Acupuncture

Overview of Acupuncture

Acupuncture has become a popular complementary treatment in cancer care as patients search for natural alternatives to help manage their disease, alleviate symptoms and improve quality of life [1]. As part of traditional Chinese medicine (TCM), acupuncture is a technique that has been practiced for thousands of years in China and other Asian countries [2]. It involves the insertion of fine needles into the skin at specific points on the body known as acupuncture points [3]. The needles may be manipulated manually or stimulated with small electrical currents (electroacupuncture) [4].

According to TCM these acupuncture points are located at specific areas along channels, or paths, known as meridians. There are 12 primary meridians each flowing in a particular direction and connecting different parts of the body. There are 360 points along these channels that can provide insight into certain disorders and serve as locations for acupuncture treatment [2].

Qi (life-force energy) is believed to flow through these meridians and regulate various bodily functions [2]. When blockages in the flow of Qi occur symptoms of illness are thought to arise. Acupuncture promotes the flow and balance of Qi in the body helping to alleviate disease symptoms and release pain-relieving or feel-good chemicals in the brain [5].

Since the 1970s acupuncture has become relatively widely accepted in Western medicine with a growing body of clinical evidence supporting its benefits and therapeutic application to help cancer patients manage their symptoms. It is prescribed clinically to manage cancer-related symptoms, treat side effects caused by conventional cancer therapies, boost blood cell count, and enhance immune function by increasing natural killer cell and lymphocyte activity [2].

Clinical research has demonstrated that acupuncture is safe and appears to be beneficial in terms of improving quality of life for cancer patients. It helps to mitigate a range of common symptoms such as cancer pain, chemotherapy-induced nausea and vomiting, weight loss, anxiety, depression, insomnia, poor appetite, fatigue, neuropathy, digestive issues and more [2]. However, varying quality of many clinical studies on acupuncture has hindered widespread acceptance and continued research using validated methodology is still needed [1].

Historical Perspective of Acupuncture

Acupuncture originated as a therapy in traditional Chinese medicine, which is an indigenous and comprehensive system of medicine practiced for thousands of years in China [6]. Acupuncture can be traced back archaeologically over 4,000 years ago when stone needles were used [2].

During its long history, acupuncture has been applied for a wide variety of conditions. One of the oldest written medical texts, the ancient classic Huang Di Nei Jing (The Yellow Emperor's Classic of Internal Medicine) published around the second century BC, documents nine types of needles and their different therapeutic functions [2]. Ancient medical textbooks classify cancer as a condition of blood stasis and describe methods to remedy it with acupuncture [2].

The spread of acupuncture to other countries outside of China dates back centuries. The first medical description of the therapy by a European physician was in about 1680 by Ten Rhijne who witnessed acupuncture practice in Japan [7]. Interest in acupuncture in both the USA and UK boomed in the first half of the 19th century with several publications appearing in the scientific literature including an editorial article in the Lancet [7]. However, interest quickly waned and by mid-century acupuncture had fallen into disrepute [7].

The brief history of acupuncture in the USA dates back about 200 years when Dr. Franklin Bache published a report in the North American Medical and Surgical Journal on the treatment of lower back pain with acupuncture [2]. However, it wasn’t until the 1970s when US-Chinese diplomatic relations were restored that acupuncture became more accepted and widely applied in the Western world [2].

In 1998, a consensus panel from the National Institutes of Health reported that acupuncture was effective for postoperative pain and chemotherapy-related nausea and vomiting [8]. From that point onwards respected institutions such as the National Cancer Institute (NIH) and the National Center for Complementary and Alternative Medicine have sponsored clinical trials to evaluate the use of acupuncture for symptom management in cancer care [3].

Research supporting Acupuncture

Research suggests that acupuncture may provide clinical benefit for cancer patients with a wide range of treatment-related adverse effects such as nausea and vomiting, post-operative pain, cancer-related pain, chemotherapy-induced leukopenia (low white blood cell count), post-chemotherapy fatigue, xerostomia (dry mouth), insomnia, depression and anxiety [9]. It is generally considered clinically effective for these symptoms and helps to improve patient quality of life [1] [9].

Over half of cancer patients suffer significant pain and this adversely affects quality of life [1]. A 2019 systematic review and meta-analysis of 17 clinical trials with over 1000 patients found that acupuncture was associated with significantly reduced cancer pain and decreased the use of painkillers [10]. However, the level of evidence was only moderate. Researchers called for more rigorous trials to allow for integration into clinical care and help reduce opioid use [10]. Other studies have shown that acupuncture can help to reduce opioid use [11].

The NIH has declared that “acupuncture is a proven effective treatment modality for nausea and vomiting” [1] [8]. Stimulation of acupuncture point PC6 (on the inside of the wrist) has been repeatedly shown in clinical trials to be a useful antiemetic treatment for postoperative and chemotherapy-related nausea and vomiting [1] [3] [12] [13].

Fatigue is an extremely common problem experienced by cancer patients and is also an adverse effect of chemotherapy and radiation [1]. Several clinical studies in patients with different types of cancer, including breast and lung cancer, show acupuncture can significantly decrease fatigue [14] [15] [16].

Xerostomia (dry mouth) is often experienced by cancer patients and is a distressing side effect of radiation therapy for head and neck cancers [1]. Loss of taste and difficulty swallowing are troubling hallmarks of the condition [1]. Acupuncture given alongside radiotherapy has been shown in clinical trials to significantly reduce xerostomia and improve quality of life in patients [1] [17] [18].

Overall, acupuncture is considered safe with minimal side effects and effective for the management of an array of cancer-related symptoms [1]. However, despite positive results in clinical trials there is still some controversy around the most appropriate controls for acupuncture studies [2]. Some researchers criticize the design of the clinical research and question claims of efficacy citing a high risk of bias [3].

Potential Applications of Acupuncture

According to a European survey over a third of cancer patients are utilizing complementary and alternative methods to treat their cancer symptoms or manage the side effects of standard treatments, which indicates an unmet demand within conventional cancer care [1 [19]. Acupuncture has grown in popularity as a supportive therapy in oncology as patients seek non-pharmaceutical alternatives to control symptoms [1].

How acupuncture works has been of great interest to many researchers. Current scientific evidence indicates that the benefits of acupuncture are related to how it affects the nervous system. Numerous studies on acupuncture in animal models and humans suggest that it stimulates the neuroendocrine system and induces responses, which involve the central and peripheral nervous systems [9]. It is believed to activate the hypothalamus and pituitary gland resulting in a broad spectrum of systemic effects in the body including changes in peptides (signaling molecules), hormones, neurotransmitters and the regulation of blood flow in the body [2]. Evidence suggests that acupuncture acts via the autonomic nervous system (which regulates involuntary automatic processes) to balance the sympathetic nervous system (related to fight-or-flight response) and the parasympathetic nervous system (related to rest and digest functions) [2]. The anti-inflammatory effects of acupuncture are believed to be related to its effects on neurotransmitters, cytokines and neuropeptides [2].

The benefits of acupuncture for chronic pain have been widely studied and are the best understood. During treatment the release of many different neurotransmitters and changes in brain signals are observed in functional MRIs [1]. MRI studies reveal that acupuncture can activate the reward and pleasure centers in the brain, while deactivating the amygdala and other areas of the brain, which are responsible for our fight-or-flight stress response and feelings of pain [1]. These findings show that acupuncture modulates brain function and affects pain perception [1]. Many studies provide evidence that opioid peptides are released during acupuncture and that the treatment upregulates natural opioid production within the body [1] [20].

However, the mechanisms of how acupuncture works are not very well understood and may differ depending on the specific symptom being treated, point selection, and type of needle stimulation [3]. With other symptoms such as nausea, fatigue, hot flashes, and xerostomia, the benefits of acupuncture may be related to different mechanisms than for pain [3].

Overall, acupuncture has a wide variety of potential therapeutic applications and benefits for cancer patients, which have been validated in clinical trials. To summarize these are detailed in the list below.

• Cancer treatment symptoms
• Pain
• Sleep
• Fatigue
• Anxiety
• Nausea and vomiting
• Constipation
• Dry mouth
• Hot flashes
• Neuropathy
• Gastrointestinal side-effects
• Shortness of breath
• Depression

Acupuncture also has potential as an adjuvant therapy in the palliative care and end-of-life setting with its ability to help reduce symptoms without the need for medication [1]. There are also other situations outside of cancer such as addiction, stroke rehabilitation, headaches, menstrual cramps, fibromyalgia, lower back pain, carpal tunnel syndrome and asthma, in which acupuncture may serve as a beneficial treatment or supportive therapy as part of a comprehensive management approach [8]. More research is likely to reveal new areas where acupuncture will have beneficial therapeutic applications.

Risks and Side-Effects of Acupuncture

Many clinical studies have confirmed that acupuncture is safe when performed correctly [3] [9]. Provided the procedure is in the hands of a competent practitioner there are very few adverse effects and it is minimally invasive [3].

Most serious adverse events occur as a result of a lack of training or negligence on the part of the acupuncturist rather than any inherent danger of the treatment itself [3]. A large study reported no serious adverse events and only 43 minor adverse events in 34,407 treatments [9].

The most common adverse events are very minor:

• Minor bleeding
• Needling pain
• Faintness (needle shock)

Serious adverse events are incredibly rare. The largest study to date on acupuncture including 760,000 treatments in 97,733 patients in Germany reported only 6 cases of potentially serious adverse effects [21]. These included:

• Exacerbated depression
• Hypertensive crisis (severe increase in blood pressure)
• Fainting
• Asthma attack
• Collapsed lung

The safety of the treatment and low side-effect profile is partly what adds to its popularity amongst cancer patients [1].