Acupuncture, a complementary and alternative therapy used in cancer management,[1-4] 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,[4,5] chemotherapy-induced nausea and vomiting (N/V),[6,7] and other symptoms that affect a patient’s quality of life, including weight loss, anxiety, depression, insomnia, poor appetite, xerostomia, hot flashes, peripheral neuropathy, and gastrointestinal symptoms (constipation and diarrhea).[8-10] Acupuncture is acceptable and safe for children.
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). In recent years, some schools have begun to offer programs for Doctor of Acupuncture and Oriental Medicine with an additional 1,200 hours of clinical-based doctoral training. Some Western medical training, including the study of anatomy, physiology, and clean-needle technique is included in the curriculums of these schools. Postgraduate training programs in medical acupuncture for physicians also exist. In the United States, training to be a licensed acupuncturist is regulated according to individual state law. 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 (www.nccaom.org). Third-party reimbursements also vary from state to state. Some insurance companies cover acupuncture or limited acupuncture treatment. Federal payers such as Medicare do not generally reimburse for acupuncture treatment.
Acupuncture has been practiced in China and other Asian countries for more than 4,000 years.[12-14] 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.[15,16] 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 eight 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. Along the meridians are approximately 360 points that serve as both pathognomonic signs of disorder and as loci for acupuncture treatments.[14,17] 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. Chinese medicine proposes that the purpose of acupuncture therapy is to normalize 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 mm 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 occurs, in which the patient may feel heaviness, numbness, or tingling 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 or heat lamps).
Classical techniques of acupuncture include needling, moxibustion, and cupping. Acupressure, using fingers or mechanical devices to apply pressure on acupuncture points is based on the same principles as acupuncture. 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 acupuncture, scalp acupuncture, face acupuncture, hand acupuncture, nose acupuncture, and foot acupuncture. Of these, auricular acupuncture is the most commonly used.
In clinical practice, most acupuncturists in the United States follow the traditional theories and principles of Chinese medicine. However, there are other schools of acupuncture practice, including medical acupuncture, which have different theories regarding meridians and acupuncture point locations.
Although acupuncture has been practiced for millennia, it has come under scientific investigation only recently. In 1976, the U.S. Food and Drug Administration (FDA) classified acupuncture needles as investigational devices (Class III) (www.fda.gov), resulting 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. 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 N/V.” 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.[21,22] 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.[1,22-31] Many studies provide evidence that opioid peptides are released during acupuncture and that acupuncture analgesia is mediated by the endogenous opioid system.[32,33]
Laboratory and animal cancer studies exploring the mechanisms of acupuncture have focused mainly on the activation and modulation of the immune system. 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 enhancing NK cell and lymphocyte activity.[34-36] According to one animal 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,[8,29,32,38-41] 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 [10,23,42-46] and chemotherapy-induced N/V.[25,27,47-55] Studies have also been done on the effect of acupuncture on radiation -induced xerostomia (dry mouth), proctitis, dysphonia, weight loss, cough, thoracodynia, hemoptysis, fever, esophageal obstruction, poor appetite, night sweats, hot flashes in women and men, dizziness, fatigue, anxiety, and depression in cancer patients.[8-10,57-60] 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. There is controversy about the most appropriate control for acupuncture, which also limits the interpretability of the results of clinical trials. The positive results of the studies on chemotherapy-induced N/V, which benefit from scientifically sound research designs, are the most convincing.References
- Wong R, Sagar CM, Sagar SM: Integration of Chinese medicine into supportive cancer care: a modern role for an ancient tradition. Cancer Treat Rev 27 (4): 235-46, 2001. [PUBMED Abstract]
- Pan CX, Morrison RS, Ness J, et al.: Complementary and alternative medicine in the management of pain, dyspnea, and nausea and vomiting near the end of life. A systematic review. J Pain Symptom Manage 20 (5): 374-87, 2000. [PUBMED Abstract]
- Norheim AJ, Fønnebø V: Attitudes to the contribution of placebo in acupuncture--a survey. Complement Ther Med 10 (4): 202-9, 2002. [PUBMED Abstract]
- Sellick SM, Zaza C: Critical review of 5 nonpharmacologic strategies for managing cancer pain. Cancer Prev Control 2 (1): 7-14, 1998. [PUBMED Abstract]
- Charlton JE: Cancer pain management. Cah Anesthesiol 41 (6): 621-4, 1993. [PUBMED Abstract]
- Ezzo J, Vickers A, Richardson MA, et al.: Acupuncture-point stimulation for chemotherapy-induced nausea and vomiting. J Clin Oncol 23 (28): 7188-98, 2005. [PUBMED Abstract]
- Ezzo JM, Richardson MA, Vickers A, et al.: Acupuncture-point stimulation for chemotherapy-induced nausea or vomiting. Cochrane Database Syst Rev (2): CD002285, 2006. [PUBMED Abstract]
- Xia YQ, Zhang D, Yang CX, et al.: An approach to the effect on tumors of acupuncture in combination with radiotherapy or chemotherapy. J Tradit Chin Med 6 (1): 23-6, 1986. [PUBMED Abstract]
- Johnstone PA, Polston GR, Niemtzow RC, et al.: Integration of acupuncture into the oncology clinic. Palliat Med 16 (3): 235-9, 2002. [PUBMED Abstract]
- Niemtzow RC: Integration of complementary disciplines into the oncology clinic. Part I. Acupuncture. Curr Probl Cancer 24 (4): 184-93, 2000 Jul-Aug. [PUBMED Abstract]
- Kemper KJ, Sarah R, Silver-Highfield E, et al.: On pins and needles? Pediatric pain patients' experience with acupuncture. Pediatrics 105 (4 Pt 2): 941-7, 2000. [PUBMED Abstract]
- Liu G, Hyodo A, eds.: Fundamentals of Acupuncture & Moxibustion. Tianjin, China: Tianjin Science & Technology Translation & Publishing Corp, 1994.
- Cheng X, ed.: Chinese Acupuncture and Moxibustion. Beijing, China: Foreign Languages Press, 1987.
- O'Connor J, Bensky D, eds.: Acupuncture: A Comprehensive Text. Chicago, Ill: Eastland Press, 1981.
- Lao L: Traditional Chinese medicine. In: Jonas WB, Levin JS, eds.: Essentials of Complementary and Alternative Medicine. Philadelphia, Pa: Lippincott Williams & Wilkins, 1999, pp 216-233.
- Ergil KV: China's traditional medicine. In: Micozzi MS, ed.: Fundamentals of Complementary and Alternative Medicine. New York, NY: Churchill Livingstone, 1996, pp 185-223.
- Stux G: History of acupuncture. In: Stux G, Pomeranz B: Acupuncture: Textbook and Atlas. New York, NY: Springer-Verlag, 1987, pp 36-7.
- Lao L: Acupuncture techniques and devices. J Altern Complement Med 2 (1): 23-5, 1996. [PUBMED Abstract]
- NIH Consensus Conference. Acupuncture. JAMA 280 (17): 1518-24, 1998. [PUBMED Abstract]
- Acupuncture needle. In: U.S. Food and Drug Administration: Code of Federal Regulations Title 21 [Database]. Rockville, Md: U.S. Food and Drug Administration, 2009, Sec. 880.5580. Available online. Last accessed October 7, 2014.
- Lao L, Zhang G, Wei F, et al.: Electro-acupuncture attenuates behavioral hyperalgesia and selectively reduces spinal Fos protein expression in rats with persistent inflammation. J Pain 2 (2): 111-7, 2001. [PUBMED Abstract]
- Zijlstra FJ, van den Berg-de Lange I, Huygen FJ, et al.: Anti-inflammatory actions of acupuncture. Mediators Inflamm 12 (2): 59-69, 2003. [PUBMED Abstract]
- Dang W, Yang J: Clinical study on acupuncture treatment of stomach carcinoma pain. J Tradit Chin Med 18 (1): 31-8, 1998. [PUBMED Abstract]
- Moyad MA, Hathaway S, Ni HS: Traditional Chinese medicine, acupuncture, and other alternative medicines for prostate cancer: an introduction and the need for more research. Semin Urol Oncol 17 (2): 103-10, 1999. [PUBMED Abstract]
- Dundee JW, Ghaly RG, Fitzpatrick KT, et al.: Acupuncture prophylaxis of cancer chemotherapy-induced sickness. J R Soc Med 82 (5): 268-71, 1989. [PUBMED Abstract]
- Hoskin PJ, Hanks GW: The management of symptoms in advanced cancer: experience in a hospital-based continuing care unit. J R Soc Med 81 (6): 341-4, 1988. [PUBMED Abstract]
- Dundee JW, Ghaly RG, Fitzpatrick KT, et al.: Optimising antiemesis in cancer chemotherapy. Br Med J (Clin Res Ed) 294 (6565): 179, 1987. [PUBMED Abstract]
- Harris PF, Remington PL, Trentham-Dietz A, et al.: Prevalence and treatment of menopausal symptoms among breast cancer survivors. J Pain Symptom Manage 23 (6): 501-9, 2002. [PUBMED Abstract]
- Zhou RX, Huang FL, Jiang SR, et al.: The effect of acupuncture on the phagocytic activity of human leukocytes. J Tradit Chin Med 8 (2): 83-4, 1988. [PUBMED Abstract]
- Petti F, Bangrazi A, Liguori A, et al.: Effects of acupuncture on immune response related to opioid-like peptides. J Tradit Chin Med 18 (1): 55-63, 1998. [PUBMED Abstract]
- Johnstone PA, Bloom TL, Niemtzow RC, et al.: A prospective, randomized pilot trial of acupuncture of the kidney-bladder distinct meridian for lower urinary tract symptoms. J Urol 169 (3): 1037-9, 2003. [PUBMED Abstract]
- He CJ, Gong KH, Xu QZ, et al.: Effects of microwave acupuncture on the immunological function of cancer patients. J Tradit Chin Med 7 (1): 9-11, 1987. [PUBMED Abstract]
- Mayer DJ: Biological mechanisms of acupuncture. Prog Brain Res 122: 457-77, 2000. [PUBMED Abstract]
- Wu P, Cao Y, Wu J: Effects of moxa-cone moxibustion at Guanyuan on erythrocytic immunity and its regulative function in tumor-bearing mice. J Tradit Chin Med 21 (1): 68-71, 2001. [PUBMED Abstract]
- Liu LJ, Guo CJ, Jiao XM: [Effect of acupuncture on immunologic function and histopathology of transplanted mammary cancer in mice] Zhongguo Zhong Xi Yi Jie He Za Zhi 15 (10): 615-7, 1995. [PUBMED Abstract]
- Sato T, Yu Y, Guo SY, et al.: Acupuncture stimulation enhances splenic natural killer cell cytotoxicity in rats. Jpn J Physiol 46 (2): 131-6, 1996. [PUBMED Abstract]
- Lao L, Zhang G, Wong RH, et al.: The effect of electroacupuncture as an adjunct on cyclophosphamide-induced emesis in ferrets. Pharmacol Biochem Behav 74 (3): 691-9, 2003. [PUBMED Abstract]
- Wu B, Zhou RX, Zhou MS: [Effect of acupuncture on interleukin-2 level and NK cell immunoactivity of peripheral blood of malignant tumor patients] Zhongguo Zhong Xi Yi Jie He Za Zhi 14 (9): 537-9, 1994. [PUBMED Abstract]
- Wu B, Zhou RX, Zhou MS: [Effect of acupuncture on immunomodulation in patients with malignant tumors] Zhongguo Zhong Xi Yi Jie He Za Zhi 16 (3): 139-41, 1996. [PUBMED Abstract]
- Wei Z: Clinical observation on therapeutic effect of acupuncture at zusanli for leukopenia. J Tradit Chin Med 18 (2): 94-5, 1998. [PUBMED Abstract]
- Ye F, Chen S, Liu W: Effects of electro-acupuncture on immune function after chemotherapy in 28 cases. J Tradit Chin Med 22 (1): 21-3, 2002. [PUBMED Abstract]
- Li QS, Cao SH, Xie GM, et al.: Combined traditional Chinese medicine and Western medicine. Relieving effects of Chinese herbs, ear-acupuncture and epidural morphine on postoperative pain in liver cancer. Chin Med J (Engl) 107 (4): 289-94, 1994. [PUBMED Abstract]
- Alimi D, Rubino C, Leandri EP, et al.: Analgesic effects of auricular acupuncture for cancer pain. J Pain Symptom Manage 19 (2): 81-2, 2000. [PUBMED Abstract]
- He JP, Friedrich M, Ertan AK, et al.: Pain-relief and movement improvement by acupuncture after ablation and axillary lymphadenectomy in patients with mammary cancer. Clin Exp Obstet Gynecol 26 (2): 81-4, 1999. [PUBMED Abstract]
- Filshie J, Redman D: Acupuncture and malignant pain problems. Eur J Surg Oncol 11 (4): 389-94, 1985. [PUBMED Abstract]
- Wen HL: Cancer pain treated with acupuncture and electrical stimulation. Mod Med Asia 13 (2): 12-6, 1977.
- Shen J, Wenger N, Glaspy J, et al.: Electroacupuncture for control of myeloablative chemotherapy-induced emesis: A randomized controlled trial. JAMA 284 (21): 2755-61, 2000. [PUBMED Abstract]
- Dundee JW, Yang J, McMillan C: Non-invasive stimulation of the P6 (Neiguan) antiemetic acupuncture point in cancer chemotherapy. J R Soc Med 84 (4): 210-2, 1991. [PUBMED Abstract]
- Dundee JW, Yang J: Prolongation of the antiemetic action of P6 acupuncture by acupressure in patients having cancer chemotherapy. J R Soc Med 83 (6): 360-2, 1990. [PUBMED Abstract]
- Aglietti L, Roila F, Tonato M, et al.: A pilot study of metoclopramide, dexamethasone, diphenhydramine and acupuncture in women treated with cisplatin. Cancer Chemother Pharmacol 26 (3): 239-40, 1990. [PUBMED Abstract]
- Dundee JW, McMillan CM: Clinical uses of P6 acupuncture antiemesis. Acupunct Electrother Res 15 (3-4): 211-5, 1990. [PUBMED Abstract]
- Dundee JW, Ghaly RG, Fitzpatrick KT, et al.: Acupuncture to prevent cisplatin-associated vomiting. Lancet 1 (8541): 1083, 1987. [PUBMED Abstract]
- Price H, Lewith G, Williams C: Acupressure as an antiemetic in cancer chemotherapy. Complementary Medical Research 5 (2): 93-4, 1991.
- Stannard D: Pressure prevents nausea. Nurs Times 85 (4): 33-4, 1989 Jan 25-31. [PUBMED Abstract]
- McMillan C, Dundee JW, Abram WP: Enhancement of the antiemetic action of ondansetron by transcutaneous electrical stimulation of the P6 antiemetic point, in patients having highly emetic cytotoxic drugs. Br J Cancer 64 (5): 971-2, 1991. [PUBMED Abstract]
- Lee MS, Kim KH, Shin BC, et al.: Acupuncture for treating hot flushes in men with prostate cancer: a systematic review. Support Care Cancer 17 (7): 763-70, 2009. [PUBMED Abstract]
- Porzio G, Trapasso T, Martelli S, et al.: Acupuncture in the treatment of menopause-related symptoms in women taking tamoxifen. Tumori 88 (2): 128-30, 2002 Mar-Apr. [PUBMED Abstract]
- Zhang ZH: Effect of acupuncture on 44 cases of radiation rectitis following radiation therapy for carcinoma of the cervix uteri. J Tradit Chin Med 7 (2): 139-40, 1987. [PUBMED Abstract]
- Yao W: Prof. Sheng Canruo's experience in acupuncture treatment of throat diseases with yan si xue. J Tradit Chin Med 20 (2): 122-5, 2000. [PUBMED Abstract]
- Feng RZ: Relief of oesophageal carcinomatous obstruction by acupuncture. J Tradit Chin Med 4 (1): 3-4, 1984. [PUBMED Abstract]
- Moffet HH: Sham acupuncture may be as efficacious as true acupuncture: a systematic review of clinical trials. J Altern Complement Med 15 (3): 213-6, 2009. [PUBMED Abstract]