Oncology Acupuncture Program Assessment at Oregon Health and Science University

A retrospective review of patient population, cancer diagnosis, and use of acupuncture over a 12-month period at an NCI-designated cancer center

By Yiyi Chen, PhD, Charles R. Thomas, Jr, MD, Shushan Rana, MD, and Angie Rademacher, ND, LAc

Printer Friendly PagePrinter Friendly Page

Abstract

Objective: To describe demographic characteristics, clinical characteristics, and patterns of symptom management in patients undergoing oncology acupuncture. Methodology: A retrospective chart review of cancer patients who received acupuncture between May 2013 and April 2014. Setting: A regional, tertiary care academic medical center and National Cancer Institute (NCI)-Designated Cancer Center. Patients: 50 patients; 15 men and 35 women. Variables assessed: Gender, age, cancer diagnosis, treatment modalities received, primary symptom prompting acupuncture referral, and number of acupuncture treatments received. Results: Among 50 patients with cancer who were treated with acupuncture, 42 were diagnosed with a solid tumor and 8 with a hematologic malignancy. Neuropathy was the most common complaint prompting acupuncture treatment, followed by arthralgia and nausea. Of the patients with solid tumors, 19 were women diagnosed with breast cancer, all of whom had a primary symptom of neuropathy. The most common treatment administered for these women were taxanes and alkylating agents. Radiation therapy was strongly correlated with neuropathy. Conclusion: Among cancer patients who received acupuncture, breast cancer was the most common tumor type, with neuropathy being the most common chief complaint prompting acupuncture treatment.

Registration

The study obtained Institutional Review Board Approval (IRB00010921).

Introduction

Cancer therapy often causes myriad unwanted symptoms and side effects that lead patients to seek medical management for symptom relief. In 2017 more than 1.6 million people in the United States were diagnosed with cancer, most undergoing some form of surgery, chemotherapy, and/or radiation to treat their disease.1 Integrative medicine has been a welcome addition to conventional prophylactic and palliative standards of treatment, offering another avenue of clinical support.

Acupuncture in the oncology setting has been used in China for many centuries and, in recent decades, has become available as an integrative therapy in the Western medical culture. Our institution has adopted supportive care practices based on the success of numerous respected institutions. The addition of acupuncture as a treatment option at the Oregon Health and Science University (OHSU) has greatly enhanced oncology patient care, on a physical and psychosocial dimension.

A growing body of evidence supports the use of acupuncture for a multitude of symptoms patients frequently experience as a result of cancer itself or cancer treatment.

Over the past 20 years, acupuncture has gained a strong foothold in the medical community as an adjunct therapy for pain, infertility, neurological conditions, and cancer treatment–related side effects. Clinical research suggests the use of acupuncture in the oncology setting may be beneficial for symptoms and conditions such as post-chemotherapy fatigue,2,3 chemoradiation-induced nausea and vomiting,4-7 peripheral neuropathy,8 xerostomia,9-12 hot flashes,13-19 insomnia and anxiety,20 pain, and postoperative ileus.21-26

In the inaugural year of the OHSU oncology acupuncture service, we reviewed patient demographic and clinical characteristics to identify factors promoting the use of acupuncture. With these data, we will optimize symptom assessments to ascertain the clinical efficacy of acupuncture among subset populations who frequently use this service.

Methods and Materials

Upon institutional review board approval, we analyzed records of patients with a cancer diagnosis who elected to receive supportive acupuncture treatment between May 1, 2013 and April 29, 2014 at OHSU. A total of 50 patients were identified, with a majority (n=48) having received at least 1 primary oncologic treatment modality (surgery, chemotherapy, or radiation). Patients sought acupuncture for symptoms primarily related to cancer treatment–related side effects.

Initiation of acupuncture therapy came from either a physician referral or patient self-referral. Treatments were performed by a sole, licensed acupuncturist, in an outpatient clinical oncology setting. On each visit the acupuncturist reviewed patients’ charts for medical history, current course of treatment, and clinical updates. Current symptoms and complete review of systems were also assessed, along with tongue and pulse diagnosis.

A Traditional Chinese Medicine (TCM) diagnosis was determined by patient history, tongue, and pulse. Acupuncture points were selected based on standard TCM point prescriptions according to diagnosis and research-supported protocols. Needles were inserted and manipulated until de qi (a sensation experienced by the patient such as tingling, aching, or heaviness and a grasping sensation on the needle by the acupuncturist) was achieved. Depth of needle placement was generally 1 cun, traditionally defined as the width of the thumb at the knuckle or ~33.33 mm, or less with point placement on full body, auricular, and scalp. Needle retention was 20 to 30 minutes with manipulation of needles after 10 to 15 minutes with even, reinforcing, or reducing techniques to reinvigorate the de qi sensation.

Variables selected for data acquisition and analysis included patient demographics, which included gender and age; cancer type; treatment modalities; chemotherapy class; and type and number of symptoms prompting acupuncture referral. Inferential statistical analysis was limited to a stepwise logistic regression model to determine significant contributors to symptoms leading to acupuncture use.

Results

Acupuncture utilization among oncology patients

A total of 50 patients (median age 59; interquartile range [32-80]) received acupuncture, with more women (n=35; median age 59) than men (n=15; median age 61). Forty-two (84%) of the cohort were diagnosed with a solid tumor while 8 (16%) had a hematologic malignancy. A majority of patients (n=40; 80%) requested acupuncture for 1 to 2 clinical complaints. Overall, cancer treatment–related neuropathy (n=21) was the most common complaint prompting acupuncture treatment, followed by arthralgia (n=12), and nausea (n=12; Figure 1). A majority of patients did receive chemotherapy (n=43; 86%) and there was no correlation between number of chemotherapy agents used and number of symptoms prompting acupuncture referral.

Acupuncture among radiation therapy patients

Among the 50 patients whose records were analyzed, 26 patients, including 8 men (median age 64) and 18 women (median age 59.5), received radiation therapy. Twenty-two patients also received chemotherapy, and 15 in the chemoradiation cohort underwent surgery (Table 1). Patients with breast cancer (n=11) were the most prevalent users of acupuncture, followed by patients with head and neck (n=4) and lung cancer (n=3). Most patients (n=20) requested assistance with 1 to 2 symptoms, with the most common symptoms being neuropathy (n=6), arthralgias (n=6), and nausea (n=6). Among breast cancer patients who underwent radiation, the most common chief complaints were arthralgias (n=6), myalgias (n=5), and neuropathy (n=4), and the most commonly used chemotherapy were taxanes (n=9). The median number of complaints (n=1.5) for which patients requested acupuncture did not differ among those who underwent mastectomy vs lumpectomy followed by radiation. Among radiation therapy patients who received an aromatase inhibitor alone for adjuvant endocrine therapy, there were more symptoms for which the patient requested acupuncture referral than among patients who received tamoxifen alone (Table 2). Stepwise linear regression found radiation, apart from other therapeutic modalities, was mainly responsible for neuropathy prompting acupuncture referral (P=0.0063).

Table 1. Frequency and Distribution of Radiation Therapy and Concurrent Treatment

Treatment modality Total number receiving modality Men (%) Women (%)
Radiation alone 1 100 0
Radiation + surgery 3 0

100

Radiation + chemotherapy 7 43 57

 

Table 2. Breast Cancer Radiotherapy Patients’ Surgical and Systemic Interventions

  Surgery       Endocrine Therapy  
  Lumpectomy Mastectomy No endocrine therapy Tamoxifen AI Tamoxifen + AI
Number receiving modality 8 4 5 3 2 1
Median number of complaints prompting acupuncture referral 1.5 1.5 3 1 3.5 1

Abbreviation: AI, aromatase inhibitor

Breast cancer patient subset analysis

Of the solid tumor patients, 19 (median age, 59; interquartile range [32-71]) were diagnosed with breast cancer, all of whom had a chief complaint of neuropathy. The most common treatment administered for these 19 women were taxanes (n=16; 84%) and alkylating agents (n=10; 53%). Fewer women with mastectomy than lumpectomy requested acupuncture referral.

Discussion

Few studies have examined the overall application of acupuncture in the oncology setting. Though this study is small, we believe by identifying areas of utilization in specific demographics and symptom management we will shed light on patient needs for which they are seeking assistance in their cancer experience.

It is estimated that between 1.7% and 31% of patients with cancer have used acupuncture as a therapeutic treatment.27-29 A 2007 study examining acupuncture use among American adults revealed that 65% of the 344 individuals who had recently used acupuncture were women.30 Women tend to be more frequent users of complementary and alternative medicine (CAM), with breast cancer patients being the most consistent users of CAM compared to women with other tumor types.29,31,32

The use of acupuncture to treat women with breast cancer for common symptoms such as hot flashes, arthralgias, and nausea has been a focal area of acupuncture research. Climacteric “hot flash” studies have shown a decrease in hot flash scores, with secondary improvements in mood, sleep quality, and overall quality of life. In our study, breast cancer patients were the most prevalent users of acupuncture looking for support with the aforementioned symptoms with the addition of neuropathy.

Small studies suggest acupuncture reduces symptoms of chemotherapy-induced peripheral neuropathy, with improvements seen in function, nerve conduction, and neuropathic pain.8,33-37 Neuropathy is a difficult symptom to treat, and standard medications used to relieve the pain and discomfort often create unwanted side effects. Acupuncture for aromatase inhibitor–induced arthralgia in women with breast cancer has also been proven effective as an analgesic aid.21,22 Patients often welcome the additional option for pain relief without the side effects commonly seen from pain-relieving medications.

Patients with head and neck cancers frequently receive a combination of chemoradiation as part of their cancer treatment. Xerostomia and nausea are common side effects experienced in this population due to the area of treatment and local tissue changes in the oral cavity and throat. Acupuncture has been well-documented to help with nausea and vomiting related to chemotherapy4-7 and radiation.38 Compounding effects of oral dryness create added barriers to proper hydration, nutrition, and overall oral health throughout the course of treatment and thereafter. Utilizing acupuncture as a therapeutic treatment to minimize nausea and xerostomia can minimize overall toxicity of treatments, helping support a full course of therapy.9

Seeking out integrative therapies to manage symptoms is certainly a growing trend among patients with cancer. With many patients receiving a combination of care that includes chemotherapy, radiation and surgery, there are many opportunities for acupuncture use along the spectrum of care. Within our radiation cohort, more than half received all 3 cancer treatment modalities. Each treatment modality produces different side effects that acupuncture may help manage throughout the continuum of care. Acupuncture, increasingly available in the oncology setting, is a safe and effective treatment that can offer the additional support patients are looking for to manage symptoms associated with cancer and cancer treatment.

About the Authors

Yiyi Chen, PhD, is an associate professor of biostatistics of the Oregon Health & Science University (OHSU) – Portland State University (PSU) School of Public Health (SPH). Her primary areas of expertise include statistical methods in clinical trials, adaptive design, Bayesian method, decision theory and computational statistics. She has received more than 15 research grant supports from various resources and has over 70 peer-reviewed publications.

Charles R. Thomas, Jr, MD, is professor and chair of the Department of Radiation Medicine and professor of hematology/oncology in the Department of Medicine at the Oregon Health & Science University in Portland, OR. He is also an active member of the Knight Cancer Institute. Thomas has received triple-board certification in radiation oncology (American Board of Radiology), medical oncology and internal medicine (American Board of Internal Medicine). He is a member of the NCI Rectal-Anal Cancer Task Force. He also has an interest in cancer disparities and was one of the editors for the special edition on cancer disparities that was published in The Journal of Clinical Oncology in 2006. He is the author or coauthor of more than 240 journal articles and is a coeditor of multiple textbooks. 

Shushan Rana, MD, is an instructor in the Department of Radiation Medicine at Oregon Health & Science University. Rana’s primary research interest lies in molecular mediators of radiation-induced vascular inflammation as well as radiation therapy artificial intelligence applications. Among his major clinical interests, he focuses on optimal radiation therapy toxicity management through alternative medicine. Rana is funded by 2 nationally recognized extramural grants and is the author of 11 peer-reviewed publications.

Angie Rademacher, ND, LAc, has an integrative primary care practice joining naturopathic, Chinese, and Western medicine. She is also an acupuncturist at Oregon Health and Science University with the hematology oncology division. She graduated from the National University of Natural Medicine in Portland, Oregon, where she completed her doctorate in naturopathic medicine and master of science in Oriental medicine, followed by a 2-year residency at the An Hao Natural Health Care Clinic in Portland.

References

  1. Siegel RL, Miller KD, Jemal A. Cancer Statistics, 2017. CA Cancer J Clin. 2017;67(1):7-30.
  2. 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(4):228-237.
  3. Vickers AJ, Straus DJ, Fearon B, Cassileth BR. Acupuncture for postchemotherapy fatigue: a phase II study. J Clin Oncol. 2004;22(9):1731-1735.
  4. Ezzo JM, Richardson MA, Vickers A, et al. Acupuncture-point stimulation for chemotherapy-induced nausea or vomiting. Cochrane Database Syst Rev. 2006(2):CD002285.
  5. McMillan C, Dundee JW, Abram WP. Enhancement of the antiemetic action of ondansetron by transcutaneous electrical stimulation of the P6 antiemetic point, in patients having highly emetic cytotoxic drugs. Br J Cancer. 1991;64(5):971-972.
  6. Enblom A, Lekander M, Hammar M, et al. Getting the grip on nonspecific treatment effects: emesis in patients randomized to acupuncture or sham compared to patients receiving standard care. PLoS One. 2011;6(3):e14766.
  7. Shen J, Wenger N, Glaspy J. Electroacupuncture for control of myeloablative chemotherapy-induced emesis: a randomized controlled trial. JAMA. 2000;284(21):2755-2761.
  8. Donald GK, Tobin I, Stringer J. Evaluation of acupuncture in the management of chemotherapy-induced peripheral neuropathy. Acupunct Med. 2011;29(3):230-233.
  9. Meng Z, Garcia M, Hu C. Randomized controlled trial of acupuncture for prevention of radiation-induced xerostomia among patients with nasopharyngeal carcinoma. Cancer. 2012;118(13):3337-3344.
  10. Cho JH, Chung WK, Kang W, Choi SM, Cho CK, Son CG. Manual acupuncture improved quality of life in cancer patients with radiation-induced xerostomia. J Altern Complement Med. 2008;14(5):523-526.
  11. Johnstone PA, Niemtzow RC, Riffenburgh RH. Acupuncture for xerostomia: clinical update. Cancer. 2002;94(4):1151-1156.
  12. Blom M, Lundeberg T. Long-term follow-up of patients treated with acupuncture for xerostomia and the influence of additional treatment. Oral Dis. 2000;6(1):15-24.
  13. Hervik J, Mjaland O. Acupuncture for the treatment of hot flashes in breast cancer patients, a randomized, controlled trial. Breast Cancer Res Treat. 2009;116(2):311-316.
  14. Frisk J. Managing hot flushes in men after prostate cancer--a systematic review. Maturitas. 2010;65(1):15-22.
  15. Frisk J, Carlhall S, Kallstrom AC, Lindh-Astrand L, Malmstrom A, Hammar M. Long-term follow-up of acupuncture and hormone therapy on hot flushes in women with breast cancer: a prospective, randomized, controlled multicenter trial. Climacteric. 2008;11(2):166-174.
  16. Walker EM, Rodriguez AI, Kohn B, et al. Acupuncture versus venlafaxine for the management of vasomotor symptoms in patients with hormone receptor-positive breast cancer: a randomized controlled trial. J Clin Oncol. 2010;28(4):634-640.
  17. de Valois BA, Young TE, Robinson N, McCourt C, Maher EJ. Using traditional acupuncture for breast cancer-related hot flashes and night sweats. J Altern Complement Med. 2010;16(10):1047-1057.
  18. Beer TM, Benavides M, Emmons SL, et al. Acupuncture for hot flashes in patients with prostate cancer. Urology. 2010;76(5):1182-1188
  19. Ashamalla H, Jiang ML, Guirguis A, Peluso F, Ashamalla M. Acupuncture for the alleviation in hot flashes in men treated androgen ablation therapy. Int J Radiat Oncol Biol Phys. 2011;79(5):1358-1363.
  20. Spence DW, Kayumov L, Chen A, et al. Acupuncture increases nocturnal melatonin secretion and reduces insomnia and anxiety: a preliminary report. J Neuropsychiatry Clin Neurosci. 2004;16(1):19-28.
  21. Crew KD, Capodice JL, Greenlee H, et al. Pilot study of acupuncture for the treatment of joint symptoms related to adjuvant aromatase inhibitor therapy in postmenopausal breast cancer patients. J Cancer Surviv. 2007;1(4):283-291.
  22. Crew KD, Capodice JL, Greenlee H, et al. Randomized, blinded, sham-controlled trial of acupuncture for the management of aromatase inhibitor-associated joint symptoms in women with early-stage breast cancer. J Clin Oncol. 2010;28(7):1154-1160.
  23. Alimi D, Rubino C, Pichard-Leandri E, Fermand-Brule S, Dubreuil-Lemaire ML, Hill C. Analgesic effect of auricular acupuncture for cancer pain: a randomized, blinded, controlled trial. J Clin Oncol. 2003;21(22):4120-4126.
  24. Li QS, Cao SH, Xie GM, et al. Combined traditional Chinese medicine and Western medicine. Relieving effects of Chinese herbs, ear-acupuncture and epidural morphine on postoperative pain in liver cancer. Chin Med J (Engl). 1994;107(4):289-294.
  25. He BM, Li WS, Li WY. Effect of previous analgesia of scalp acupuncture on post-operative epidural morphine analgesia in the patient of intestinal cancer. Zhongguo Zhen Jiu. 2007;27(5):369-371.
  26. Poulain P, Leandri EP, Laplanche A, Montange F, Bouzy F, Truffa-Bachi J. Electroacupuncture analgesia in major abdominal and pelvic surgery: a randomised study. Acupuncture in Medicine. 1997;15:10-13.
  27. Cui Y, Shu XO, Gao Y, et al. Use of complementary and alternative medicine by Chinese women with breast cancer. Breast Cancer Res Treat. 2004;85(3):263-270.
  28. Lafferty WE, Bellas A, Corage Baden A, Tyree PT, Standish LJ, Patterson R. The use of complementary and alternative medical providers by insured cancer patients in Washington State. Cancer. 2004;100(7):1522-1530.
  29. Morris KT, Johnson N, Homer L, Walts D. A comparison of complementary therapy use between breast cancer patients and patients with other primary tumor sites. Am J Surg. 2000;179(5):407-411.
  30. Zhang Y, Lao L, Chen H, Ceballos R. Acupuncture use among American adults: what acupuncture practitioners can learn from National Health Interview Survey 2007? Evid Based Complement Alternat Med. 2012;2012:10750.
  31. Balneaves LG, Bottorff J, Hislop G, Herbert C. Levels of commitment: exploring complementary therapy use by women with breast cancer. J Altern Complement Med. 2006;12(5):459-466.
  32. DiGianni LM, Garber JE, Winer EP. Complementary and alternative medicine use among women with breast cancer. J Clin Oncol. 2002;20(18 Suppl):34S-38S.
  33. Garcia MK, Cohen L, Guo Y, et al. Electroacupuncture for thalidomide/bortezomib-induced peripheral neuropathy in multiple myeloma: a feasibility study. J Hematol Oncol. 2014;7:41.
  34. Xu WR, Hua BJ, Hou W, Bao YJ. Clinical randomized controlled study on acupuncture for treatment of peripheral neuropathy induced by chemotherapeutic drugs. Zhongguo Zhen Jiu. 2010;30(6):457-460.
  35. Schroeder SG, Meyer-Hamme G, Epplee S. Acupuncture for chemotherapy-induced peripheral neuropathy (CIPN): a pilot study using neurography. Acupunct Med. 2012;30(1):4-7.
  36. Wong R, Sagar S. Acupuncture treatment for chemotherapy-induced peripheral neuropathy--a case series. Acupunct Med. 2006;24(2):87-91.
  37. Bao T, Zhang R, Badros A, Lao L. Acupuncture treatment for bortezomib-induced peripheral neuropathy: a case report. Pain Res Treat. 2011;2011:920807.
  38. Enblom A, Johnsson A, Hammar M, Onelov E, Steineck E, Borjeson S. Acupuncture compared with placebo acupuncture in radiotherapy-induced nausea--a randomized controlled study. Ann Oncol. 2012;23(5):1353-1361.