Acupuncture for Chemotherapy-Induced Nausea and Vomiting: A Retrospective Review of Patients' Experience at a Single Institution and a Review of the Literature

Abstract

Background:

Powerful antiemetics have controlled disabling chemotherapy-induced nausea and vomiting (CINV) for many patients. However, significant side-effects continue to impair patients' quality of life. Alternate modalities, such as acupuncture, have been used to alleviate the effects of chemotherapy.

Objective:

This report reviews the experience of patients who received acupuncture in the Cancer Center at Massachusetts General Hospital and analyzes the world's literature on this topic.

Materials and Methods:

The medical records of patients undergoing acupuncture during chemotherapy from 2003 to 2009 were reviewed. A patient self-reporting scoring system was used with the following values: 0=no change; 1=mild improvement (<than 50% response); 2=moderate improvement (>50% response); and 3=complete resolution.

Results:

From 2003 to 2009, there were 899 acupuncture sessions. All patients who received chemotherapy also received ondansetron. Using the patient self-reporting scoring system, complete resolution of symptoms was as follows: anxiety 90%; constipation 100%; neuropathy 50%; nausea 70%; vomiting 80%; and joint pain 40%. Acupuncture points PC 6 and Sp 9 were most commonly used.

Conclusions:

According to the results of this a retrospective review patient self-reporting suggests a robust alleviation of many symptoms. Many studies have also concluded that acupuncture may alleviate CINV, and may be useful for symptoms that are refractory to standard premedication.

Introduction

Chemotherapy, an effective treatment for cancer, produces unwanted and troublesome side-effects. Nausea, anorexia, lethargy, and fatigue from chemotherapy and severe constipation from 5-hydroxytryptamine 3 (5-HT3) receptor antagonists impair patients' quality of life (QoL).¹ Poorly controlled chemotherapy-induced nausea and vomiting (CINV) can lead to dehydration, electrolyte disturbances, acid–base imbalance, impaired nutritional intake, and fatigue. CINV can also disrupt daily routines and reduce a patient's QoL severely.²

The ability to deliver adequate dosing and scheduling of emetogenic chemotherapy agents was revolutionized in the 1980s with metoclopramide. By the 1990s, the addition of 5-HT3 receptor antagonists such as ondansetron dramatically improved disabling chemotherapy-related anticipatory nausea, vomiting, and delayed posttherapy vomiting.³

The development of serotonin receptor antagonists in the 1990s greatly reduced the occurrence of CINV. Unfortunately, these antiemetics produce their own side-effects, which include constipation and headache.⁴ Another potential problem is the high price of serotonin receptor antagonists, which are rationed by insurance companies.

Antiemetic medication reduces CINV significantly but does not eradicate it completely. Up to 60% of patients receiving antiemetics continue to experience CINV.⁵ This places a severe burden on patients' QoL; causing patients to demand alternative solutions. In the face of such a challenge, patients have looked to alternative modalities, such as acupuncture, relaxation response, and yoga for alleviation of the side-effects caused by chemotherapy.

The goal of this endeavor was to review retrospectively both the authors' experiences with patients who received acupuncture in the Cancer Center at Massachusetts General Hospital, in Boston, MA, and review the current literature on acupuncture as an adjuvant antiemetic for CINV. Studying the efficacy of acupuncture presents many challenges. The entire experience of the acupuncture treatment—which includes more than just single-point stimulation—is thought to be of therapeutic value. This does not easily permit study via randomized, treatment-controlled, blinded clinical trials. Keeping this in mind, this article presents and reviews the current medical literature, clinical trials, and case reports on the efficacy of acupuncture in conjunction with antiemetics as a treatment for reducing CINV. With the purpose of gathering all pertinent information and meshing both Eastern and Western philosophies, the article includes both classical clinical trials as well as studies that may not been previously reviewed because of their alternative trial types.

Materials and Methods

Review of Patient Treatments

The medical records of patients undergoing acupuncture during chemotherapy from 2003 to 2009 were reviewed. Patients sought out acupuncture during the period of their active chemotherapy protocols and 21 encounters involved patients in Protocol 04-082: “Acupuncture for chemotherapy induced neutropenia in patients with gynecologic malignancies.”⁶ Patients signed consent forms for acupuncture treatment and a universal protocol for patient identification was performed in compliance with the hospital's policies for patient care and procedures. Review of the patients' records was approved by the Partners Human Research Committee of Massachusetts General Hospital for obtaining data involving human subjects. The following protocols covered the review of retrospective data: Protocol # 2008-P-000914/6; Protocol # 2008-P-000911/3, MGH; Protocol # 2008-P-000912/4, MGH; and Protocol # 2008-P-000913/3, MGH.

For all patients, indications for acupuncture, symptom scores, treatment points, and immediate responses were recorded. The following self-reporting scoring system was used: 0=no change in nausea; 1=mild improvement (<than 50% response); 2=moderate improvement (>50% response); and 3=complete resolution. As this was a retrospective review, only immediate responses to acupuncture were recorded and long-term effects from acupuncture could not be determined. A “patient encounter” was defined as one acupuncture session. Each patient had a mean of 7 sessions with a range of 1–20.

Japanese-style acupuncture was used for all patients except for those who were enrolled in Protocol 04-082 wherein Chinese-style needle placement was used. The needle locations for this group have been reported separately.⁶ SEIRIN J-type needles were used for all patients (Japanese gauge 1, 0.16-mm thickness, 30-mm length; SEIRIN-America, Weymouth, MA). Standard depth of needle placement varied with location. Sp 9 was needled perpendicularly to a depth of 1 cm with twirling. PC 6 was needled perpendicularly to a depth of 1 cm with clockwise stimulation.

An average of 10 needles was placed per session. Most placements were bilateral unless the particular patient's anatomy did not allow for bilateral placement. For example, some patients had lymphedema or concerns regarding cellulitis; thus needles were not placed in affected limbs. Responses to needles were determined by changes in pulse properties or by changes in the Hara exam as reported in detail elsewhere.⁷ The average time per session was 1 hour.

All patients were treated sequentially in supine and then in prone positions. The room was darkened and patients selected music for the sessions. No aromatherapy or moxibustion was used. Infrared heat therapy was used to augment most sessions (a TDP CQ-36 heat lamp). For patients whose treatment was supplemented by magnets to be worn at home, Accu-band 800 magnets were used. Patients were instructed to wear magnets for 2 days but to remove the magnets immediately upon experiencing any irritation.

All patients were treated by a single acupuncturist (A.G.). A.G. is an MD acupuncturist who received her training in 2001 via the 300-hour course, “Medical Acupuncture for Physicians,” at Harvard Medical School and directed by Joseph Audette, MD, and David Euler, LicAc.

Review of the Literature

For the literature review, one of the authors (E.C.B.) conducted an electronic search using MEDLINE® (1950 to June 2011 with a daily update), the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, the Cumulative Index to Nursing & Allied Health Literature (CINAHL, 1982 to June 2011), PsycINFO (1967 to June 2011), Alt HealthWatch, and EMBASE. The search terms acupuncture, nausea and vomiting, neoplasms/ or cancer, antiemetic drugs, and antineoplastic agents were exploded. The terms cisplatin, and medicine, oriental traditional/ or medicine, Chinese traditional/ or medicine, kampo/ or medicine, Tibetan traditional/ were also used. The search was limited to the English language. Bibliographies were reviewed in to identify additional relevant materials.

Twenty-seven articles were identified that described studies having nausea and vomiting outcomes for an adult population receiving chemotherapy whose CINV was being addressed by antiemetics and acupuncture. These articles were obtained and reviewed in detail. For this article, many different modalities of acupuncture (needling, acupressure, acustimulation) were grouped into one broad category. With respect to current clinical relevance, studies were excluded in which a serotonin-receptor antagonist was not included. One article was excluded,⁸ because acupuncture for nausea was only a small aspect of a larger study. Nineteen^9–27 articles, all published after 1990, met inclusion criteria and were considered to be appropriate for analysis.

Outcome data on nausea, vomiting, and nausea and vomiting combined were extracted from these articles. To sort useful information, each outcome was analyzed separately. Of the 19 articles, 12 included nausea outcome data.^{9,15–19,21–24,26,27} The experience of nausea was recorded on a numerical scale and divided into four categories with 0 corresponding to no nausea. The lowest fourth on the scale represented a minimal nausea experience, the next fourth represented a mild nausea experience, the subsequent fourth represented a moderate nausea experience, and the highest fourth represented a severe nausea experience. Seven articles reported the mean for the acute nausea scale response for the different treatment arms^{18,19,21–24,27} with acute nausea defined as occurring within 24 hours of chemotherapy administration. Two articles recorded similar results for delayed nausea, which was defined as occurring within a time period that was >1 day postchemotherapy.^16,26 A descriptive cross-study outcome comparison determined where the reported mean fell the fourths of the scale. An additional two studies reported nausea experience using scales with scores ranging from 0 to 3. In these two studies, individual participants' scores were recorded rather than mean scores. Five articles reported the number of participants who experienced complete protection from nausea.^9,15–17,26

Outcome data for vomiting was measured in most articles by mean/median number of acute and delayed emetic episodes, as well as by number of participants with complete protection from vomiting. Studies also assessed outcomes by combining nausea and vomiting into a single experience. Because of the heterogeneity of the measurement scales, the only data that were extracted from this information was number of participants who reported complete protection from nausea and vomiting. This then was related to the individual nausea outcome and vomiting outcome groups.

The remaining six studies that looked at nausea, vomiting, and nausea and vomiting combined could not be grouped with the studies; however, these six studies contained pertinent information and are discussed on an individual basis later in this article.^{10–13,20,25}

Results

Patient Treatments

From 2003 to 2009, there were 899 patient encounters for acupuncture by one acupuncturist (A.G.). Indications for treatment included anxiety, chemotherapy-induced nausea and vomiting, chemotherapy-induced neuropathy, constipation, depression, fatigue, insomnia, fibromyalgia, lymphedema, joint pain, pelvic pain, altered taste, hiccups, and trigeminal neuralgia. In addition, all patients received ondansetron.

Table 1 shows the diagnoses for which patients were receiving chemotherapy.

Table 1.

Cancer Diagnoses and Distribution of the 899 Acupuncture Patient Encounters

Cancer diagnoses	Acupuncture patient encounters N (%)
Ovarian	539 (60%)
Cervical	24 (2.7%)
Endometrial	100 (11.1%)
Breast	70 (7.8%)
Gastric	93 (10.3%)
Melanoma	63 (7%)
Brain tumor	10 (1.1%)

Using the patient self-reporting scoring system, complete resolution of symptoms was as follows: anxiety 90%; constipation 100%; neuropathy 50%; nausea 70%; vomiting 80%; and joint pain 40%. Acupuncture points PC 6 and Sp 9 were most commonly used. Additional benefit from use of low-dose magnets placed on PC 6 for home stimulation was reported in 80% of patients with nausea and vomiting. An example of a treatment schedule is shown in Box 1.

Box 1. Example of Acupuncture Treatment Session

Diagnosis: Stage IV gastric cancer

Indications for acupuncture:

Fatigue

Depression

Nausea

Treatment:

Total time 60 minutes; infrared heat used over legs; at end of the session, 9 gauss magnets placed at PC 6 for home use

Step One

Bilateral St 36

Left LR 4 and LU 5

Bilateral LI 11

Bilateral PC 6

Bilateral HT 7

Bilateral auricular shenmen

Step Two

Bilateral PC 6

Bilateral LI 4 and 11

Bilateral Sp 3 and 9

Bilateral KI 3

Bilateral bafeng

Literature

An indepth analysis of the world literature identified nineteen studies suitable for analysis although they included heterogeneous patient populations, different trial types, and distinct outcome measurements. The unifying item was that each trial was conducted to determine whether acupuncture was an effective adjuvant antiemetic therapy for chemotherapy-induced nausea and vomiting. Of the nineteen studies reviewed, sixteen concluded that acupuncture was, in fact, an effective and safe adjuvant therapy. Three studies reported no significant effect. Findings were presented according to treatment outcome and efficacy of treatment options.

Nausea outcome. Eleven trials were identified that measured the experience of nausea in participants receiving chemotherapy. Seven of these trials measured acute nausea on a rating scale that provided the mean scale value for all patients in a specific treatment arm.^{18,19,21–24,27} The scales from these trials were manipulated for comparison purposes (Table 2). Analyzed in this way, three studies showed a difference between the level of nausea experience in the treatment group and the control group, and the control group in all three cases had a higher mean, or more-severe level of nausea. The other four studies showed no change in level of nausea experience among treatment group, control group, and sham group.

Table 2.

Acute Nausea Scale ^a and Acupuncture for Chemotherapy-Induced Nausea in the Medical Literature

Study ^b	Scale	Minimal	Mild	Moderate	Severe
Molasstois et al.¹⁸	0–8	0–2	2–4	4–6	6–8
TG		0.66
CG			2.16
ShG
Nystrom et al.¹⁹	1–7	1–2.5	2.5–4	4–5.5	5.5–7
TG		2.0667
CG				4.2
ShG
Roscoe et al.²¹	1–7	1–2.5	2.5–4	4–5.5	5.5–7
TG		1.9
CG			2.9
ShG
Roscoe et al.²²	1–7	1–2.5	2.5–4	4–5.5	5.5–7
TG		2.2
CG		2.4
ShG		2.2
Roscoe et al.²³	1–7	1–2.5	2.5–4	4–5.5	5.5–7
TG			3.1
CG			2.9
ShG			2.9
Roscoe et al.²⁴	1–7	1–2.5	2.5–4	4–5.5	5.5–7
TG			2.6
CG			3
ShG
Treish et al.²⁷	(1–10)	1–3.25	3.25–5.5	5.5–7.75	7.75–10
TG		0.71
CG
ShG		0.71

Acute nausea mean scale used.

Superscript numbers represent references for studies.

TG, treatment group; CG, control group; ShG, sham group.

Three articles measured the experience of delayed nausea with a mean scale.^22,23,27 These scales were adjusted in the same manner as the acute nausea scales (Table 3). Reports of delayed nausea showed no changes in severity of nausea among the treatment arms for the three studies.

Table 3.

Delayed Nausea ^a,b Scale and Acupuncture for Chemotherapy-Induced Nausea in the Medical Literature

Study^c	Minimal	Mild	Moderate	Severe
Roscoe et al.²²	1–2.5	2.5–4	4–5.5	5.5–7
TG		2.6
CG		2.8
ShG	2.4
Roscoe et al.²³	1-2.5	2.5-4	4–5.5	5.5–7
TG		2.8
CG		3.4
ShG		3.1
Treish et al.²⁷	1–3.25	3.25–5.5	5.5–7.75	7.75–10
TG	1.8
CG
ShG	3.1

Delayed nausea was defined as nausea occurring after the first 24 hours after chemotherapy.

Delayed nausea mean scale was used.

Superscript numbers represent numbers for studies.

TG, treatment group; CG, control group; ShG, sham group.

Two studies measured acute nausea severity on scales that ranged from 0 to 3 (0=no nausea and 3=severe nausea).^9,15 Rather than providing the mean score for each treatment arm, these studies reported the number of people who recorded each category of the scale (Table 4) and demonstrated a trend of less-severe nausea in the treatment group.

Table 4.

Acute Nausea Severity Scale and Acupuncture for Chemotherapy-Induced Nausea in the Medical Literature

	n for each category
Study ^a	0	1	2	3
Choo et al.⁹
TG	3	16	8	0
CG	0	5	19	3
Josefson & Kreuter¹⁵
TG	10	18	3	8
CG	3	9	10	17

Superscript number represents reference.

0=no nausea; 3=severe nausea.

TG, treatment group; CG, control group.

Five articles reported the number of participants with complete protection from nausea.^9,15–17,26 The percent of participants who experienced no nausea is shown in Table 5. All but one study showed that the treatment group had a greater percent of participants who experienced complete protection than the control or sham groups did. One article showed the opposite occurrences for both acute and delayed vomiting.²⁶

Table 5.

Medical Literature % of Participants Who Experienced No Nausea with Acupuncture

	Complete protection from nausea (%) ^a
Type of nausea	Choo et al. ⁹ TG	Choo et al. ⁹ CG	Josefson & Kreuter ¹⁵ TG	Josefson & Kreuter ¹⁵ CG	McMillan & Dundee ¹⁶ TG	McMillian & Dundee ¹⁶ CG	Melchart et al. ¹⁷ TG	Melchart et al. ¹⁷ ShG	Streitberger et al. ²⁶ TG	Streitberger et al. ²⁶ ShG
Acute	11.11	0.00	25.64	7.69	18.75	6.25			56.10	66.67
Delayed					67.19	37.50			19.51	33.33
Total							58.33	50.00

Superscript numbers represent references.

TG, treatment group; CG, control group, ShG, sham group.

Vomiting outcomes. Of eighteen articles, nine presented outcomes vomiting experiences. Four articles reported the patient's vomiting experience as a mean or median number of emetic episodes.^9,15,17,27 Table 6 shows that three of the studies demonstrated that the treatment group experienced less vomiting than the control group did. One study reported otherwise.¹⁷ Six studies, summarized in Table 7, reported the number or percent of patients who had complete protection from vomiting and demonstrated that that, in all but two measurements (delayed vomiting), more participants in the treatment groups experienced complete protection from vomiting than those in control group.^17,26

Table 6.

Medical Literature Reports on Total Episodes of Vomiting with Acupuncture Versus Control for Chemotherapy Induced Nausea

	Mean and median outcome data for total episodes of vomiting
Study ^a	Mean (TG)	Mean (CG)	Median (TG)	Median (CG)
Choo et al.⁹	3	7	1	6
Josefson & Kreutzer¹⁵	0.59	3.33	0	0
Melchart et al.¹⁷	3.3	2.3
Treish et al.²⁷	1.9	4.6

Superscript numbers represent references.

TG, treatment group; CG, control group.

Table 7.

Medical Literature Reports of Complete Protection from Vomiting with Acupuncture Versus Control for Chemotherapy-Induced Nausea

	% complete protection from vomiting
Study ^a	Choo et al.⁹ TG	Choo et al.⁹ CG	Josefson & Kreutzer¹⁵ TG	Josefson & Kreutzer¹⁵ CG	McMillian & Dundee¹⁶ TG	McMillian & Dundee¹⁶ CG	Melchart et al.¹⁷ TG	Melchart et al.¹⁷ ShG	Streitberger et al.²⁶ TG	Streitberger et al.²⁶ ShG
Acute	37.04	0.00			18.75	6.25			90.24	82.05
Delayed					67.19	37.50			48.78	51.28
Total			79.49	53.85			70.83	75.00

Superscript numbers represent references.

TG, treatment group; CG, control group; ShG. sham group.

Individual articles. Five articles collected for this review fit all the inclusion criteria but were not appropriate for descriptive statistical analysis based on trial design. Analyzing acupuncture outcomes is a challenge, and it has been questioned whether the results of randomized controlled trials are representative of the true acupuncture experience.²⁸ With this in mind, the current authors that the following five studies contained useful information and should be carefully reviewed.

Two articles reported that acupuncture (via an acupressure modality) is an effective as a treatment for CINV.^10,11 Numerical data regarding delayed emesis and delayed nausea was difficult to extract from the results. Dibble et al. reported a pilot study consisting of 17 participants with breast cancer using the Rhodes Index of Nausea, Vomiting, and Retching (INVR) scale. The acupuncture treatment group reported significantly improved scores on the INVR (F=10.44, p<0.01), significant reductions of nausea experienced as well as significant differences in nausea intensity (measured by an 11-point numeric scale; F=5.255, p<0.04). In a 2007 follow-up study of 160 patients with breast cancer, acupressure at the P 6 point was reported as being a valuable method for reducing delayed CINV. Outcomes were measured with the Rhodes Index of Nausea (RIN) scale, the INVR scale, and a numeric rating scale for nausea intensity. While no significant differences were found across treatment arms for acute nausea and vomiting, significant decreases were found across treatment arms for delayed emesis in the treatment group. A decline in vomiting episodes occurred across all groups, however the decline was greater for the P 6 acupressure group than for the sham group (t=3.13, p=0.002, odds ratio [OR]=1.3) or the control group (t=4.81, p<0.0001, OR=1.4). Similarly, a decline in nausea (RIN scores) was greater for the acupressure group than for the control group (t=2.77, p<0.006, internal rate of return [IRR]=1.05), while no change was found between the acupressure and sham groups.¹¹

The two articles with only a treatment group reported that acupuncture (via an acupressure wristband) may be an effective adjuvant therapy for CINV.^12,13 One trial involved 40 patients, both male and female, with advanced cancer.¹² Twenty-eight of these 40 patients (70%) patients had symptom relief. There were no significant differences between gender or cancer histotype. A 2007 follow-up reported on 100 patients with advanced cancer (male and female), 68 of whom (68%) had reduced emetic symptomology.¹³ There were no significant differences in acupressure response between cancer histotype; however, there was a difference in type of chemotherapeutic agents used. The least-desirable emetic symptom profile occurred with administration of anthracyclines. In addition, patients treated with 5-fluorouracil, oxaliplatin, irinotecan, gemcitabine, vinorelbine, taxol, ethoposide, and cisplatin benefited most from the acupressure treatment.

There was one series of 8 patients who had each received at least one course of chemotherapy before the round in which acupuncture was administered and therefore served as their own controls.¹⁴ Seven of the 8 patients had a lower emetic response to chemotherapy when receiving acupuncture treatments.

Pearl et al. analyzed 32 patients who were randomized to a transcutaneous electrical neural stimulation unit with chemotherapy and noted that this was an effective adjunct to standard antiemetic agents.²⁰ Shin et al. evaluated the use of finger acupressure to P 6 in a group of 20 patients with gastric cancer compared to antiemetics alone. These researchers found significant differences between intervention and control groups in severity of nausea and vomiting, duration of nausea, and frequency of vomiting.²⁵

Discussion

Current standard antiemetic regimens reduce the incidence CINV, but there remains a demonstrable need for additional improvements. This article reviewed a retrospective experience with acupuncture for chemotherapy-induced side-effects, in which nearly 75% of treatments were performed for patients with gynecologic malignancies. Although the clinical data were limited because of the retrospective nature and lack of information regarding delayed nausea and vomiting, the authors feel that this report is an important addition to the growing body of literature demonstrating beneficial outcomes with acupuncture as an adjunct for treating CINV. In the authors' clinical practice of nearly 900 acupuncture treatment encounters, 70% of patients reported complete resolution of nausea symptoms, and 80% reported no episodes of emesis.

In Traditional Chinese Medicine (TCM) a diagnosis is constructed from a qualitative image in the context of the both physical symptoms and life experiences. The target of diagnosis is disharmony within the individual; or an imbalance of Yin and Yang.²⁹ Disruption of this balance is caused by a blockage of meridians, or interconnecting pathways that allow Qi to flow through the body. Qi, a complex entity in Eastern traditions, has been described as the “motive force that arouses and moves the functional activity of all the organs.”³⁰ Acupuncture points lie along meridians, and stimulating these points is thought to clear pathways to reestablish the flow of Qi and promote restoration of balance and health. While the most common points for CINV reside at PC 6 and St 36,³¹ the current authors utilized the well-known, proven, antiemetic acupuncture points PC 6 and Sp 9 for the patient population discussed in this review. Kuwahara described the Spleen pathway as thought to affect the intestinal tract by moving stagnation and dispelling damp. He described the Pericardium pathway as regulating Yin and balancing the Stomach.³²

Traditionally, a large randomized clinical trial is the way to demonstrate proof of the utility of a treatment, and acupuncture for CINV will not be held to a different standard. While Western medicine regards the randomized clinical trial (RCT) as the method by which to guide medical practice, the reality is that many epidemiologic and treatment paradigms have been and are established using “lesser” levels of research evidence. In a similar way, differences in the underlying philosophy between Eastern and Western medicine may make it difficult to assess acupuncture using a standard RCT design. One reason may be that the beneficial effects of acupuncture, in addition to the placebo effect discussed previously, come from the entire therapeutic encounter—including the patient–provider interaction.²⁸ In addition, many acupuncturists may tailor their sessions by using herbs, massage, music, and moxibustion. Therefore, each patient, though having similar problems to other patients, may receive a different combination of acupuncture points and adjunctive therapies than those other patients would recieve.³³ To conduct an RCT, certain artificial constraints are placed on use of the modality and therefore do not emphasize the importance of the entire encounter or other adjunctive treatments—the RCT focuses instead on the utility of only one or two acupuncture points.

The results of this review were derived from a large number of patient encounters with acupuncture treatments provided by a single practitioner—minimizing variation in treatment administration. Another strength of this report is that all but 21 patient encounters occurred with acupuncture as an adjunct therapy for CINV and were not part of a clinical trial. While retrospective studies have inherent weaknesses, the potential bias created by the Hawthorne effect is minimized in the current work, because the degree to which patients either continued to experience symptoms or reported resolution was used only for their symptomatic control and further treatment plans. Thus, the patients derived no benefit from artificially reporting—either consciously or subconsciously—greater symptom resolution than they were actually experiencing. Therefore, these findings were likely to represent true symptom reduction for these patients.

The authors observed significant reductions not only in the degree of nausea and vomiting, but also a 90% reduction in anxiety, 100% reduction in constipation, 50% reduction in neuropathy, and a 40% reduction in joint pain proximate to chemotherapy administration. There is certainly a complex interplay of factors that lead to the success in the authors' practice, and these factors include physical symptom burden, patient perceptions, psychosocial influences, motivation to receive treatment, and expectation for success. On a positive note, these patients sought acupuncture as an adjunct for CINV. While this created a significant selection bias, it also demonstrates a principle that is acknowledged throughout medicine: motivated patients have improved outcomes.

There are other weaknesses in this report aside from the selection bias that must be discussed when interpreting the data. Patients who seek a certain modality of therapy create an expectation that the modality will work positively for them. This has been discussed previously by Roscoe noting that both a placebo effect and an expectation effect may be at play in patients receiving acupuncture/acupressure for CINV.²⁵ All of these biases would tend to affect the results in a direction that is more favorable for acupuncture as a beneficial therapy.

In the face of the biases inherent in this study and others, one may wonder if it matters whether study designs are optimal, or if the degree to which the effects are “real” are enhanced by patient expectation or result from a placebo effect. How should we define success when using treatments that are both safe and have the potential to make a positive impact on QoL? There are many modalities that are considered complementary or alternative (e.g., acupuncture, massage, reiki, meditation, herbal remedies, yoga, etc.) that patients may use to help them “feel better.” The authors believe the goal for any treatment used is to improve a patient's QoL. There are many patients who understand as little about the serotonin antagonist pathway that ondansetron manipulates as they do about the restoration of Qi through acupuncture. Yet, one key point cannot be disputed—patients feel better using the acupuncture. This study lends additional evidence to the concept that acupuncture does reduce the experience of CINV in at least a subset of motivated patients.

The authors rigorously reviewed the experience of other practitioners in the Results section. This analysis adds comprehensive and detailed information on how acupuncture affects and alters the emetogenic response to chemotherapy. Studies of acupuncture for CINV have been reviewed by other investigators. Ezzo et al. reviewed 11 RCTs and stated that acupuncture in conjunction with antiemetics reduced the proportion of patients that experienced acute CINV.³⁴ A Cochrane update from 2011 analyzed 11 trials with 1247 patients. The reviewers concluded that acupuncture-point stimulation with antiemetics produced significant reduction in acute vomiting (RR 0.82, 95% CI Acup 0.69 to 0.99, p=0.04).³⁵

Given that studies reviewed in the current were heterogeneous, the authors created a scale using four categories to describe the degree of nausea experienced by patients as detailed in Materials and Methods. The statistical significance of the individual reports was not altered with the rearrangement of the data and the authors did not represent the results as a statistical manipulation, such as performed in the meta-analysis by Ezzo, et al.³⁵ noted above. The current authors' method of tabulation allowed for easy comparison of results among all the articles presented in this article.

The majority of articles reviewed demonstrated reductions in nausea, vomiting, or both for patients who were given acupuncture. Three of five articles showed a greater percent of patients who experienced complete protection from acute or delayed nausea (Table 5) and/or acute or delayed vomiting (Table 7). These results support the retrospective clinical findings as 70% of the authors' patient encounters resulted in chemotherapy treatments that were nausea-free and 80% that were emesis-free. In addition, five of eight articles reported a decrease in nausea severity for patients who utilized acupuncture over those using only standard antiemetic treatments (Tables 2 and 4). These results support those findings as, once again, 70% of the patient encounters resulted in chemotherapy treatments that were nausea-free and 80% that were emesis-free. This collection of findings is neither meant to be, nor should be, considered as definitive proof that acupuncture will alleviate nausea, vomiting, and other symptoms associated with chemotherapeutics, but the growing evidence for benefit cannot be ignored. Ongoing prospective studies incorporating clinical symptoms, psychosocial parameters, and potential contributions of physiologic processes through translation studies are necessary to begin to elucidate the complex interactions of physical and psychological suffering that patients endure and the degree to which acupuncture, or any therapy, will be beneficial during chemotherapy treatments.

While the common call is for data from a large RCT in to begin to move acupuncture from “complementary,” “alternative,” or “adjunctive” status and into regular use is well-intentioned, it may not be the most useful method for studying and validating acupuncture as being effective for patients who experience chemotherapeutic side-effects. Whether by placebo effect, increased patient–provider interaction, a yet-unknown physiological response, or a true restoration of the flow of Qi, the article presents another review demonstrating that patients benefit from this treatment modality to alleviate nausea, vomiting, and other symptoms associated with chemotherapy in patients with cancer.

Conclusions

The authors recommend offering acupuncture to any patient who is undergoing chemotherapy. There is a growing body of literature from both clinical trials and retrospective studies that support the use of acupuncture to alleviate nausea, vomiting, and other symptoms associated with administration of chemotherapy. When performed by a formally trained acupuncturist, the potential risk is extremely small, while the potential QoL benefits are significant.

Footnotes

Disclosure Statement

No potential conflicts of interest exist.

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