Acupuncture for Cancer-Related Fatigue
By Christina M. Seluzicki, MBE, Susan Schwartz, RN, OCN®, CBCN®, and Jun J. Mao, MD, MSCE
Fatigue is one of the most prevalent and challenging side effects that people with cancer experience. Commonly known as cancer-related fatigue (CRF), the National Comprehensive Cancer Network (https://oncolife.com.ua/doc/nccn/fatigue.pdf) defines it as “a distressing, persistent, subjective sense of physical, emotional, and/or cognitive tiredness or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and interferes with usual functioning.”
CRF affects 50%–90% of patients (https://academic.oup.com/annonc/article/22/6/1273/216617) and can diminish quality of life, lead to functional impairment, and is associated with significant morbidity (https://www.nature.com/articles/6602012). Although it improves in many patients (https://www.ncbi.nlm.nih.gov/pubmed/25113839) the year following treatment, CRF may persist over a much longer period (https://ascopubs.org/doi/10.1200/JCO.2000.18.4.743) in some.
Growing evidence suggests that inflammatory processes are involved in CRF, including dysregulation of the proinflammatory cytokine network, documented primarily in breast cancer survivors. Other contributing factors include alterations in the hypothalamic-pituitary-adrenal axis and autonomic nervous system, both also closely connected to inflammatory activity (https://www.ncbi.nlm.nih.gov/pubmed/25113839).
Acupuncture for CRF
Acupuncture, an important component of traditional Chinese medicine, involves stimulating specific predetermined points (acupoints) on the body with needles for therapeutic effect. Current evidence of its effectiveness against CRF is encouraging. A randomized controlled trial (RCT) involving breast cancer patients (n=302) compared acupuncture (six weekly treatments) with enhanced usual care (booklet on managing fatigue). Researchers found improvements in general fatigue (P<0.001) as well as in physical and mental aspects of fatigue (https://ascopubs.org/doi/full/10.1200/JCO.2012.41.6222) (P<0.001). In a follow-up study, participants were re-randomized to determine the effects of self-needling versus therapist-administered acupuncture. But additional improvements in fatigue were non-significant after four weeks (P=0.07), with no difference in self- versus therapist-administered treatment (https://academic.oup.com/annonc/article/24/6/1645/180526).
In another three-arm RCT of postmenopausal breast cancer survivors (n=67) with aromatase inhibitor-associated arthralgia, electro-acupuncture (10 treatments over 8 weeks plus a 4-week follow up) resulted in significant improvements in fatigue (P=0.0095), anxiety (P=0.044), and depression (P=0.015) compared to waitlist control. Sham acupuncture (needles do not penetrate the skin, or are inserted at non-acupuncture points) did not produce the same improvements in fatigue or anxiety, although it did result in significant improvement in depression compared to usual care (https://onlinelibrary.wiley.com/doi/full/10.1002/cncr.28917). Also, a double blind, sham-controlled RCT in breast cancer survivors (n=100) found that true acupuncture did not improve post-chemotherapy chronic fatigue; however, the study was limited by the number of patients lost to follow-up (https://www.ncbi.nlm.nih.gov/pubmed/23334562).
A recent meta-analysis of 10 RCTs (n=1,327) found that acupuncture is effective and should be recommended for management of CRF (P<0.01), especially for breast cancer patients and for those undergoing treatment; however, the trials included did not report on variations in related symptoms that can affect CRF (https://www.ncbi.nlm.nih.gov/pubmed/29128952).
The mechanisms via which acupuncture relieves fatigue are not fully understood. Studies using animal models showed that needling may modulate the endogenous serotonin (https://www.ncbi.nlm.nih.gov/pubmed/12377374) (5-hydroxytryptamine) system that is believed to contribute to fatigue (https://theoncologist.alphamedpress.org/content/12/suppl_1/22.short). Data from imaging studies using positron emission tomography scans and functional magnetic resonance imaging suggest that acupuncture-like processes and acupuncture needling may modify limbic structures (https://www.ncbi.nlm.nih.gov/pubmed/23395475) known to process cognition, anger, and fear. Such modification could decrease patient-perceived fatigue by mitigating psychological distress. Furthermore, specific acupoints and type of needle stimulation may also influence acupuncture’s effect on fatigue (https://ascopubs.org/doi/10.1200/JCO.2012.43.5818).
What Oncology Nurses Need to Know
Cancer-related fatigue is a distressing symptom and can persist for years following treatment, with few effective approaches. Accumulating clinical evidence supports the utility of acupuncture for CRF, especially in breast cancer patients and survivors. The Society for Integrative Oncology (SIO) guidelines, endorsed by the American Society of Clinical Oncology (ASCO) (https://ascopubs.org/doi/full/10.1200/JCO.2018.79.2721), state that “acupuncture can be considered for improving post-treatment fatigue” for patients with breast cancer (https://www.ncbi.nlm.nih.gov/pubmed/28436999). It is now offered at many cancer centers in keeping with the growing interest in non-pharmacological strategies to address cancer symptoms. A review of NCI-designated comprehensive cancer centers identified acupuncture, along with massage, as the most frequently available modality (https://academic.oup.com/jncimono/article/2017/52/lgx004/4617819).
Given its increased availability and growing evidence of effectiveness against cancer symptoms, oncology nurses should consider incorporating acupuncture into clinical care for managing CRF. Patients often express renewed energy and reduced stress after receiving acupuncture, and it is safe when performed by qualified practitioners with experience working in the oncology setting. Minor side effects such as bleeding, hematoma, dizziness, and pain have been reported. Pneumothorax and local infections are rare occurrences (https://pediatrics.aappublications.org/content/early/2011/11/16/peds.2011-1091..info?versioned=true).
Patients can also be referred to the Memorial Sloan Kettering Cancer Center’s About Mind-Body Therapies (https://www.mskcc.org/cancer-care/diagnosis-treatment/symptom-management/integrative-medicine/mind-body) database, a reliable source of evidence-based information about complementary modalities – including acupuncture – that help alleviate symptoms associated with cancer and its treatments.