Does Acupuncture Have a Role in Cancer Treatment?

Acupuncture is a method in which special fine needles are inserted at specific points on the body to relieve symptoms such as pain and fatigue and psychological problems. Its name comes from the Latin words "Acus," meaning needle, and "Punctura," meaning to pierce. Although it is claimed that needles made from pointed stones, bone, and bamboo were used to relieve pain in East Asia before the common era, it mainly became an important part of Chinese medicine approximately 2000 years ago. Its use began in other Asian countries and Europe in the 1700s and in America in the 1800s. The first scientific acupuncture studies began in America in 1976, and 20 years later, in 1996, acupuncture needles were approved as medical devices by the FDA (American Food and Drug Administration). Since then, acupuncture has become increasingly widespread and has developed into a medical discipline taught in medical schools. In our country, the Acupuncture Departments at Yeditepe University Faculty of Medicine and Gazi University Faculty of Medicine also actively continue their training and activities.

How Does Acupuncture Work?

Traditional Chinese medicine holds that energy channels pass through specific points in the body and that problems with energy flow cause disease. Acupuncture at these points is believed to restore the flow, rebalance the body, stimulate its self-healing, and thereby improve health. Scientific studies, however, have found that acupuncture works by stimulating nerves and causing the release of certain substances. These substances affect certain bodily functions and relieve symptoms such as pain and fatigue. For example, natural morphine-like substances called endorphins relieve pain, while serotonin, also called the happiness hormone, relieves pain and psychological problems.

How Is Acupuncture Performed?

Before acupuncture begins, the physician acupuncturist takes the patient's history, performs an examination, and arranges the necessary laboratory and imaging tests. A treatment plan is prepared considering many factors, including age, lifestyle, nutritional status, sleep patterns, general condition, diseases, symptoms, treatments received, and treatment side effects, with information and support from the patient's treating physician. The number and duration of sessions and the method to be used are determined.

Although many types of needles are used in acupuncture, disposable stainless steel needles are most common. Needles sterilized and reused are not as healthy as disposable needles and are more likely to cause side effects such as infection. The next step is selecting the treatment points from more than 2000 acupuncture points according to the patient and their complaint. These acupuncture points are locations where nerves run close to the body surface. The acupuncturist then uses special techniques to insert very fine, special needles painlessly under the skin or into muscle. Depending on the patient's condition, the needles usually remain in place for several minutes, sometimes less and sometimes longer. Sometimes the acupuncturist leaves special needle types under the skin or in areas such as the ear for days to maintain symptom relief. In some cases, patients may also be taught special acupuncture techniques for use at home. Occasionally, the physician performing the procedure may move needles up and down or rotate them to stimulate nerves. Patients do not feel pain during these procedures but may experience some tingling or numbness. Afterward, the patient lies down and rests in a quiet room for a while, completing the session.

What Methods Are Used in Acupuncture?

Many methods besides simple needle stimulation can be used in acupuncture:

• Laser acupuncture: Stimulation is provided using weak laser beams.
• Electroacupuncture: Stimulation is provided with a low-voltage electrical current. It may be applied through needles or pads placed on the skin without needle insertion.
• Sonopuncture: Stimulation is provided through sound waves.
• Microwave acupuncture: Stimulation is provided by transmitting microwave radiation through a device attached to the needles.
• Moxibustion acupuncture: Heat stimulation is provided by burning moxa herbs attached to the tops of needles inserted at acupuncture points or on special sticks. Blood flow increases in the treated area, and the odor released by the burning herb has a sedative (calming, soothing) effect.
• Acupressure: Stimulation is provided by applying pressure to acupuncture points with fingers or specially developed devices (such as balls and wristbands).
• Cupping: Stimulation is provided by cupping, that is, by suction.

The appropriate method is selected according to the patient's condition and preferences. Whatever method is used, however, the aim is to stimulate acupuncture points.

Who Can Perform Acupuncture Treatment?

Under the Acupuncture Treatment Regulation published by the Ministry of Health in 1991, acupuncture may be performed by medical doctors who successfully complete training courses opened with permission from the Acupuncture High Commission and receive certification, and by dentists provided they comply with the regulation and use it only within their own field. However, it is difficult to say that the certification training is sufficient or that finding competent, reliable physicians to perform this method in our country is easy. Another important problem is that physicians performing it are mostly general practitioners without sufficient knowledge and experience of cancer treatment. Therefore, cancer patients wishing to use these methods for symptom relief must do so with their oncologists' knowledge and supervision.

Acupuncture can benefit appropriately selected patients when performed correctly. However, it must be performed by physicians well trained in this field. In particular, no credence should be given to those claiming to cure cancer and many other diseases through this method. It should be remembered that its use in cancer patients is solely for symptom relief.

Points to Consider When Choosing an Acupuncture Center:

Make absolutely certain that the person performing the procedure is a physician. Some centers have a physician and medical diploma to meet legal requirements, but nonphysicians perform the procedure. Pay particular attention to this.

Pay close attention to their approach to you and your problems. Give no credence to those claiming to cure many diseases, particularly cancer, through this method.

Always ask how they perform the procedure, what tests and checks they do beforehand, and whether they contact your treating physician. Assess whether the procedure is performed as described in the "How Is Acupuncture Performed?" section above.

Always ask where the physician trained, what certificates they hold, how many years they have performed this method, and their experience with cancer patients. The physician's experience will both reduce side effects caused by incorrect application and improve the procedure's effectiveness.

Ask whether the acupuncture needles used are disposable. Disposable needles are important for protecting you against side effects such as infection.

What Are the Side Effects and Risks of Acupuncture Treatment?

Side effects during acupuncture usually result from nonsterile needles, insertion at the wrong sites, patient movement, or defective needles. Sterility is particularly important for cancer patients because treatments such as chemotherapy and radiotherapy weaken the immune system. When choosing an acupuncture center, it is therefore important to prefer centers using disposable needles. Another important point is to assess the patient's immune status by checking white blood cell counts in blood tests.

Possible side effects of acupuncture include:

• Pain during the procedure
• Bleeding or bruising at the needle site
• Infection (particularly hepatitis B infection)
• Nerve damage
• Feeling tired
• Drowsiness
• Dizziness
• Lightheadedness

What Is Sham Acupuncture?

Sham acupuncture uses needles that do not penetrate the skin but create the sensation of penetration instead of real acupuncture needles. When these specially made needles are pressed against the skin, the needle section retracts into the handle, and adhesive at the tip makes it appear to remain inserted. The patient thus believes the procedure is real acupuncture and psychologically believes they will improve, which has a positive effect. In other words, a placebo effect is created. The placebo effect is the positive effect produced when a patient believes a medically ineffective drug or method is effective and will work. It is frequently used in medical research when assessing a drug or method. In these studies, one group receives the real drug or method, while another receives an ineffective drug or method they believe is real. This allows assessment of whether the drug's effect is based on placebo, that is, whether it is a genuine or psychological effect.

Some circles believe acupuncture's effects are also based on placebo. Many studies have therefore compared real acupuncture with placebo acupuncture, also called sham acupuncture. Although some studies claim its effects are mainly placebo, studies showing that real acupuncture is superior to placebo in relieving certain symptoms are more prevalent. According to many studies, acupuncture is not as effective as general medical treatments for long-term symptomatic treatment, but provides significant short-term relief of certain symptoms.

Why Should Cancer Patients Receive Acupuncture?

Cancer patients should use acupuncture as a complementary treatment alongside standard treatment to reduce symptoms related to cancer and/or cancer treatment. Scientific studies provide no evidence that acupuncture alone is an effective cancer treatment.

Studies have shown acupuncture to benefit the following symptoms in cancer patients:

• Pain
• Fatigue
• Nausea
• Vomiting
• Psychological problems
• Dry mouth
• Lymphedema
• Leukopenia
• Hot flashes
• Sensory disturbances
• Shortness of breath

Acupuncture and Cancer Pain

Clinical studies have demonstrated positive effects of acupuncture on pain control. A study conducted in 2003 involving 90 patients found that electroacupuncture around the ear significantly reduced cancer pain. Another study published in 2010 involving 58 cancer patients who had undergone neck surgery found that acupuncture also helped reduce postoperative pain in cancer patients. Another study showed that acupuncture reduced muscle and joint pain caused by aromatase inhibitors (such as anastrozole and exemestane), frequently used in hormone-sensitive breast cancer. Overall, however, insufficient studies have evaluated acupuncture's effect on cancer pain. Well-designed, comprehensive studies are therefore needed before a clear conclusion can be drawn.

Acupuncture and Fatigue

Fatigue is reduced functional ability due to a lack of energy and feeling tired and exhausted because of distress. It is a common problem after chemotherapy and radiotherapy in cancer patients and significantly affects quality of life. In 2012, “Journal of Clinical Oncology” published a study involving 302 breast cancer patients that concluded acupuncture was effective for cancer-related fatigue and contributed positively to patients' quality of life. However, because patients in this study were followed for only 18 weeks, and follow-up in other studies was also short, the long-term results of acupuncture in reducing fatigue remain uncertain.

Acupuncture and Nausea and Vomiting

Although some studies evaluating acupuncture for nausea and vomiting related to cancer and its treatment produced negative results, studies with positive findings predominate. One study showed that acupressure wristbands reduced nausea and vomiting and the need for medication for these symptoms. However, another study comparing an acupressure wristband in one group with a sham wristband in another found no significant difference, suggesting that the effect might be psychological (a placebo effect). Similarly, a study comparing real and sham acupuncture for radiotherapy-induced nausea and vomiting found no superiority of real acupuncture, strengthening this interpretation. (Placebo effect: the positive effect resulting when a patient believes a medically ineffective drug or method is effective and will work.)

Acupuncture and Psychological Problems

Studies have shown that serotonin released in the body during acupuncture helps reduce a general feeling of low mood. One study observed fewer depressive symptoms when cancer patients received acupuncture and massage after surgery. Studies in patients without cancer have also shown that acupuncture significantly reduces anxiety (anxiety disorder). Nevertheless, there is no strong evidence that it directly benefits cancer-related anxiety, depression, and sleep problems. High-quality studies on this subject are needed.

Acupuncture and Dry Mouth

Dry mouth is common in head and neck cancer patients receiving radiotherapy and significantly affects quality of life. Some clinical studies have observed that acupuncture helps treat and prevent dry mouth and increases saliva production. A study published in 2013 in Annals of Oncology involving head and neck cancer patients who had chronic dry mouth for more than 18 months after radiotherapy, with 145 patients enrolled, observed increased saliva production and significant symptom relief in the acupuncture group.

Acupuncture and Lymphedema

Lymphedema, also popularly known as elephantiasis, is swelling caused by lymph fluid leaking into and accumulating between tissues. In cancer patients, it occurs in the arms and legs following radiotherapy or removal of lymphatic vessels/lymph nodes in the groin or underarm. Lymphedema is an important problem that reduces cancer patients' quality of life by causing pain and restricted movement. There are insufficient comprehensive studies evaluating acupuncture's effect on lymphedema, and high-quality studies are needed. However, a small study involving 35 patients suggested that moxibustion, a type of acupuncture, might help reduce lymphedema.

Acupuncture and Leukopenia

Leukopenia is a reduction in the number of white blood cells in the blood. It commonly occurs in patients receiving chemotherapy and/or radiotherapy because of suppression of the bone marrow where blood cells are produced, increasing cancer patients' risk of infections. Although the English-language medical literature contains no studies on acupuncture's effect on leukopenia, studies conducted in China suggest some benefit in chemotherapy- and radiotherapy-induced leukopenia. However, this is not strong evidence, and it is advisable to await reliable study results.

Acupuncture and Hot Flashes

Hormonal treatments frequently used in women with breast cancer and men with prostate cancer cause hot flashes and sweating. Venlafaxine (Efexor) is standardly used to reduce these symptoms in these patients. However, a study published in 2010 in the Journal of Clinical Oncology comparing acupuncture with venlafaxine found acupuncture as effective for hot flashes as venlafaxine, while side effects caused by venlafaxine, such as nausea, dry mouth, and anxiety, were not observed in the acupuncture group. It therefore concluded that acupuncture was a safe and effective treatment for hot flashes. However, considering the number of participants, it would not be wrong to say that the study needs support from further research.

Acupuncture and Sensory Disturbances

Few studies have evaluated acupuncture for chemotherapy-induced sensory problems such as numbness, tingling, and altered sensation in the hands and feet (peripheral neuropathy), and their findings are conflicting.

Acupuncture and Shortness of Breath

A few small studies have evaluated acupuncture for cancer-related shortness of breath, but their findings are also conflicting. Comprehensive, well-designed studies are therefore needed before a clear statement can be made about acupuncture's effect on shortness of breath.

In conclusion, acupuncture, is not a method that can be used to improve cancer treatment effectiveness or to treat cancer itself. Nevertheless, helping patients improve their quality of life with a nonpharmacological method with few side effects is also extremely important. Acupuncture may help reduce certain cancer-related symptoms and side effects of cancer treatments and might even become standard practice in oncology in the future. Unfortunately, however, most practitioners use it purely commercially and without adequate knowledge, and finding physicians who perform it most reliably and correctly is quite difficult. Great care is therefore needed when selecting a center. In particular, no credence should be given to those presenting these methods as miracles and claiming to treat cancer. Consulting your physicians and seeking their guidance at every step you take for your health will always be the safest course.