Treatment of Chemotherapy-Induced Peripheral Neuropathy in Integrative Oncology: A Survey of Acupuncture and Oriental Medicine Practitioners

Abstract

Objectives:

Complementary and alternative medicine is increasingly integrated into cancer care. We sought detail on the treatment of chemotherapy-induced peripheral neuropathy (CIPN) with acupuncture and oriental medicine (AOM) by surveying practitioners at integrative oncology (IO) sites across the United States.

Design:

Online survey of licensed acupuncturists.

Setting/Location:

IO sites in the United States.

Subjects:

Fifteen licensed acupuncturists who completed the survey between February 2014 and June 2014.

Outcome measures:

Demographics, IO setting characteristics, AOM treatment characteristics, and practitioner-reported outcomes.

Results:

Respondents reported an average of 31.3 ± 17.2 patients per week, and one-third (10.1 mean; 7.2 standard deviation [SD]) were treated for CIPN. Medical doctors (86.7%) were the most common providers with whom respondents worked. Traditional Chinese medicine style acupuncture was utilized by a majority of respondents (86.7%), and the most commonly used points were local, typically in the hands and feet, such as Ba Feng, Ba Xie, LV3, and LI4. In addition to acupuncture, nutritional advice was the most frequent auxiliary modality provided by respondents (85.7%). On average, respondents provided 12.75 ± 4.17 treatments for CIPN patients, and a majority (53%) reported treating patients once per week. Timing of the treatments relative to chemotherapy infusion was evenly distributed between “1–2 days after infusion” (60%), “at time of infusion” (53.3%), and “1–2 days before infusion” (46.7%). Sixty percent of respondents rated outcomes as “moderately successful with moderate improvement seen.”

Conclusion:

This survey provides detail regarding IO sites using acupuncture for CIPN as well as real-world treatment patterns, including common point combinations, visit characteristics, and practitioner-reported outcomes. This information contributes to the emerging evidence on the use of acupuncture to address unmet needs of CIPN patients, and supports the development of best practice guidelines for the treatment of CIPN with acupuncture in the IO setting.

Introduction

Chemotherapy-induced peripheral neuropathy (CIPN) results from the neurotoxicity of chemotherapeutic drugs and is often a disabling side-effect for many cancer patients.¹ The symptoms include the following: dysfunction of the sensory, motor, and/or autonomic neurons of the peripheral nervous system, resulting in pain, loss of sensation, and decreased balance and mobility.² Some of these symptoms may never fully resolve, and the effects can be so severe that oncologists may limit the chemotherapeutic dose in an attempt to lessen symptoms, limiting potential efficacy.³ Although medications have been employed to treat the symptoms associated with CIPN, few are consistently effective or tolerable.^2,3 Duloxetine is the one agent clinicians consider an acceptable first-line treatment as recommended by The American Society of Clinical Oncology CIPN guideline committee, but it is not yet approved by the U.S. Food and Drug Administration specifically for this purpose.^4,5

The use of adjunctive acupuncture by patients undergoing chemotherapy and other cancer treatments is increasing.^6,7 Most studies on the benefits of acupuncture and oriental medicine (AOM) for the side-effects of chemotherapy have focused on the treatment of nausea and vomiting.^8
–10 Research has also suggested that acupuncture is helpful in reducing cancer-related pain,^11,12 cancer-related fatigue,¹³ lymphedema,^14,15 cancer-related psychological symptoms,¹⁶ radiation-induced xerostomia,¹⁷ and improving quality of life.¹⁸ However, only a small number of studies have reported the use of acupuncture specifically for CIPN, many of which are case reports.^19

–25 While significant heterogeneity among these studies makes comparison difficult,²⁶ positive outcomes suggest potential benefit for acupuncture in treating CIPN and warrants further research.

As oncology treatment continues to move toward an integrative model,²⁷ elucidating the current state of AOM in this setting will help facilitate “best practices” and real-world applications of AOM for treatment of CIPN. We conducted a survey of AOM practitioners working within integrative oncology (IO) centers across the United States. By surveying providers at the forefront of integrative cancer care, our goal is to describe practitioner and patient demographics and AOM practice patterns, and develop a clearer picture of AOM for CIPN within the emerging IO model. Some of the questions we hope to answer include the following: Is the IO center the best setting for patients with CIPN? Are AOM providers in these settings able to deliver the care they want to deliver, or are their treatments limited? How are those treatments and modalities currently delivered, and what results do practitioners report? Answering these questions will help inform future studies of AOM in the treatment of CIPN, and optimize the way it is integrated with other modalities in IO settings.

Materials and Methods

Data were gathered using a self-administered survey of practitioners utilizing AOM in the treatment of CIPN. The survey measures included the following: multiple choice; Likert-type rating scale; ranking; and open-ended questions. The study was approved by the Oregon College of Oriental Medicine (OCOM) Institutional Review Board (IRB). Participants were licensed acupuncturists identified by contacting IO hospitals and centers in the United States.

Procedures

A 28-question survey was sent to acupuncturists working within IO settings; it included a letter introducing the project and a required “Consent to Participate” document. Our participant list was created by researching IO hospitals and centers using acupuncture from the following publicly held lists:

(1) Society for Integrative Oncology (SIO)—Integrative Oncology Practitioner list

(2) Society for Integrative Oncology (SIO)—Integrative Oncology Programs list

(3) FON Therapeutics—Integrative Oncology Centers list

(4) Office of Cancer Complementary and Alternative Medicine (OCCAM)—Integrative Medicine Programs list

(5) Consortium of Academic Health Centers for Integrative Medicine (CAHCIM)—Members list

A link to the survey was sent by e-mail. When an e-mail address was unavailable, the survey link was sent by mail to the physical address. Only one response was solicited for each invitation, and responses were collected between March 24th 2014 and June 16th 2014. Informed consent was obtained from each respondent, all data were anonymized, and all respondents were included in the final analysis.

Data were collected in four primary domains: (1) Practitioner Demographics, (2) IO Setting Characteristics, (3) AOM Treatment Characteristics, and (4) AOM Treatment Planning and Outcomes. All survey data were stored in a database for qualitative and quantitative analyses. For close-ended questions, data were presented as mean ± standard deviation (SD), and relative frequency if applicable. Responses to open-ended questions were coded for qualitative analysis.

Results

Practitioner demographics

Fifteen practitioners at IO sites in the United States completed the survey. Eleven (73.3%) were female and 4 (26.7%) were male. The average age was 45 ± 6.9, and the average number of years in practice was 10.9 ± 6.4. Eleven respondents (73.3%) reported formal Masters level training, 3 (20%) reported formal Doctoral level training, and 1 (6.7%) reported training by apprenticeship. Eight (53.3%) reported holding additional licenses or degrees, including naturopathic doctor (ND), registered nurse (RN), Masters in Public Health, and licensed massage therapist (LMT) (Table 1).

Table 1.

Practitioner Demographics

Gender	n	%
Female	11	73.3
Male	4	26.7
Age	45.4 (mean)	6.9 (SD)
Years in practice	10.9 (mean)	6.4 (SD)
Training	n	%
Masters (MAcOM)	11	73.3
Doctoral (DAOM)	3	20.0
Internship/externship/apprenticeship	1	6.7
MD w/medical acupuncture training	0	0.0
Additional licensure/degrees	n	%
ND	5	33.3
RN	1	6.7
MPH	1	6.7
LMT	1	6.7
None	7	46.6

LMT, licensed massage therapist; MD, medical doctor; MPH, Masters in Public Health; ND, naturopathic doctor; RN, registered nurse; SD, standard deviation.

IO setting characteristics

A majority of respondents (73.3%) reported their work setting as an “integrative clinic with other practitioners”; other settings included university-affiliated hospitals (40%) and private hospitals (33.3%). Respondents reported a wide variety of practitioner types working within these settings, including medical doctor (86.7%), RN (73.3%), LMT (66.7%), nurse practitioner (NP) (53.3%), and ND (46.7%). Across all setting types, respondents reported treating an average of 31.3 ± 17.2 patients per week, and a third of these patients (10.1 ± 7.2) were treated for CIPN (Table 2). A majority of respondents (87.6%) described their integrative clinical setting as well equipped to deliver complementary and alternative medicine (CAM) modalities to their patients.

Table 2.

Integrative Oncology Setting Characteristics

Setting type	n	% ^a
Integrative clinic with other practitioners	11	73.3
University-affiliated hospital	6	40.0
Private hospital	5	33.3
Private clinic as solo practitioner	4	26.7
Not-for-profit clinic	2	13.3
State or city hospital	1	6.7
Private integrative oncology clinic	1	6.7
Patients treated per week w/acupuncture	31.3 (mean)	17.2 (SD)
Patients treated per week w/acupuncture for CIPN	10.1 (mean)	7.2 (SD)
Other practitioners	n	% ^a
Medical doctor (MD)	13	86.7
Registered nurse (RN)	11	73.3
Licensed massage therapist (LMT)	10	66.7
Nurse practitioner (NP)	8	53.3
Naturopathic doctor (ND)	7	46.7
Mental health specialist	6	40.0
Doctor of osteopath (DO)	5	33.3
Doctor of chiropractic (DC)	3	20.0
Physical therapist (PT)	1	6.7
Registered dietician (RD)	1	6.7

Respondents could select more than one answer. Values are shown as a percentage of total responses for each selection.

CIPN, chemotherapy-induced peripheral neuropathy.

Factors that were favorable to the delivery of CAM modalities were as follows: “well staffed,” “multiple practitioners (in addition to licensed acupuncturists),” “adequate time within a treatment session,” and “adequate facilities.” Factors that limited the delivery of CAM modalities were as follows: “building did not allow burning of moxa,” “restriction on bleeding or herbs,” “time restrictions,” and “space restrictions.”

Breast cancer was the most common cancer type for patients treated for CIPN, with 12 respondents (85.7%) reporting that many, most, or all of their patients were diagnosed with breast cancer. In addition, all respondents reported seeing some or many patients with other cancer diagnoses, including ovarian, lung, gastrointestinal, hematological, bone, pancreatic, and cervical.

AOM treatment characteristics for CIPN

There are numerous styles of acupuncture practiced in the field of AOM. For the treatment of CIPN, 86% of respondents (n = 13) reported using traditional Chinese medicine (TCM) style “always” or “very often,” and Auricular style acupuncture was used “always” or “very often” by 41.7% (n = 5). Korean hand style acupuncture was the least utilized style, with 90% (n = 9) of respondents saying they used it “rarely” or “never” (Table 3).

Table 3.

Acupuncture Style

	Always/very often (combined)		Rarely/never (combined)
	n	% ^a	n	% ^a
TCM	13	86.7	1	6.7
Master tung	2	18.2	7	63.6
Japanese	3	27.3	6	54.5
Korean	0	0.0	9	90.0
Scalp	3	27.3	5	45.5
Auricular	5	41.7	2	16.7

Respondents could select more than one answer. Values are shown as a percentage of total responses for each selection.

TCM, traditional Chinese medicine.

We asked the participants to choose and rank which TCM patterns they most commonly see in CIPN patients. A majority (80%) of respondents identified “Qi and Blood stasis” as the most common pattern differentiation. The other patterns in order of most to least diagnosed were: “Qi and Blood deficiency,” “Kidney Qi deficiency,” and “Kidney Yin deficiency.”

For those who use TCM differentiation, the acupuncture points most commonly used for CIPN were local points, typically in the hands and feet, such as Ba Feng, Ba Xie, LV3, and LI4. Additional common points included ST36, SP6, LI11, TB5, GB34, KI3, SP10, ST41, LU7, NADA 5NP protocol, Master Tung points appropriate for the symptom and area being addressed, scalp motor line, GV20, Si Shen Cong, and following auricular points: Shen Men, Sympathetic, Hand and Foot (Fig. 1).

FIG. 1.

Commonly used TCM points for CIPN. CIPN, chemotherapy-induced peripheral neuropathy; TCM, traditional Chinese medicine.

Those who practice a style other than TCM reported using primarily Master Tung points, 5NP, and Auricular points, such as “Hand,” “Foot.” For those who use Master Tung style, points are chosen based on symptoms such as follows:

• numbness of the face: Da Bai (22.04), He Gu (LI-4)

• numbness of the hand and arms: Ren Huang (77.21) with Zhong Jiu Li (88.25), Shen Guan (77.18)

• numbness of the lower extremities: Zhou Shui (1010.25)

• numbness of the feet: San Cha points (A.02, A.03, A.04)

• numbness of the whole body: Ling Gu (22.05), Zhong Jiu Li (88.25) with Qi Li (A.01) Dao Ma, Shen Guan (77.18), or Xia San Huang (77.18, 77.19, 77.21)

• alternate each treatment with: Mu Liu (66.06) and Mu Dou (66.07) Dao Ma

Respondents were asked to report minimum, maximum, and typical needle retention times for patients with CIPN (Table 4). Five (45.5%) reported minimum retention time of 21–30 min, and a similar percentage (45.5%) reported maximum retention time of 31–40 min. Overall, the majority (53.3%) reported typically that they retained needles for 21–30 min when treating CIPN.

Table 4.

Needle Retention Time

	Typical retention time		Minimum retention time		Maximum retention time
	n	% ^a	n	% ^a	n	% ^a
Less than 10 min	0	0.0	1	9.0	0	0.0
10–20 min	1	6.7	4	36.3	0	0.0
21–30 min	8	53.3	5	45.5	2	18.2
31–40 min	4	26.7	1	9.0	5	45.5
41–50 min	2	13.3	0	0.0	3	27.3
Greater than 50 min	0	0.0	0	0.0	1	9.0

Some missing responses. Values are shown as percentage of total responses for each selection.

Use of auxiliary modalities, in addition to acupuncture, is reported in Table 5. Nutrition advice (85.7%) and TDP heat lamp (60%) were both common. Conversely, bleeding (92.9%), cupping (85.7%), Gua Sha (85.7%), Shiatsu (78.6%), and Tuina (69.2%) were used rarely or never for CIPN patients.

Table 5.

Use of Auxiliary Acupuncture and Oriental Medicine Modalities

	Always/very often (combined)		Rarely/never (combined)
	n	% ^a	n	% ^a
Bleeding	0	0.0	13	92.9
Cupping	0	0.0	12	85.7
Electroacupuncture	5	33.3	7	46.7
Gua Sha	0	0.0	12	85.7
Internal herbs	3	21.4	6	42.9
External herbs	3	21.4	7	50.0
Moxa	6	40.0	7	46.7
Nutrition	12	85.7	1	7.1
Shiatsu massage	1	7.1	11	78.6
Tuina massage	2	15.4	9	69.2
TDP lamp	9	60.0	1	6.7
Qigong	4	28.6	5	35.7

Some missing responses. Values are shown as percentage of total responses for each question.

AOM treatment planning and outcomes for CIPN

On average, respondents provided 12.75 ± 4.17 acupuncture treatments for patients with CIPN (Table 6). A majority (53%) reported treating patients for CIPN once per week, while 33% (n = 5) reported treating twice per week. No respondents reported treatment plans less than once per week or more than four times per week (Table 6).

Table 6.

AOM Treatment Planning for CIPN

Number of AOM treatments	12.75 (mean)	4.17 (SD)
Treatment frequency	n	%
1 time per week	8	53.3
2 times per week	5	33.3
3 times per week	1	6.7
4 times per week	1	6.7
Timing of AOM treatments and infusion	n	%^a
1–2 days after infusion	9	60.0
At time of infusion	8	53.3
1–2 days before infusion	7	46.7
Determining conclusion of AOM treatments	n	%^a
Symptoms have been resolved to patient satisfaction	14	93.3
Patient discontinued treatment due to dissatisfaction with outcomes	10	67.7
Lack of third-party funding or financial support for continued care	9	60.0
Change in patient's condition	9	60.0
Patient discontinues care due to financial hardship	7	46.7
Symptoms have been resolved to practitioner satisfaction	6	40.0
Practitioner discontinued care due to dissatisfaction with outcomes	5	33.3
Course of treatment is a predetermined length of time	2	13.3

Respondents could select more than one response. Values are shown as a percentage of total responses for each selection.

AOM, acupuncture and oriental medicine.

Timing of the acupuncture treatments relative to chemotherapy infusion was evenly distributed between “1–2 days after infusion” (60%), “at time of infusion” (53.3%), and “1–2 days before infusion” (46.7%) (Table 6).

Ninety-three percent (n = 14) reported concluding treatment when “symptoms have been resolved to the patient's satisfaction,” 67.7% (n = 10) when “patient discontinued treatment due to dissatisfaction with outcomes,” and 40% (n = 6) when “symptoms have been resolved to practitioner satisfaction.” Funding issues also appear to present a significant barrier to continued treatment: 46.7% (n = 7) reported financial hardship causing patients to end treatment, and 60% (n = 9) reported “lack of third-party funding or support for continued care” as the determining factor in concluding treatment (Table 6).

To evaluate the effectiveness of AOM treatment outcomes, a majority of respondents reported using either, or both, a visual analog or other pain scale (91.7%), or other subjective findings (78.6%). A minority (33.3%) used objective findings (such as nerve conduction tests) to evaluate effectiveness (Table 7). Sixty percent of respondents (n = 9) rated treatment success for CIPN with AOM as being “Moderately successful with moderate improvement seen,” while 33.3% (n = 5) reported it as “Very successful with significant improvement seen” (Table 7).

Table 7.

Acupuncture and Oriental Medicine Treatment outcomes for Chemotherapy-Induced Peripheral Neuropathy

Assessment tools to evaluate treatment outcomes	n	%^a
Visual analog or other pain scale	11	91.7
Other subjective findings (e.g., PGIC or physical function questionnaire)	11	78.6
Objective findings (e.g., nerve conduction tests)	4	33.3
Practitioner-rated treatment success	n	%
Very successful with significant improvement seen	5	33.3
Moderately successful with moderate improvement seen	9	60.0
Minimally successful with minimal improvement seen	1	6.7
Not successful with no improvement seen	0	0.0

Respondents could select more than one answer. Values are shown as a percentage of total responses for each selection.

PGIC, 5-point patient global impression of change.

Discussion

To our knowledge, this study is the first to survey the current practices of AOM providers treating CIPN in IO settings. In addition to practitioner demographics, the study presents practitioner-reported treatment details, including setting, acupuncture style and points, TCM pattern diagnosis associated with CIPN, treatment planning, correspondence of acupuncture and chemotherapy treatments, and the use of auxiliary AOM modalities. Among these domains, the study generated a number of notable findings.

One, we found that ∼1/3 of all patients treated weekly by the acupuncturists at IO sites were treated for CIPN, suggesting that, similar to other trials,²⁸ there is a sizable unmet need among cancer patients for effective treatments. While CIPN is a common side-effect of chemotherapy, with an aggregate prevalence reported as high as 48%,²⁹ many of the usual care treatments such as anticonvulsants, antidepressants, and nutraceuticals such as antioxidants and vitamins, have limited effects.^28,30,31 Patients may be turning to acupuncture for relief of CIPN, particularly if offered in the IO setting.

Two, our survey found that breast cancer was the most common cancer diagnosis of patients treated by respondents. Given the prevalence of breast cancer in developed countries,³² this is not necessarily surprising and likely reflects that patients undergoing taxane-based chemotherapy typically report higher incidences of CIPN as well.^33,34 Furthermore, a 2014 survey assessing the willingness of 300 breast cancer patients to participate in acupuncture trials reported high interest,³⁵ suggesting that cancer patients in this specific demographic may be more likely to seek acupuncture treatment for the side-effects of chemotherapy.

Three, similar to other studies,^19,23,36 our survey found that local acupuncture points on the hands and feet (in particular the Ba Feng and Ba Xie points) were the most commonly utilized points. From a pathophysiological perspective, CIPN is described as dysfunction or damage to the sensory, motor, and/or autonomic neurons of the peripheral nervous system, with theories about chemotherapy's effects on neuronal microtubules and their transport function, neuronal mitochondria damage, disruption of ion channels, and accumulation of toxins in the dorsal root ganglia.³³ From a biomedical standpoint, the choice of using local points to treat CIPN appears fitting. Acupuncture has been shown to increase local blood circulation,^37,38 presumably inducing healing of surrounding local structures by carrying in oxygen and nutrients, and removing metabolic waste. Furthermore, research suggests that acupuncture's therapeutic effects may be communicated through its interplay with connective tissues, particularly by stimulating contraction, which has been shown to promote wound healing and tissue remodeling.³⁹ As connective tissue constitutes a broad system surrounding muscles, organs, nerves, blood vessels, and lymphatics, it is possible that acupuncture induces local nerve repair through the contraction of nearby connective tissue.

Four, respondents reported that the typical treatment plan for CIPN patients was once per week for an average of 12 sessions. Previous studies have reported treatment protocols ranging from 6 to 12 sessions,^20,22,25 with varying rates of success. CIPN can often be a chronic, refractory condition for many patients, and it seems likely that longer treatment protocols are therefore indicated. Given that over 90% of practitioners in our survey reported that treating CIPN in this manner was either “moderately successful” or “very successful” suggests that this treatment frequency is a good starting point for developing best practice guidelines and a useful visit protocol for future acupuncture studies.

Five, we were surprised to find that time of acupuncture treatment relative to chemotherapy infusion was distributed relatively evenly between 1 and 2 days before infusion (46.7%), 1–2 days after (60%), and during infusion (53.3%). It is unclear what impact, if any, the relationship between acupuncture and time of infusion has on CIPN outcomes. It is possible that treatment before or during infusion acts preventatively to limit tissue damage or treatment postinfusion can stimulate the tissue to recover more rapidly. These questions could be explored in future studies. As our study specifically targeted AOM practitioners working in IO settings, it is unclear what, if any, barriers to AOM treatment exist for CIPN patients treated outside this setting. Research by Mao et al. has found that patients perceive factors such as “additional appointments” and “travel” as barriers to treatment.³⁵ It is possible that the convenience of bundling AOM and chemotherapy infusion at the same time and location increases patient compliance, which may lead to improved CIPN outcomes.

Limitations

The group of respondents was self-selected, constituting only those who chose to respond to our survey inquiry. In addition, the findings reflect the perceptions from a small number of acupuncturists in the United States. Given the small sample size, these findings may not be characteristic of every practitioner or IO site treating CIPN.

Future directions

We anticipate this study will contribute to the development of best practice guidelines for the successful treatment of CIPN, and help inform future studies testing these guidelines. Based on our findings, future research directions might include the following: studies exploring whether larger therapeutic doses of chemotherapy drugs could be administered if CIPN were better managed with the addition of acupuncture; controlled trials assessing the preventative nature of acupuncture for chronic CIPN (e.g., chemotherapy + acupuncture vs. chemotherapy alone for long-term CIPN outcomes); and trials comparing effectiveness of whole systems AOM to acupuncture alone.

Conclusion

This survey provides detail regarding IO sites using acupuncture for CIPN as well as real-world treatment patterns, including common point combinations, visit characteristics, and practitioner-reported outcomes. This information contributes to the emerging evidence on the use of acupuncture to address unmet needs of CIPN patients, and will support the development of best practice guidelines for the treatment of CIPN with acupuncture in the IO setting.

Footnotes

Acknowledgments

The authors would like to thank Abigail Ballaban, LAc, and Anya Leigh, LAc, for help conducting the survey and collecting data, and to Tamsin Lee, LAc, and Sarah Snyder for editing the final paper.

Author Disclosure Statement

No competing financial interests exist.

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