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Acupuncture in Cancer Treatment - What you as a patient ought to know

Acupuncture, a complementary and alternative (CAM) therapy used in cancer
management, has been used clinically to manage cancer-related symptoms, treat side
effects induced by chemotherapy or radiation therapy, boost blood cell count, and
enhance lymphocyte and natural killer (NK) cell activity. In cancer treatment, its
primary use is symptom management; commonly treated symptoms are cancer pain,
chemotherapy-induced nausea and vomiting, and other symptoms that affect a
patient’s quality of life, including weight loss, anxiety, depression, insomnia, poor
appetite, and diarrhea.

More than 40 states and the District of Columbia have laws regulating acupuncture
practice. The National Certification Commission for Acupuncture and Oriental
Medicine offers national certification examinations for practitioners of acupuncture
and Traditional Chinese medicine (TCM) (www.nccaom.org); most, but not all, states
require this certification. More than 50 schools and colleges of acupuncture and
Oriental medicine operate in the United States, many of which offer master’s-level
programs and are accredited by, or have been granted candidacy status by, the
Accreditation Commission for Acupuncture and Oriental Medicine (ACAOM). ACAOM
standards for a master's-level degree require a 3-year program (approximately 2,000
hours of study) for acupuncture and a 4-year program for Oriental medicine, which
includes acupuncture and herbal therapy (www.ACAOM.org). Some Western medical
training, including the study of anatomy, physiology, and clean-needle technique, is
included in the curriculum of these schools. Postgraduate training programs in medical
acupuncture for physicians also exist; these programs require approximately 200-300
hours of study (e.g., the program at the UCLA School of Medicine, http://www.medsch.
ucla., and the program of the American College of Acupuncture,(www.
acupuncturesociety.com). Because the educational and licensing requirements for
acupuncture practice vary from state to state, one should inquire from each state
board of acupuncture (or other relevant board) for particular information. Third-party
reimbursements also vary from state to state. Some insurance companies cover
acupuncture or limited acupuncture treatment. Federal payers such as Medicaid and
Medicare do not generally reimburse for acupuncture treatment.

Acupuncture has been practiced in China and other Asian countries for more than
4,000 years. In China, acupuncture is part of a TCM system of traditional medical
knowledge and is practiced along with other treatment modalities such as herbal
medicine, tui na (massage and acupressure), mind/body exercise (e.g., qigong and tai
chi), and dietary therapy. In the United States, several different acupuncture styles
are practiced in addition to TCM. These include Japanese acupuncture (e.g., meridian
therapy), English acupuncture (e.g., five element or traditional acupuncture), French
acupuncture (e.g., French energetic acupuncture), Korean acupuncture (e.g.,
constitutional acupuncture), and American medical acupuncture. Most of these are
derived from ancient Chinese medical philosophy and practices. All are based on the
view that the human body must be perceived and treated as a whole and as part of
nature; health is the result of harmony among bodily functions and between the body
and nature, and disease occurs when this harmony is disrupted. TCM therapeutic
interventions, including acupuncture, are used to restore the state of harmony.

Acupuncture is closely associated with Chinese meridian theory. According to this
theory, there are 12 primary meridians, or channels, and 8 additional meridians, each
following a particular directional course along the body. A vital energy known as qi
flows through these meridians and participates in the homeostatic regulation of
various bodily functions. Some 360 points distributed along the meridians serve as
both pathognomic signs of disorder and as loci for acupuncture treatments. When the
normal flow of energy over a meridian is obstructed (e.g., as a result of tissue injury
or a tumor), pain or other symptoms result.

The purpose of acupuncture therapy is to re-open the normal energy flow,
thereby relieving the symptoms by stimulating specific sites (acupuncture points) on
the meridians. In acupuncture treatment, stainless steel needles, usually ranging from
0.22 to 0.25 mm in diameter, are inserted into relevant acupuncture points to
stimulate the affected meridians. A needling sensation known as de qi sensation, in
which the patient feels heaviness, numbness, or tightness, is often required during an
acupuncture treatment. Length and frequency of treatment vary according to the
condition being treated. Chronic conditions usually require a longer treatment period.
Typically, two or three sessions per week are required initially and may decrease to
once a week after several weeks of treatment. Needles are typically left in place for
15 to 30 minutes after insertion, and their effects may be augmented with manual or
electrical stimulation and/or heat (e.g., moxibustion).

Classical techniques of acupuncture include needling, moxibustion, and cupping.
Acupressure, using fingers to apply pressure on acupuncture points, is also considered
a form of acupuncture treatment. Moxibustion is a method in which an herb (Artemisia
vulgaris) is burned above the skin or on an acupuncture point for the purpose of
warming it to alleviate symptoms. Cupping promotes blood circulation and stimulates
acupuncture points by creating a vacuum or negative pressure on the surface of the
skin. During the past several decades, various new auxiliary devices have been
developed. Acupuncture devices such as electroacupuncture (EA) machines and heat
lamps are commonly used to enhance the effects of acupuncture.

In addition to classical acupuncture techniques, other techniques have been developed
and are sometimes used in cancer management. These include trigger point
acupuncture, laser acupuncture, acupuncture point injection, and techniques focusing on
particular regions of the body: auricular (ear) acupuncture, scalp acupuncture, face
acupuncture, hand acupuncture, nose acupuncture, and foot acupuncture. Of these,
auricular acupuncture is the most commonly used.

Although acupuncture has been practiced for millennia, it has come under scientific
investigation only recently. To date, most studies and clinical trials of the mechanisms
and efficacy of acupuncture in cancer management have been carried out in China. In
1976, however, the U.S. Food and Drug Administration (FDA) classified acupuncture
needles as investigational devices (Class III) (www.fda.gov). This resulted in a number
of research studies on the effectiveness and safety of acupuncture. In November
1994, the Office of Alternative Medicine (the predecessor of the National Center for
Complementary and Alternative Medicine) at the National Institutes of Health (NIH)
sponsored an NIH-FDA workshop on the status of acupuncture needle usage. Two
years later, the FDA reclassified acupuncture needles as medical devices (Class II)
without, however, giving specific indications for their use (www.fda.gov). In 1997, NIH
held a Consensus Development Conference on Acupuncture to evaluate its safety and
efficacy. The 12-member panel concluded that promising research results showing the
efficacy of acupuncture in certain conditions have emerged and that further research
is likely to uncover additional areas in which acupuncture intervention will be useful.
The panel stated that “there is clear evidence that needle acupuncture treatment
is effective for postoperative and chemotherapy nausea and vomiting.” It also
stated that there are “a number of other pain-related conditions for which
acupuncture may be effective as an adjunct therapy, an acceptable alternative,
or as part of a comprehensive treatment program,” and it agreed that further
research is likely to uncover additional areas in which acupuncture intervention will be
useful.

These actions by the FDA and NIH have resulted in the establishment of a number of
active programs of research into the mechanisms and efficacy of acupuncture, much of
which is, or is potentially, relevant to cancer management. To date, the most
extensively investigated aspect of these mechanisms has been the effect of
acupuncture on pain management. The NIH Consensus Panel concluded that
“acupuncture can cause multiple biological responses,” local and distal, “mediated
mainly by sensory neurons…within the central nervous system.” Acupuncture “may
also activate the hypothalamus and the pituitary gland, resulting in a broad
spectrum of systemic effects,” including “alterations in peptides, hormones and
neurotransmitters and the regulation of blood flow.” Recent studies show the
effect of acupuncture on chronic inflammatory pain. Evidence suggests that
acupuncture operates through the autonomic nervous system to balance the
sympathetic and parasympathetic systems and suggests that the anti-inflammatory
effects of acupuncture are mediated by its electrophysiologic effects on
neurotransmitters, cytokines, and neuropeptides. Many studies provide evidence that
opioid peptides are released during acupuncture and that acupuncture analgesia is
mediated by the endogenous opioid system.

Laboratory and animal cancer studies exploring the mechanisms of acupuncture have
focused mainly on the activation and modulation of immune functions. Acupuncture
treatment points are located by using standard anatomic landmarks and comparative
anatomy. EA is the most commonly used treatment intervention; a few studies have
used moxibustion. These studies show that acupuncture may boost animal immune
function by increasing blood cells and enhancing NK cell and lymphocyte activity.
According to one animal behavioral study, acupuncture may be a useful adjuvant for
suppressing chemotherapy-induced emesis.

Although several studies published in China examined the effect of acupuncture on the
human immune system, most cancer-related human clinical studies of acupuncture
evaluated its effect on patient quality of life. These investigations mainly focused on
cancer symptoms or cancer treatment–related symptoms, predominantly cancer pain
and chemotherapy-induced nausea and vomiting. Studies have also been done on the
effect of acupuncture on radiation-induced xerostomia (dry mouth), rectitis,
dysphonia, weight loss, cough, thoracodynia, hemoptysis, fever, esophageal obstruction,
poor appetite, night sweats, hot flashes, dizziness, fatigue, anxiety, and depression in
cancer patients. The evidence from most of these clinical studies is inconclusive,
despite their positive results; either poor research design or incompletely described
methodologic procedures limit their value. The positive results of the studies on
chemotherapy-induced nausea and vomiting, which benefit from scientifically
sound research designs, are the most convincing.