Abstract
The Precision Medicine Initiative of 2015, together with a growing focus on patient-centered care, has challenged the U.S. health care system to provide the correct treatment to the correct individual patient rather than to a collective population. This demonstrates that acupuncture—with its history as an individualized therapy and with growing evidence-based clinical findings—is the ideal model for personalized medicine within oncology care. The current author and colleagues used previously conducted oncology acupuncture trials for pain, hot flashes, and insomnia to demonstrate that precise delivery of acupuncture might depend on a patient's genetics. Individual preferences and perceived evidence surrounding treatments might also factor into patient treatment choices. Further effectiveness evidence comparing acupuncture to drugs or cognitive–behavioral therapy provides insight on the relative benefit or harm of each treatment, which, in turn, can help clinicians and patients to choose the best treatment plans centered on patients' goals. To advance precision oncology acupuncture research, appropriate biomarkers and psychologic attributes should be incorporated into adequately powered and well-designed clinical trials to evaluate how acupuncture can be delivered to the correct patients.
Introduction
The goals of the 2015 Precision Medicine Initiative combined with efforts to deliver patient-centered care lend themselves to a system wherein health care decisions and quality measures are aimed at individuals rather than at heterogeneous, collective groups.1,2 Medicine is personalized when we account for genotype, patient preference, and expectancy. Acupuncture is an ideal model in the quest for personalized medicine in oncology care, as acupuncture has exemplified personalized medicine for 2500 years and has a growing evidence base of clinical results.
Discussion
Electroacupuncture for Breast Cancer Pain
In a Phase II randomized controlled trial of women with breast cancer receiving an aromatase inhibitor, verum electroacupuncture (EA) was compared to control and sham acupuncture on self-reported arthralgia pain. Verum acupuncture produced clinically relevant and lasting improvement in arthralgia-related pain, compared to usual care, in this patient group. Sham acupuncture also produced a similar effect. 3 When examining single nucleotide polymorphisms (SNPs) in catechol-O-methyltransferase (COMT) and T-cell leukemia 1A, it was found that 47.4% of patients had a combination of desirable SNPs and, of those, 77.8% were responsive to acupuncture. 4 This information, if confirmed in future studies, offers an opportunity to understand further how genetic polymorphisms contribute to a patient's unique acupuncture response for pain management. 4
EA for Hot Flashes in Breast Cancer
In another study of breast cancer survivors, the effects of EA, compared to gabapentin, on hot flashes were assessed, and acupuncture maintained durable results for 4 months off therapy. The results also showed that, compared to gabapentin, acupuncture caused larger placebo and smaller nocebo effects. These findings suggest that, as a hot flash, treatment EA might have fewer adverse effects and greater effectiveness than gabapentin. 5 Previously, it was found that breast cancer survivors who preferred natural approaches and worried about drug side effects were more likely to choose acupuncture, compared to drugs. 6 Thus, the research evidence from this trial, together with recognizing patients' personal beliefs and preferences, can help inform more patient-centered care.
Recently, several genetic SNPs were explored that were possibly associated with responses to acupuncture (verum EA or sham). For this study, 57 patients with breast cancer were treated with acupuncture. Of that group, it was found that carriers of at least one of 6 genotypes of COMT and ADORA1 (associated with neurotransmission), TRPV1 (associated with thermoregulation), and TCLA1 (associated with inflammation) versus noncarriers were more likely to respond to acupuncture treatment for hot flashes (70.3% versus 37.5%). 7 Moreover, the study showed that, in women who underwent pharmacologic treatment for hot flashes, these genotypes were not associated with responses to the drugs. Similar to the SNP studies in arthralgia, 4 this research suggests that identifying patients' specific genetic variabilities in association with responses to acupuncture can aid in delivering individualized oncology care.
Acupuncture for Insomnia
The effectiveness of acupuncture was also compared with cognitive–behavioral therapy for insomnia (CBT-I) in cancer survivors. The findings showed clinically meaningful reduction in the severity of insomnia, an improvement that was sustained for up to 20 weeks in each treatment; however, CBT-I was overall more effective. 8 Yet, it was also found that acupuncture reduced pain severity more than CBT-I. 8 Subgroup analyses showed that CBT-I was more effective for highly educated (P < 0.001), white (P = 0.003), male (P < 0.001) patients who had no pain at baseline (P < 0.001). However, despite the fact that CBT-I has been known as the “gold standard” for managing insomnia, acupuncture might be an appropriate treatment option for women, nonwhites, and patients of lower education levels with baseline pain. 8
A subset of trial participants were also interviewed to examine factors that contributed to patient-treatment preferences for acupuncture or CBT-I, including unique patient factors or circumstances; personal or externally sourced treatment experiences and expectations; and awareness of the evidence base. 9 Understanding what treatments are available for specific patients as well as patients' personal preferences could help guide cooperative decision-making, optimize outcomes, and advance personalized care.
Conclusions
Acupuncture has the potential to be delivered with precision to maximize effectiveness as part of patient-centered cancer care. Precision oncology acupuncture research requires the integration of biologic insights with psychologic attributes through translational research and clinical trials that are appropriately designed and sufficiently large enough to allow for meaningful subgroup analyses. By acknowledging biologic differences and individual beliefs and preferences, it would be possible to provide acupuncture to the correct oncology patients to achieve optimal efficacy.
Footnotes
Acknowledgments
Dr. Mao would like to thank Colleen Smith, Project Coordinator at the Memorial Sloan Kettering Cancer Center's Integrative Medicine Service, for her editorial assistance.
Author Disclosure Statement
Dr. Mao reports grants from Tibet Cheezheng Tibetan Medicine Co. Ltd., and from Zhongke Health International, LLC outside the submitted work.
Funding Information
This work was supported in part by a National Institutes of Health/National Cancer Institute grant (no. P30 CA008748) and by the Translational and Integrative Medicine Research Fund at Memorial Sloan Kettering Cancer Center.