I just completed a summary review looking at the latest research assessing the effectiveness of acupuncture in the treatment of chemotherapy-induced peripheral neuropathy (CIPN) - there is sufficient evidence for acupuncturists, oncology nurses, and oncologists to begin recommending acupuncture as a safe complimentary treatment for CIPN. Please enjoy and share this paper (PDF link to full paper) to medical doctors, nurses, and/or family and friends that may find this valuable and interesting.
Acupuncture has been widely studied in clinical settings as a treatment for the untreatable and devastating effects of cancer treatment, with emphasis on the secondary impacts of neuropathic pain and reduced quality of life. Several recent clinical reviews of clinical research have begun focusing on the specific concern of chemotherapy-induced peripheral neuropathy (CIPN), assessing the safety and effectiveness of acupuncture as treatment for CIPN. There are two systematic reviews published within the last year, both acknowledging a need for an effective treatment for CIPN, the safety of acupuncture, the continued need for more, high-quality research. These reviews have found that acupuncture, in randomized and controlled clinical trials repeatedly shows significant and measurable improvement in treating the symptoms of CIPN while being safe (Li, Giustini, & Seely, 2019; Baviera, Olson, Paula, Toneti, & Sawada, 2019; Magram & Deng, 2019).
Looking more broadly, Magram & Deng (2019) summarized their clinical review titled Acupuncture and Cancer Pain by stating:
"Acupuncture is commonly used in several cancer-related pain syndromes including aromatase inhibitor-induced musculoskeletal pain, chemotherapy-induced peripheral neuropathy, and cancer-induced bone pain. Although much is still unknown about acupuncture, it is a relatively safe form of treatment that may present a significant form of pain treatment for patients with cancer-related pain." (p. 488)
Observing a pattern of consistent and cumulative evidence in support of acupuncture as a helpful treatment for patient suffering from CIPN, I strongly encourage acupuncturists, oncology nurses, and oncologists to begin recommending the incorporation of acupuncture into their complimentary and integrative treatment plans.
Definitions & Impacts of Chemotherapy-Induced Peripheral Neuropathy
Chemotherapy-Induced Peripheral Neuropathy is the one of most common side-effect of cancer treatment, as is well documented and discussed in one the most recent clinical trials (D’Alessandro et al., 2019). D’Alessandro et al. (2019) succinctly explain CIPN and its many impacts, stating:
"Neurotoxicity induced by antineoplastic drugs may occur both in the peripheral nervous system and the central nervous system. Symptoms range from purely motor to purely sensory or even major autonomic dysfunctions. A broad spectrum of symptoms can be found, from mild discomfort to complete sensory and motor dysfunction of the limb. The clinical features are highly dependent on the type of drug and their toxicity. Many patients develop burning sensation, tingling sensation and functional disabilities. As a result, neurotoxicity can cause high risk of falls and fractures, an inability to walk freely, loss of independence and a poorer quality of life (QoL) and ability to work." (p. 1)
With CIPN occurring in 68.1% of chemotherapy patients within the first month of treatment, and with CIPN continuing to negatively impact a patient’s quality of life far beyond treatment, there is an arguably urgent need for effective amelioration of this condition (Seretny et al., 2014). Acupuncture repeatedly demonstrates effectiveness in randomized and controlled clinical settings and offers promising results despite limitations of a relatively small number of high quality studies (Baviera et al., 2019; Franconi, Manni, Schröder, Marchetti, & Robinson, 2013; Lau et al., 2016; Li et al., 2019). The limitations of the evidence, as some of the researchers have concluded, should in no way preclude the integration of acupuncture into treatment plans, and should merely temper expectations while providing treatment options to patients seeking complimentary care especially when their symptoms are severe and/or they need additional support (Lau et al., 2016).
Current Integration of Acupuncture into Cancer Care
Acupuncture has been implemented at a handful of American medical centers, notably the Dana-Farber Cancer Institute (DFCI) in Boston, the Memorial Sloan-Kettering Cancer Center in New York, and the M.D. Anderson Cancer Center in Houston (Lu, Dean-Clower, Doherty-Gilman, & Rosenthal, 2008). Cancer patients are increasingly requesting and incorporating acupuncture as complimentary care in the cancer treatment, with as many as “between 1.7% and 31%” (Lu et al., 2008, p. 1) of cancer patients specifically utilizing acupuncture for cancer treatment as far back as 10-15 years ago. River et al. (2018) looked at international statistics on usage of complementary and alternative (CAM) therapies for cancer treatment, which includes but is not specific to acupuncture, and note, “International research estimates that between 50 and 87% of cancer patients use CAM therapies as an adjunct to standard cancer treatments.”
The convergence of growing clinical evidence along with a high need to address the severe side-effects of cancer treatment and the significant impacts on quality of life has led to the gradual integration of acupuncture into cancer treatment guidelines and clinical practice guidelines. Birch, Lee, Alraek, & Kim (2018) analyzed general recommendations for acupuncture in published treatment clinical practice guidelines and found, “A total of 2189 positive recommendations were found for the use of acupuncture. Of these, 1486 were related to 107 pain indications and 703 were related to 97 non-pain indications” (p. 3).
Acupuncture has been widely studied and repeatedly demonstrates benefit in clinical trials such that and number of guidelines have begun including it as recommended complimentary care. In 2009, the Society for Integrative Oncology published clinical guidelines titled Evidence-Based Clinical Practice Guidelines for Integrative Oncology: Complementary Therapies and Botanicals that concluded:
"Acupuncture is strongly recommended as a complementary therapy when pain is poorly controlled, when side effects from other modalities are clinically significant, when chemotherapy- induced nausea and vomiting (CINV) are poorly controlled, or when reducing the amount of pain medicine becomes a clinical goal." (Cassileth, 2009, p. 86)
A 2015 Cochrane Review titled Acupuncture for Cancer Pain in Adults reported, “Up to 70% of patients with cancer pain do not receive adequate pain relief and this reduces their quality of life. It has been claimed that acupuncture has a role in the management of cancer pain and guidelines exist for treatment of cancer pain with acupuncture” (Paley, Johnson, Tashani, & Bagnall, 2015, p. 2). In 2016, the American Society of Clinical Oncology (ASCO) published a chronic pain related practice guideline, Management of Chronic Pain in Survivors of Adult Cancers recommended integrative therapies, which includes acupuncture, promoting, “nonpharmacologic interventions available to mitigate chronic pain or improve pain-related outcomes” (Lu & Rosenthal, 2018, p. 520). In 2017, the National Cancer Institute at the National Institutes of Health (NIH) included acupuncture as a recommended treatment option for cancer-related pain and provided evidence-based guidelines on how it can be utilized (PDQ® Integrative, Alternative, and Complementary Therapies Editorial Board, 2019; Birch et al., 2018).
With respect to acupuncture effectively treating CIPN, since the publication of these systematic reviews and clinical guidelines, higher-quality clinical research has brought further evidence to reinforce the previous, modest results aggregated through systematic reviews (D’Alessandro et al., 2019; Molassiotis et al., 2019). With so much support for the inclusion of acupuncture in the treatment plan for cancer-related pain, and specifically the treatment of CIPN, the question is not, “is there evidence?”, the question is, “how much evidence do we need before acupuncture is recommended for CIPN?” With little to no adverse effects, increasing evidence, and high demand from patients, acupuncture is a prime candidate for evidence-based complementary treatment in cancer patients suffering from CIPN.
What Is Preventing the Incorporation of Acupuncture?
Despite the strong and encouraging evidence for incorporating acupuncture into CIPN treatment guidelines, there remain limiting factors to prevent wider spread adoption. River et al. (2018) performed a qualitative investigation into the integration of complementary and alternative therapies with conventional cancer treatment, discovering that one of the limiting factors is the unwillingness to adopt new treatment tools, especially newer, complimentary treatments, by oncologists (p. 4). Another limitation River et al. (2018) found centers around the questions about who covers the cost of care (p. 4-5). Cost and access to care is a recognized challenge in the United States, where healthcare is mediated by restrictive third-party insurance, such that medical professionals and researchers in oncology note that, “third-party coverage for acupuncture needs to be made available to allow patients from diverse socioeconomic backgrounds better access to acupuncture for cancer symptom management” (Zia et al., 2017, p. 72). These problems can and should continue to be challenged, resolved, and overcome through an initial inclusion in treatment clinical practice guidelines.
What Does the Most Recent Evidence Say?
There have been multiple systematic reviews looking to asses the quality of research and evidence into the effectiveness of acupuncture in the treatment of CIPN and its related symptoms (Baviera et al., 2019; Lau et al., 2016; Li et al., 2019).
Acupuncture for cancer pain
Lau et al. (2016) performed a broader review and meta-analysis of “acupuncture and related therapies for palliative cancer care”, including 13 randomized controlled trials, and 969 cancer patients. Their systematic review found that, “Acupuncture and related therapies significantly reduced pain in cancer patients with a quicker analgesic effect and longer analgesic duration when compared with conventional medicine” (p. 11).
Acupuncture for CIPN
Looking more specifically at acupuncture as treatment for CIPN, Baviera et al. (2019) performed a systematic review of available literature, narrowing down from 607 articles to 5, which met their strict criteria. They concluded that, “The authors of all studies showed that acupuncture was associated with an improvement in CIPN symptoms in at least some participants and no one experienced adverse events” and that four of the five articles were of very good methodological quality and thus, “were good studies of the effects of the intervention in CIPN patients” (Baviera et al., 2019, p. 7).
Published a month later in April of 2019, Li et al. published another systematic review of acupuncture as treatment for CIPN, narrowing their research down to 3 different randomized controlled trials (RCTs) from those reviewed by Baviera et al.. They note that two of the three RCTs showed acupuncture was effective in achieving a significant, positive result. They decided on a more conservative, cautious conclusion, stating:
Acupuncture could be chosen as an inexpensive, safe alternative treatment, but clinicians should use due diligence and vigilant monitoring when recommending acupuncture therapy. Given that the quality and quantity of the literature concerning this topic are limited, a potentially beneficial effect might exist, but future rigorous RCTs with appropriate controls should be conducted. (Li et al., 2019, p. e153)
More Recent Clinical Trial Not Included in Systematic Reviews
Just published in the January 2019 issue of Integrative Cancer Therapies, was the first fully powered RCT looking specifically at the effectiveness of acupuncture in treating CIPN. This RCT randomized 87 patients, used both subjective and objective measures, and achieved the following results, “The primary outcome (pain intensity and pain interference) was significantly better at the end of the intervention in the acupuncture arm than the control arm (P < .05 and P < .01, respectively)” (Molassiotis et al., 2019, p. 6). With these results, the finalized their discussion by addressing limiting factors with the noted recommendation, “Acupuncture can be a treatment option for patients experiencing CIPN, although access to such a service and costs for private treatments may affect the uptake of acupuncture from patients. Specific attention should be paid to the ‘dose’ and duration of treatment and the specific acupoints used” (Molassiotis et al., 2019, pp. 10–11). Adding the results of high quality, pragmatic trials such as this only further substantiate the existing evidence that CIPN is a strong candidate for inclusion as a recommended treatment for patients suffering from CIPN.
In the Future - Indispensable
In 2016, the National Cancer Institute held a conference on acupuncture for symptom management in oncology bringing together The Division of Cancer Treatment and Diagnosis, the Office of Cancer Complementary and Alternative Medicine, at the National Cancer Institute (NCI), which was summarized in a monograph published in the Journal of the National Cancer Institute Monographs. The authors completed their summary by acknowledging that the current level of research is substantial and should lead to the implementation of education and training for acupuncturists, primary care providers, oncologists, and patients in order to educate, “about the evidence for acupuncture to manage cancer symptoms in order to direct appropriate referrals” (Zia et al., 2017, p. 72). Throughout the healthcare system, all levels of provider and patient must be informed on the widespread adoption already underway as well as the current research already performed.
Lu & Rosenthal (2018) summarized their review of oncology acupuncture by declaring, “The current ASCO (The American Society of Clinical Oncology) practice guidelines and its recommendations for using acupuncture for chronic pain needs to be followed and disseminated. In the near future, specialized oncology acupuncture will have an indispensable place in cancer pain management” (p. 530). With indicators of change emerging in conventional clinical guidelines, the recommendation of acupuncture as a complimentary treatment for CIPN is all but a certainty. With this in mind, I hope acupuncturists and integrative oncologists feel confident in their introducing protocols and guideline recommendations to medical groups, hospitals, and insurance companies.
Baviera, A. F., Olson, K., Paula, J. M. de, Toneti, B. F., & Sawada, N. O. (2019). Acupuncture in adults with Chemotherapy-Induced Peripheral Neuropathy: A systematic review. Revista Latino-Americana de Enfermagem, 27(0). https://doi.org/10.1590/1518-8345.2959.3126
Birch, S., Lee, M. S., Alraek, T., & Kim, T.-H. (2018). Overview of Treatment Guidelines and Clinical Practical Guidelines That Recommend the Use of Acupuncture: A Bibliometric Analysis. The Journal of Alternative and Complementary Medicine, 24(8), 752–769. https://doi.org/10.1089/acm.2018.0092
Cassileth, B. R. (2009). Society for Integrative Oncology—Evidence-Based Clinical Practice Guidelines for Integrative Oncology: Complementary Therapies and Botanicals. Cancer Control, 12(3), 181–181. https://doi.org/10.1177/107327480501200306
D’Alessandro, E. G., Nebuloni Nagy, D. R., de Brito, C. M. M., Almeida, E. P. M., Battistella, L. R., & Cecatto, R. B. (2019). Acupuncture for chemotherapy-induced peripheral neuropathy: A randomised controlled pilot study. BMJ Supportive & Palliative Care, bmjspcare-2018-001542. https://doi.org/10.1136/bmjspcare-2018-001542
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Molassiotis, A., Suen, L. K. P., Cheng, H. L., Mok, T. S. K., Lee, S. C. Y., Wang, C. H., … Yeo, W. (2019). A Randomized Assessor-Blinded Wait-List-Controlled Trial to Assess the Effectiveness of Acupuncture in the Management of Chemotherapy-Induced Peripheral Neuropathy. Integrative Cancer Therapies, 18, 153473541983650. https://doi.org/10.1177/1534735419836501
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Zia, F. Z., Olaku, O., Bao, T., Berger, A., Deng, G., Yin Fan, A., … Mao, J. J. (2017). The National Cancer Institute’s Conference on Acupuncture for Symptom Management in Oncology: State of the Science, Evidence, and Research Gaps. JNCI Monographs, 2017(52). https://doi.org/10.1093/jncimonographs/lgx005