelets less than 20,000/µL, INR greater than 4.0, or new-onset cardiac arrhythmia. It also should not be done at the site of primary or metastatic neoplasm; or when the patient has a medical device/prosthesis, open wound, active infection, or fistula; or has recently undergone treatment with radiotherapy.
Availability of acupuncture therapy and the degree of its integration into mainstream healthcare varies by geographic location, institution type, and the demographics of the patient population. Laws regulating the practice of acupuncture vary across states. In most states, acupuncture falls within the scope of practice for conventionally trained physicians. Some states require additional training in acupuncture, which varies from 100–300 hours. Others do not require such training.
Most states grant licenses or certifications to individuals who are not graduates of conventional medical schools, but who have successfully completed training in a qualified education program in acupuncture and traditional Oriental medicine. Such acupuncture schools exist in the US and abroad. The National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) is the national organization that validates entry-level competency in the practice of acupuncture and Oriental medicine through professional certification. In some states, acupuncture can also be provided by chiropractors, dentists, and podiatrists who may not have received additional acupuncture training.[34,35]
What's the Bottom-Line Message?
Acupuncture is a complementary medicine modality that can be usefully incorporated as a component of supportive oncology care. Although acupuncture does not treat cancer directly, it may reduce some common symptoms experienced by cancer patients. Current research supports its use in the reduction of pain and CINV. Other research suggests it may also reduce radiation-induced dry-mouth, although this indication requires further study.
Acupuncture is best provided as part of a multimodality treatment approach. It has a good safety record when given by qualified practitioners. Acupuncturists should exercise special safety precautions when treating cancer patients.
To view information about acupuncture from the National Institutes of Health's National Center for Complementary and Alternative Medicine (NCCAM), please visit: http://nccam.nih.gov/health/acupuncture/. Information about acupuncture is also available on Memorial Sloan-Kettering Cancer Center's website, "About Herbs, Botanicals & Other Products," at http://www.mskcc.org/mskcc/html/69111.cfm.
Financial Disclosure: The authors have no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.