Acupuncture For Cancer Summery.ppt 1l4p4u

Acupunctur e in cancer Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist

Acupuncture is defined as the application of stimulation such as needling, moxibustion, cupping, and acupressure on specific sites of the body known as acupuncture points

Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist

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) Dietary therapy Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist

Acupuncture has been practiced in China and other Asian countries for more than 4,000 years


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


The U.S. Food and Drug istration approved the acupuncture needle as a medical device in 1996


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


Acupuncture is closely associated with Chinese meridian theory According to this theory, there are 12 primary meridians, or channels, and 8 additional meridians, each following a particular directional course along the body



A vital energy known as qi flows through these meridians and participates in the homeostatic regulation of various bodily functions. Along the meridians are approximately 360 points that serve as both pathognomonic signs of disorder and as loci for acupuncture treatments



When the normal flow of energy over a meridian is obstructed (e.g., as a result of tissue injury or a tumor), pain or other symptoms result The purpose of acupuncture therapy is to normalize energy flow, thereby relieving the symptoms by stimulating specific sites (acupuncture points) on the meridians Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist


Acupuncture Mechanisms


Acupuncture Mechanisms Activate the hypothalamus and the pituitary gland Balance the sympathetic and parasympathetic systems Anti-inflammatory effects Endogenous opioid system Boost animal immune function by enhancing NK cell and lymphocyte activity


Laboratory and animal studies to explore the mechanisms of acupuncture for cancer treatment have focused mainly on the role of acupuncture in the activation of immune functions, such as increasing blood cell count and enhancing lymphocyte and natural killer cell activity


Acupuncture indications in cancer Manage cancer-related symptoms Treat side effects induced by chemotherapy or radiation therapy Boost blood cell count Enhance lymphocyte and natural killer (NK) cell activity Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist

Primary use is symptom management Cancer pain Chemotherapy-induced nausea and vomiting


The positive results of the studies on chemotherapyinduced N/V, which benefit from scientifically sound research designs, are the most convincing


Other indications Weight loss Anxiety Depression Insomnia Poor appetite Xerostomia Hot flashes Peripheral neuropathy Gastrointestinal symptoms (constipation and diarrhea) Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist


Laboratory & Animal Preclinical Studies Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist

At least seven animal studies investigating the effects of acupuncture in cancer or cancer-related conditions have been reported in the scientific literature


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


In a study involving normal rats, electroacupuncture applied at the point Tsu-Sanli (St36) for 2 hours daily on 3 consecutive days enhanced the cytotoxicity of splenic natural killer (NK) cells compared with a stimulation of a non acupuncture control point in the abdominal muscle

“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”


Another study found that NK cell activity and Tlymphocyte transformation rate were increased in a mouse model of transplanted mammary cancer compared with a control after eight sessions of acupuncture and moxibustion

“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.”


A study 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

“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”


Repeated EA treatments (12 treatments istered over 30 days) in PCO rats significantly lowered the concentrations of NGF in the ovaries, compared with untreated PCO rats “Stener-Victorin E, Lundeberg T, Waldenström U, et al.: Effects of electro-acupuncture on nerve growth factor and ovarian morphology in rats with experimentally induced polycystic ovaries. Biol Reprod 63 (5): 1497503, 2000”


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 significantly reduced the total number of emetic episodes by % 36-73

“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”


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 and regulate the autonomic nervous system Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist

Only one study reported a decrease in tumor volume in animals treated with acupuncture compared with control animals (Limited scientific value)

“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”



Human/Clinical Studies


Effect of Acupuncture on Immune Function


At least seven human studies have evaluated the effect of acupuncture on immune system function in patients (all in china) Acupuncture Four randomized controlled trials enhanced or regulated One nonrandomized clinical study immune Two case series function


The first randomized controlled trial immune

Acupuncture treatment enhanced platelet count and prevented leukocyte decrease after radiation therapy or chemotherapy 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


Second study immune

Leukocyte phagocytosis was enhanced in the treated group, compared with the baseline measurement (P < .01) 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.


Third study immune

The data showed that IL-2 level and NK cell activity were significantly increased in the acupuncture group, compared with the control group (P < .01)

“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”


Fourth study immune

The data showed that acupuncture treatment increased the proportion of the CD3+ and CD4+ T-lymphocyte subsets, the CD4+/CD8+ ratio (P < .01), and the level of beta-EP The investigators suggested that the anticancer effect of acupuncture may be mediated via the mechanism of immunomodulation

“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”


Fifth study immune

Electroacupuncture in patients undergoing chemotherapy experienced no declines in T cells (CD3+, CD4+, CD8+) or in NK cell activity, both of which are usually suppressed by chemotherapy

“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”


Sixth study immune

48 patients with leukopenia —including two cancer patients—who were treated with manual acupuncture experienced improvements in leukocyte count, and immunoglobulin (IgG, IgA, and IgM) levels after 14 daily acupuncture treatments, compared with their pretreatment levels

“Wei Z: Clinical observation on therapeutic effect of acupuncture at zusanli for leukopenia. J Tradit Chin Med 18 (2): 94-5, 1998” Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist


Effect of Acupuncture on Cancer Pain


First study pain

Randomized trial compared two type acupuncture and conventional analgesic treatment in patients with gastric cancer pain There was equivalent analgesic effect among the three groups observed after 2 months of treatment; however, the conventionally treated group experienced significantly superior analgesia in first 10 days of treatment “Dang W, Yang J: Clinical study on acupuncture treatment of stomach carcinoma pain. J Tradit Chin Med 18 (1): 31-8, 1998”


Second study pain

In 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. pain intensity decreased or remained stable after auricular acupuncture in all patients, with a significant average pain intensity decrease of 33 mm (P < .001)

“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” Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist

Third study Pain

In a case series involving 183 cancer patients who were treated with acupuncture for cancer-related pain, 52% were significantly helped (P value not stated

“Filshie J, Redman D: Acupuncture and malignant pain problems. Eur J Surg Oncol 11 (4): 389-94, 1985” Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist

Forth study pain

case series, 29 patients with malignant tumors who developed pain received EA treatment . All experienced various degrees of pain relief, and 25 out of 29 were able to either reduce or eliminate their analgesic requirements following multiple EA treatments

“Wen HL: Cancer pain treated with acupuncture and electrical stimulation. Mod Med Asia 13 (2): 126, 1977” Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist

Most of these studies were positive but 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 Absence of adequate randomization



Effect of Acupuncture on Cancer Treatment–related Side Effects


Pain due to cancer treatment -1 A RCT evaluated the effect of various combinations of auricular acupuncture, Chinese herbs, and epidural morphine to relieve postoperative pain in 16 patients with liver cancer All of the combination treatment groups experienced better analgesia than did the placebo -treated control group

“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” Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist

Pain due to cancer treatment -2 The effect of acupuncture in postoperative pain management and arm movement in breast cancer patients after surgical excision of the cancer and axillary lymph node: The acupuncture group had significant pain relief during arm movement on the fifth and seventh days following surgery and at the time of discharge. The range of arm motion also increased significantly in the treatment group, (P < .001)

“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”


Pain due to cancer treatment -3 A small retrospective case review of acupuncture for chemotherapy-induced peripheral neuropathy in 18 patients showed benefit with reduced symptoms in 82%

“Donald GK, Tobin I, Stringer J: Evaluation of acupuncture in the management of chemotherapyinduced peripheral neuropathy. Acupunct Med 29 (3): 230-3, 2011”


Arthralgias and myalgias from aromatase inhibitors True acupuncture was significantly more effective than sham acupuncture, as measured by Brief Pain InventoryShort Form scores in relieving t symptoms

“Crew KD, Capodice JL, Greenlee H, et al.: Randomized, blinded, sham-controlled trial of acupuncture for the management of aromatase inhibitor-associated t symptoms in women with early-stage breast cancer. J Clin Oncol 28 (7): 1154-60, 2010.” Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist

Chemotherapy-induced nausea and vomiting The positive effect of acupuncture on chemotherapyinduced nausea and vomiting (N/V) is the most convincing, as demonstrated by the consistency of the results of a variety of clinical study types


Chemotherapy-induced nausea and vomiting A systematic review of the effect of acupuncture on N/V describes five clinical trials of chemotherapy-induced N/V, conducted by different investigators on different groups of patients and using different forms of acupuncture point stimulation All five trials yielded positive results

“Vickers AJ: Can acupuncture have specific effects on health? A systematic review of acupuncture antiemesis trials. J R Soc Med 89 (6): 303-11, 1996.” Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist

Radiation-induced nausea and vomiting In one randomized study, patients who were randomly assigned to acupuncture experienced fewer episodes of nausea and vomiting than did those who received standard care

“Enblom A, Lekander M, Hammar M, et al.: Getting the grip on nonspecific treatment effects: emesis in patients randomized to acupuncture or sham compared to patients receiving standard care. PLoS One 6 (3): e14766, 2011.”


Vasomotor symptoms Some studies have reported that acupuncture may be effective in reducing vasomotor symptoms among postmenopausal women with breast cancer and prostate cancer patients on androgen-deprivation therapy


Vasomotor symptoms -1 In women with hormone receptor–positive breast cancer. Acupuncture was just as effective as venlafaxine and caused fewer adverse effects

“Walker EM, Rodriguez AI, Kohn B, et al.: Acupuncture versus venlafaxine for the management of vasomotor symptoms in patients with hormone receptor-positive breast cancer: a randomized controlled trial. J Clin Oncol 28 (4): 634-40, 2010.”


Vasomotor symptoms -2 An uncontrolled prospective case series of 50 women on tamoxifen for early breast cancer evaluated women After acupuncture vasomotor symptoms dropped by 49.8% (P < .0001)

“de Valois BA, Young TE, Robinson N, et al.: Using traditional acupuncture for breast cancer-related hot flashes and night sweats. J Altern Complement Med 16 (10): 1047-57, 2010.”


Vasomotor symptoms -3 • In retrospective evaluation of 194 patients with predominantly breast or prostate cancer found long-term relief of vasomotor symptoms associated with acupuncture.

“Filshie J, Bolton T, Browne D, et al.: Acupuncture and self acupuncture for long-term treatment of vasomotor symptoms in cancer patients--audit and treatment algorithm. Acupunct Med 23 (4): 171-80, 2005.”


Fatigue In a RCT, 47 cancer patients with moderate to severe fatigue were randomly assigned to one of three groups. The study concluded that acupuncture was a more effective method than acupressure or sham acupressure

“Molassiotis A, Sylt P, Diggins H: The management of cancer-related fatigue after chemotherapy with acupuncture and acupressure: a randomised controlled trial. Complement Ther Med 15 (4): 22837,2007.”


In next study, 302 breast cancer patients were randomly assigned to a 6-week course of either daily Acupuncture significantly reduced fatigue and improved quality of life over that of the "enhanced usual care" group

“Molassiotis A, Bardy J, Finnegan-John J, et al.: Acupuncture for cancer-related fatigue in patients with breast cancer: a pragmatic randomized controlled trial. J Clin Oncol 30 (36): 4470-6, 2012.”


Xerostomia 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 Braga FP, Lemos Junior CA, Alves FA, et al.: Acupuncture for the prevention of radiation-induced xerostomia in patients with head and neck cancer. Braz Oral Res 25 (2): 180-5, 2011 Mar-Apr. Meng Z, Garcia MK, Hu C, et al.: Randomized controlled trial of acupuncture for prevention of radiation-induced xerostomia among patients with nasopharyngeal carcinoma. Cancer 118 (13): 3337-44, 2012. Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist

Xerostomia Compared with standard care, acupuncture significantly improved xerostomia symptoms in patients who experienced the condition following radiation therapy Simcock R, Fallowfield L, Monson K, et al.: ARIX: a randomised trial of acupuncture v oral care sessions in patients with chronic xerostomia following treatment of head and neck cancer. Ann Oncol 24 (3): 776-83, 2013

.

Pfister DG, Cassileth BR, Deng GE, et al.: Acupuncture for pain and dysfunction after neck dissection: results of a randomized controlled trial. J Clin Oncol 28 (15): 2565-70, 2010. Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist


Other Treatment-related Side Effects


In a RCT 76 patients with various types of cancer, including esophageal cancer,gastric cancer, lung cancer The acupuncture group in combination with radiation therapy or chemotherapy, had the below benefits : significantly more body weight (P < .001) Greater improvements in the symptoms of cough, thoracodynia, hemoptysis, and fever for patients with lung cancer and the symptoms of chest pain, mucus vomiting, and difficulty in swallowing for patients with esophageal suffered 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.


An RCT of 138 patients treated with acupuncture plus massage versus usual care showed decreased pain (P = . 05) and a decrease in depressive mood (P = .003) in postoperative cancer patients

Mehling WE, Jacobs B, Acree M, et al.: Symptom management with massage and acupuncture in postoperative cancer patients: a randomized controlled trial. J Pain Symptom Manage 33 (3): 258-66, 2007. Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist

A retrospective survey study : acupuncture clinics for : Pain (53%), Xerostomia (32%) Hot flashes (6%) Nausea/loss of appetite (6%)

Patients were referred to 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

“Johnstone PA, Polston GR, Niemtzow RC, et al.: Integration of acupuncture into the oncology clinic. Palliat Med 16 (3): 235-9, 2002.”



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