Roxanne Nelson, RN, BSN
December 24, 2019
A systematic review of 17 randomized clinical trials and a meta-analysis of 14 trials found a significant association between real acupuncture, as compared to sham acupuncture, and a reduction in pain.
In addition, acupuncture was associated with less use of analgesics.
Overall, the evidence level was "moderate," say the authors.
"Cancer pain is inadequately managed clinically due to limited and effective therapeutic options," explained study author Charlie Changli Xue, PhD, School of Health and Biomedical Sciences, RMIT University, Melbourne, Australia. "This study demonstrated that acupuncture and acupressure should be considered as an option in clinical setting, particularly when pharmacotherapy alone has not offered adequate relief."
Acupuncture and acupressure should be better integrated into practice guidelines for patients with cancer pain, he told Medscape Medical News. "Acupuncture/acupressure can be delivered by doctors with adequate acupuncture training or qualified acupuncturists accredited by regulatory bodies or members of reputable professional associations," he said.
The study was published online December 19 in JAMA Oncology.
More than 70% of patients with cancer experience pain, but it is inadequately controlled in nearly half of patients, note the authors. The current opioid crisis in the United States has exacerbated challenges in pain management, and there has been an increasing interest in nonpharmacologic interventions to relieve pain. Both the American Society for Clinical Oncology and the National Comprehensive Cancer Network have recommended the use of nonpharmacologic methods for managing pain, including acupuncture, despite inconsistent results in studies.
The authors point out that although 20 systematic reviews have established an association between acupuncture and cancer pain relief, none reached a definitive conclusion. But more recent rigorous randomized clinical trials were not included in previous systematic reviews.
Reduction in Pain
In this study, Xue and colleagues conducted an analysis of published randomized clinical trials in order to evaluate the relationship between acupuncture and acupressure and pain reduction in cancer patients.
A total of 17 randomized trials were included in the systematic review or qualitative synthesis. Of these, results of 14 studies, which included 920 patients, were pooled through a meta-analysis. The studies were conducted globally; seven (41%) were conducted in China, six (35%) in the United States, and one (6%) each in Australia, Brazil, France, and Korea.
Of the 17 studies, nine (53%) were sham controlled, and eight (47%) were open-label trials.
Random-effects modeling was used to calculate the effect sizes of the randomized clinical trials that were included.
With regard to pain intensity, pooled results from seven blinded randomized studies that were deemed high quality by the study authors showed an association between pain reduction and real acupuncture vs sham acupuncture (mean difference, −1.38 points; 95% confidence interval [CI], −2.13 to −0.64; I² = 81%).
Results from six open-label trials showed that, in comparison with analgesics, pain intensity was reduced when acupuncture was combined with acupressure (mean difference, −1.44 points; 95% CI, −1.98 to −0.89; I² = 92%). A significant reduction in pain without heterogeneity was seen in three studies that compared acupuncture with control persons who were on a wait list (mean difference,−1.63 points; 95% CI,−2.14 to −1.13). The evidence grade was moderate because of the substantial heterogeneity among studies, say the authors.
Two of the open-label studies without heterogeneity reported that a maintenance dose of analgesics was administered during the trial period. Pooled results showed that there was a significant decrease in the dose of analgesics among patients who received acupuncture plus analgesic therapy in comparison with the patients who received only analgesics (mean difference, −30.00 mg morphine equivalent daily dose; 95% CI, −37.5 mg to −22.5 mg).
Integrating acupuncture into pain and symptom management plans for cancer patients remains a challenge. Factors include the cost of treatments and lack of insurance coverage. Both have been identified as major barriers to the use of acupuncture.
"While action is needed from insurance companies to reconsider their position — the inclusion of acupuncture for the such patients — I think, in longer term, research is also needed to demonstrate value for money by including acupuncture/acupressure for rebate," said Xue. "As stated in the paper, we encourage further trials on specific types of cancer to further improve the level of evidence to support better clinical decision making and to assist the insurance companies' decision making for inclusion of acupuncture/acupressure into plans."
The study was supported in part by the Specific Research Fund for TCM Science and Technology from the Guangdong Provincial Hospital of Chinese Medicine, the Traditional Chinese Medicine Bureau of Guangdong Province, and the Guangdong Provincial Academy of Chinese Medical Sciences, RMIT University (via the China-Australia International Research Center for Chinese Medicine), and the National Cancer Institute. Xue has disclosed no relevant financial relationships. Several coauthors have disclosed relationships with industry, as noted in the original article.