MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.

Many cancer patients will suffer from severe, debilitating fatigue during the course of their illness. The exact cause of this common symptom is not entirely clear. Most likely it is due to a combination of the cancer and the treatments used to cure it. Managing cancer-related fatigue (CRF) is thus an important part of the palliative and supportive care of cancer patients. Acupuncture is often advocated for this purpose and many centres use it routinely. The question therefore is, does it work?

The most recent trial on this subject was aimed at assessing the effectiveness of maintenance acupuncture in the management of CRF; acupuncture or self-acupuncture/self-needling was compared with no such treatment. Breast cancer patients who previously had received acupuncture were randomized to have 4 acupuncturist-delivered weekly sessions, 4 self-administered weekly acupuncture sessions (self-needling); or no acupuncture at all. The primary outcome-measure was general fatigue, while mood, quality of life and safety served as secondary endpoints. In total, 197 patients were randomized: 65 to therapist-delivered sessions, 67 to self-acupuncture/self-needling and 65 to no further acupuncture. The results failed to demonstrate significant inter-group differences in any of the parameters evaluated. The authors concluded that “maintenance acupuncture did not yield important improvements beyond those observed after an initial clinic-based course of acupuncture“.

But this is just one single of several available studies. Acupuncture-fans might suspect me of cherry-picking a largely negative study. If we want a fair verdict, we must consider the totality of the evidence. The aim of our systematic review was therefore to critically evaluate the effectiveness of acupuncture (AT) for CRF based on all the trial data available to us.

Fourteen databases were searched from their respective inception to November 2012. Randomized clinical trials (RCTs) of AT for the treatment of CRF were considered for inclusion. The risk of bias/methodological quality was assessed using the method suggested by the Cochrane Collaboration. Seven RCTs met the eligibility criteria. Most were small pilot studies with serious methodological flaws. Four of them showed effectiveness of AT or AT in addition to usual care (UC) over sham AT, UC, enhanced UC, or no intervention for alleviating CRF. Three RCTs failed to demonstrate an effect of AT over sham treatment.

Our conclusion had to be cautious: “Overall, the quantity and quality of RCTs included in the analysis were too low to draw meaningful conclusions. Even in the positive trials, it remained unclear whether the observed outcome was due to specific effects of AT or nonspecific effects of care. Further research is required to investigate whether AT demonstrates specific effects on CRF

There will, of course, be those who claim that no trial evidence is needed in this case; if a cancer-patient benefits from the treatment, she should have it regardless of whether it works as a placebo or has effects beyond that. I do sympathize with this attitude but should point out that there are a number of points to consider when making it:

1) Acupuncture is not risk-free.

2) There are other treatments against CRF; if we blindly advocate acupuncture, we might not offer the best option to our patients.

3) If we spend our limited resources on acupuncture, we might not afford treatments which are more effective.

4) If we are happy using acupuncture because it conveys a sizable placebo-effect, how will we make progress in finding treatments that are more effective?

It is therefore difficult to decide whether or not to recommend acupuncture for CRF. There are some arguments for both sides. Skeptics or critical thinkers or clinicians adhering to the principles of evidence-based medicine are unlikely to condone it, and some people might accuse them for cruelly  and heartlessly denying severely ill patients help which they so badly need. Personally, I fail to see what is cruel or heartless in insisting that these patients receive the treatment which demonstrably works best – and that does not seem to be acupuncture.

8 Responses to Acupuncture for cancer-related fatigue? Not if you want the best for cancer patients.

  • Edzard, f you walked into the chemo rooms at the royal Marsden and announced, today we are starting an exercise regime as the evidence is clear this is the most effective way of dealing with fatigue, they would laugh you out of the building. All through treatment you are warned of fatigue as a side effect of treatment, during radiation and oral chemotherapy it was rare. Three weeks after surgery I was swimming, I remember the surgeon asked me if I had the energy to swim, I said I did not but where would I get the energy if I did not exercise, so I was in good shape as I started inter venous chemotherapy but the fatigue hit me like a train. Fatigue does not even begin to describe it, walking to the door was an effort, as though I had two bags of cement attached to my legs and i could not swim because, the chemo drug Oxaliplatin makes you sensitive to cold and damages nerves. I had trained and stayed fit right up to that point but two months into chemo all I wanted to do was lay down and eat crisps. I forced myself to walk the kids to school which after four months was beyond me, I put on 10 Kilos. Here lies the problem how do you get people like this to exercise, which as you point out is probably is the best “treatment” for fatigue?

    What changed my life was a small study I read on a food supplement called Carnitine which apparently helps the cells oxadise fats more efficiently and produce ATP. I am sure the evidencefor carnitine is no more convincing than acupuncture, however when I started taking it it was like night and day and I would say to anyone its worth trying as is anything that might get you out of the downward spiral you find yourself in.

    At the Marsden you can have a range of CAM therapies not because they are supported by strong evidence, but because cancer effects everybody differently and the oncologists priority is to get the patient as comfortable and as happy they can so they can get through the medical treatment they are giving, most patients are not able to do it in one go, even the medical interventions for cancer are hardly supported by cast iron evidence

    • 1) exercise is only one of several effective treatments; i only used it as an example [in fact, it was the first cochrane review which came on my screen].
      2) exercise does not need to be excessive and can be tailored to the patient’s capacity.
      3) when you say they would laugh me out of the building, you replace your usual anecdotes with pure speculation; i know patients who did very well on exercise and loved it.
      4) carnitine is at least more plausible than acupuncture; but your experience might merely reflect the natural history of CRF which eventually does wear off, even if you do not treat it at all
      5) few things in life are supported by cast iron evidence [some by better data than others though]
      6) i did offer both view-points, however, you seem to just want to see yours. the issues are clearly complex but i do repeat: it is not heartless to want the best documented treatment for patients, on the contrary, this [EBM] is good, compassionate heathcare, in my view.

      • 1) I would be very interested to hear what other treatments you have discovered that are more effective according to the evidence than acupuncture
        2) Isnt that how I described it working for me. However not many oncology doctors don’t have the expertise to tailor exercise programs according to individual needs. I used the “Cooper test” and modified the exercise accordingly.
        3) “I know patients who did very well on exercise and loved it” obviously I am not disagreeing with you on this point, having described how exercise helped me. The difficulty is convincing people who are absolutely exhausted to exercise. This illustrates a problem in using the “scientific evidence” as gospel when the experienced clinician might take a view this patient is not going to respond well to being given an exercise program and more likely to feel energized from, say a massage.
        4) Agreed, my experience is anecdotal, however I did stop taking carnitine for three days and began to feel tired again. Plan to stop taking them after i have completed the Great wall Marathon and see how it goes as you know I place much value on empirical evidence.
        5/6) again dont disagree with you.No one is saying it is “cruel or heartless in insisting that these patients receive the treatment which demonstrably works best”. However because the evidence is not there does not mean the intervention is not worth trying, especially if a patient “believes” in it. No doubt why Sacketts third pillar of his EBM model was “Patient Values”

  • Also, it’s very difficult to measure fatigue in a meaningful and reliable manner. This makes it harder to justify using a treatment on the basis that some evidence indicates it may lead to improvements in ‘what-was-measured-as-fatigue’, but without supporting evidence for the mechanism by which this may occur.

  • this was just published:
    True acupuncture as provided in this study did not reduce post-chemotherapy chronic fatigue more than did sham acupuncture. The study is limited by the number of patients lost to follow-up. We also cannot exclude the possibility that a more intensive treatment regimen may be more effective.
    Supportive Care in Cancer
    June 2013, Volume 21, Issue 6, pp 1735-1741

  • Very interesting article.
    I do agree acupuncture 1 time a week or even 2 or 3 times a week for even 3 months may do little on helping fatigue on CRF.

    Worse is self acupuncture which I do not recommend.

    I also agree that CRF and even Chemo Induce Neuropathy is a big problem with even poor results of care with many Western, Natural and Eastern Medicine Care is only applied at minimum frequency.

    However, we must help to provide patients with other safe options like simple relaxation meditation, Visualization, Simple Gentle Movement or Exercise or Tai Chi .

    There are some good Integrated Cancer Centres in Canada and USA that have trained Exercise Therapist with either a Kinesiology or Physical Therapy background Focus in Cancer Care that MD can recommend.

    Luckily in British Columbia, Canada.
    We have places like Inspire Health.

    In USA top Cancer Centres may have similar Exercise and Meditation Care.

    I believe Relaxation and monitored Individualize Exercise Program may reduce some of the CRF.

    Thank you for you articles.
    Keep up good work.

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