Acupuncture for cancer pain in adults: Cochrane systematic review
Forty per cent of individuals with early or intermediate stage cancer and 90% with advanced cancer have moderate to severe pain and up to 70% of patients with cancer pain do not receive adequate pain relief. It has been claimed that acupuncture has a role in management of cancer pain and guidelines exist for treatment of cancer pain with acupuncture. This is an updated version of a Cochrane Review published in Issue 1, 2011, on acupuncture for cancer pain in adults.Objectives
To evaluate efficacy of acupuncture for relief of cancer-related pain in adults.Search methods
For this update CENTRAL, MEDLINE, EMBASE, PsycINFO, AMED, and SPORTDiscus were searched up to July 2015 including non-English language papers.Selection criteria
Randomised controlled trials (RCTs) that evaluated any type of invasive acupuncture for pain directly related to cancer in adults aged 18 years or over.Data collection and analysis
We planned to pool data to provide an overall measure of effect and to calculate the number needed to treat to benefit, but this was not possible due to heterogeneity. Two review authors (CP, OT) independently extracted data adding it to data extraction sheets. Data sheets were compared and discussed with a third review author (MJ) who acted as arbiter. Data analysis was conducted by CP, OT and MJ.Main results
We included five RCTs (285 participants). Three studies were included in the original review and two more in the update. The authors of the included studies reported benefits of acupuncture in managing pancreatic cancer pain; no difference between real and sham electroacupuncture for pain associated with ovarian cancer; benefits of acupuncture over conventional medication for late stage unspecified cancer; benefits for auricular (ear) acupuncture over placebo for chronic neuropathic pain related to cancer; and no differences between conventional analgesia and acupuncture within the first 10 days of treatment for stomach carcinoma. All studies had a high risk of bias from inadequate sample size and a low risk of bias associated with random sequence generation. Only three studies had low risk of bias associated with incomplete outcome data, while two studies had low risk of bias associated with allocation concealment and one study had low risk of bias associated with inadequate blinding. The heterogeneity of methodologies, cancer populations and techniques used in the included studies precluded pooling of data and therefore meta-analysis was not carried out. A subgroup analysis on acupuncture for cancer-induced bone pain was not conducted because none of the studies made any reference to bone pain. Studies either reported that there were no adverse events as a result of treatment, or did not report adverse events at all.Authors' conclusions
There is insufficient evidence to judge whether acupuncture is effective in treating cancer pain in adults.
Paley Carole A, Johnson Mark I, Tashani Osama A, Bagnall Anne-Marie
Acupuncture for cancer-related pain in adults
Up to 70% of patients with cancer pain do not receive adequate pain relief and this reduces their quality of life. It has been claimed that acupuncture has a role in the management of cancer pain and guidelines exist for treatment of cancer pain with acupuncture.
Purpose of this research
The authors of this Cochrane Review decided to evaluate the evidence for whether acupuncture is effective in reducing pain directly associated with the development of cancer.
The search for evidence
We searched a wide range of electronic medical databases up to July 2015 for relevant studies. We included studies written in any language that included adults and compared treatment with acupuncture for cancer pain against no treatment, or usual treatment, or sham acupuncture, or other treatments. Since we were only interested in robust research, we restricted our search to randomised controlled trials (in which participants are randomly allocated to the methods being tested).
What we found
We found five studies (with a total of 285 participants) that compared acupuncture against either sham acupuncture or pain-killing medicines. All five identified studies had small sample sizes, which reduces the quality of their evidence.
One pilot study was well designed, but was too small to identify any differences in pain in women with ovarian cancer after electroacupuncture or a sham treatment. One study found that auricular (ear) acupuncture reduced cancer pain when compared with sham auricular acupuncture that was given at non-acupuncture points. However, the people in the sham acupuncture group could have been aware that they were not in the real acupuncture group and this could have affected the level of pain they reported. Another study found a difference between an electroacupuncture group and sham group in people with pancreatic cancer but again, there was no reported attempt to conceal which group people were in. One study found that acupuncture was as effective as pain-killing medication, and one study found that acupuncture was more effective than medication, but both studies were poorly designed and the study reports lacked detail.
None of the studies described in this review were big enough to produce reliable results. None of the studies reported any harm to the participants. We conclude that there is insufficient evidence to judge whether acupuncture is effective in relieving cancer pain in adults. Larger, well-designed studies are needed to provide evidence in this area.
Implications for practice
For patients with cancer pain:
There is not enough evidence to be able to conclude that acupuncture is effective for treating cancer pain, although some small studies contain evidence which is promising. Since the last version of this review, none of the new relevant studies have provided additional information to change these conclusions. Some patients use acupuncture for its other benefits (Garcia 2013; Lian 2014; Qaseem 2008), and as acupuncture is an intervention with few side-effects, it can be used, provided that patients are aware of its limitations.
There is insufficient evidence to provide a judgement on whether acupuncture is effective in treating cancer pain in adults. Nevertheless, acupuncture continues to be used quite widely for cancer pain and for other cancer-related conditions (Garcia 2013; Lian 2014; Qaseem 2008). As peer-reviewed guidelines exist for the use of acupuncture in cancer patients (Filshie 2006), it is suggested that practitioners follow these guidelines and that patients are made aware of the potential limitations of this type of intervention.
For policy-makers and funders:
The available evidence does not yet suggest that acupuncture is effective for treating cancer pain, although it has been used with some success in other cancer-related conditions such as vasomotor symptoms that occur as a result of cancer treatments (Harding 2009; Lian 2014), and chemotherapy-induced nausea and vomiting (Chao 2009).
Implications for research
Acupuncture is widely used to treat cancer-related pain, but the available evidence is of low quality. Therefore a judgement on whether acupuncture is effective cannot be made. Trials of acupuncture comparing it with placebo interventions which control for patients' expectations and beliefs about the effects of treatment have been used to determine whether acupuncture has specific effects over and above a placebo response (Ernst 2004; Ernst 2006; Johnson 2006). However, findings have been inconsistent and there is an ongoing debate as to whether placebo acupuncture is appropriate as a control because it may not be physiologically inert and could be as effective as true acupuncture (Lund 2009; Lundeberg 2008). Therefore pragmatic trials of the effectiveness of acupuncture on cancer pain compared with standard treatment may provide useful information (Lundeberg 2009), but attention should be given to ensuring an adequate dose of acupuncture is given in line with current recommendations (White 2008). As no studies investigating acupuncture for cancer-induced bone pain were identified, this is an area that should be specifically targeted for further research.
The design of future randomised controlled trials in this area should include:
- power calculations to ensure adequate sample sizes;
- homogeneity of cancer pain conditions under study;
- use of optimal dose of acupuncture;
- assessor blinding;
- use of valid and reliable pain outcome measures;
- details about the nature of the control used.
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