by NCI staff
In a large clinical trial, researchers tested two types of acupuncture to treat chronic pain in cancer survivors, including auricular (ear) acupuncture, called “battlefield acupuncture.”
Credits: Image courtesy of Matthew Weitzman, Memorial Sloan Kettering Cancer Center
Two types of acupuncture may help reduce chronic pain in cancer survivors, results from a large clinical trial suggest. Cancer survivors in the study reported slightly improved pain after receiving acupuncture compared to patients receiving standard pain treatment.
Although some studies have found that acupuncture appears to reduce pain in people without cancer, this trial showed that acupuncture did not reduce pain in survivors of various cancers. One of the first large randomized clinical studies aimed at testing whether cancer-related pain can be alleviated.
The researchers leading the new trial acknowledged several factors that may have influenced the results, including the lack of a group of participants who received a placebo version of acupuncture. Other researchers not involved in the study also noted that because there was no placebo “arm” in the trial, it is possible that the improvement in pain reported by those who received acupuncture was the result of a “placebo effect.” He pointed out that it is difficult to eliminate.
The trial enrolled a broad group of cancer survivors with a history of breast cancer, prostate cancer, lymphoma, and other types of cancer, and tested two types of acupuncture; No experts said that was a strength of this study.
“When we look specifically at cancer pain management in cancer survivors, this certainly adds something new,” said Robert Swarm, MD, director of the division of pain management at the University of Washington School of Medicine. Stated. “I think this study will be of interest to oncologists and those involved in the care of cancer survivors.”
Researchers compared the effectiveness of “battlefield acupuncture,” a type of auricular acupuncture developed by the Veterans Affairs (VA) Health System, to electroacupuncture, commonly used by licensed acupuncturists, in reducing symptoms. We wanted to compare this with usual care to alleviate the symptoms. Cancer-related pain.
The advantage of auricular acupuncture, according to study leaders, is that it is easy to train medical professionals to administer the treatment.
The study, led by Mao Jun, M.D., director of integrative medical services at Memorial Sloan Kettering Cancer Center, found that participants who received electroacupuncture had slightly better pain control than those treated with auricular acupuncture. reported. Both types of acupuncture were superior to conventional treatment. Overall, the pain relief lasted long beyond the last treatment session and lasted up to four months, researchers he reported March 18. JAMA Oncology.
“It’s very remarkable that the effects of acupuncture persisted over time,” said Dr. Heather Greenlee, director of the Integrative Medicine Program at Fred Hutchinson Cancer Research Center. Although he was not involved in this study, he was a researcher. Early trials of acupuncture to reduce pain in women undergoing treatment for breast cancer.
“Similar results were observed in our trial; a much shorter period of acupuncture demonstrated sustained clinical effects on pain relief,” Dr. Greenlee continued.
Compared to survivors who received electroacupuncture, participants who received auricular acupuncture reported side effects, primarily ear pain, and were more likely to discontinue treatment due to side effects.
The need for non-pharmaceutical pain management
Research shows that 30% to 40% of cancer survivors experience chronic pain related to cancer or its treatment. Researchers continue to test new ways to manage that pain, including painkillers and complementary medicine approaches such as yoga and acupuncture.
“Cancer survivors struggle with whether to live with the pain or take medications, such as anti-inflammatory drugs, which may improve the pain but increase the risk of kidney damage and gastrointestinal bleeding.” said Dr. Mao.
Due to the opioid abuse epidemic, cancer survivors report increased barriers to these medications and heightened concerns about addiction.
“Most patients who are taking painkillers are trying to get off the painkillers,” says Matthew Weitzman, chief acupuncturist in the Integrative Medicine Service at Memorial Sloan Kettering Cancer Center.
“While some patients are taking opiates, there is certainly awareness of the dangers of opiates, especially with long-term use. There are other ways for patients with chronic pain to cope with their pain. If they can find one, they’ll be pretty enthusiastic about it.”
Dr. Greenlee said non-drug treatments have another potential benefit. “There is no need to worry about acupuncture interfering with the oncology treatment the patient is receiving.”
Despite the appeal of non-pharmacological treatments, approaches such as acupuncture have come under intense criticism from some researchers. Skeptics point to the fact that research has failed to identify the biological mechanisms by which acupuncture alleviates pain and other problems. Other criticisms include the variability in how acupuncture studies are conducted, from where the needles are inserted into the body to how placebo or sham treatments are performed.
Studies of human acupuncture to treat pain have had mixed results, with some people reporting that it actually helps with problems such as pain and nausea, while others show little or no improvement. Some people.
A 2017 expert report from an NCI-sponsored conference on the topic found that “in animal and human experiments, needle insertion and manipulation induce a variety of physiological effects, both central and peripheral.” .
However, the report concludes that “significant scientific gaps remain in our understanding of the relationship between these mechanisms and the responses to acupuncture observed in clinical trials.”
Understanding test results
The trial, led by Dr. Mao, enrolled 360 participants, all of whom had previously been diagnosed with cancer but had no current evidence of cancer and had cancer-related musculoskeletal symptoms. had reported pain for at least 3 months. Most of the participants were elderly and 70% were women.
Participants were randomly assigned to one of two types of acupuncture or usual pain care, which included painkillers, physical therapy, and steroids. Treatment included 10 weekly sessions, and participants were followed for an additional 16 weeks.
The primary outcome was self-reported pain intensity based on a tool called the Brief Pain Inventory (BPI). The BPI measures pain on a scale from 0 (no pain) to 10 (worst pain imaginable). At the beginning of the study, participants reported moderate pain (mean 5.2 points on the BPI) that had lasted an average of 5 years. Approximately 60% used painkillers regularly.
An experienced acupuncturist will perform both acupuncture treatments. Auricular acupuncture used a battlefield protocol developed by the VA Medical System. The protocol involves inserting up to five sterile stud needles into each ear and asking participants to walk around for 1 minute and rate the severity of their pain.
“In many, but not all cases, participants experienced immediate symptom relief,” Weitzman said. Participants were instructed to keep the inserted stud in their ear for 4 days and then remove it. “The idea is that continuous stimulation of acupressure points increases the therapeutic effect,” says Weitzman.
The same acupuncturist administered electroacupuncture using a device that sends a low-voltage electrical current to four needles inserted into acupuncture points near the area of pain. Four more needles were inserted at more distant sites, Weitzman explained.
“Similar devices are used in physical therapy, where instead of using needles, the therapist applies a patch to the skin and sends pulsating sensations to the muscles, causing them to relax,” he said.
During the 12-week study period, electroacupuncture reduced pain severity by 1.9 points on the BPI, and ear acupuncture reduced pain severity by 1.6 points.
The improvement in pain was just below the two-point threshold typically considered clinically meaningful for patients, Dr. Swarm explained. But “even if there is a small benefit and a small risk of adverse events, it is a reasonable effort,” he said.
Approximately 11% of patients receiving auricular acupuncture discontinued treatment due to side effects, compared with less than 1% of patients receiving electroacupuncture. The most common complaint in the ear acupuncture group was ear pain, whereas in the electroacupuncture group it was bruising.
Although auricular acupuncture has been shown to be effective in reducing pain, “some patients may not tolerate it as well as other acupuncture treatments,” Dr. Greenlee said. “When thinking about scaling up acupuncture, it is important to understand what is acceptable to patients.”
The investigators also acknowledged that participants were not “blind” to the treatment they received, which is considered an important way to limit the possibility of a placebo effect.
In this particular case, Dr. Swarm noted, it’s almost inevitable. “This is a common problem when studying these types of treatments.”
Ready for widespread use in cancer pain management?
When Dr. Mao designed this study, he had in mind scaling up acupuncture. Since 2016, VA has trained more than 2,700 clinicians with no formal acupuncture experience to provide battlefield acupuncture across the health care system.
“This type [of acupuncture] You can teach a doctor in one day. I think we can adopt a similar model for cancer survivors across the country,” Dr. Mao said. Acupuncture may also provide an additional tool for pain management in areas hit particularly hard by the opioid crisis, he said.
