Acupuncture for Oxaliplatin Chemotherapy–Induced Peripheral Neuropathy in Colon Cancer: A Retrospective Case Series

Abstract

Background:

Chemotherapy-induced peripheral neuropathy (CIPN) is a common and debilitating side-effect resulting from chemotherapy agents. CIPN is a significant concern for patients who have cancer, as CIPN has a negative impact on quality of life and can be a dose-limiting side-effect of chemotherapy, leading to decreased treatment efficacy. Currently, there are very few effective treatments for mitigating CIPN. However, several studies have shown that Traditional Chinese Medicine (TCM)–based acupuncture may be effective for preventing and/or treating CIPN. This article describes the current authors' experience in an integrative oncology setting, illustrating the use of TCM-based acupuncture for treating CIPN resulting from oxaliplatin chemotherapy regimens.

Materials and Methods:

This was a retrospective case series of 10 patients who were treated by physicians at the Southwestern Regional Medical Center (SRMC) of the Cancer Treatment Centers of America (CTCA) at. At this medical center, advances in cancer treatment are combined with integrative oncology services, such as acupuncture, as a standard of care. Each patient who underwent acupuncture to treat or prevent CIPN received a TCM diagnosis and points were selected on an individual basis for each visit. Verbal consent was received and documented for each patient included in this report.

Results:

With the use of TCM-based acupuncture, the 10 patients had considerable improvement with respect to prevention and mitigation of symptoms associated with CIPN. Individualized treatment plans that utilized frequent, aggressive acupuncture to increase blood flow to distal points produced the best outcomes in these patients.

Conclusions:

The current authors' experience suggests that an individualized approach using TCM-based acupuncture may be beneficial in the prevention and treatment of CIPN.

Introduction

Chemotherapy-induced peripheral neuropathy (CIPN) is a common, often debilitating side-effect resulting from the neurotoxicity of chemotherapy agents. With CIPN, patients often feel abnormal sensations, such as paresthesia, dysesthesia, and/or cold sensitivity in the hands and/or feet that spreads in a “glove and stocking” distribution.¹ The severity of peripheral neuropathy ranges from slight discomfort to severe debilitation with symptoms that begin suddenly or slowly progress over time. Clinically, CIPN is distinct from other peripheral neuropathies and has specific diagnostic characteristics that distinguishes it. The symptoms associated with CIPN are typically symmetrical, distal, and have a length-dependent distribution. In addition, these symptoms are predominantly sensory (especially pain, numbness, and tingling), have an onset after the administration of chemotherapy, and are typically dose-dependent.¹

It is estimated that CIPN affects ∼30%-40% of all patients who undergo chemotherapy.² Moreover, CIPN is the second most common side-effect resulting from chemotherapy with agents, including platinum-containing drugs, vinca alkaloids, and taxanes; as well as newer agents, such as bertezomib, thalidomide, and lenalidomide.^1,3 CIPN is a growing concern in oncology treatment, as this side-effect can result in delays in treatment, dose reductions, or premature treatment cessation, leading to decreased efficacy of chemotherapy and higher rates of relapse.^4,5 Moreover, CIPN can have a significant impact on patient care and is associated with decreased quality of life (QoL), reduction of functional capabilities, and an increased risk of falls during and following treatment in patients.^6,7 The incidence of CIPN varies based on factors, such as the chemotherapeutic agent, timing of chemotherapy administration, and patient comorbidities, as well as other risk factors for neuropathy, such as radiculopathy from degenerative disease or preexisting diabetic neuropathy.⁴

Neurotoxic Mechanisms of Chemotherapy

The precise mechanism of neurotoxicity has yet to be fully elucidated for each class of chemotherapy agent. However, several mechanisms have been proposed based on in vitro and animal model studies. The platinum-containing compounds have been shown previously to produce direct damage to dorsal root ganglion (DRG) neurons. These agents have been found to accumulate in the DRG resulting in DNA alterations, morphologic changes, and ultimately cellular apoptosis.^8,9 Cisplatin, taxanes, and vinca alkaloids have also been shown to exert damage to microtubules resulting in the disruption of axonal transport and thereby signal transduction in these nerve fibers.^10–12 Previous studies have also shown that oxaliplatin toxicity may be associated with calcium chelation caused by oxalate release, which produces adverse effects on ion channels and synaptic transmission.^13,14 Overall, although the exact molecular mechanisms are still unclear, physical damage to neurons by the chemotherapeutic agent is a common mechanism that seems to underlie the symptom pathology.

TCM Theory of CIPN

Traditional Chinese Medicine takes into account the current state of health of each individual as a whole, which is one of TCM's unique strengths. In TCM, CIPN is primarily caused by abnormalities in the flow of Blood and Qi. Essentially, Blood is the substance that nourishes the tissues, and Qi moves the Blood to the tissues. CIPN results from the body lacking nourishment to the muscles (Blood) and the body not directing the Blood to the limbs (Qi). Although there is a common list of symptoms associated with each chemotherapy agent, these drugs affect each person differently. In TCM-based acupuncture, the state of the individual as a whole is analyzed in order to determine the acupoints needed to treat them most effectively.

In TCM-based practice, colon cancer is associated with a number of syndromes. The syndromes are individualized for each patient and include one or many of the following general TCM diagnoses. For example, tumors are generally considered to be “Stagnation.” Stagnation results from a disruption of flow, which can make an impact on the balance of the body. Heat Stagnation is indicated by an area that is hot to the touch, red skin, an area that feels hot to the patient, red tongue, rapid pulse, dry stool, and constipation. Toxin Stagnation is usually considered to be Heat and is typically caused by an external source such as chemotherapy. Symptoms of Toxin Stagnation include strong smelling stool and diarrhea. Phlegm/Damp Stagnation typically occurs in fatty tumor types and is indicated by feelings of heaviness, mucus in the stool, slippery pulse, a puffy tongue, and loose stools. Qi Stagnation has symptoms including bloating, flatus, irritability, moving pain, and a purple tongue. Blood Stagnation is indicated by stabbing pains, an immovable tumor, feeling “stuck,” and dark stools that are difficult to pass.

In the current authors' experience, most patients with cancer have Deficiency. In this situation, the body is not strong enough to move energy to all of the tissues. Therefore, the energy stagnates. This is the often the case with CIPN. Chemotherapy is generally considered to be Heat and/or Toxins. In addition, chemotherapy affects the Spleen and Stomach organs (the Vital Qi of the body). In TCM, the Spleen and Stomach are considered the Earth organs, as these organs are responsible for extracting the nourishment from food and the environment and turning it into usable energy for our body. The Spleen disperses the nourishing Qi upward to feed the organs and tissues of the upper body, while the Stomach disperses nourishing Qi downward to feed the organs and tissues of the lower body. When this balance is disrupted, Stagnation begins to occur, and the tissues and organs do not get the nourishment they need from ingested food and the environment. Emotionally, this can lead to fatigue and abnormal compassion (a lack of compassion or empathy because of Spleen Deficiency).

In TCM theory, the Spleen is a well of energy that is fed by daily choices in food, drink, thought, and climate. This is the energy that enables the body to perform at its peak. If this energy is in constant competition with chemotherapy, then, eventually, parts of the body do not get what they need to perform. The extremities tend to be the first areas affected by this internal struggle. In this situation, the blood flow will slow and no longer get distributed to the fingers and toes. Therefore, the nourishment is cut off and the tissue will die over time. Because of modern advances in targeted and individualized therapy, the damage inflicted by chemotherapy is not always immediate and is often not permanent. Therefore, there is an opportunity to treat or prevent this before permanent damage occurs.

Acupuncture is an effective treatment option for CIPN because acupuncture not only stimulates the body to send blood flow to the site of the needle but also helps strengthen the underlying condition of Deficiency. When acupuncture is used in the extremities, it will act as a local therapy bringing Blood and nourishment to help treat the damage caused by chemotherapy. In addition, by strengthening the body against its underlying Deficiency, acupuncture helps restore balance to the body.

CIPN in Colorectal Cancer

Oxaliplatin is a platinum-based chemotherapy agent that has become a central component for treating colorectal cancer. This agent is typically used in a regimen with folinic acid and 5-fluorouracil (5-FU) in a combination known as FOLFOX. However, neurotoxicity is a main side-effect of oxaliplatin that can result in both acute and chronic symptoms of CIPN.¹ Acute, cold-induced dysesthesia has been reported to occur in 85%–95% of patients,^15,16 while persistent, chronic symptoms of neuropathy are reported to occur in 10%–18% of people undergoing a chemotherapy regimen that contains oxaliplatin.^17–20 Acute symptoms of oxaliplatin CIPN usually resolve within a week. However, chronic symptoms are dose-limiting, and recent studies have reported residual neuropathy in patients even 2 or more years after treatment with oxaliplatin-based therapy.⁵ Moreover, although acute symptoms resolve, patients with advanced cancer are likely to remain on chemotherapy indefinitely.

Several pharmacologic agents—including serotonin-norepinephrine reuptake inhibitors, antiseizure medications, opioids, and topical agents—have been studied for treating CIPN caused by oxaliplatin. However, these agents have shown limited success in mitigating CIPN symptoms and few agents have shown proven efficacy in large clinical trials.²¹ Thus, novel treatment options are necessary to manage CIPN. This article presents the current authors' experience with usingTCM-based acupuncture in an integrative oncology setting for preventing and treating CIPN in patients with colorectal cancer who received oxaliplatin-based chemotherapy.

Materials and Methods

This was a retrospective case series of 10 patients who were treated by physicians at Cancer Treatment Centers of America at Southwestern Regional Medical Center. At this facility, recent advances in cancer treatment are combined with integrative oncology services, such as acupuncture, as standard of care. Every patient who underwent acupuncture to treat or prevent CIPN received a TCM diagnosis.

Acupoints were selected on an individual basis at each visit. During acupuncture treatments, surgical-grade, stainless steel acupuncture needles that were 1/2″–1″ in length and ∼36–38 gauge were used (DongBang Corporation, South Korea). Ba Feng, Ba Xie, and Jing-well points were inserted with a guide tube and left alone. The needles were not twisted and were inserted at variable depths. Only even methods were used. Patients currently undergoing chemotherapy tended to be in a mostly Deficient condition and did not require much needle manipulation. Needle-retention time ranged from 10 minutes to 45 minutes with an average retention time of 20 minutes, and needling was performed without electrostimulation. CIPN was graded according to the Common Terminology Criteria for Adverse Events version 4.0 (CTCAE v.4.0).²² Verbal consent was received and documented for each patient included in this report.

Cases/Results

Stage II Colon Cancer

Case 1

A 49-year-old male with stage IIB colon cancer started acupuncture 1 day after starting chemotherapy with the FOLFOX6 regimen (oxaliplatin, leucovorin, and 5-FU) with the intention of preventing CIPN. Upon examination, he had a TCM diagnosis of: Stomach Yin Xu; Qi and Blood Stagnation; Liver Qi Constraint; and Disturbed Shen, which is consistent with the development of colon cancer according to TCM principles. The patient received 21 acupuncture treatments with an average of 1 session per week during his chemotherapy treatment of 12 cycles of FOLFOX6 over 6 months.

At 1 month after his chemotherapy treatments, the patient was diagnosed with mild CIPN, mostly in the left foot and right hand. He also reported slight difficulty with fine motor tasks. However, at 1 year post treatment the patient reported no peripheral neuropathy. During the acupuncture treatments that took place during chemotherapy, this patient was able to withstand aggressive treatment. Most of his treatment involved the following acupoints: 5 NP for detoxification, Ba Feng, Ba Xie, LI 4, LR 3, SP 6, ST 36, LU 7, LI 10, and Yin Tang. During his treatment, Teding Diancibo Pu (TDP) lamps were used on his hands and feet interchangeably but were mostly used on his feet. He occasionally received treatments to the Sheng Ba Feng, Ba Feng, and Jing-well points as well if he reported any symptoms of peripheral neuropathy. In addition to tailoring treatments to prevent CIPN, his other side-effects, such as abdominal pain and digestive upset, were treated.

Case 2

A 40-year-old female with stage IIa colon cancer began acupuncture prior to starting chemotherapy with oxaliplatin plus capecitabine to treat anxiety and aid in smoking cessation. Initially, CIPN prevention was not a focus during her acupuncture treatments. Her TCM diagnosis was: Stomach Yin Xu; Qi and Blood Stagnation; Liver Qi Constraint; and Disturbed Shen. Upon starting chemotherapy, she had difficulty with oxaliplatin side-effects in general. She only tolerated 2 cycles of the prescribed dose, and the remaining 2 cycles were reduced to half-strength. CIPN onset occurred at each chemotherapy dose every 3 weeks. The patient began to receive acupuncture at each chemotherapy visit and her CIPN was gone after 15 days. She was unable to withstand aggressive acupuncture and generally had the the following acupoints treated: 5 NP for detoxification; LI 4; LR-3; Yin Tang; LU 7 or LU 9; GB 34; and SP 6. In addition, TDP lamps were used on her feet. This patient is still currently undergoing treatment and has 4 cycles of chemotherapy left. Unfortunately, she is unable to get weekly acupuncture treatments. However, she is able to undergo one to two acupuncture treatments every 3 weeks when she receives chemotherapy. Overall, she feels that acupuncture is a necessary part of her treatment to reduce the side-effects of her chemotherapy.

Case 3

A 53-year-old male with stage II colon cancer began acupuncture more than 6 months after starting chemotherapy with oxaliplatin. Because his acupuncture was started after chemotherapy had already begun, the side-effects from his treatment were in full effect. His TCM diagnosis was: Heat/Toxins Burning Yin and Blood; Qi and Blood Stagnation; and Liver Qi Constraint. In addition, he showed signs of Spleen Qi Xu and Damp Retention. After 6 cycles of oxaliplatin chemotherapy, he had 30 cycles of the same chemotherapy without the oxaliplatin.

He was only able to receive acupuncture when he was in town to receive chemotherapy and had severe edema in one leg that limited the use of acupuncture needles. The points used during his treatment were typically: Ba Feng (right side); 5 NP; SP 9; LR 3; LI 4; ST 40 (right side); KI 6 (right side); SP 6 (right side); ST 36 (right side); LI 11; LV 5 (right side); and Ba Xie with TDP lamps used on his feet. His CIPN stabilized after starting acupuncture. Thus, progression of CIPN was prevented, and his symptoms still remain mild as of this writing. Overall, these mild symptoms do not affect his balance or daily QoL.

Case 4

A 56-year-old female with stage II adenocarcinoma of the cecum started acupuncture after receiving 6 cycles of FOLFOX6. At this time, she was diagnosed with CIPN. Her TCM diagnosis was Qi and Blood Stagnation; Kidney, Lung, and Bladder Qi Xu; and Lower Jiao Damp Heat. After receiving only three acupuncture treatments, her symptoms began to be reduced. After 6 months of receiving one acupuncture treatment per month, she mostly had CIPN in her right hand and feet. After 2 years of monthly acupuncture treatments, she reported no CIPN symptoms in her hands and only mild CIPN in her feet. She was extremely sensitive to needles and was unable to have much stimulation. Therefore, her treatments were limited to one acupuncture needle per TCM diagnosis. A typical treatment for her consisted of the following acupoints: LI 4 (right side); LR 3 (left side) for Stagnation; KI 4 (right side) for Lower Jiao Damp Heat; KI 3 (left side) for Ki/Lu Xu; and SP 9 for Dampness/Spleen Qi Xu.

Stage III Colon Cancer

Case 5

A 38-year-old female with stage III colon cancer started oxaliplatin in 2006. Following her initial diagnosis and treatment, this patient started acupuncture in January of 2013. Her TCM diagnosis was Kidney Qi, Yin Xu, and Disturbed Shen. As of this writing, she continues to receive maintenance chemotherapy and undergoes acupuncture before each chemotherapy cycle. She presented with preliminary symptoms of CIPN initially consisting of leg and foot cramps. Her other concerns were anxiety and nausea. She reported that her initial symptoms of CIPN were gone before her first acupuncture treatment. Therefore, the goal of acupuncture has been to treat her other side-effects and prevent further CIPN from developing. This patient was able to tolerate moderate needling. The acupuncture treatments do not address CIPN prevention specifically, but they have prevented cramping successfully, using the following acupoints: LI 4; LR 3; GB 34; and SP 6.

Stage IV Colon Cancer

Case 6

A 68-year-old female with stage IV colon cancer began acupuncture 1 year after finishing treatment with oxaliplatin. Blood Deficiency was her primary TCM treatment diagnosis. During her treatment, she had symptoms of CIPN in her feet. However, with the addition of a new chemotherapy regimen that did not contain oxaliplatin, her CIPN increased significantly. She only received two acupuncture treatments, but, after these treatments, she reported no further complaints of CIPN. During her treatments, the following acupoints were used: Ba Feng; Ba Xie; GB 41; LU 9; KI 3; LI 4; and LR 3.

Case 7

A 40-year-old male with stage IV colon cancer began acupuncture 1 year after starting treatment with oxaliplatin chemotherapy. At that time, CIPN was a primary complaint of this patient. However, after receiving one acupuncture treatment, the focus of treatment shifted to stress relief and smoking cessation. He still currently receives acupuncture 2–5 times per week. This patient no longer complains of having CIPN and has not mentioned it in almost a year. He continues to receive chemotherapy and receives acupuncture at each visit for which he receives chemotherapy. During his treatment, the focus is not specifically on CIPN prevention. Instead, the treatment is mostly focused on treating on Liver Qi Stagnation, Qi and Blood Stagnation, and Spleen and Kidney Qi Xu constitutionally. He is able to withstand aggressive treatment. Typical acupoints used during his treatments were: 5 NP; LI 4; LR 3; GB 34; GB 41; HT 3; LU 5; Yin Tang; LI 10; ST 36; SP 6; KI 3; and LV 5. This patient prefers aggressive needling but has recently become averse to 5NP.

Case 8

A 65-year-old male with stage IV colon cancer had one session of acupuncture before starting FOLFOX chemotherapy. His TCM diagnosis was Qi and Blood Stagnation, Liver Qi Stagnation, and Stirring Wind. He currently receives one acupuncture treatment per month and has never complained of CIPN as a primary concern. He is a patient with Deficiency and receives light acupuncture treatment. He feels that acupuncture helps with prevention and amelioration of the side-effects of his chemotherapy. During his acupuncture treatment, the patient was placed in a lateral recumbent position for comfort. The typical points used during his treatment included: SI 3 (right side) and BL 62; STP 9; ST 36; GB 40; BL 60 to KI 3; LR 3; LI 4; and GB 20 (all on the left side).

Case 9

A 67-year-old female with stage IV colon cancer received treatment with FOLFOX and avastin. She began acupuncture treatment prior to starting the FOLFOX regimen. Her TCM diagnosis was Lower Jiao Damp Heat, Kidney Qi Xu, Disturbed Shen, and Liver Qi Stagnation. After receiving 3 months of oxaliplatin chemotherapy, she had symptoms of CIPN in her feet and toes. She received fifteen acupuncture treatments from the start of the oxaliplatin-based chemotherapy. These treatments were started out aggressively and utilized the following acupoints: Ba Feng; Ba Xie; some Jing-well points; SP 4; and GB 4. However, currently, these aggressive points are no longer needed. TDP lamps were also always utilized. One year after she completed her oxaliplatin treatment, she no longer has symptoms of CIPN. She is still currently undergoing acupuncture treatments at every chemotherapy visit.

Case 10

A 55-year-old male with stage IV rectal adenocarcinoma began acupuncture after starting treatment with FOLFOX. Before finishing 6 cycles of FOLFOX, this patient began having symptoms of CIPN in his face and hands. After 3 months of treatment, his toes and feet were also affected. The patient started acupuncture within a month after beginning 14 cycles of FOLFOX and avastin. His TCM diagnosis was Liver Qi Stagnation and Kidney/Heart Disharmony. After starting acupuncture, the patient reported immediate relief of CIPN symptoms and stated that he did not think that he could tolerate chemotherapy without acupuncture. To date, he only complains of pain and tightness in right hand and left toe. During his acupuncture treatments, he was able to tolerate aggressive treatment. However, aggressive treatment was not necessary throughout his entire treatment. Acupoints used throughout his treatments are as follows: 5 NP; LI 4; LR 3; SP 9; ST 36; KI; 7; KI 3; LI 10; TB 5 to PC 6; and various other points. Notably, he has reported that acupuncture has changed his life and made him a better person.

Discussion

TCM-based treatment implies that each patient is treated as a unique individual. Integrative oncology care is very similar to this treatment paradigm as integrative oncology is aimed to treat each patient as a whole in an individualized manner. Thus, the current authors' acupuncture treatments take into account the patient's current state as well as history, just as chemotherapy is dependent on a patient's constitution and past treatments in addition to his or her cancer type and stage. In addition to typical treatment regimens for cancer treatment—including radiation, chemotherapy, surgery, or a combination of those—the current authors use TCM that utilizes the tongue and pulse to assess constitution and emotions in order to treat the individual. In the current authors' experience, individualized cancer care is accomplished by utilizing both Western and Eastern medicine in an integrative setting.

Although the physiologic mechanisms of acupuncture in preventing and/or treating symptoms of CIPN are not fully understood, using TCM-based acupuncture for the treatment of CIPN has several advantages. First, compared with pharmacologic agents, side-effects are minimal and it has been shown to be safe and effective in preliminary studies.^23–26 In addition, pharmacologic agents may only be beneficial for a minority of patients.²⁷ Moreover, because TCM focuses on the individual as a whole, treatment plans are personalized each visit and various adverse effects of chemotherapy can be treated simultaneously.

Furthermore, acupuncture has also been shown to potentially regulate the immune system, which could have an added benefit to antitumor therapy.²⁸ Based on the current authors' clinical experience, acupuncture has the potential for benefit with respect to CIPN in 3 ways: (1) prevention of CIPN with use of acupuncture before chemotherapy; (2) inhibition of the progression of CIPN by using acupuncture during chemotherapy; (3) elimination or reduction of latent symptoms by using acupuncture following chemotherapy. Although the timing of when patients first started acupuncture during their chemotherapy varied, all of the patients reported on had improvement in their CIPN grades after starting acupuncture (Table 1). In addition, although this was not a controlled study and adverse events were not formally collected, there were no reports of side-effects directly related to acupuncture (Table 2).

Table 1.

Summary of Patient Outcomes

Patient	Age	Gender	Chemotherapy	Cancer type & stage	Duke's Classification	Maximum CIPN Grade	End CIPN Grade
1	49	M	FOLFOX6	Colon II	B2	II	0
2	40	F	Oxaliplatin/capecitabine	Colon II	B1	IV^*	I
3	53	M	FOLFOX6	Colon II	D	III	II
4	56	F	FOLFOX6	Colon II	C2	II	II
5	38	F	FOLFOX	Colon III	C2	I	0
6	68	F	FOLFOX6	Colon IV	D	IV^*	II
7	40	M	FOLFOX	Colon IV	D	III	I
8	65	F	FOLFOX	Colon IV	D	I	0
9	67	M	FOLFOX	Colon IV	D	III	I
10	55	M	FOLFOX	Colon IV	D	III	II

All patients who received acupuncture had either an improvement from their maximum CIPN grade or their symptoms were stabilized. Asterisks (^*) indicate that a chemotherapy intervention (reduction or cessation of therapy) was given to treat CIPN. CIPN was graded according to CTCAE v4.0.

CIPN, chemotherapy-induced peripheral neuropathy; FOLFOX, combination of oxaliplatin, folinic acid and 5-fluorouracil.

Table 2.

Details of CIPN Symptoms and Side-Effects ^a

Patient	Areas affected	Maximum CIPN symptoms	Response to acupuncture	Acupuncture side-effects
1	Hands/feet/legs	Cramping, “bunched socks” & cold sensitivity	Resolved; no long -term effects	None
2	Hands/feet	Symptoms at chemotherapy onset, but resolved 15 days after acupuncture treatment	Resolved; no long -term effects	None
3	Hands/feet/legs	Numbness & tingling	Able to prevent progression	None
4	Hands/feet	Numbness & tingling	Able to prevent progression	None
5	Hands/feet	Mild numbness & tingling	Resolved; no long -term effects	None
6	Feet	tingling & pain	Improvement	None
7	Hands/feet/legs	Pain, numbness, cramping & tingling	Improvement	None
8	Hands/feet	Serious fall from loss of balance	Able to prevent progression	None
9	Feet/toes	Numbness & tingling	Improvement	None
10	Face/hands/toes/feet	Numbness & tingling	Improvement	None

Because this was not a controlled study, adverse events were not collected. However, there were no reported side-effects directly related to acupuncture treatments.

CIPN, chemotherapy-induced peripheral neuropathy.

The current authors' experience with treating CIPN with TCM-based acupuncture supports that better outcomes are observed with the use of more distal points. These points were chosen not only based on the TCM diagnosis of each patient, but also to increase blood flow and circulation to benefit the affected tissue. The TCM diagnosis is important to support the patient as an individual effectively, but basic physiology must also be taken into account.

In the current authors' treatments, the goal is to combine Eastern and Western practices in order to best provide for the patient. Overall, the best outcomes occurred with frequent, aggressive acupuncture treatment with several needles. The most basic of this aggressive treatment would utilize the following points at a minimum: 5 NP; Ba Feng; Ba Xie; LI 4; LR 3; GB 41; GB 34; and SP 6. Ideally, Sheng Ba Feng, Sheng Ba Xie, and Jing-well points should also be added as needed and tolerated. In the current retrospective cases, 4 patients tolerated aggressive treatment and were the best responders to acupuncture therapy. These patients tolerated chemotherapy longer before reporting symptoms of CIPN, reported less-severe symptoms of CIPN, had fewer areas of the body affected by CIPN symptoms, and had more-immediate responses to treatment and recovery from CIPN in general. Moreover, 3 patients were able to undergo treatment up to 3 times per week. Although these were the same patients that were able to tolerate aggressive treatment, these patients were also among the group that had better response.

Although aggressive treatment resulted in the best responses in our patient population, this type of treatment may not be possible in all patients because of individual needle sensitivity. The patients who tolerated aggressive treatment were not immune to the needles. Of the 4 patients that received aggressive acupuncture treatments, 3 patients reported feeling the needles and felt discomfort. However, the patients were willing to withstand the discomfort in order to alleviate or prevent symptoms of CIPN. Interestingly, 1 patient reported really enjoying the acupuncture and actually preferred the increased use of needles. Moreover, 2 patients who tolerated aggressive acupuncture treatment did not end up needing it. They responded well to moderate treatment, which was discovered during treatments in which these patients were particularly sensitive and requested fewer needles but still had the same results.

However, most patients will notice worsening CIPN if a treatment is missed, and many do not get the same results with fewer needles. Ba Feng, Ba Xie, Sheng Ba Feng, and Sheng Ba Xie are all Extra points, meaning that they are points that are not on an acupuncture channels/meridians. These points are instead viewed as empirical points, or points that have been found over time to have a certain effect on the body. All of the Extra points used with these patients were found in the hands and feet. Eastern medicine utilizes acupuncture as somewhat of an empirical system. However, if a needle is placed in the hands or feet, blood flow will go to that area. Thus, regardless of how one explains it, these Extra points deliver Qi and Blood (blood flow and nourishment) to the extremities.

It must also be noted that, at the current authors' facility, the majority of patients live 400+miles away and come for treatment at intervals. For this reason, these patients can only receive acupuncture at those times. Nevertheless, even providing acupuncture at intervals can prevent and/or successfully treat most CIPN. However, if acupuncture could be provided on a consistent, more-frequent basis, it would be of advantage to patients. In many cases, receiving acupuncture both at the current authors' hospital and by a practitioner at home could improve the outcomes.

Conclusions

Merging Western and Eastern practices in an integrative setting allows each patient to be treated on an individual basis as a whole person. Thus, the use of TCM-based practices has several advantages to the patient in the oncology setting. In the current authors' experience, TCM-based acupuncture, prescribed frequently and aggressively, and focused on the distal extremities may be effective for preventing and treating CIPN. Further studies are necessary to elucidate the physiologic mechanisms behind this phenomenon. However, the current authors' experience has illustrated its utility benefiting the physical as well as mental well-being of oncology patients.

Footnotes

Acknowledgments

The authors thank Chelsey Meier, PhD, a medical writer at Cancer Treatment Centers of America, for help with editing, formatting, and preparation of this article.

Disclosure Statement

No competing financial interests exist.

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