The potential role for acupuncture in treating symptoms in patients with lung cancer: an observational longitudinal study

Original Article

Integrative Oncology

The potential role for acupuncture in treating symptoms in patients with lung cancer: an observational longitudinal study


G. Kasymjanova , MD , * , M. Grossman , N PhD * , T. Tran , BSc-PhT * , R.T. Jagoe , MD PhD , V. Cohen , MD * , C. Pepe , MD * , D. Small , MD * , J. Agulnik , MD *

*Peter Brojde Lung Cancer Centre, Montreal, QC.
Jewish General Hospital, Montreal, QC.
McGill Cancer Nutrition Rehabilitation Clinic, Montreal, QC.

doi: http://dx.doi.org/10.3747/co.20.1312


ABSTRACT

Background

Most lung cancer patients experience multiple symptoms related either to the disease or its treatment. The commonly reported symptoms are pain, depression, anxiety, nausea, and poor well-being. The aim of the present study was to evaluate the effect of acupuncture as a potential treatment modality in symptomatic lung cancer patients.

Methods

This prospective observational study enrolled 33 lung cancer patients from the Peter Brojde Lung Cancer Centre between August 2010 and May 2012. All patients received 45-minute sessions of acupuncture, 1–2 times weekly for a minimum of 4 sessions. Symptom severity was assessed using the Edmonton Symptom Assessment System ( esas ) before and after completion of acupuncture.

Results

The study cohort included 30 patients with non-small- cell lung cancer and 3 with small-cell lung cancer. Mean age was 62 years (range: 36–88 years); 17 of the patients were women. Most of the patients had advanced-stage cancer (73%) and good performance status (Eastern Cooperative Oncology Group 0–1: 88%). Of these patients, 67% received anticancer treatment (chemotherapy or radiotherapy, or both) with acupuncture. Of the remaining 10 patients, 8 received acupuncture after a complete surgical resection of their tumour, and because of their advanced age, 2 received acupuncture and best supportive care. The median number of acupuncture sessions was 7 (interquartile range: 4–13 sessions). Statistically significant improvements in pain, appetite, nausea, nervousness, and well-being were observed. A clinically important improvement (2 points on the esas ) was reported by 61% of patients for pain and by 33% for well-being.

A significant positive correlation between improved well-being and the number of acupuncture sessions was observed. This correlation remained significant even after controlling for treatment and narcotic use. Receiver operating characteristic analysis demonstrated that a minimum of 6 acupuncture sessions are required for a 70% chance of a clinically important improvement in well-being.

Conclusions

The present study is the first to demonstrate that acupuncture may be an effective approach for improving symptoms—in particular, pain and well–being—in lung cancer patients. Acupuncture is a safe and minimally invasive procedure, and it is potentially useful even in patients undergoing anticancer treatment.

KEYWORDS: Acupuncture , lung cancer , Edmonton Symptom Assessment System , esas , pain , integrative oncology clinics , narcotics

1.  BACKGROUND

Most lung cancer patients experience multiple symptoms related either to the cancer or to treatment side effects. This increase in symptom load includes pain, fatigue, nausea and vomiting, distress, depression, and anxiety, and it contributes to impaired quality of life and decreased functional capacity17. In response to the severity and persistence of their symptoms, patients often try complementary modalities ( cm s) such as mindful meditation, deep relaxation techniques, massage, and acupuncture in conjunction with standard treatments811.

Use of cm s in cancer patients ranges from 7% to 64% in various studies12, but the additional benefit of various cm s in controlling symptoms in cancer is less clear. Several studies of varying methodologic rigour suggest that acupuncture can potentially help manage cancer symptoms such as pain, lack of appetite, nausea, emotional distress, depression, and anxiety1319. However, no study has focused exclusively on lung cancer patients, despite that cancer being one of the commonest in men and women alike20,21. The aim of the present study was therefore to evaluate the effects of acupuncture as a potential treatment modality for symptom control in lung cancer patients.

2.  METHODS

Our study was conducted at the Peter Brojde Lung Cancer Centre ( pblcc ) between August 2010 and May 2012. The pblcc was established in 2009 within the Segal Cancer Centre of the Jewish General Hospital in Montreal. The pblcc uses an integrative oncology clinic prototype focused on lung cancer patients and seeks to use clinical research to identify how best to combine current medical treatments with cm s to improve outcomes. The cm modalities offered by the pblcc include nutrition interventions, acupuncture, massotherapy, and physiotherapy.

All patients with lung cancer at the Jewish General Hospital are seen by the Pulmonary Oncology service, and symptomatic patients are referred to the pblcc integrative oncology clinic. Patients seen in the pblcc and referred for acupuncture were eligible for inclusion in the current study if they had received a minimum of 4 sessions of acupuncture and had completed a baseline and end-of-treatment Edmonton Symptom Assessment System ( esas ) questionnaire. The study was conducted in adherence to institutional research guidelines, and all patients signed an informed consent that had been approved by the hospital research ethics committee. Acupuncture was provided by the licensed acupuncturist on the interdisciplinary team within the pblcc integrative oncology clinic.

Acupuncture sessions lasted 45 minutes, and patients were typically treated 1–2 times weekly. Nine acupuncture points were used: 6 body points (Li4, Liv3, St36, Sp6, P6, Lu7) and 3 auricular points (Shenmen, Subcortex, Zero)22. The chosen points included at least 1 specific point for each symptom being evaluated. Dry stainless steel needles were inserted in the skin to an estimated depth of 0.5–1 cun (1–2.5 cm) to produce a de-qi sensation—that is, a sensation of numbness, distension, or electrical tingling at the needling site, which radiates along the corresponding meridian. The inserted needles were maintained for 30 minutes and turned every 10 minutes. During the session, the acupuncturist observed the patients for side effects, such as a stinging sensation, bruising, fainting, muscle spasms, bleeding, and nerve damage.

The esas was used for symptom assessment at the first visit to the acupuncturist (before any treatment) and again after the last treatment. The esas is a validated instrument developed to measure 9 symptoms: pain, strength, nausea, depression, anxiety, drowsiness, appetite, shortness of breath, and overall well-being23. Patients were asked to rate the severity of each symptom on a scale from 0 to 10, with 10 being most severe.

2.1  Statistical Analysis

Baseline characteristics of the patients were collected from medical charts: age, sex, diagnosis, Eastern Cooperative Oncology Group ( ecog ) performance status ( ps ), stage, medical treatment, and use of narcotics. Binary variables were created for any anticancer treatment or narcotic that was given during acupuncture.

The primary outcome was change in well-being and pain scores. To evaluate the effect of acupuncture, the pre- and post-treatment scores for each symptom were compared using the Wilcoxon signed-rank test. The level of significance was set at p < 0.05 (two-tailed). The intensity of symptoms was classified as mild (score = 0–3) or moderate-to- severe (score ≥ 4). Chi-square analysis was used to identify the effect of acupuncture on symptom intensity. Recommendations for a minimal clinically important difference on visual analog scales for various symptoms, including pain, are highly variable, ranging from 1.4 to 2.92426. For the present study, we defined the minimal clinically important change as a 2-point difference in the post- and pretreatment symptom scores. Patients were categorized as clinically improved (score reduction of 2 points or more); stable (change of between −1.9 and 2.0 points), or clinically worse (score increase by more than 2 points).

The interaction between change in symptom scores and number of acupuncture sessions was tested using a Pearson correlation test. In addition, two separate linear regression models were tested for the differences in pain score and the differences in well-being score (dependent variables). The explanatory variables included in the first model were cancer stage, use of concurrent anticancer treatment, and use of narcotics. The second model included age, sex, and ecog ps . Variables were selected based on clinical significance, and the number of explanatory variables was limited to 3 to preserve a power of 0.8 and a significance level of 0.05.

All analyses were conducted using the PASW Statistics software application (version 18.0, SPSS, Chicago, IL, U.S.A.).

3.  RESULTS

Of the 37 patients referred for acupuncture, 33 (89%) had received 4 or more sessions of acupuncture at the time of analysis. Of the 33 patients analyzed, 30 (91%) had non-small-cell lung cancer, and 3 (9%) had small-cell lung cancer. Mean age was 62 years (range: 36–88 years), and 17 of the patients (52%) were women. Almost three quarters (73%) had advanced lung cancer (stage iiib , iv , or extensive), and most had an ecog performance status of 0–1 (88%, Table i). In 23 patients (67%), acupuncture was given while the patient was also undergoing chemotherapy or radiation therapy. Of the remaining 10 patients, 8 received acupuncture after surgical resection of their tumour, and 2 received acupuncture with best supportive care only. No significant side effects attributable to the acupuncture were observed.

Table I   Demographics for the study group

 

The median number of acupuncture sessions was 7 (interquartile range: 4–13 sessions). Statistically significant improvements in pain, appetite, nausea, nervousness, and well-being were observed (Table ii). At the end of treatment, pain had improved clinically in 20 patients (61%), remained stable in 11 (33%), and deteriorated in 2 (6%, Figure 1). The 2 patients whose pain deteriorated stopped acupuncture after 4 sessions, one because of cancer progression, and the other because of frailty.

Table II   Outcome of repeated measures presenting the effect of acupuncture on the Edmonton Symptom Assessment System score

 

 


 

Figure 1 Difference in pain scores pre- and post-acupuncture. Each bar represents a patient. The horizontal lines represent a difference of 2 points, which is considered a minimal clinically important difference. Only 2 patients (case numbers 11 and 14) reported worsening of pain.

Reported pain intensity improved significantly after acupuncture treatment. Before acupuncture, 22 patients (67%) reported moderate-to-severe pain (score ≥ 4); after acupuncture, the number of patients with moderate-to-severe pain had declined to 11 (33%, chi-square test p = 0.05). During acupuncture treatment, 8 patients were taking narcotics for pain. These subjects also reported a statistically significant reduction in mean pain score to 2.25 after treatment from 5.75 before treatment ( p < 0.001). No significant correlation was found between change in pain score and number of acupuncture sessions ( r = 0.046, p = 0.8), even after controlling for use of narcotics ( r = 0.043, p = 0.814). Furthermore, other factors, such as cancer stage and concurrent cancer treatment, did not significantly alter the observed effects of acupuncture treatment on pain (Table iii).

Table III   Linear model to evaluate the effect of other parameters on improvement in Edmonton Symptom Assessment System score

 

Similar results were seen for improvements in well-being. (Figure 2).A clinically important improvement in well-being was reported by 11 patients (33%), with 21 patients (64%) remaining stable, and just 1 patient with clear cancer progression feeling worse. Initially, 17 patients (52%) reported a well-being score of 4 or higher. After acupuncture, only 11 patients (33%) reported a score of 4 or higher (chi-square p = 0.05). Linear regression modelling for change in well-being score failed to show any significant effect of stage, active treatment, or use of narcotics (Table iii). Age, sex, and ecog ps also had no effect on differences in the well-being score (data not shown). Change in well-being was significantly correlated with the number of acupuncture sessions ( r = −0.438, p = 0.012), and it remained significant even after controlling for anticancer treatment ( r = −0.476, p = 0.007) and use of narcotics ( r = −0.434, p = 0.015). One outlier with 43 acupuncture sessions (>3 standard deviations above the mean) was excluded from this correlation analysis. Receiver operating characteristic analysis demonstrated that a minimum of 6 sessions was required for a 70% chance of a clinically significant (2-point or more) reduction in well-being score.

 


 

Figure 2 Difference in well-being scores pre- and post-acupuncture. Each bar represents a patient. The horizontal lines represent a difference of 2 points, which is considered a minimal clinically important difference. Only 1 patient (case number 14) reported worsening of well-being.

4.  DISCUSSION

To our knowledge, the present study is the first to analyze the efficacy of acupuncture in alleviating symptoms in lung cancer patients. Our results show that acupuncture is feasible, safe, and well tolerated. Furthermore, patients undergoing acupuncture in the pblcc integrative oncology clinic experienced significant improvements in 5 of 9 symptoms assessed on the esas . We focused specifically on two of those symptoms (pain and overall well-being) and showed that, as far as could be assessed using statistical methods, the effect of acupuncture was independent of age, sex, ps , concurrent cancer treatment, and use of narcotics. The number of acupuncture sessions completed was significantly correlated with improvement in well-being (but not pain), and our results suggest that 6 sessions, at a minimum, are needed to achieve a clinically significant effect on well-being.

Being a single-institution nonrandomized observational prospective study, our research has strengths and limitations. Acupuncture was delivered by a single, experienced acupuncturist, and the 9-point acupuncture intervention was standardized for the study. That standardization ensured minimal variability across the acupuncture sessions and, at the same time, created effective patient–acupuncturist communication and strengthened the subsequent commitment to treatment by the patients. Other aspects of treatment were not standardized; for example, treatment duration varied between 4 and 26 weeks.

Interpretation of the results and some aspects of the statistical analysis are limited by the size of the study and the absence of a control group. Thus, to assess whether our results are reproducible and generalizable, they should ideally be confirmed in a larger randomized controlled trial with multiple acupuncturists.

There is increasing evidence that the use of acupuncture for symptom control in severe or life-threatening illness is plausible. That evidence includes results of earlier clinical trials. For example, a review of 27 randomized controlled trials of acupuncture in palliative care concluded that acupuncture should be included as a modality for use in the palliation of pain27. However, the use of acupuncture has not yet been accepted as a standard of care in adjunctive medical treatment. The general applicability of the results from acupuncture studies to date are limited because of the use of different acupuncture techniques (for example, electrical or manual), controls (with or without comparison groups), outcome measures, needle protocols, and duration of treatment13,15,16,27. Most importantly from our perspective, no earlier acupuncture trials have focused specifically on lung cancer patients, despite the large numbers of patients diagnosed with lung cancer and their evident need for control of frequent, severe, and debilitating symptoms28,29. In a randomized controlled study with two control groups (nonpoint and noninvasive), Alimi and colleagues15 reported pain improvement in 36% of patients treated with auricular acupuncture. However, that study population consisted of mixed cancer patients with only 2 of 70 being lung cancer patients, both of whom were randomized to placebo.

The mechanisms associated with acupuncture’s analgesic action are complex, but appreciation that this treatment modality has physiologically relevant effects is growing and strengthening the case for its use in symptom control. Acupuncture practitioners recognize meridians or energy pathways that correspond to neurovascular connective tissue planes connecting various parts of the body3033. One hypothesis is that acupuncture stimulates a somatosensory system that results in the release of endogenous opioids34,35. Acupuncture is known to trigger electrophysiologic changes in various areas of the nervous system, including the autonomic nervous system, the pituitary gland, the hypothalamus, and other parts of the brain, causing the release of neurotransmitters, neuropeptides, and other hormones that can affect a range of bodily functions36,37. The proposal is that, through this biologic response, acupuncture can modulate blood pressure and body temperature, enhance immunity, decrease inflammation, and subsequently improve cancer- and treatment-related symptoms13,30,31,38.

5.  CONCLUSIONS

This study is the first to demonstrate that acupuncture may be an effective approach for improving symptoms—in particular, pain and well-being—in a lung cancer population. Acupuncture is a safe and minimally invasive modality, and it may have a particularly useful role in patients undergoing anticancer treatment—such as those who constituted the greater proportion of the patients in the present study.

A large-scale randomized controlled trial is needed to confirm the beneficial effects of acupuncture in this population and to gather more precise information about the frequency and duration of acupuncture treatments required to achieve optimal symptom control. Patients and practitioners need answers to important practical questions about the symptoms that are most amenable to relief through acupuncture, and the point in the patient’s treatment trajectory when it is best to use acupuncture.

6.  CONFLICT OF INTEREST DISCLOSURES

All persons who have made substantial contributions to the work reported in this manuscript are included as authors, and none have relevant financial interests in this manuscript.

7. REFERENCES

1 Akin S, Can G, Aydiner A, Ozdilli K, Durna Z. Quality of life, symptom experience and distress of lung cancer patients undergoing chemotherapy. Eur J Oncol Nurs 2010;14:400–9.
cross-ref  pubmed  

2 Hopwood P, Stephens RJ. Depression in patients with lung cancer: prevalence and risk factors derived from quality-of-life data. J Clin Oncol 2000;18:893–903.
pubmed  

3 Zabora J, BrintzenhofeSzoc K, Curbow B, Hooker C, Piantadosi S. The prevalence of psychological distress by cancer site. Psychooncology 2001;10:19–28.
cross-ref  pubmed  

4 Kasymjanova G, Correa JA, Kreisman H, et al. Prognostic value of the six-minute walk in advanced non-small cell lung cancer. J Thorac Oncol 2009;4:602–7.
cross-ref  pubmed  

5 Larsson M, Ljung L, Johansson BB. Health-related quality of life in advanced non-small cell lung cancer: correlates and comparisons to normative data. Eur J Cancer Care (Engl) 2012;21:642–9.
cross-ref  

6 Maione P, Perrone F, Gallo C, et al. Pretreatment quality of life and functional status assessment significantly predict survival of elderly patients with advanced non-small-cell lung cancer receiving chemotherapy: a prognostic analysis of the multicenter Italian lung cancer in the elderly study. J Clin Oncol 2005;23:6865–72.
cross-ref  pubmed  

7 Steinberg T, Roseman M, Kasymjanova G, et al. Prevalence of emotional distress in newly diagnosed lung cancer patients. Support Care Cancer 2009;17:1493–7.
cross-ref  pubmed  

8 Lu W, Dean–Clower E, Doherty–Gilman A, Rosenthal DS. The value of acupuncture in cancer care. Hematol Oncol Clin North Am 2008;22:631–48,viii.
cross-ref  pubmed  pmc  

9 Molassiotis A, Panteli V, Patiraki E, et al. Complementary and alternative medicine use in lung cancer patients in eight European countries. Complement Ther Clin Pract 2006;12:34–9.
cross-ref  pubmed  

10 O’Regan D, Filshie J. Acupuncture and cancer. Auton Neurosci 2010;157:96–100.
cross-ref  

11 Pan CX, Morrison RS, Ness J, Fugh–Berman A, Leipzig RM. 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 2000;20:374–87.
cross-ref  pubmed  

12 Ernst E, Cassileth BR. The prevalence of complementary/alternative medicine in cancer: a systematic review. Cancer 1998;83:777–82.
cross-ref  pubmed  

13 Dean–Clower E, Doherty–Gilman AM, Keshaviah A, et al. Acupuncture as palliative therapy for physical symptoms and quality of life for advanced cancer patients. Integr Cancer Ther 2010;9:158–67.
cross-ref  

14 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 2007;15:228–37.
cross-ref  pubmed  

15 Alimi D, Rubino C, Pichard–Léandri E, Fermand–Brulé S, Dubreuil–Lemaire ML, Hill C. Analgesic effect of auricular acupuncture for cancer pain: a randomized, blinded, controlled trial. J Clin Oncol 2003;21:4120–6.
cross-ref  pubmed  

16 Lee H, Schmidt K, Ernst E. Acupuncture for the relief of cancer-related pain—a systematic review. Eur J Pain 2005;9:437–44.
cross-ref  pubmed  

17 Pavão TS, Vianna P, Pillat MM, Machado AB, Bauer ME. Acupuncture is effective to attenuate stress and stimulate lymphocyte proliferation in the elderly. Neurosci Lett 2010;484:47–50.
cross-ref  pubmed  

18 Samuels N. Acupuncture for nausea: how does it work? [Hebrew]. Harefuah 2003;142:297–300,316.

19 Shen J, Wenger N, Glaspy J, et al. Electroacupuncture for control of myeloablative chemotherapy-induced emesis: a randomized controlled trial. JAMA 2000;284:2755–61.
cross-ref  pubmed  

20 Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM. Estimates of worldwide burden of cancer in 2008: globocan 2008. Int J Cancer 2010;127:2893–917.
cross-ref  

21 Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D. Global cancer statistics. CA Cancer J Clin 2011;61:69–90. [Erratum in: CA Cancer J Clin 2011;61:134]
cross-ref  pubmed  

22 Acupuncture Products. Atlas of Acupuncture Points: Point Location. Pottstown PA: Acupuncture Products; 2007. [Available online at: http://www.chiro.org/acupuncture/ABSTRACTS/Acupuncture_Points.pdf; cited July 30, 2012]

23 Bruera E, Kuehn N, Miller MJ, Selmser P, Macmillan K. The Edmonton Symptom Assessment System (esas): a simple method for the assessment of palliative care patients. J Palliat Care 1991;7:6–9.
pubmed  

24 Bedard G, Zeng L, Zhang L, et al. Minimal clinically important differences in the Edmonton Symptom Assessment System in patients with advanced cancer. J Pain Symptom Manage 2012;:[Epub ahead of print].
cross-ref  

25 Kelly AM. Does the clinically significant difference in visual analog scale pain scores vary with gender, age, or cause of pain? Acad Emerg Med 1998;5:1086–90.
cross-ref  pubmed  

26 Lee JS, Hobden E, Stiell IG, Wells GA. Clinically important change in the visual analog scale after adequate pain control. Acad Emerg Med 2003;10:1128–30.
cross-ref  pubmed  

27 Standish LJ, Kozak L, Congdon S. Acupuncture is underutilized in hospice and palliative medicine. Am J Hosp Palliat Care 2008;25:298–308.
cross-ref  pubmed  

28 Laird BJ, Scott AC, Colvin LA, et al. Pain, depression, and fatigue as a symptom cluster in advanced cancer. J Pain Symptom Manage 2011;42:1–11.
cross-ref  pubmed  

29 Ferreira KA, Kimura M, Teixeira MJ, et al. Impact of cancer-related symptom synergisms on health-related quality of life and performance status. J Pain Symptom Manage 2008;35:604–16.
cross-ref  pubmed  

30 Ahn AC, Kaptchuk TJ. Advancing acupuncture research. Altern Ther Health Med 2005;11:40–5.
pubmed  

31 Sagar SM. Acupuncture as an evidence-based option for symptom control in cancer patients. Curr Treat Options Oncol 2008;9:117–26.
cross-ref  pubmed  

32 Lin JG, Chen WL. Acupuncture analgesia: a review of its mechanisms of actions. Am J Chin Med 2008;36:635–45.
cross-ref  pubmed  

33 Chang S. The meridian system and mechanism of acupuncture—a comparative review. Part 1: the meridian system. Taiwan J Obstet Gynecol 2012;51:506–14.
cross-ref  

34 Han JS. Acupuncture and endorphins. Neurosci Lett 2004;361:258–61.
cross-ref  pubmed  

35 Harris RE, Zubieta JK, Scott DJ, Napadow V, Gracely RH, Clauw DJ. Traditional Chinese acupuncture and placebo (sham) acupuncture are differentiated by their effects on muopioid receptors (mors). Neuroimage 2009;47:1077–85.
cross-ref  pubmed  pmc  

36 Dhond RP, Yeh C, Park K, Kettner N, Napadow V. Acupuncture modulates resting state connectivity in default and sensorimotor brain networks. Pain 2008;136:407–18.
cross-ref  pubmed  pmc  

37 Kim SK, Bae H. Acupuncture and immune modulation. Auton Neurosci 2010;157:38–41.
cross-ref  pubmed  

38 Bonta IL. Acupuncture beyond the endorphin concept. Med Hypotheses 2002;58:221–4.
cross-ref  pubmed  


Correspondence to: Goulnar Kasymjanova, Peter Brojde Lung Cancer Centre, Segal Cancer Centre, Jewish General Hospital, 3755 Cote Ste-Catherine, Montreal, Quebec H3T 1E2. E-mail: gkasymja@jgh.mcgill.ca

(Return to Top)



Current Oncology , VOLUME 20 , NUMBER 3 , JUNE 2013








Copyright © 2017 Multimed Inc.
ISSN: 1198-0052 (Print) ISSN: 1718-7729 (Online)