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This information is produced and provided by the National Cancer Institute (NCI). The information in this topic may have changed since it was written. For the most current information, contact the National Cancer Institute via the Internet web site at http://cancer.gov or call 1-800-4-CANCER.
This cancer information summary provides an overview of the use of acupuncture as a treatment for individuals with cancer or cancer-related disorders. The summary includes a brief history of acupuncture practice, a review of laboratory and animal studies, the results of clinical observations and trials, and possible side effects of acupuncture therapy. Information presented in some sections of the summary can also be found in tables located at the end of those sections.
This summary contains the following key information:
Many of the medical and scientific terms used in this summary are hypertext linked (at first use in each section) to the NCI Dictionary of Cancer Terms, which is oriented toward nonexperts. When a linked term is clicked, a definition will appear in a separate window.
Reference citations in some PDQ cancer information summaries may include links to external websites that are operated by individuals or organizations for the purpose of marketing or advocating the use of specific treatments or products. These reference citations are included for informational purposes only. Their inclusion should not be viewed as an endorsement of the content of the websites, or of any treatment or product, by the PDQ Integrative, Alternative, and Complementary Therapies Editorial Board or the National Cancer Institute.
Acupuncture, a complementary therapy used in symptom management,[1,2,3,4] is 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, fatigue, xerostomia, hot flashes, chemotherapy-induced peripheral neuropathy, gastrointestinal symptoms (constipation and diarrhea) and postoperative ileus.[8,9,10] 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 and Medicaid do not generally reimburse for acupuncture treatment.
Acupuncture has been practiced in China and other Asian countries for more than 4,000 years.[12,13,14] 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.
Although acupuncture has been practiced for millennia, it has come under rigorous 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 Integrative Health) 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.[1,22,23,24,25,26,27,28,29,30,31] Many studies provide evidence that opioid peptides are released during acupuncture and that acupuncture analgesia is mediated by the endogenous opioid system.[32,33]
Although the mechanism of acupuncture is not fully understood, it has been proposed that beneficial results are mediated by changes in neurohormones and cytokines. Animal research suggests that acupuncture achieves its anesthetic effect by stimulating nerves in the muscle, which then relay the signal to the spinal cord, midbrain, and hypothalamus-pituitary system, ultimately triggering release of neurotransmitters and hormones, such as endorphins and enkephalins.[34,35] Laboratory and animal cancer studies have also explored the mechanisms of acupuncture through the activation and modulation of the immune system. Previous animal and human studies have suggested that acupuncture worked through immunomodulation, with significant changes in cytokines including interleukin (IL)-1, IL-6, IL-8, IL-10, and tumor necrosis factor-alpha (TNF-alpha).[36,37,38,39,40] These studies were limited by small sample size and occasional conflicting results. Acupuncture has been associated with significant changes in proinflammatory cytokines including IL-1-beta, IL-6, IL-17 and TNF-alpha.[36,37,38,39,40,41]
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.[42,43,44] 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,[8,29,32,46,47,48,49] 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 [10,23,50,51,52,53,54] and chemotherapy-induced N/V.[25,27,55,56,57,58,59,60,61,62,63] Studies have also evaluated 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.[8,9,10,65,66,67,68] 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.
The generally accepted history of acupuncture /moxibustion (known as zhen jiu) is part of traditional Chinese medicine (TCM), an indigenous, coherent system of medicine that has been practiced in China for thousands of years. The history of acupuncture/moxibustion in China can be traced back archeologically at least 4,000 years, when bian (stone needles) were in use. During the long history of recorded practice, acupuncture has been applied to many disorders. The earliest written medical text, the ancient classic Huang Di Nei Jing (Yellow Emperor's Inner Classic, second century BC), records nine types of needles and their therapeutic functions.
The dissemination of acupuncture and TCM to other regions dates back centuries; first to Korea and Japan and then to other Asian countries. The use of acupuncture in Europe was documented in the middle of the 16th century. The relatively brief history of acupuncture in the United States can be traced back about 200 years, when Dr. Franklin Bache published a report in the North American Medical and Surgical Journal on his use of acupuncture to treat lower back pain. However, until the 1970s, when U.S.–Chinese diplomatic ties were resumed, the practice of acupuncture in this country was mainly limited to Chinatowns.
For centuries, Chinese acupuncturists treated cancer symptomatically. Ancient literature and acupuncture textbooks classify cancer as a Zhi syndrome or blood stasis condition and document acupuncture treatment principles and methods.[5,6,7] Since the development of modern conventional medicine, acupuncture has primarily been used clinically as an adjunct to conventional cancer treatment.
At least seven animal studies investigating the effects of acupuncture in cancer or cancer-related conditions have been reported in the scientific literature.[1,2,3,4,5] Two of the studies were conducted in China, one of which was published in Chinese with an English abstract. One study was conducted in Japan, one in Sweden, and one in the United States. Four of the studies were ex vivo laboratory investigations using blood or tissue samples;[1,2,3,5] the remaining study was an animal behavioral study testing the effect of acupuncture on chemotherapy -induced nausea and vomiting. 
The four ex vivo studies suggested that acupuncture is useful in anticancer therapy either by actively stimulating immune activity or by preventing chemotherapy suppression of immune activity.[1,2,3,5]
In a study involving normal rats, electroacupuncture (EA) (1 Hz, 5–20 V, 1-millisecond pulse width, 2 hours) applied at the point Zu-Sanli (S36) for 2 hours daily on 3 consecutive days enhanced the cytotoxicity of splenic natural killer (NK) cells compared with a stimulation of a nonacupuncture control point in the abdominal muscle.
Another study found that NK cell activity and T-lymphocyte transformation rate were increased in a mouse model of transplanted mammary cancer compared with a control (P < .05) after eight sessions of acupuncture and moxibustion.
A study involving tumor -bearing mice (sarcoma S180) using moxibustion to warm the acupuncture point Guanyuan (CV4) once a day for 10 days found significantly increased production of erythrocytes, compared with a nontreatment control.
The fourth ex vivo study used a rat model to investigate the effect of EA on nerve growth factor (NGF), which is associated with polycystic ovary syndrome (PCOS). Women with PCOS have an increased risk of endometrial cancer and other diseases. Repeated EA treatments (12 treatments administered over 30 days) in PCO rats significantly lowered the concentrations of NGF in the ovaries, compared with untreated PCO rats.
A study of cyclophosphamide -induced emesis in a ferret behavioral model used acupuncture as an adjunct therapy in treating the emetic side effects of chemotherapy. EA at 100 Hz, 1.5 V, for 10 minutes in combination with subeffective doses of antiemetics such as ondansetron (0.04 mg/kg), droperidol (0.25 mg/kg), and metoclopramide (2.24 mg/kg) significantly reduced the total number of emetic episodes by 52%, 36%, and 73%, respectively (P < .01), in this ferret model.
A rat model has been established by injecting AT-3.1 prostate cancer cells into the tibia of the adult male Copenhagen rat, which closely mimics prostate cancer-induced bone cancer pain. The cancer-caused pain was treated with 10 Hz EA for 30 minutes a day at acupuncture point gallbladder 30 (GB30) from days 14 to 18 after cancer-cell injection. For sham control, EA needles were inserted into GB30 without stimulation. Thermal hyperalgesia, a decrease in paw withdrawal latency to a noxious thermal stimulus, and mechanical hyperalgesia, a decrease in paw withdrawal pressure threshold, were measured at baseline and 20 minutes after EA. EA significantly attenuated the hyperalgesia compared with sham control. Moreover, the EA inhibited up-regulation of preprodynorphin mRNA and dynorphin as well as interleukin-1beta (IL-1beta) and its mRNA compared with sham control. Intrathecal injection of antiserum against dynorphin A (1–17) and IL-1 receptor antagonist significantly inhibited the cancer-induced hyperalgesia. These data suggests that EA alleviates bone cancer pain at least in part by suppressing spinal dynorphin and IL-1beta expression.[7,8]
Another cutaneous cancer pain model has been established by injecting B16-BL6 melanoma cells into the plantar region of one hind paw of C57BL/6 mice. A single EA treatment showed significant analgesia on day 8 but not on day 20. EA treatments once every other day starting on day 8 showed analgesia at day 20, but EA starting on day 16 did not. The results indicate that EA exerts antihyperalgesic effects on early stage but not on late stage cutaneous cancer pain. These animal studies support the clinical use of EA in the treatment of cancer pain.
The findings of these studies suggest that acupuncture may be effective in treating cancer-related symptoms and cancer treatment–related disorders and that acupuncture may be able to activate immune functions [1,2,3] and regulate the autonomic nervous system.[4,5] Only one study reported a decrease in tumor volume in animals treated with acupuncture compared with control animals; however, the scientific value of this report is limited because of insufficient information about the research methodology.
Effect of Acupuncture on Immune Function
There has been limited research, mostly performed in China, evaluating the effect of acupuncture on immune system function in cancer patients, suggesting that acupuncture improves immune function.[1,2,3,4,5,6,7]
Effect of Acupuncture on Cancer Pain
Seven clinical studies of acupuncture as a treatment for cancer-related pain have been reported in the English language (refer to Table 1).[8,9,10,11,12,13] Two studies were randomized controlled trials (RCTs), with one study conducted in China and one in France.[9,13] Four studies were case series, with one each from England, France, Hong Kong, and the United States.[8,10,11,12]
One randomized trial compared classical Chinese acupuncture, acupuncture point injection with freeze-dried human transfer factor, and conventional analgesic treatment in patients with gastric cancer pain. The investigators reported an equivalent analgesic effect among the three groups observed after 2 months of treatment; however, the conventionally treated group experienced significantly superior analgesia compared with both acupuncture treatment groups during the first 10 days of treatment. The researchers reported that the patients in both acupuncture treatment groups also experienced improved quality of life and a decrease in the side effects of chemotherapy, in addition to analgesia.
In addition, a nonrandomized, single-arm, observational clinical study evaluated the effect of auricular acupuncture in 20 cancer patients who were still experiencing pain after treatment with analgesics. While patients continued their analgesic medication, auricular acupuncture needles were embedded in ear acupuncture points, chosen according to clinical symptoms and electrodermal response, and were left in place until they fell out. In some cases, the needles remained in place for 35 days, while in others they fell out after 5 days. Pain intensity was measured by a nurse on the Visual Analog Scale (VAS) on day 0 and day 60, and the data were analyzed using a t test. The results showed that pain intensity decreased or remained stable after auricular acupuncture in all patients, with a significant average pain intensity decrease of 33 mm (P < .001). The same investigators later reported a larger (n = 90) randomized, blinded, controlled trial in which cancer pain intensity was significantly decreased (by 36%) in an auricular acupuncture treatment group, in comparison with control groups (by 2%, acupuncture at placebo points or auricular seeds placed at placebo points) after 2 months of treatment (P < .001).
Although most of these studies were positive and demonstrated the effectiveness of acupuncture in cancer pain control, the findings have limited significance because of methodologic weaknesses such as small sample sizes, an absence of patient blinding to treatment in most cases, varying acupuncture treatment regimens, a lack of standard outcome measurements, and an absence of adequate randomization. Further investigations into the effects of acupuncture on cancer pain using rigorous scientific methodology are warranted.
Effect of Acupuncture on Cancer Treatment–related Side Effects
Acupuncture for postsurgical pain
Five RCTs published in English have addressed the use of acupuncture for pain related to cancer treatment, mostly postsurgical pain (refer to Table 2). One RCT of 106 cancer patients who experienced post-thoracotomy pain showed no statistical difference in the real acupuncture (RA) group compared with the sham acupuncture (SA) group in patients' pain scores measured by the Brief Pain Inventory at the 30-, 60-, and 90-day follow-up. The efficacy of the unique intradermal needles used in this study was questionable.
Another smaller RCT (N = 27) showed a trend of lower VAS pain scores in patients who received electroacupuncture (EA) when compared with patients who received SA on postoperative days 2 and 6; and a statistically significant lower cumulative dose of patient controlled analgesia on postoperative day 2 (P < .05). However, this study was limited by its small sample size.
One RCT (N = 93) compared acupuncture with massage therapy and usual care in controlling postoperative pain, nausea, vomiting and depressive moods. This study showed that postoperative acupuncture and massage in addition to usual care significantly improved pain control when compared with usual care alone.
Another study showed that in cancer patients with chronic pain or dysfunction as a result of neck dissection, four weekly acupuncture treatments significantly reduced pain and improved function compared with standard care alone. Additionally, a study of 80 patients with breast cancer showed that when compared with usual care alone, acupuncture significantly improved postoperative pain and range of movement. However, with no sham therapy group in these two studies, it is difficult to determine how much of the improvement is because of the placebo effect, and whether RA needles and professionally trained acupuncturists and massage therapists are required in the intervention.
Acupuncture for aromatase inhibitor-associated musculoskeletal symptoms
Four RCTs have compared the effects of RA with SA in reducing aromatase inhibitor -associated musculoskeletal symptoms (AIMSS).[19,20,21,22] (Refer to Table 3 for more information.)
Three trials were conducted in the United States and one in Australia. All trials enrolled breast cancer survivors with history of nonmetastatic hormone receptor–positive breast cancer who were taking an aromatase inhibitor and suffering from AIMSS. All studies assessed the difference in joint and/or muscle pain after intervention. One study focused on the effect of RA or SA on function changes by using the Health Assessment Questionnaire Disability Index score. Three studies had two arms (RA vs. SA), and one study has three arms (RA, SA or waitlist control [WLC]). The studies all had relatively small sample sizes that ranged from 29 to 67, although they were divided into three arms of 23 patients each. Two studies [19,20] used manual acupuncture and the other two used EA.[21,22] Two studies [19,22] used individualized treatment and the other two used standard protocol (same acupuncture treatment for all patients).[20,21]
All four trials showed no significant adverse reaction to either RA or SA treatment. One trial  showed RA was significantly better than SA in improving joint muscle pain, whereas this finding was not confirmed by the other three trials. Another study had an additional arm of WLC, showing statistically significant greater pain reduction in the RA arm when compared with the WLC arm.
These four RCT results are consistent with the existing observational studies showing that acupuncture is safe, patients benefit from both RA and SA, and there is significant benefit in either RA or SA when compared with usual care alone. A 2012 systematic review of 17,922 patients showed that acupuncture is significantly better than SA in reducing chronic pain, with modest effect size of 0.23 (95% confidence interval, 0.13–0.33). This further suggests that studies with larger sample sizes may be needed to establish the effectiveness of acupuncture compared with SA. There have been two systematic reviews on acupuncture for AIMSS studies, and both have shown that acupuncture has potential benefits to improve AIMSS. Further clinical trials of larger sample sizes and longer follow-ups are needed.[25,26] The ongoing Southwest Oncology Group (SWOG) study has a sample size of 228 patients (SWOG-S1200 [NCT01535066]) and randomly assigns patients to one of three arms (RA, SA, or usual care); this study may be able to further clarify the role of acupuncture in helping breast cancer survivors with AIMSS.
Nausea and vomiting
Chemotherapy-induced nausea and vomiting
Of all the investigated effects of acupuncture on cancer-related or chemotherapy-related symptoms and disorders, the positive effect of acupuncture on chemotherapy-induced nausea and vomiting (N/V) is the most convincing, as demonstrated by the consistency of the results of a variety of clinical study types, including RCTs, nonrandomized trials, prospective consecutive case series, and retrospective studies (refer to Table 4). Consistent with the findings from clinical studies of acupuncture on N/V due to other causes (i.e., postoperative N/V and morning sickness), these studies showed acupuncture to be effective in the treatment of chemotherapy-induced N/V.
A 2013 systematic review of literature on acupuncture in cancer care screened 2,151 publications and identified 41 RCTs studying the effect of using acupuncture to treat eight cancer treatment-related symptoms (pain, nausea, hot flashes, fatigue, radiation-induced xerostomia, prolonged postoperative ileus, anxiety/mood disorders and sleep disturbance). The review concluded that acupuncture is an appropriate adjunctive treatment for chemotherapy-induced N/V (CINV), but additional studies are needed because most RCTs had unclear bias or a high risk of bias.
In 2005, a comprehensive meta-analysis of 11 RCTs (N = 1,247) evaluating the effect of acupuncture-point stimulation in controlling CINV showed that acupuncture-point stimulation significantly reduced the proportion of acute vomiting (relative risk, 0.82; 95% CI, 0.69–0.99, P = .04), although the meta-analysis did not show that acupuncture reduced the mean number of acute emetic episodes or acute or delayed nausea severity compared with control.
The trials in the meta-analysis were published between 1987 and 2003, and the sample sizes ranged from ten patients in the smallest trial  to 747 patients in the largest trial. Among the ten trials that reported a chemotherapy regimen, all patients received moderate to high emetogenic chemotherapy. Eight of the trials used 5-HT3-receptor antagonist, ondansetron, containing antiemetic regimen. The other three trials used methotrexate alone, methotrexate with prednisone, or methotrexate with dopaminergic antagonists as antiemetic regimen. None of the antiemetic regimens contained aprepitant because the trials all predated this drug.
A meta-analysis of acupuncture in N/V is the most comprehensive summary of clinical research on the role of acupuncture-point stimulation in controlling CINV. It found that acupuncture-point stimulation decreases the proportion of patients who experience acute chemotherapy-induced vomiting and concurred with the previous systemic review and meta-analysis.[33,34] It suggested that acupressure may relieve chemotherapy-induced nausea, even though the studies were limited by lack of an effective control arm to rule out the placebo effect. It also suggested differences among acupuncture-point stimulation modalities, with invasive-point stimulation to be more effective than noninvasive -point stimulation in reducing acute CINV. It has since been cited multiple times by review articles and oncology practice guidelines.[35,36,37]
The acupuncture point specificity is worth mentioning because most of the earlier acupuncture CINV trials used the PC6 point and showed positive results. A well-designed, randomized, placebo-controlled trial published in 2014 showed that K1 acupoint acustimulation combined with antiemetics did not prevent cisplatin -induced or oxaliplatin -induced nausea.
Radiation-induced nausea and vomiting
Acupuncture has also been used to relieve radiation-induced N/V. In one randomized study, patients who were randomly assigned to receive either verum or SA experienced fewer episodes of N/V than did those who received standard care.
Some studies have reported that acupuncture may be effective in reducing vasomotor symptoms among postmenopausal women with breast cancer and prostate cancer patients receiving androgen-deprivation therapy.[50,51,52,53,54,55,56]
Six RCTS have studied the role of acupuncture in reducing hot flashes in breast cancer survivors.
In 2007, one study reported results from a randomized, sham-controlled trial on the effect of acupuncture in treating breast cancer survivors who experienced three or more hot flashes per day. The investigators reported that the mean number of hot flashes per day at week 6 changed from 8.7 to 6.2 in the RA arm, and from 10.0 to 7.6 in the SA arm. However, the difference between the RA group and the SA group was not statistically significant (P = .3). When patients in the SA group crossed over to receive RA, their hot flash frequency further reduced from 7.6 to 5.8. The reduction in hot flashes in all patients persisted during the 6 months of follow-up (RA arm, 6.1 per day; SA arm, 6.8 per day). On the basis of fewer hot flashes in both groups, the authors concluded that acupuncture reduced hot-flash frequency, although the difference between the RA and SA groups was not statistically significant.
In 2009, one study reported another randomized SA-controlled trial on the effect of acupuncture in treating women with breast cancer who suffered from hot flashes after receiving tamoxifen for at least 3 months. Fifty-nine women were randomly assigned to either 15 sessions (5 weeks biweekly followed by 5 weeks weekly) of RA or SA. The authors reported that at the end of the treatment period, the mean number of daytime hot flashes was reduced significantly from 9.5 to 4.7 (P = .001) in the RA group and from 12.3 to 11.7 (P = .382) in the SA group. At 12 weeks follow-up, further reduction was observed in the RA group (from 4.7 to 3.2) but not in the SA group (from 11.7 to 12.1). The difference between the RA group and SA group was statistically significant (P < .001). The authors concluded that acupuncture provided effective relief from hot flashes in women with breast cancer who suffered from hot flashes while taking tamoxifen. The evidence generated from these two trials suggests that acupuncture effectively decreases hot-flash frequency, although it is not clear whether it is superior to SA.
Another clinical trial compared the effects of EA with hormonal therapy in breast cancer survivors with vasomotor symptoms; in 19 out of 27 women who completed 12 weeks of EA treatment, the number of hot flashes was significantly reduced from 9.6 per day to 4.3 per day. The improvement persisted at the 12-month follow up. In the hormonal treatment group, the median number of hot flashes dropped from 6.6 at baseline to 0 at week 12. Although hot flashes decreased less in the EA group than in the hormonal treatment group, health-related quality of life improved at least to the same extent. It suggests that EA could be further evaluated as treatment for women with breast cancer and climacteric complaints, particularly since hormonal treatment is no longer recommended for breast cancer survivors.
In 2010, another RCT compared the effect of acupuncture with venlafaxine in treating vasomotor symptoms in breast cancer patients suffering from more than 13 hot flashes per week. Changes in hot flash frequency from baseline and at 3-, 6-, 9- and 12-month follow-up were used as the primary outcome. Fifty patients were randomly assigned to 12 weeks (biweekly for 4 weeks, followed by weekly for 8 weeks) of acupuncture versus daily venlafaxine (37.5 mg for 1 week, then 75 mg for 11 weeks). The investigators observed a significant reduction in hot flash frequency and severity in both groups. In addition, 2 weeks after treatments were stopped, patients randomly assigned to venlafaxine reported increased hot-flash frequency, whereas the acupuncture group remained at a low level of hot flashes. There was no significant difference between the acupuncture arm and the venlafaxine arm. There were 18 reported adverse events (i.e., nausea, dizziness, headache) in the venlafaxine arm and none in the acupuncture arm. The authors concluded that acupuncture appears to be as effective as venlafaxine and is a safe and durable treatment option for breast cancer patients experiencing vasomotor symptoms.
In 2013, a study reported the results of a three-arm RCT (N = 94) comparing RA (N = 31) with SA (N = 29) and usual care alone (N = 34) in reducing hot flashes in breast cancer survivors. In the acupuncture group, 16 (52%) patients experienced a significant reduction in hot flashes compared with 7 (24%) in SA group (P < .05). There was also a statistically positive effect on sleep when RA was compared with SA. Importantly, the researchers measured the plasma estradiol level and determined that there was not a correlation between symptoms improvement and an increase in estradiol level.
In 2014, a study reported the results of a two-arm RCT (N = 47) on the effect of acupuncture in reducing AIMSS and hot flashes as one of the secondary end points. When compared with baseline, acupuncture significantly improved hot-flash severity, frequency, and function. SA significantly improved the Hot Flash Related Daily Interference Scale only. However, there was no significant difference between the two groups.
These trials once again confirmed that acupuncture is safe. They showed that acupuncture reduced hot flashes significantly when compared with baseline, although the benefit of RA versus SA was not clear.
A recent systematic review of acupuncture to control hot flashes in cancer patients showed that in all eight studies included in the review, acupuncture resulted in significant improvement from the baseline, and three studies showed RA was significantly better than sham acupuncture in different aspects of hot flashes. However, none of the studies were rated with a low risk of bias. Consequently, there is insufficient evidence supporting or refuting using acupuncture to treat hot flashes. Further studies are needed.
An electroacupuncture hot flashes study published in 2015 randomly assigned 120 breast cancer survivors who were suffering from hot flashes at least twice daily to one of four of the following arms: EA, SA, gabapentin (GP), and placebo pills (PP) for 8 weeks. Unlike other acupuncture efficacy trials, however, the primary end point was the change in hot flash composite scores (HFCS) between SA and PP at week 8, with secondary end points including posttreatment comparisons of all groups at different time points and examination of treatment durability at week 24. It showed that SA produced significantly greater reductions in HFCS than did PP by week 8, indicating a greater placebo effect with SA. Compared with baseline scores, although all arms experienced HFCS reductions, SA produced significantly better results than did both GP and PP interventions (EA, −7.4; SA, −5.9; GP, −5.2; and PP, −3.4). In addition, SA had a smaller nocebo effect than PP, as evidenced by the significantly higher percentage of reported adverse events for PP compared with SA (20.0% vs. 3.1%, respectively). Another intriguing finding is the more-durable effect in HFCS reductions produced at week 24 (16 weeks posttreatment) with both EA and SA treatments (EA, −8.5; SA, −6.1) than with GP (GP, −2.8), suggesting that both types of acupuncture may elicit underlying physiologic changes not induced by pharmacologic intervention. On the other hand, the effect size of EA compared with SA was small at week 8 (Cohen's d, 0.21) but got bigger at week 24 (Cohen's d, 0.31), suggesting EA may produce additional or longer-lasting physiological effects than would SA.
Fatigue is a common symptom in patients with cancer and a frequent side effect of chemotherapy and radiation therapy. No effective treatment exists. Several RCTs have been conducted to study the effect of acupuncture in reducing cancer-related fatigue (refer to Table 6).
One pilot RCT enrolled 47 cancer patients experiencing moderate to severe cancer fatigue and randomly assigned them to one of three groups: acupuncture (n = 15), acupressure (n = 16), or sham acupressure (n = 16). Patients in the acupuncture group received six 20-minute acupuncture sessions during a 2-week period; patients in the two acupressure groups were taught to massage real versus sham acupuncture points daily for 2 weeks. The Multidimensional Fatigue Inventory was used to assess their responses at baseline, and at week 2 and week 4 follow-up. At the end of week 2, general fatigue, physical fatigue, activity, and motivation significantly improved in the acupuncture and acupressure groups when compared with baseline. At the end of week 2, fatigue level improved by 36% in the acupuncture group, 19% in the acupressure group and 0.6% in the control group. Moreover, the improvement was maintained at the week 4 follow-up. Acupuncture was found to be a more effective method than acupressure or sham acupressure. The authors concluded that acupuncture showed a greater potential for managing cancer-related fatigue; further testing in a multi-center RCT with larger sample sizes is warranted.
A follow-up RCT (N = 302) by the same group of investigators was published in 2013; among the 246 evaluable patients, acupuncture significantly reduced cancer-related fatigue, anxiety, and depression, and improved quality of life when compared with usual care. The investigators again randomly assigned197 patients to receive 4 weeks of therapist-delivered acupuncture (N = 65), self-acupuncture (N = 67), or no acupuncture (N = 65) to determine the effect of maintenance therapy for cancer-related fatigue, and found that there was no difference between the therapist-delivered acupuncture and self-acupuncture; there was a nonsignificant trend in improving fatigue when comparing the acupuncture groups with the no-acupuncture group (P = .07).
Conversely, two RCTs showed no significant difference between RA and SA in reducing cancer-related fatigue (refer to Table 6).[65,66] One study reported in 2009 that among the 27 patients receiving daily radiation therapy, both weekly RA and SA treatment improved fatigue, fatigue distress, quality of life and depression from baseline to 10 weeks, but the differences between the two interventions were not significant. In 2013, another study reported the results of an RCT of RA compared with SA involving 101 patients with postchemotherapy chronic fatigue; among the 74 evaluable patients, both groups had a one-point decrease in Brief Fatigue Inventory score; however, there was no statistically significant difference between the groups. This study was limited by the large number of patients (27) lost to follow up.
The effect of acupuncture on cancer-related fatigue was also studied as one of the secondary end points in acupuncture for the AIMSS study published in 2014. When compared with WLCs, EA significantly improved fatigue, anxiety, and depression, although SA did not improve fatigue or anxiety but did improve depression. In this study, the investigators did not compare EA with SA directly because the study was not powered to detect a difference between EA and SA, especially for secondary end points. Lastly, an Australian pilot study (N = 30) showed that when compared with controls, acupuncture significantly reduced fatigue and improved well-being in breast cancer patients with post-treatment fatigue.
These results showed that acupuncture significantly improved fatigue when compared with usual care alone, although whether it is significantly better than SA will warrant further study.
A number of clinical studies have investigated the effect of acupuncture for the treatment and prevention of xerostomia in nasopharyngeal carcinoma and head and neck cancer patients.
Acupuncture was associated with a decrease in the onset of symptoms and an increased saliva flow in two randomized studies that compared acupuncture with standard care for preventing xerostomia in patients undergoing radiation therapy.[70,71]
Compared with standard care, acupuncture significantly improved xerostomia symptoms in patients who experienced the condition following radiation therapy.[17,72]
Two randomized controlled studies, one for prevention, and one for treatment of radiation-induced xerostomia revealed increases in salivary flow rates following RA and SA (superficial needling 1 or 2 cm away from acupuncture points), although differences between groups were not significant.[73,74] It also reported improvements in quality of life after acupuncture treatment, but there were no significant differences between the groups.
In 2012, one group published two studies on the effect of acupuncture for preventing xerostomia. The first was a pilot study (N = 23); when compared with SA, RA significantly reduced xerostomia questionnaire scores from week 3 through the 1-month follow-up after radiation therapy. However, they did not find significant difference in salivary flow rates between the groups. The other study (N = 86) showed that when compared with standard care acupuncture significantly lowered the xerostomia questionnaire scores in weeks 3 to 6 during 6 weeks of chemoradiation therapy. In addition, greater saliva flow was noticed in the acupuncture group than in the control group at weeks 7 and 11 and at the 6-month follow-up.
Another study examined long-term effects of acupuncture on xerostomia. Patients who received RA were followed for 6 months and up to 3 years. Compared with baseline, significant differences in salivary flow rates were seen in patients 6 months after acupuncture treatment. At 3 years, patients who received additional acupuncture exhibited greater saliva flow rates than patients who did not continue acupuncture treatment.
Two ongoing phase III clinical trials are evaluating the effect of acupuncture for treatment (NCT01141231 and NCT01266044) of xerostomia in head and neck cancer patients. Information about ongoing clinical trials is available from the NCI website.
The findings from these studies are summarized in Table 7 below.
Chemotherapy-induced peripheral neuropathy
Chemotherapy-induced peripheral neuropathy (CIPN), a common side effect of chemotherapy, includes a variety of symptoms, such as paresthesia, pain and muscle weakness. CIPN can be serious enough to limit or delay the dose of administered chemotherapy and may warrant discontinuation of treatment. Long-term CIPN often produces substantive functional decline and diminished quality of life.[78,79] For patients with persistent CIPN, treatment has been limited to symptom management with narcotics, antidepressants and antiepileptics. Studies suggest that analgesic regimens typically produce only modest relief of pain and other common side effects such as dizziness, sedation, dry mouth and constipation.
Some relatively small studies have examined acupuncture's ability to reduce the symptoms of CIPN. In a blinded RCT, cancer patients with chronic peripheral or central neuropathic pain following cancer therapy were treated with auricular acupuncture. At 2 months, patients experienced a 36% reduction in pain intensity compared with a 2% reduction for SA-treated patients (P < .0001). A case series of five patients suggested the potential efficacy of acupuncture in treating patients with CIPN.
Another pilot study demonstrated that, among 11 patients with CIPN, five of six patients treated with acupuncture had improved nerve conduction compared with only one of five patients who showed improvement in the control group. In addition, objective nerve conduction studies demonstrated significant improvement with acupuncture, approximately 3 months postintervention compared with usual medical care. A positive correlation between improved CIPN and nerve conduction was found in 21 patients receiving acupuncture therapy, compared with 26 patients in the control group who received best medical care. A pilot study of 27 multiple myeloma patients with moderate to severe bortezomib -induced peripheral neuropathy demonstrated significantly reduced neuropathic pain and improved function after 10 weeks of acupuncture treatment. Another single-arm study of 19 patients showed that EA was safe and may be effective in treating thalidomide/bortezomib-induced peripheral neuropathy in multiple myeloma patients; in this study, the Functional Assessment of Cancer Therapy-Neurotoxicity score improved significantly after 9 weeks of treatment. Conversely, a 2013 four-arm RCT of 60 patients with CIPN showed that EA, hydroelectric baths, and vitamin B were not superior when compared with placebo. This negative result may be because of small sample sizes (N = 15 in each arm), and further RCTs with larger samples are warranted.
Treatment-induced lymphedema may be a lifelong concern for some breast cancer survivors. There have been a number of case reports, retrospective chart review and pilot studies demonstrating that acupuncture was safe and potentially effective in reducing swelling and improving symptoms in patients with upper- and lower-extremity edema.[85,86,87,88] A 2013 single-arm clinical trial (N = 37) evaluated the safety and potential of efficacy of acupuncture in treating patients with breast cancer-related lymphedema (BCRL). In this trial, the investigators enrolled 37 breast cancer survivors with moderate to severe unilateral chronic BCRL; the survivors received eight sessions of standard acupuncture treatment given twice per week for 4 weeks. Four patients were not able to be evaluated because of early withdrawal. Acupuncture was deemed to be safe; no serious adverse events were reported after 255 acupuncture treatment sessions. Twelve of the 33 evaluable patients reported at least one incidence of mild bruising or minor pain/tingling in the arm, shoulder, or acupuncture site; no infections were reported, although the standard acupuncture treatment protocol involved inserting four acupuncture needles in the limb with lymphedema. This pilot study, although not an RCT, suggested a trend toward efficacy with a mean reduction in arm circumference of 0.90 cm in patients who received acupuncture treatment; eleven patients (33%) experienced at least a 30% reduction in arm circumference. Two patients did not use any additional lymphedema treatment during the trial. Most patients (28 of the remaining 31 patients) reported making no changes in their standard regimens to treat lymphedema during treatment. The authors concluded that acupuncture for BCRL is safe and may be effective. The same research group is conducting an RCT to further determine the efficacy of acupuncture in reducing BCRL symptoms (NCT01706081). However, in 2014, a pilot RCT of 17 women that compared acupuncture with usual care showed that 12 acupuncture treatment on the nonlymphoedematous limb during 8 weeks did not change extracellular fluid or any patient-reported lymphedema outcomes. The authors concluded that acupuncture may stabilize symptoms; however, further study is needed.
Three RCTs have studied the effect of acupuncture in reducing duration of postoperative ileus and have generated conflicting results. In 2010, one study reported the results of a RCT studying the effect of EA compared with usual care and found that EA did not significantly prevent prolonged postoperative ileus.
In 2012, another study reported the results of a phase II RCT that compared RA with SA (N = 90) for reducing postcolectomy ileus. No significant differences were reported between RA and SA in reducing postcolectomy ileus as measured by the time that the patient first tolerated solid food and the time that the patient first passed flatus or a bowel movement.
In 2013, a third study reported the results of a three-arm RCT (N = 165) that compared EA with SA and no acupuncture in reducing duration of postoperative ileus after laparoscopic surgery for colorectal cancer. EA significantly shortened the time to defecation and the hospital stay compared with SA and no acupuncture.
A number of RCTs have studied the effect of acupuncture in improving depression and sleep quality in cancer patients. In 2011, one study (N = 80) reported that acupuncture significantly improved depression and sleep quality when compared with fluoxetine. Patients receiving acupuncture reported significantly greater reductions in Self-rating Depression Scale (SDS), Hamilton Depression Rating Scale (HAMD) and Pittsburgh Sleep Quality Index (PSQI) scores.
The effect of acupuncture on sleep was also studied as one of the secondary end points in acupuncture for AIMSS study published in 2014. When compared with WLCs, EA resulted in a nonsignificant improvement in sleep disturbance (P = .058). Further studies are warranted.
Other treatment-related side effects
Many studies have reported on the effects of acupuncture on cancer or other cancer treatment–related symptoms, including weight loss, cough, hemoptysis, fever, anxiety, depression, proctitis, dysphonia, esophageal obstruction, and hiccups.[1,8,51,94,95,96,97,98] These studies were from China,[1,95,96,97] Japan, and Sweden.[8,19,94,98] The findings from these studies are summarized in Table 8 below.
In an RCT, 76 patients with various types of cancer, including 38 with esophageal cancer, 24 with gastric cancer, and 14 with lung cancer, were randomly assigned to two groups (n = 38 per group). The treatment group received acupuncture in combination with radiation therapy or chemotherapy, and the control group was treated with radiation therapy or chemotherapy alone. The data showed that the patients in the acupuncture group gained significantly more body weight than patients in the control group (P < .001). In patients with lung cancer, the acupuncture group also showed greater improvement than the controls in the symptoms of cough, thoracodynia, hemoptysis, and fever; in patients with esophageal cancer, the acupuncture group showed greater improvement in the symptoms of chest pain, mucus vomiting, and difficulty in swallowing. In addition, the acupuncture group suffered fewer side effects (e.g., poor appetite, N/V, dizziness, or fatigue) from radiation therapy or chemotherapy than the control group. However, no statistical analysis was performed on these data. An RCT of 138 postoperative cancer patients treated with acupuncture plus massage showed decreased pain (P = .05) and a decrease in depressive mood (P = .003) compared with usual care.
A retrospective study involved patients at an oncology clinic who were offered acupuncture treatment for potential palliation of symptoms. Among 89 patients treated with acupuncture, 79 responded to a telephone questionnaire survey. The data indicated that the major reasons for referral included pain (53%), xerostomia (32%), hot flashes (6%), and nausea/loss of appetite (6%). Sixty percent of the patients showed at least 30% improvement in their symptoms, and about one-third had no change in the severity of symptoms. Patients were not questioned about acupuncture-treatment expectations.
Current Clinical Trials
Serious adverse effects of acupuncture are rare. Reported accidents and infections appear to be related to violations of sterile procedure, negligence of the practitioner, or both.[1,2] A systematic review of case reports on the safety of acupuncture, involving 98 papers published in the English language from 22 countries during the period from 1965 to 1999, found only 202 incidents. The number of incidents appeared to decline as training standards and licensure requirements were enhanced. Among the 118 (60%) reported incidents involving infection, 94 (80%) involved hepatitis, occurring mainly in the late 1970s and early 1980s. Very few hepatitis or other infections associated with acupuncture have been reported since 1988, when widespread use of disposable needles was introduced and national certification requirements for clean-needle techniques were developed and enforced as an acupuncture licensure requirement.[3,4] Because cancer patients who are undergoing chemotherapy or radiation therapy are immunocompromised, precautions must be taken and strict clean-needle techniques must be applied when acupuncture treatment is given.
Minor adverse effects of acupuncture, such as pain at needling sites, hematoma, tiredness, lightheadedness, drowsiness, and localized skin irritation, have been reported.[6,7,8,9,10] These minor adverse effects can be minimized by appropriate patient management, including local pressing and massage at the needling site after treatment.[11,12] Acupuncture in children has not been studied extensively. However, adverse effects appear to be rare and limited to the same effects as observed in adults.[13,14]
It is noteworthy that almost all reported clinical studies on the effects of acupuncture on cancer or cancer therapy –related symptoms focus on symptom management rather than the disease itself. Investigations into the effects of acupuncture on chemotherapy -induced nausea and vomiting, many of which were randomized and well-controlled, produced the most convincing findings. A number of randomized controlled trials have reported on the effect of acupuncture in alleviating other cancer treatment-associated side effects, with many showing promising evidence supporting the use of acupuncture. Additional phase III clinical trials are ongoing.
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Purpose of This Summary
This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about the use of acupuncture in the treatment of people with cancer. It is intended as a resource to inform and assist clinicians who care for cancer patients. It does not provide formal guidelines or recommendations for making health care decisions.
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PDQ® Integrative, Alternative, and Complementary Therapies Editorial Board. PDQ Acupuncture. Bethesda, MD: National Cancer Institute. Updated <MM/DD/YYYY>. Available at: http://www.cancer.gov/about-cancer/treatment/cam/hp/acupuncture-pdq. Accessed <MM/DD/YYYY>. [PMID: 26389159]
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