And The Cancer Patient
Kenneth A. Conklin, MD
The use of acupuncture in oncology, for management of treatment-related
adverse effects and for palliative care, is finding greater acceptance
in Western medicine. Although the evidence is not extensive and for
many applications, randomized controlled trials are lacking, acupuncture
appears to be of benefit for managing chemotherapy-induced nausea and
vomiting; cancer-related pain; generalized symptoms that result from
treatment, including fatigue, insomnia, diarrhea, and anorexia; radiotherapy-induced
xerostomia; brachial plexopathy resulting from axillary lymphadenectomy
for breast cancer; treatment-related vasomotor symptoms; radiotherapy-induced
rectitis; dysphagia due to carcinomatous obstruction; and end-of-life
symptoms such as dyspnea. Studies further suggest that acupuncture enhances
immune function and is effective for treatment of chemotherapy- or radiotherapy-induced
Acupuncture, Xerostomia, Cancer, Radiotherapy, Nausea, Chemotherapy,
Chemotherapy, biological therapy, and radiation therapy are based on
an understanding of cancer cell characteristics such as how the cancer
cell cycle differs from the cycle of normal cells and the processes
involved in the development of cancer including initiation, promotion,
and progression. Although Eastern medicine views cancer quite differently
than does Western medicine, using acupuncture to treat cancer patients
and manage adverse effects induced by conventional cancer therapies
is based on sound Eastern principles. This review addresses cancer and
the development of therapy-induced adverse effects from both an Eastern
and Western perspective; it also reviews the literature regarding use
of acupuncture for treatment of chemotherapy- and radiotherapy-induced
adverse effects and cancer-related symptoms.
Cancer: Western and Eastern Perspectives
Western science views cancer as resulting from genetic-environmental
interactions causing multiple genetic alterations that affect coding
of oncogenes for growth factors, growth factor receptors, and tumor
suppresser genes. When oncogenes are inactivated, they fail to control
the normal process of cell growth and death. Thus, normal cells become
cancer cells through a series of events that result in loss of regulation
of cell proliferation and programmed cell death (apoptosis).
Despite events that result in derangements of regulatory mechanisms
for cell growth and death, dysfunction of the host immune system plays
an important role in the development of cancer. One of the vital functions
of the immune system is immune surveillance, i.e., the recognition and
elimination of cells that have undergone neoplastic transformation.
Cancer cells express antigens that serve as targets for antitumor immunity
and make them vulnerable to immune effector cells such as natural killer
(NK) cells, lymphokine- activated killer cells, tumor-specific cytotoxic
T lymphocytes, and macrophages. Development of cancer can thus be viewed
as a failure of immune surveillance.
In Traditional Chinese Medicine (TCM), uncontrolled cell proliferation
and dysfunction of the immune system can be attributed to a decline
of deficiency of Essence (Jing). Essence, stored in the Kidneys, governs
reproduction, growth, and development. Thus, it exerts primary control
over the processes of cellular differentiation and proliferation. Improper
control over these processes due to a deficiency of Essence may result
in uncontrolled cellular growth, which manifests as cancer. Essence
also determines basic constitutional strength and resistance to exterior
pathogenic factors (although Wei Qi is primarily responsible for protection
from exterior pathogenic factors, it draws its strength and has its
root in Kidney Essence). Essence is the basis of Marrow, which produces
the common matrix of bone marrow, brain, and spinal cord. Thus, Essence
has an important role in maintaining proper immune function by producing
Marrow, which, in turn, produces bone marrow that contains the pluripotent
stem cells that give rise to immune effector cells. The differentiation
of stem cells and subsequent proliferation of immune effector cells
are also governed by Essence. Thus, a decline or deficiency of Essence
could result in an individuals immune system failing to recognize
and eliminate cells that have undergone neoplastic transformation.
The physical manifestation of cancer (tumors) can also be viewed as
resulting from a decline or deficiency of Essence. Essence, in its dynamic
and rarefied form as Original Qi (Yuan Qi) with its origin in the Kidneys,
can be viewed as the force that arouses and moves the functional activity
of all the organs. Thus, the development of tumors results from a deficiency
of Essence and Yuan Qi, which result in deranged functions of the internal
organs. The results of the derangements can lead to stasis of Blood
and formation of Phlegm, either of which may be manifest as tissue masses.
Although all tissue tumors are not necessarily malignant (e.g., uterine
fibroids, nerve ganglia, and lipomas), and some tumors or nodules may
be transient (e.g., lymphadenopathy during infections), those resulting
from Blood stasis or congealed Phlegm are manifestations of malignant
Common causes of Blood stasis are Qi deficiency or Qi stagnation. If
Qi becomes too weak to move Blood, or if Qi stagnates, Blood congeals.
Masses resulting from Blood stasis most commonly manifest as fixed abdominal
masses associated with pain of a boring or stabbing character.
The primary cause for formation of Phlegm is Spleen deficiency. The
Spleen governs transformation and transportation. If the Spleen fails
to transform and transport body fluids, they will accumulate and form
Phlegm. Although Spleen deficiency is the primary factor in the formation
of Phlegm, failures of the Lungs to disperse and lower fluids or failure
of the Kidneys to transform and excrete fluids may also result in their
accumulation into Phlegm. If Phlegm congeals, it may manifest as tissue
masses, more commonly as subcutaneous nodule such as enlarged lymph
nodes and thyroid tumors but also as tumors in the uterus.
Adverse Effects of Western Therapies
Chemotherapy and radiotherapy can result in numerous side effects (Table
1). Mucositis (inflammation of the gastrointestinal mucosa), myelosuppression,
and hair loss are more or less associated with all chemotherapy regimens.
Chemotherapy is cytotoxic to cells that proliferate rapidly. Although
it is directed at rapidly growing cancer cells, the rapidly growing
cells of the gastrointestinal tract, bone marrow, and hair follicles
are also affected. Similarly, radiation therapy is also most toxic to
cells with a high rate of proliferation.
Mutagenesis/carcinogenesis, which results in the development of secondary
malignancies, is one of the most serious adverse effects of chemotherapy
and radiation therapy. Secondary malignancies occur in up to 10% of
individuals who receive either or both of these treatments. Secondary
malignancies most commonly develop approximately 5 years following treatment
of the primary malignancy and are generally more resistant to treatment
than the original cancer.
Adverse Effects of Cancer Therapies
of the gastrointestinal mucous membranes
- Hair loss
TCM holds that the cause of mucositis is stagnation of noxious dampness
in the Middle Heater resulting from dysfunction of the Spleen and Stomach.1
The Spleens function of transformation and transportation is crucial
to the process of digestion. If this function is impaired, diarrhea
(Spleen Qi descending instead of ascending), poor appetite, and impaired
digestion may result. If Stomach Qi ascends instead of descends, nausea
and vomiting will result (rebellious Stomach Qi). Therefore, mucositis
may be viewed primarily as an impact of chemotherapy on the Spleen and
Blood dyscrasias, anemia, and immune dysfunction in TCM are considered
disorders of blood (the more physical aspect of Blood) resulting from
dysfunction of the Spleen as it oversees the formation and distribution
of blood and fluids in the body. The Spleen must extract Food Qi (Gu
Qi) from food and send it upward to the Lungs, which begin the process
of transformation into Blood, and send the Food Qi to the Heart where
Original Qi and Essence facilitate the further
transformation into Blood. Essence also contributes to the formation
of Blood because it is the basis of Marrow which produces bone marrow.
Myelosuppression and immunosuppression can thus be viewed as chemotherapy
impacting primarily the Spleen and Kidneys but also, the Lungs and Heart.
The hair relies on the nourishment of Kidney Essence to grow, and Kidney
vitality manifests in the moistness and strength of the head hair. The
Lungs receive fluids from the Spleen and distribute them to the skin.
This gives the skin and body hair nourishment and moisture without which
the hair will be dry and wither. Thus, hair loss can be viewed as an
impact of chemotherapy on Kidney Essence and the Lungs.
Mutagenesis/carcinogenesis comes full circle from cancer to cancer treatment
to cancer. As described above, cancer can be attributed primarily to
a decline or deficiency of Kidney Essence and Original Qi. Thus, chemotherapy
and radiation therapy can be considered an assault of these therapies
on Kidney Essence and Original Qi which lead to the development of secondary
malignancies following treatment of the original cancer.
TREATMENT OF SYMPTOMS
The efficacy of acupuncture for relief of treatment-related adverse
effects and palliative care of cancer patients has been investigated
most extensively for management of chemotherapy-induced nausea and vomiting
and cancer-related pain. The impact of acupuncture on immune function
and treatment-induced myelosuppression has also received considerable
attention. Although many studies have methodological flaws, fail to
meet the rigors of randomized controlled trials (RCTs), or use sham
acupuncture (which has been questioned as a true placebo),2 the studies
reviewed herein provide considerable evidence about the benefits of
acupuncture for individuals experiencing chemotherapy- or radiotherapy-induced
adverse effects and end-of-life symptoms.
Nausea and Vomiting
Chemotherapy-induced nausea and vomiting occur in both an acute and
a delayed form. Acute nausea and vomiting, occurring during or soon
after intravenous administration of chemotherapeutic agents, result
from stimulation of the chemoreceptor trigger zone. Delayed nausea and
vomiting result from the toxicity of antineoplastic agents to the gastrointestinal
tract, i.e., as a result of chemotherapy-induced mucositis. Peak symptoms
of delayed nausea and vomiting usually occur between 2 and 4 days following
chemotherapy. Acupuncture (Table 2) and acupuncture-related therapies
(Table 3) have been used for prophylaxis and treatment of both acute-
and delayed-onset nausea and vomiting resulting from chemotherapy.
Acupuncture. The pioneering work on the use of acupuncture for
chemotherapy-induced nausea and vomiting, as well as for postoperative
nausea and vomiting and morning sickness, was performed by the late
John W. Dundee and his colleagues, who summarized their work in several
reviews.3-7 Their initial studies of chemotherapy-induced nausea and
vomiting involved 24 inpatients receiving various chemotherapy regimens.8,9
All patients had experienced severe sickness (nausea and/or vomiting)
with a prior infusion of chemotherapy. Inpatients received 5 or 6 treatments
over 3 days with electroacupuncture (10 Hz, 5 minutes) of PC 6 (right
forearm only10), the first treatment being given prior to administration
of chemotherapy. Outpatients received 1 to 5 treatments. Eleven inpatients
and 21 outpatients had complete alleviation of emetic symptoms lasting
at least 8 hours following treatment with acupuncture while most of
the remaining patients had some improvement. Sham acupuncture (1 treatment
of 15 inpatients) using a point near the right elbow was without benefit.
In a study of 20 outpatients randomized to receive either intravenous
metoclopramide (10 mg) or electroacupuncture of PC 6 (10 Hz, 5 minutes,
right forearm) prior to their first course of chemotherapy, sickness
occurred twice as often in those treated pharmacologically although
the difference between groups was not significant.11
2. Acupuncture for Chemotherapy-Induced Nausea and Vomiting
in 3 days
PC 6, PC 6 press needle
6, ST 36
for 5 days
ST 36, SP 6, ST 34,
PC 6, LI 11, LI 4,
points based on symptoms
for 2 weeks
PC 6, ST 36,
pointsbased on symptoms
for 30 days
11, LI 4, ST 36,
SP 6, PC 6, BL 17,
BL 20, BL 21, LR 2,
for 10 days
36, PC 6, SP 4,
points based on symptoms
a study by Dundee et al12 that included 130 patients with prior chemotherapy-induced
sickness, electroacupuncture (10 Hz, 5 minutes, right forearm) of PC
6 given shortly before or soon after chemotherapy resulted in 97% of
patients experiencing complete absence of sickness or reduced sickness
for at least 8 hours. The study included 15 patients in an open pilot
design, 10 patients from their previously reported crossover RCT,9 and
105 patients (34 inpatients and 71 out-patients) in a definitive study.
Of those patients in the definitive study, 63% experienced complete
absence of sickness whereas only 5% failed to have any benefit. In this
study, acupuncture was used as an adjunct to standard antiemetic agents
including metoclopramide plus prednisolone.
Aglietti et al13 evaluated the antiemetic effect of PC 6 acupuncture
in 26 women receiving a cisplatin-containing chemotherapy regimen. All
women received intravenous antiemetic medication including 3 mg/kg of
metoclopramide prior to and after cisplatin, 20 mg of dexamethasone,
and 50 mg of diphenhydramine in addition to acupuncture. A needle was
placed in PC 6 (unilateral) for the duration of cisplatin infusion (20
minutes) and then replaced with a semipermanent press needle which was
removed after 24 hours. Patients were instructed to press the needle
gently if nausea occurred. Compared with a historical control of 51
patients who had received similar chemotherapy, the mean number of vomiting
episodes, the mean maximal score of nausea (a measure of severity of
symptoms), and the duration of nausea and vomiting were reduced, and
the percentage of patients (88.5%) with complete protection from nausea
was increased by the acupuncture treatment.
Shen et al14 compared the antiemetic effectiveness of electroacupuncture
with that of minimal needling plus mock electrical stimulation (sham
acupuncture) or antiemetic medication only in a 3-arm, parallel-group,
RCT of 104 women with breast cancer who were receiving myeloablative
chemotherapy with cyclophosphamide, cisplatin, and carmustine. All patients
received intravenous pharmacological emesis management beginning 1 hour
before chemotherapy and continuing until 48 hours following the final
chemotherapy infusion. This treatment included prochlorperazine, 10
mg loading followed by an infusion of 1 mg/m2/hour; lorazepam, 1 mg/m2
every 4 hours; and diphenhydramine, 25 mg/m2 every 6 hours. Bilateral
electroacupuncture (2-10 Hz, 0.5-0.7 milliseconds, DC, 20 minutes) was
performed after achieving De Qi using PC 6 (negative pole) and ST 36
(positive pole). In the sham acupuncture group, superficial needling,
without manipulation or stimulation, was performed at LU 7 and GB 34.
These needles were connected to the clips of an electrical stimulator
which emitted the same audiovisual stimulus for 20 minutes as in the
electroacupuncture technique, but no current was passed through the
needles. Electroacupuncture or superficial needling was performed daily
for 5 days and patients were observed for an additional 9 days following
these treatments. Patients in the electroacupuncture group had significantly
fewer emesis episodes and a greater proportion of emesis-free days than
patients in either the minimal needling group or the pharmacotherapy
group. However, patients in the minimal needling group had significantly
fewer emesis episodes than those in the pharmacotherapy group which
illustrates the difficulty in designing a mock or sham
acupuncture treatment. During the follow-up period (days 6-14), the
number of emesis episodes and the proportion of emesis-free days did
not differ between the 3 groups.
Acupuncture has also been shown to benefit patients with nausea and
vomiting when acupuncture points are selected according to TCM. Dang
and Yang15 randomized 48 patients having chemotherapy for stomach carcinoma
and being treated with analgesics for cancer-related pain to receive
either acupuncture (ST 36, SP 6, ST 34, PC 6, LI 11, LI 4, and points
based on each patients symptoms), acupuncture plus injection of
4 points per treatment (Ah Shi points, PC 2, ST 19, SP 12, or SP 10)
with human transfer factor, or no treatment other than analgesics (control
group). Each patient who received acupuncture had 4 courses of treatment
separated by 2-3 days, with each course of treatment being 1-3 treatments
daily, 20 minutes each for 2 weeks. Although statistics were not presented,
only 19% of patients in each acupuncture group experienced nausea and
vomiting whereas these symptoms occurred in 50% of controls.
Xia et al16 randomized 76 patients being treated with chemotherapy (8
patients) or radiotherapy (68 patients) for lung, esophageal, or stomach
cancer to receive either acupuncture (15-30 minutes, every other day
for 30 days) or no additional treatment (control group). PC 6 and ST
36 were used for all patients in the acupuncture group, with additional
points based on the TCM symptom complex. Only 5% of patients in the
acupuncture group experienced nausea and vomiting vs 85% in the control
3. Acupuncture-Related Therapies for Chemotherapy-Induced
Nausea and Vomiting
bilateral PC 6
bilateral PC 6
for 7 days
PC 6 and ST 36
min, as needed for nausea, for 10 days
stimulation, PC 6 and LI 4
Hz, 5 minutes every 2 hours,
for 5 days
unilateral at PC 6
and for 2 hours after chemotherapy
4. Treatment of Therapy-Induced Myelosuppression
6, ST 36, points based on symptoms
36, SP 6
10, BL 17
11, LI 4, ST 36, SP 6
36, SP 6, points based on symptoms
36, SP 6
14, LI 4, ST 36, SP 6, BL 17, BL 20, BL 21, BL 23
17, BL 20, BL 21, BL 23, GV 14
Points from CV 8, GV 14, SP 6, BL 17, BL 20, BL 21, BL 23
36, SP 6
a review of several clinical series, Zhou et al1 reported that more
than 90% of 44 patients with gastrointestinal symptoms experienced complete
relief of treatment-related nausea and vomiting with daily treatment
(30 minutes each for 10 days) using LI 11, LI 4, ST 36, SP 6, PC 6,
BL 17, BL 20, BL 21, CV 12, and LR 2.
Electroacupuncture was applied to SP 6 and ST 36. In another series
of 90 patients, nausea and vomiting were markedly reduced by 30-minute
acupuncture treatments given 15 minutes before and 2 hours following
chemotherapy. All patients were treated with ST 36, PC 6, and SP 4,
with CV 12, CV 4, LR 3, CV 17, and BL 21 added, depending on each patients
In a study of acupuncture for palliative care,17 4 patients (of 47 treated)
who were experiencing nausea were treated with acupuncture using a Western
approach (although the points used for the treatments were not stated).
One patient experienced excellent relief for nausea, 1 patient had slight
improvement, and 2 patients received no benefit from acupuncture.
Acupressure. Use of acupressure wristbands, which have a pressure
button positioned over PC 6, have been investigated as a means of controlling
nausea and vomiting. In a study of 18 patients, wristbands (bilateral)
were worn during some courses of cytotoxic chemotherapy and were not
worn during other courses so that comparisons could be made.18 When
the bands were used, the severity of nausea, as assessed by patients
and staff, the incidence of vomiting, and the amount of antiemetic medication
used were greatly reduced. Additionally, oral intake was better tolerated
and patients reported less depression when bands were worn. In a single-blind,
randomized, crossover study of wristbands (bilateral) placed at PC 6
vs placement at a sham point on the ankle, significantly better relief
of chemotherapy-induced nausea and vomiting was reported when the bands
were placed correctly.19
In a single-cycle RCT, Dibble et al20 investigated the efficacy of finger
acupressure bilaterally at PC 6 and ST 36 for relief of nausea in 17
women receiving adjuvant chemotherapy for breast cancer. Acupressure
was self-administered by the patients for 3 minutes each morning and
as needed whenever nausea arose for the first 10 days following chemotherapy.
The nausea experience, as measured by the Rhodes Index of Nausea, Vomiting
and Retching, was significantly less for 7 of the 10 days and nausea
intensity was significantly less for 1 of the 10 days in the patients
using finger acupressure.
In contrast to the above studies, Brown et al21 compared the use of
a unilateral acupressure wristband to a placebo wristband (no pressure
button) or no wristband, and found that use of the wristband was not
effective in reducing nausea and vomiting in 6 terminally ill hospice
patients (5 patients with cancer and 1 patient with renal failure).
Transcutaneous electrical stimulation (TCES). McMillan et al22
assessed the effect of TCES as an adjunct to ondansetron (8 mg intravenously
followed by 8 mg orally 3 times daily for 5 days) for relief of nausea
and vomiting in 16 patients receiving a chemotherapy regimen that included
cisplatin and cyclophosphamide. Direct current TCES of 10-15 Hz for
5 minutes every 2 hours awake for 5 days, was applied to PC 6 (negative
pole) and LI 4 (positive pole) on the patients dominant forearm.
Patients were randomly assigned to receive TCES during either the 1st
or the 2nd course of the highly emetic chemotherapy. The severity of
nausea and the incidence of vomiting were reduced by TCES treatments
in 12 of 13 patients who did not have complete relief of symptoms with
antiemetic drugs alone. In a comparison of TCES to acupuncture as an
adjunct to standard antiemetic medication for control of nausea and
vomiting, Dundee et al23 found TCES (administered as described above22)
to be beneficial in 88% of chemotherapy treatments as compared with
a beneficial effect of PC 6 electroacupuncture (unilateral, 10 Hz, 5
min) in 96% of treatments.
Magnet therapy. Liu et al24 compared the effect of placing, unilaterally,
the north pole of a 2-cm-diameter magnetic disk on PC 6 (161 patients)
to placing a non-magnetic iron disk on PC 6 (23 patients), or point
compression of PC 6 with a 0.5-cm steel ball (22 patients) for relief
of cisplatin-induced nausea and vomiting. Treatment was initiated before
and continued until 2 hours after infusion of cisplatin. Nausea and
vomiting were significantly reduced in the magnetic disk group
(61% markedly effective, 28% effective, 11% ineffective) compared with
the effect observed in the iron disk group (none markedly effective,
22% effective, 78% ineffective). Unilateral point compression was ineffective
for relief of nausea and vomiting in all patients, results that are
consistent with those of others.21
Combined treatment. Dundee et al12 noted that a single acupuncture
treatment of PC 6 was an effective adjuvant to standard antiemetic therapy
in cancer chemotherapy, but the benefit lasted only 8 hours. Investigating
a means of prolonging the antiemetic effect, Dundee and Yang25,26 placed
an acupuncture wristband (unilateral) on PC 6 immediately following
PC 6 acupuncture (unilateral, dominant forearm, 10 Hz, 5 minutes) and
instructed patients to press the button for 5 minutes every 2 hours
while awake until 24 hours following chemotherapy. In 20 inpatients
(79 chemotherapy treatments) and 20 outpatients (43 chemotherapy treatments),
use of acupressure prolonged the antiemetic effect of acupuncture for
24 hours following 95% of the treatments.
Dundee et al23 also investigated whether acupressure could prolong the
antiemetic effect of TCES (administered as described above).22 Unilateral
PC 6 acupressure applied following TCES prolonged the antiemetic effect
for 24 hours in approximately 90% of patients. Additionally and consistent
with the results of other studies,21,24 unilateral acupressure treatment
alone was ineffective for relieving chemotherapy-induced nausea and
vomiting. Thus, although unilateral PC 6 acupressure alone does not
appear to provide relief of chemotherapy-induced nausea and vomiting,21,23,24
it does appear to help prolong the antiemetic effect of
PC 6 acupuncture25,26 and TCES.23
Pain of Malignancy
Acupuncture. Evidence that acupuncture benefits patients with
pain due to malignant disease comes almost exclusively from case series.
Although details of the treatments are lacking, early studies appearing
soon after the dawn of acupuncture awareness in the United States in
the early 1970s, reported acupuncture to be effective for relief of
cancer pain in 8 patients for 3-72 hours27 and in 4 patients for 6-36
hours.28 Intensive electroacupuncture, administered daily, was also
reported to be effective for pain relief in 29 patients with terminal
Filshie and Redman30,31 investigated acupuncture using unspecified points
for 5-15 minutes with minimal manual stimulation for management of pain
in 183 patients. A total of 146 patients had pain related to malignant
disease or resulting from treatment (chemotherapy, radiotherapy, or
surgery) of the disease process, and 37 patients had pain unrelated
to cancer. Thirty percent of patients obtained some benefit (pain relief
for up to 3 days) from acupuncture treatments and 52% of patients were
helped significantly. For the patients who experienced significant benefit
from acupuncture, multiple treatments, up to 4 weekly, were nearly always
necessary. It was further stated that acupuncture was particularly useful
for myofascial pain. Although it is unclear from these reports to what
degree patients with tumor-related pain were benefited, Filshie stated
in a subsequent report of 156 patients (55 with tumor-related pain,
60 with treatment-related pain, and 41 with pain unrelated to cancer)
that worthwhile results were least likely for patients with tumor-related
Leng17 reported that weekly treatments for 4-6 weeks with acupuncture
practiced according to a Westernized approach resulted in
excellent or good relief of pain for 62% of complaints of pain in 47
patients (45 with cancer and 2 with motor neuron disease). Eight of
10 patients with myofascial pain reported excellent or good relief.
The acupuncture techniques used were described as including trigger-point
acupuncture and traditional points for specific symptoms, but further
details of the treatments were not given. Others have also reported
excellent but short-lasting relief of malignant pain following acupuncture,
but without providing a description of the treatment used.33
In contrast to reports that have not fully described the acupuncture
technique used for pain management, Xu et al34 reported the benefit
of acupuncture at ST 36 (bilateral, 15 min daily for 2 weeks) for relief
of tumor-related abdominal pain due to stomach, liver, or colon cancer
or abdominal lymphosarcoma. Fifteen patients with slight pain experienced
complete relief. Of 41 patients with moderate pain, 37% had complete
pain relief and 61% were improved. Twenty-six of 36 patients with severe
pain experienced some improvement, but the remaining 10 patients had
no benefit from acupuncture. The duration of pain relief by patients
who experienced a benefit from the treatment was not stated.
In a study of acupuncture for pain management that used a control group,
Dang and Yang15 randomized patients with pain due to stomach carcinoma
to receive TCM acupuncture, TCM acupuncture plus point injection with
human transfer factor, or treatment with Western analgesic medication
only (described earlier). The total course of treatment was 2 months;
the analgesic effect of treatment was assessed at 30 minutes (immediate
effects) and 12 hours (long-term effects) following each of the 1st
and last 10 days of treatment. During the first 10 days, the proportion
of treatments resulting in an analgesic effect (complete or partial
pain relief) with Western medicine was 100% for immediate effects and
85% for long-term effects. These results were significantly better than
those with acupuncture or acupuncture with point injection (both groups
approximately 80% immediate effects and 55% long-term effects). During
the final 10 days of treatment, analgesia (complete or partial pain
relief) was the same in all groups (approximately 95% immediate and
80% long-term effects) although the percentage of patients who experienced
complete long-term pain relief was significantly higher in the 2 acupuncture
groups (approximately 50%) than in the drug treatment group (34%). In
another randomized study of patients being treated with chemotherapy
or radiotherapy for esophageal carcinoma, Xia et al16 reported relief
of chest pain in 41% of patients treated with TCM acupuncture (described
earlier) compared with only 3% of patients in a control group (cancer
Treatment of pain due to bony metastasis is one of the most difficult
challenges in the palliative care of cancer patients. Guo et al35 investigated
the efficacy of an analgesic decoction of herbs, administered twice
daily, plus electroacupuncture for relief of pain due to bony metastasis.
The electroacupuncture technique used acupoints on meridians related
to the pain, local acupoints, and Ah Shi points (although details of
the electrical stimulation used were not given). A plate electrode was
applied over the site of pain and the other electrode applied to the
acupuncture needles. Treatments were 10-20 minutes, twice daily, with
1 course of treatment lasting 10 days. Up to 10 courses of treatment
were given with a rest period of 3 days between courses. Pain was relieved
in 83.6% of 104 patients with medium pain, described as disturbing life
and sleep and requiring analgesic drugs. Pain relief occurred in 68.6%
of 182 patients with severe pain, described as excruciating pain for
which analgesic agents were indispensable and accompanied by functional
disturbances in the autonomic nervous system.
Ahmed et al36 reported the use of percutaneous electrical nerve stimulation
(PENS) for treatment of 3 patients with pain due to bony metastasis.
Acupuncture needles were inserted into the periosteum (negative electrode)
of vertebrae at levels corresponding to the dermatomal distribution
of the patients pain, and into the soft tissue (positive electrode)
peripherally along the dermatome. A direct current of 4-100 Hz was then
applied for 30 minutes. Two patients experienced marked pain relief
lasting from 1-4 days following each of 2 (initial treatment with 15
and 30 Hz, second treatment with 100 Hz) or 3 treatments (6 Hz, 15/30
Hz, then 100 Hz). However, 1 patient receiving treatments of 4 Hz, 15/30
Hz, and 100 Hz experienced no pain relief.
Rico and Trudnowski37 also reported the use of anatomical acupuncture
for treatment of back pain due to malignant disease in 22 patients who
failed to obtain relief with conventional treatments. For 10 patients,
needles were inserted 5 cm from the midline, to a depth of 1.25 cm,
at the levels of the vertebrae above and below the dermatome of the
pain area. Electrical stimulation of 6-8 Hz for 15-30 minutes was applied
daily for 6-7 days. The remaining patients received the same electrical
stimulation, for 1-2 days every 5-10 days, of needles inserted into
both gluteal folds and popliteal areas, the median aspect of the heels,
and the most painful Ah Shi point on the back. Pain relief was greater
than 75% in 13 patients, 50%-75% in 2 patients, and less than 50% in
3 patients. Only 4 patients experienced an unsatisfactory effect. The
authors stated that the analgesic effects observed were far greater
than that of placebo although the placebo treatment was not described.
Auricular acupuncture. Auricular acupuncture also has been reported
to effectively relieve the pain of malignant disease. As part of a large
study that included 377 patients with pain due to various causes, Fischer
et al38 reported complete or substantial relief in 19 of 27 patients
with pain due to carcinoma. Treatment involved placement of semipermanent
auricular needles that were replaced once or twice weekly for an unspecified
period. The auricular points used were not indicated.
Dillon and Lucas39 applied a semipermanent press needle in a single
auricular point identified by an electrodermal response for treatment
of 28 patients (22 with metastatic cancer) with neuropathic, benign
soft tissue, benign bone, or malignant bone pain that was not controlled
by conventional means. Needles were repositioned if they became displaced
and were routinely replaced in the opposite ear at week 2 of a 4-week
observation period. Patients experienced significant pain relief 2 days
after needle insertion and 26 patients reported moderate to complete
pain relief at 2 and 4 weeks. There was no difference in pain scores
or pain relief between patients with benign or malignant disease.
Cancer-related dyspnea is a distressing symptom for many individuals
at end-of-life. Filshie et al40 reported the benefits of acupuncture
in 20 patients for treatment of breathlessness that was directly related
to malignancy and was refractory to conventional medications. A needle
was inserted into each LI 4, and 2 needles were placed 1-2 cm apart
in the upper sternum and advanced to the periosteum. Needles were left
in place for 10 minutes without stimulation. Seventy percent of patients
reported marked subjective benefit from the treatment, with significant
improvements in visual analog scale (VAS) scores of breathlessness,
relaxation, and anxiety lasting at least 6 hours following acupuncture.
There was also a reduction of respiratory rate following the treatment,
an effect that was sustained for the 90-minute period during which it
was measured. Pulse rate and oxygen saturation were unchanged by the
treatment. In an attempt to prolong symptom relief, in-dwelling needles
were placed in the sternal points of 8 patients who had reported benefit
from the treatment. Patients were instructed to massage the studs in
the event of a breathless attack. All 8 patients reported some benefit
lasting up to 2 weeks. Leng17 also reported that acupuncture given according
to a Westernized approach provided good relief from breathlessness
in 4 of 8 patients
with cancer-related dyspnea.
Dang and Yang15 and Xia et al16 reported the benefits of acupuncture
for treating generalized symptoms resulting from chemotherapy or radiotherapy.
In both studies, acupuncture treatments were administered according
to TCM theories (described earlier) and comparisons were made between
patients treated with acupuncture and those of a control group who were
treated with Western therapies only. Dang and Yang15 found that the
incidence of chemotherapy-related adverse effects was less in the acupuncture
group as compared with the incidence in the control group (anorexia:
22% vs 75%; diarrhea: 0% vs 13%; dizziness: 16% vs 69%; insomnia: 6%
vs 44%; and weakness: 22% vs 100%). Xia et al16 found the incidence
of chemotherapy- or radiotherapy-induced adverse effects was less in
the acupuncture group as compared with the incidence in the control
group (anorexia: 5% vs 90%; diarrhea: 3% vs 20%; dizziness: 13% vs 85%;
insomnia: 8% vs 45%; and fatigue: 5% vs 100%).
In their review of several clinical series, Zhou et al1 reported greater
than 90% relief of treatment-related diarrhea and constipation in a
series of 44 patients treated (30 minutes daily for 10 days) using LI
11, LI 4, ST 25, ST 36, ST 37, SP 6, PC 6, BL 20, BL 21, and CV 12.
Electroacupuncture was applied to ST 36 and SP 6 although details of
the electrical stimulation used were not given. In another series of
70 patients, daily acupuncture treatments of 30-40 minutes each for
4 days, using ST 36 and SP 4, were used to treat chemotherapy-induced
diarrhea. Moxa was also applied to CV 12, CV 8, and ST 25. Seventy-three
percent of patients experienced complete relief of diarrhea and 21%
had some relief. In a third series, patients were treated with 30 minutes
of electroacupuncture at ST 36 immediately before chemotherapy and the
following 2 days. Auricular press pellets on Stomach, Diaphragm, Shen
Men, and Adrenal Gland were used in addition to ST 36 acupuncture in
patients with severe symptoms. Symptom relief was reported in 87% of
patients. Although these results are encouraging for the use of acupuncture
for treatment of gastrointestinal symptoms, the results are difficult
to interpret because control groups were not used and the natural course
of treatment-related symptoms is improvement following completion of
each cycle of chemotherapy.
Blom and colleagues41-43 investigated the effects of acupuncture for
treatment of xerostomia in patients who received radiotherapy for head
and neck malignancies. Following encouraging results from a pilot study
of 2 patients,41 they treated 20 patients with acupuncture and 18 patients
with placebo-acupuncture.42 All patients received 2 treatments of 20
minutes each weekly for a total of 24 treatments with a 2-week interval
between the first 12 treatments and the final 12 treatments. Acu-
puncture treatments were administered according to TCM with De Qi elicited
for each point, and included local points in the head and neck selected
from ST 3, ST 5, ST 6, ST 7, SI 17, LI 18, TE 17, and GV 20 and distal
points selected from PC 6, HT 7, LI 4, LI 10, LI 11, SI 3, KI 3, KI
5, KI 7, SP 3, SP 6, SP 8, LR 3, and ST 36. A total of 5-8 points were
selected, most bilaterally. Two to 4 ear points selected from Mouth,
Kidney, Sympathetic, Shen Men, Stomach, GI Parotis, and Subcortex were
also used. Placebo acupuncture was performed by inserting needles superficially
(intradermally), without manipulation, about 1 cm away from the classic
acupuncture points. Improvement of unstimulated and paraffin-chewing
stimulated salivary flow rates was observed in both groups.
Although the difference in flow rates between the groups was not significant,
the changes in the placebo group were somewhat less and appeared after
a longer latency period than in the acupuncture group. The improved
flow rates persisted for the 1 year-long observation period of the study,
but for some patients the flow rates were decreased at 6 or 12 months
following treatment. Some patients also reported improved taste, diminished
pain in the tongue, and lessened hoarseness following the treatments.
Blom and Lundeberg43 subsequently reported their results of a long-term
follow-up of 70 patients with xerostomia which included 38 patients
(apparently from their prior study42) with post-radiotherapy xerostomia.
The points selected for treatment were similar to those of their prior
study with the addition of TE 17 to the head and neck points, and TE
5 and GB 41 instead of SI 3. In the extremity point group, LI 10, SP
3, SP 8, and KI 7 were used. Each treatment was described as including
4 points from the local group and 6 points from the distal group, some
bilaterally, for a total of 12-15 needles. Auricular points were also
used in 47 patients. For the 38 patients with post-radiotherapy xerostomia,
objective (stimulated and unstimulated flow rates) and subjective changes
in salivary flow rates were reported at 6 months, following
a series of 24 acupuncture treatments over 4 months. Twenty patients
had both subjective and objective improvement, 6 patients had objective
improvement only, and 5 patients experienced subjective improvement
without any objective changes. If this assessment was made following
the treatment of the 38 patients as reported in their prior publication,42
(in this report) the authors made no apparent distinction between patients
in the acupuncture group and those in the placebo group. Following the
initial 6 months of the study, patients were offered a series of 5-12
additional acupuncture treatments as needed for 3 years. Of the 8 patients
in the post-radiotherapy group who chose to receive additional treatments,
stimulated and unstimulated salivary flow rates were consistently higher
than those of patients who chose not to continue acupuncture.
Johnstone et al44 reported the effects of acupuncture for treatment
of pilocarpine-resistant xerostomia in 18 patients who had received
radiotherapy bilaterally for head and neck malignancies. Treatment,
as described in their preliminary report,45 was a 2-phase approach.
Needles were initially (phase 1) inserted bilaterally into LI 2 or LI
3 and into auricular points Point Zero, Shen Men, and Salivary Gland
II. Needles were removed and phase 2 was performed. The 2nd phase incorporated
bilateral electrostimulation of Salivary Gland II and Salivary Gland
(F) I (10 Hz, 40 mA, 30 seconds), followed by replacement of Salivary
Gland II needles and bilateral piezoelectric stimulation for 10 seconds
of LI 4. Two treatments were given the first week, followed by 3-4 weekly
treatments. All but 2 patients experienced better salivation subjectively.
Objective results obtained with the Xerostomia Index, an 11-item survey
administered before and after treatment, noted a significant quality
of life improvement for half of the patients.
Rydholm and Strang46 investigated the use of acupuncture for treatment
of xerostomia due to underlying malignancy, previous chemotherapy, or
ongoing treatment with opioids, diuretics, antihistamines, or anticholinergic
drugs in 20 patients (17 with cancer) receiving late-stage palliative
care. Manual acupuncture stimulation of ST 4, ST 5, ST 6, and ST 7 for
20 minutes was performed twice weekly for 5 weeks. Dryness of mouth
and difficulty with swallowing or speaking due to xerostomia
were assessed by means of a VAS at baseline and before each treatment.
For symptoms of dryness, speech problems (10 patients), and dysphagia
(10 patients), significant improvements were observed following 5 treatments
with further improvements being noted after completion of 10 treatments.
Postsurgical Brachial Plexopathy
He et al47 investigated the benefits of acupuncture for treatment of
pain and limited upper extremity movement following axillary lymphadenectomy
in patients with breast cancer. Forty-eight patients received acupuncture
on the 3rd, 5th, and 7th postoperative day and on the day of discharge
(postoperative day 14, approximately). Their symptoms were compared
with those of a control group of 32 patients who had the same surgical
procedure but did not receive acupuncture. The main acupuncture points
selected based on TCM theory were GB 24, TE 6, PC 3, LR 14, and GV 14;
LU 2 was needled if pain radiated to the chest, LU 3 and GV 10 if pain
radiated to the inside and backside of the arm, GV 15 and GV 16 if the
patient complained of a convulsive feeling in the shoulder area,
and HT 7, CV 6, or CV 17 depending on the patients basic health.
Pain at rest was significantly less in patients receiving acupuncture
on the 3rd and 5th postoperative day although pain at rest was similar
in the 2 groups for the remainder of the hospital stay. However, the
maximum abduction angle without pain was significantly greater in the
treated group than in the control group following the initial acupuncture
treatment and for the duration of hospitalization. Others have reported
that acupuncture is an effective treatment for relief of chronic pain
and diminished upper extremity strength and range of motion following
surgery for breast cancer although details of the treatment were not
Alimi et al48 treated 20 patients with malignant disease, most of whom
had postoperative pain and 11 had post-mastectomy brachial plexopathy,
with semipermanent press needles applied to auricular points identified
by an electrodermal response. Needles were retained for 5-35 days after
their initial placement and were not replaced when they fell out. Average
pain intensity was 74 mm on a 100-mm VAS before treatment and fell to
an average of 41 mm, a significant decrease, 60 days following needle
placement. Although the response of the patients with post-mastectomy
pain was not stated separately, these results suggest that auricular
acupuncture may effectively relieve this postoperative complication.
Niemtzow49 also reported that electroauriculotherapy (details not provided)
was effective for relieving chronic pain and diminished upper extremity
range of motion following mastectomy.
Vasomotor symptoms (hot flushes and sweating), frequent symptoms of
menopause, also result from certain therapies of malignant disease including
orchiectomy or medical castration with gonadotropin-releasing hormone
analogs for prostate cancer, and antiestrogen therapy with tamoxifen
or therapy with aromatase inhibitors for breast cancer. Hammar et al50
treated 7 men with vasomotor symptoms following castration with twice-weekly
acupuncture treatments of 30 minutes each for 2 weeks, followed by weekly
treatments for 10 weeks. Electroacupuncture at 2 Hz was applied bilaterally
at BL 23 and BL 32. Also needled were BL 15 bilaterally, GV 20, and
HT 7, PC 6, LR 3, SP 6, and SP 9 unilaterally. Six of 7 patients experienced
a significant decrease of the number of hot flushes after 6, 10, and
24 weeks following the start of treatment. The 7th patient discontinued
therapy after 3 weeks (5 treatments) because severe back pain prevented
him from undergoing further treatments.
Climacteric vasomotor symptoms which result from diminished blood levels
of estrogens have been shown to respond favorably to acupuncture.51,52
In a study of women with breast cancer, Towlerton et al53 also demonstrated
that acupuncture weekly sessions using SP 6 and LR 3 reduced hot flushes
due to tamoxifen therapy. The authors additionally used semipermanent
acupuncture needles applied to SP 6 bilaterally for 4-36 months for
12 patients who continued to experience hot flushes despite conventional
therapy and intermittent acupuncture at SP 6 and LR 3. Eight of the
12 patients reported that use of the studs abolished or attenuated the
severity or duration of their hot flushes. Niemtzow49 also reported
that acupuncture relieved therapy-related vasomotor symptoms in several
patients with breast cancer.
Zhang54 used acupuncture to treat 44 women who developed rectitis following
intracavitary irradiation for carcinoma of the cervix. Twenty-minute
treatments were performed daily for 3-8 days using LI 4, ST 25, ST 37,
and ST 36 bilaterally, with CV 6 added for serious tenesmus, SP 6 and
GB 34 for mucous stools, and ST 39 for hematochezia. Seventy-two percent
of patients reported complete resolution of symptoms, 9% noted a marked
improvement of symptoms, and 18% experienced some improvement of symptoms.
Feng55 treated 2 patients with advanced esophageal carcinoma who experienced
dysphagia due to cancer-related obstruction that was con-firmed by barium
swallow. The 1st patient received 6 treatments, each consisting of 2
consecutive days of acupuncture (20-30 minutes) followed by a 3-day
interval before the next treatment. ST 25, ST 40, and BL 25 were used
on both days of treatment, with CV 12, CV 22, ST 36, and SP 4 added
on the 1st day, and BL 17, BL 21, BL 46, and PC 6 added on the 2nd day.
The 2nd patient was treated with CV 12, CV 22, ST 35, SP 4, and PC 7
on the 1st and 2nd day of each treatment. Both patients experienced
relief of dysphagia without recurrence of the symptom for the remaining
few months of their lives. Xia et al16 reported that relief of dysphagia
occurred in 41% of patients who received acupuncture (described earlier)
during treatment with chemotherapy or radiotherapy for esophageal carcinoma
whereas 3% of patients who did not receive acupuncture experienced relief
of this symptom.
TREATMENT OF MYELOSUPPRESSION/IMMUNOSUPPRESSION
Acupuncture. In a randomized study of 76 patients with lung,
esophageal, or stomach cancer, Xia et al16 assessed the impact of acupuncture
on leukocytopenia and thrombocytopenia resulting from chemotherapy (7
consecutive days of 5-fluorouracil every 13 days, 8 patients) or radiotherapy
(5 times weekly, 68 patients). Patients receiving acupuncture (15-30
minutes every other day for 30 days) were treated using PC 6 and ST
36 plus additional points based on each individuals TCM symptom
complex, whereas those in the control group received no additional treatment
(Table 4). Following 30 days of cancer treatment, there was a significant
35% decline in leukocyte count and an 18% (non-significant) decline
in platelet count in the control group and no change in the leukocyte
count, and a significant 17% increase in the platelet count in the acupuncture
He et al56 treated 20 patients with chemotherapy-induced leukocytopenia
with microwave acupuncture which has a heating effect similar to moxibustion.
Bilateral treatment of ST 36 and SP 6 for 20 minutes was performed daily
for 10 days. A significant rise in the leukocyte count from 2.65 x 109/L
to 3.80 x 109/L was observed in the acupuncture group, whereas a non-significant
rise from 3.31 x 109/L to 3.83 x 109/L was observed in a control group
(no acupuncture) of 29 patients. Wu et al57 reported that daily microwave
acupuncture to SP 10 and BL 17 was effective for raising the leukocyte
count of patients receiving chemotherapy although they did not have
a control group in their study.
In their summary of several clinical series, Zhou et al1 reported that
during chemotherapy, patients receiving daily treatments of 15-30 minutes
for 7 days using LI 11, LI 4, ST 36, and SP 6 had significantly higher
leukocyte counts than patients in a control group. In a 2nd clinical
series, electroacupuncture of ST 36 and SP 6 plus needling of points
selected from LI 11, LI 4, PC 6, BL 18, BL 20, SP 10, GB 39, and GV
14 (daily treatment for 10-30 days) was also reported to elevate the
decreased hemoglobin levels and leukocyte and platelet counts caused
by chemotherapy although a control group was not included in this study.
In another study that lacked a control, Chen and Huang58 reported that
acupuncture with moxibustion of ST 36 and SP 6 effectively elevated
the leukocyte count in 88% of 121 cases of chemotherapy-induced leukocytopenia.
In addition to the above studies of leukocytopenia due to cancer treatments,
Wei59 demonstrated that acupuncture was an effective treatment for 90%
of 48 patients with leukocytopenia described as idiopathic (32 patients)
or resulting from hypersplenism (6 patients), drug adverse effects (3
patients), rheumatoid arthritis (2 patients), or aplastic anemia (1
patient). Only 4 patients in this series had leukocytopenia that was
cancer-related or due to chemotherapy or radiotherapy. ST 36 was needled
bilaterally once daily for 14 consecutive days. After De Qi was elicited,
needles were retained for 20 minutes with manipulation every 5 minutes.
Before treatment, the leukocyte count was less than 2.0 x 109/L in all
patients. Following the 14-day therapeutic course, the leukocyte count
was above 5.0 x 109/L in 18 patients, above 4.0 x 109/L in 15 patients,
improved in 10 cases, and unchanged in 5 cases.
Acupuncture point injection. Yin et al60 treated 104 patients
with chemotherapy-induced leukocytopenia (leukocyte count <4.0 x
109/L) with daily injections of a solution containing 5 mg of dexamethasone,
20 mg of adenosine triphosphate, and 0.1 g of inosine into ST 36 bilaterally.
Twenty-three patients in a control group received twice-daily subcutaneous
injections of filgrastim (granulocyte colony-stimulating factor). Treatment
was considered effective if the leukocyte count rose above 4.0 x 109/L.
After 3 days, treatment was effective in 39% of patients in the acupuncture
group and 61% of patients in the control group. After 7 days, treatment
was 91%-92% effective in both groups. Zhou et al1 reported a study in
which injection of ST 36 with 5-10 mg of dexamethasone initially, followed
by daily injections of either dexamethasone or inosine, elevated severely
depressed leukocyte counts in 97% of 60 patients being treated with
chemotherapy. Although these studies suggest that injection of ST 36
is an effective treatment for leukocytopenia, the results can also be
attributed to the parenteral administration of dexamethasone. This treatment
results in elevation of the granulocyte count by causing their release
from bone marrow, reducing the rate of their removal from the circulation,
and increasing their demargination from blood vessel walls.
Moxibustion. Zhou et al1 reviewed 3 clinical studies in which
moxibustion was used for treatment of chemotherapy-induced leukocytopenia.
Daily treatment with moxibustion applied to GV 14, LI 4, ST 36, SP 6,
BL 17, BL 20, BL 21, and BL 23 for 10-15 minutes, followed by mild massage
of each point for 3-5 minutes, was reported to effectively treat leukocytopenia
in 82% of 49 patients. In a series of 114 leukocytopenic patients, daily
moxibustion of BL 17, BL 20, BL 21,
BL 23, and GV 14 increased the leukocyte count above 4.0 x 109/L in
46% of patients following 1-3 treatments. An additional 30% of patients
and 17% of patients responded favorably following 4-6 treatments and
7-9 treatments, respectively. In a 3rd study, a significant elevation
of the leukocyte count was observed in 31 of 37 leukocytopenic patients
following 6-18 moxibustion treatments of 3 points selected from CV 8,
GV 14, SP 6, BL 17, BL 20, BL 21, and BL 23. Chen and Huang58 also
reported that moxibustion of ST 36 and SP 6 effectively elevated the
leukocyte count in 91% of 221 cases of chemotherapy-induced myelosuppression.
Although these results suggest that moxibustion may be effective for
treating leukocytopenia, these studies lack control groups.
Several investigators have shown that acupuncture enhances various parameters
of cell-mediated immunity in patients with cancer who exhibit immunosuppression
In a double-blind RCT of 40 patients with malignancies, Wu and colleagues61,62
reported significant increases in CD3+ and CD4+ T-lymphocyte subgroups
and an elevated CD4+/CD8+ ratio following 10 daily treatments of 30
minutes each using PC 6, LI 4, ST 36, and CV 4. In a study of similar
design, Yuan and Zhou63 observed similar results following acupuncture
treatments using PC 6, LI 4, ST 36, and SP 6. In another double-blind
RCT, Wu et al64 reported that 10 daily treatments of 30 minutes each
using ST 36, LI 11, and CV 6 elevated the level of interleukin 2, which
induces the proliferation of thymocytes and increased NK cell activity.
Guo et al35 treated 50 patients with an analgesic decoction of herbs
twice daily plus acupuncture (points not specified) and reported a statistically
significant increase in the lymphoblast transformation rate.
Zhou et al65 randomized 40 patients to acupuncture or control following
surgery for stomach, colon, or breast cancer. Epidural anesthesia was
used in all cases to avoid the immunosuppressive effects of intravenous
or inhalational anesthetics (although surgery itself is immunosuppressive).
Patients in the acupuncture group were given 30-minute treatments daily
beginning the day following surgery, using ST 36 and either PC 6 if
the operation was above the diaphragm or SP 6 if it was below. Following
3 treatments, in acupuncture patients, leukocyte phagocytosis of bacteria
was significantly increased whereas this parameter did not change in
the control group.
Dang and Yang15 randomized 48 patients with stomach cancer to receive
TCM acupuncture, acupuncture point injection, or no treatment other
than analgesic medication which all patients received (described earlier).
Treatments were initiated at the start of chemotherapy. E-rosette forming
rate (E-RFR) was measured before and at the end of 2 months of treatment.
Before treatment, E-RFR in all 3 groups was significantly below that
of healthy controls which reflects the immunosuppression observed in
most patients with cancer. Following 2 months of treatment, E-RFR rose
to normal levels in the acupuncture and point injection group whereas
it decreased significantly in controls.
5. Treatment of Cancer-Related Immunosuppression
LI 4, ST 36, CV 4
LI 4, ST 36, SP 6
LI 11, CV 6
natural killer cell activity
plus SP 6 or PC 6
SP 6, PC 6,
ST 34, LI 4, LI 11, points
based on symptoms
ST 36, points
based on symptoms
Signs and Symptoms That Respond Favorably to Acupuncture
nausea and vomiting
symptoms resulting from cancer therapies
and/or radiotherapy-induced myelosuppression
et al16 also investigated the impact of acupuncture on E-RFR in patients
undergoing treatment for various malignancies. E-RFR was significantly
decreased in controls following completion of chemotherapy or radiotherapy.
In patients randomized to receive TCM acupuncture (described earlier)
during cancer therapy, E-RFR was significantly elevated to nearly that
of healthy controls at the end of their therapy.
Acupuncture has also been reported to enhance immune function when immunosuppression
is due to causes other than cancer or cancer treatment. Guo and colleagues66,67
investigated the impact of acupuncture in patients with immunosuppression
associated with mammary gland hyperplasia. For both studies, the acupuncture
points chosen were ST 15, CV 17, LI 4, GB 21, SI 11, and BL 18; LR 3
replaced LI 4 for cases of Fire in the Liver, KI 3 replaced BL 18 for
cases of Liver and Kidney Yin deficiency, and ST 36 replaced LI 4 for
cases of Qi and Blood deficiency. SP 6 was added for all patients with
menstrual disorders. In these authors earlier study,66 BL 20 replaced
BL 18 for cases of Qi and Blood deficiency and TE 5 was added for cases
of an oppressive feeling in the chest. Front and back points
were treated for 20-30 minutes on alternate days, with patients receiving
either 3-4 courses of 30 daily treatments66 or 1-7 courses of 10 daily
treatments.67 The E-RFR and lymphoblast transformation rate of patients
with mammary hyperplasia were significantly below that of healthy controls
before treatment. Following treatment with acupuncture, both parameters
were significantly elevated and not different from that of healthy controls.
Using classical acupuncture, Bianchi et al68 treated 10
patients for low back pain with 7 weekly treatments of 30 minutes each.
Mitogen-induced T-lymphocyte proliferation was unchanged immediately
following the 1st treatment, but it was significantly elevated following
the 7th treatment. The b-endorphin concentration of blood mononuclear
cells, which correlates with enhanced lymphocyte responses to mitogens,
was also significantly elevated following the 7th treatment, but not
after the 1st treatment. Wu61 observed a significant elevation of the
b-endorphin concentration in plasma, which correlates with that in mononuclear
cells,68 following acupuncture treatments in patients with cancer.
Zhang et al69 investigated the impact of acupuncture on suppression
of NK cell activity that follows epidural injection of morphine. Eighteen
patients undergoing cholecystectomy with epidural anesthesia were randomized
to a control group to receive 1 mg of epidural morphine for postoperative
relief, or to receive 1 mg of epidural morphine plus a 1-hour acupuncture
treatment using ST 36, SP 6, LI 4, and PC 6. An electric current (6
Hz and 25 Hz) was applied to the points on the right side. NK cell activities
were determined immediately preoperatively and on the 1st, 3rd, and
7th postoperative day. Compared with normal values, patients in all
3 groups showed decreased NK cell activities before operation. On the
1st and 3rd postoperative days, NK cell activities were below preoperative
levels in all 3 groups, with the least depression observed in the acupuncture
group and the greatest observed in the epidural morphine group. On the
7th postoperative day, NK cell activity in the control and acupuncture
groups were near their preoperative values whereas that of the epidural
morphine group was still markedly depressed.
Interest in the use of acupuncture and evidence documenting its efficacy
for treating cancer-related symptoms and therapy-induced adverse effects
have increased steadily during the past few decades. In 1997, the National
Institutes of Health Consensus Development Panel on Acupuncture, which
reviewed literature produced from January 1970-October 1997, concluded
that there is evidence that acupuncture is effective for the treatment
of chemotherapy-induced nausea and vomiting.70 The panel further concluded
that promising results have emerged for the efficacy of acupuncture
in postoperative dental pain and that it may be useful for treatment
of certain other painful conditions although cancer-related pain was
not mentioned. The results of studies presented herein suggest that
acupuncture may be less effective for management of cancer-related pain
than it is for other painful conditions. Other investigations reviewed
above suggest that acupuncture is useful for treating a variety of cancer-related
conditions (Table 6).
As part of an effort to encourage further research that has the potential
to improve the quality of life for individuals with cancer and/or HIV/AIDS,
the National Center for Complementary and Alternative Medicine released
a request for applications (RFA-AT-01-002, January 16, 2001) entitled
(CAM) at the End of Life for Cancer and/or HIV/AIDS. The grant,
to fund research over 4 years for a total of approximately $9 million,
resulted in the submission of several applications to investigate acupuncture
as the sole CAM modality and other applications that incorporated acupuncture
into a more broad-based holistic approach. Certainly, efforts such as
these will further our knowledge of the benefits of acupuncture for
individuals with cancer.
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Dr Kenneth A. Conklin is Clinical Professor of Anesthesiology at UCLA
School of Medicine in Los Angeles, California. Dr Conklin practices
Integrative Oncology, incorporating Clinical Nutrition and Medical Acupuncture
with conventional therapies for cancer.
Kenneth A. Conklin, MD, PhD*
Department of Anesthesiology
Center for the Health Sciences
UCLA School of Medicine
Los Angeles, CA 90095-1778
Phone: 310-206-6226 Fax: 310-825-2236 E-mail: firstname.lastname@example.org
*Send all correspondence and reprint requests regarding this article
to Kenneth Conklin, MD, at the address above.