Evaluation of Group Acupuncture for Cancer-Related Symptoms: A Retrospective Analysis

Introduction

Acupuncture is a form of complementary medicine commonly used for many cancer-related symptoms, including pain, nausea/vomiting, hot flashes, insomnia, and anxiety;^1–3 yet more research evaluating its efficacy is necessary. While acupuncture may have benefits for other cancer-related symptoms, we were particularly interested in whether acupuncture relieves symptoms of chemotherapy-induced peripheral neuropathy (CIPN). A few studies have demonstrated that acupuncture may reduce pain in persons with CIPN; however most of these studies have had small sample sizes and have not focused on group acupuncture.^4–6

Group acupuncture is the treatment of patients in a group setting with only the modality of acupuncture. As many as eight patients are treated in an hour. Although treatments can be abbreviated, treating multiple patients in an hour allows us to reduce the costs, keeping treatments affordable for patients with economic hardships. In this retrospective study, we sought to evaluate the effects of group acupuncture on specific cancer-related symptoms in persons with cancer receiving outpatient treatment.

Methods

For this retrospective, descriptive study, participants were receiving group acupuncture treatments through integrative oncology services in a large community oncology practice in west central Florida.

Acupuncture was administered to patients at the rate of up to eight patients an hour by a single practitioner in a staggered fashion. Patients sat in reclining chairs, all in one room. After filling out intake forms, patients were questioned about their symptoms. Only points on the extremities and head were used. Distal acupuncture points were chosen due to the inaccessibility of the back and abdomen and the acupuncturist's judgement of effectiveness of the points in treating patient symptoms. Meridian diagnosis (assessment of affected areas of complaints according to pathways on which acupunture points are located) was utilized in determining acupoint prescriptions depending on patient symptoms. Instead of standardized treatments, many factors were considered to tailor individual treatments. In the case of neuropathy, a more standardized approach was taken. The local areas of neuropathy were treated. Acupuncture was administered according to the affected areas of neuropathy. Acupuncture meridian diagnosis was used to determine the meridians (paths along which acupuncture points are located) used and the acupuncture points that were chosen. Acupuncture points are described below using standard acupuncture nomenclature. If the palms of the hands were involved, HT-8 and PC-8 were needled. LI-4 and the points between the knuckles, the baxie, were used for the fingers. If only the fingers were affected, the points on the tips of the fingers were used.

Treatment of the legs involved all of the meridians affected. If the condition extended to the knees, then the points below the knees, ST-36, SP-9, GB-34, were used along with ankle points, KD-3, BL-60, ST-41—BL-57 if there was significant calf involvement. Points near the toes and the sole of the foot were also included. The bafeng, acupuncture between the toes, was needled along with LR-3 and KD-1. As the affected areas below the knee improved, treatment was concentrated on the ankle and foot until the response warranted concentration on the foot only. If the front and sole of the foot was the only affected area remaining, SP-3 and BL-66 were added. The points on the ends of the toes were also used.

Patients were allowed to rest with the needles retained for at least 25 minutes. If there wasn't an immediate need for the chair, meaning that no one was waiting to be started on acupuncture after all the chairs were filled, patients were often allowed to rest longer, up to one hour. Among the patients seen, some were established patients and some were new patients. Established patients if they were coming for the same complaints could be treated faster than 7.5 minutes, which included both diagnosis and insertion. New patients required more time. Therefore, 60 minutes was sufficient to treat eight patients, considering the mix of established and new patients.

Patients were asked at each acupuncture session to complete a brief assessment of seven basic cancer-related symptoms, including pain/numbness, dry mouth, headache, fatigue, insomnia, and digestive problems, using a 0 to 10 numeric rating. Data from patients who completed the symptom evaluation form before the first acupuncture and at the time of the fourth acupuncture were included in this analysis.

Basic demographic information, including age, gender, race/ethnicity, and cancer type was obtained from the medical record. Paired sample t-tests were used to evaluate differences in symptoms before the first treatment and at the fourth treatment. A p value of less than 0.05 was considered statistically significant.

Results

Fifty patients completed at least four weekly acupuncture treatments in 2014. Forty-two of them completed symptom assessments at the first and fourth acupuncture treatment and were included in this study. Ages ranged from 25 to 84 with a mean age of 66.1 years. The majority of patients were white (88.1%), non-Hispanic (76.2%), and female (73.8%). Breast cancer was the most common diagnosis.

Pain and numbness were the most frequently reported symptoms (see Table 1). At the time of the fourth group acupuncture, participants reported significantly less pain/numbness and problems with digestion. No significant improvements in sleep, fatigue, dry mouth, headache, or nausea were identified, although trends toward improvement in all symptoms except headache were seen. No significant changes in symptoms were present at the third treatment.

Discussion

The results of this retrospective study lend support for group acupuncture for treatment of painful neuropathy in persons with cancer. These findings are similar to those of other researchers,^7–9 although to our knowledge this is the first study that has evaluated acupuncture delivered in a group setting. Analysis of symptom data from week three revealed no significant improvement of any symptoms from baseline assessment; therefore, a minimum of four weekly treatments may be necessary before improvements are noted. Although we saw a statistically significant difference, it is unclear whether this represents a clinically meaningful response. Anecdotally, patient comments supported noticeable improvement in symptoms; however future studies should use both subjective and objective measures of neuropathy and differentiate between painful and painless symptoms to identify clinical relevance of statistical differences.

Additional limitations include a retrospective design; use of a measure that measures pain and numbness in a single item, which was created for clinical use and of which the reliability and validity have not been previously studied; and possible response bias due to the fact that clinicians who were known to the patients were collecting the data. Small numbers of patients and low baseline values for some of the symptoms may have limited our ability to detect significant changes in symptoms. Future studies of group acupuncture for cancer-related symptoms should use a prospective, controlled design, and use validated measures to thoroughly evaluate targeted symptoms. Both those who were receiving chemotherapy and those who were not receiving any treatment but still had symptoms were included in this analysis. Future studies should evaluate which group of patients acupuncture might be more effective in treating. In summary, this pilot data indicates that group acupuncture may benefit individuals with cancer-related neuropathy. Additional research is needed to identify specific neuropathy symptoms that may respond, determine an optimal dose and frequency, and explore the extent to which effects are sustained over time.