The treatment and relief of cancer-related symptoms still represents a challenge to healthcare professionals. Up to 70% of patients with advanced stage cancer suffer from pain for which they receive inadequate pain relief and this in turn leads to impaired physical and psychological well-being, resulting in a poorer quality of life . In addition to pain, Cancer patients commonly experience other unpleasant symptoms related to the cancer or its treatment, such as hot flushes, nausea, fatigue, vomiting and dry mouth. Many practitioners consider acupuncture to be a viable treatment option, particularly in the palliative care setting where there might be limited treatment options [2, 3]. Acupuncture is also advantageous because it is safe and free of the many unpleasant side-effects resulting from medication.
In 2004, NICE published guidance on improving supportive and palliative care for adults with cancer which recognised that a large proportion of patients with cancer used complementary therapies, including acupuncture, to manage distress, anxiety, pain and nausea associated with their condition . NICE did not make recommendations about individual complementary therapies but noted that there was weak evidence to support the use of acupuncture to alleviate pain and chemotherapy-related nausea and vomiting. Cancer Research UK includes a useful section on their website describing the uses of acupuncture for cancer-related symptoms, giving a review of past and current research and the findings of several systematic reviews. A summary of the evidence for the use of acupuncture to treat some of the major cancer-related symptoms is presented below:
Pain: At present, evidence from clinical research is promising but not definitive because there are too few high-quality studies. Systematic reviews, including a recently updated Cochrane Review, investigating the efficacy of acupuncture for cancer pain are largely inconclusive due to the quality of the evidence [2, 3, 5]. However, Hu et al.  conducted a larger systematic review and found that acupuncture combined with conventional drug therapy was more effective at relieving cancer-related pain than drug therapy on its own (although acupuncture on its own was not superior to drug therapy). Also, in 2017 another systematic review concluded that acupuncture can be effective as part of a multimodal approach for reducing cancer-related pain, even though there were limitations in the studies analysed . Using clinical reasoning and our knowledge of the mechanisms of acupuncture, it is possible to provide a persuasive rationale for using acupuncture to relieve pain associated with cancer, including cancer-induced-bone pain and breakthrough pain .
Nausea and vomiting: In 2006 Ezzo et al reviewed various Cochrane Reviews on the use of acupuncture point P6 for nausea and vomiting with a variety of causes and found promising results . Wu, et al  also reviewed 23 systematic reviews and found that there is evidence for the therapeutic effects of acupuncture for the management of cancer-related fatigue, chemotherapy-induced nausea and vomiting. However, in 2013, Towler et al.  reviewed 17 systematic reviews and although there was evidence that acupuncture relieved cancer-related nausea and vomiting the review was inconclusive because of the quality of the studies included in each review. Generally, there is some very promising evidence from studies looking at acupuncture for nausea and it should therefore be considered as one of the treatment options. The point P6 has been particularly recommended.
Vasomotor symptoms: There are some small studies which show that acupuncture is effective for hot flushes and there is clinical audit evidence to support it , but a systematic review by Lee et al  and a review of reviews by Towler et al  were inconclusive. A Cochrane review on acupuncture for menopausal hot flashes was also inconclusive . Nevertheless, some patients claim to benefit and studies have shown benefit to male and female patients using acupuncture [15, 16].
Xerostermia (dry mouth): Systematic reviews by O'Sullivan and Zhuang [17, 18] did not show that acupuncture was effective for dry mouth caused by radiotherapy of the head and neck. However, there is sufficient weak evidence from small studies to justify further research.
Fatigue, Anxiety and Sleep: Although research has not shown that acupuncture can help with anxiety and improve sleep in cancer patients , there has been some promising research indicating that it can improve chemotherapy-related tiredness or fatigue .
One of the problems faced by practitioners is knowing the correct 'dose' of acupuncture treatment to give and consequently there is variability in the selection of points, number of needles, depth of insertion, manipulation and stimulation of needles, the presence of 'de qi' and in the number and duration of treatment sessions . Acupuncture is a complex treatment intervention and optimum treatment characteristics are only partially known; therefore decisions on the points used, the number of needles, the presence of 'de qi' and the duration and frequency of treatment are made according to individual need and often based on the experience of the practitioner . In 2000 Ezzo et al. recommended that the minimum effective dose for acupuncture when used to alleviate chronic pain should be at least one treatment session of more than 20 minutes each week using at least 4 points .
Another problem facing practitioners is the limitation of acupuncture treatment options in cancer patients due to frailty, pain, the presence of lymphoedema and so on. It is important that safety guidelines are observed [23, 24] but the practitioner might also have to base point selection and other decisions around difficulties such as the comfortable positioning, the ease at which clothing might be removed and how long a patient can remain still. Often, it might be necessary to consider using only peripheral points, auricular points or points on the contralateral side in the presence of lymphoedema. The use of acupuncture will depend upon the individual patient, the level of pain and stage of the disease. It is important, therefore, that practitioners understand the mechanisms involved in acupuncture analgesia and use this knowledge to inform their practice.
Evaluating clinical evidence on acupuncture is challenging and can present a confusing picture for the health care professional. However, it is clear, from the available evidence, that acupuncture is safe and may be effective in relieving unpleasant symptoms in cancer patients arising from the cancer itself or from cancer treatments. It is useful as an adjunctive treatment for pain, dry mouth and chemotherapy-related fatigue. Even in the absence of conclusive evidence, there are small studies supporting its use alongside conventional treatments. When patients are deriving benefit from it, especially where treatment options are limited, the use of acupuncture use can be clinically justified.
Acupuncture is relatively inexpensive, safe and readily accessible and there is no doubt that some patients benefit from treatment. Therefore, acupuncture should continue to be considered as a treatment option in addition to standard regimes until strong evidence from clinical research concludes otherwise.
1. van den Beuken-van Everdingen, M.H.J., et al., Prevalence of pain in patients with cancer: a systematic review of the past 40 years. Annals of oncology : official journal of the European Society for Medical Oncology / ESMO, 2007. 18(9): p. 1437-49.
2. Lian, W.-L., et al., Effectiveness of acupuncture for palliative care in cancer patients: a systematic review. Chinese Journal Of Integrative Medicine, 2014. 20(2): p. 136-147.
3. Towler, P., A. Molassiotis, and S.G. Brearley, What is the evidence for the use of acupuncture as an intervention for symptom management in cancer supportive and palliative care: an integrative overview of reviews. Supportive Care In Cancer: Official Journal Of The Multinational Association Of Supportive Care In Cancer, 2013. 21(10): p. 2913-2923.
4. National Institute for Health and Care Excellence, N., Improving supportive and palliative care for adults with cancer. Cancer service guideline [CSG4]. 2004. p. 1-204.
5. Paley, C.A., et al., Acupuncture for cancer pain in adults. Cochrane Database of Systematic Reviews, 2015(10).
6. Hu, C., et al., Acupuncture for Pain Management in Cancer: A Systematic Review and Meta-Analysis. Evid Based Complement Alternat Med, 2016. 2016: p. 1720239.
7. Chiu, H.Y., Y.J. Hsieh, and P.S. Tsai, Systematic review and meta-analysis of acupuncture to reduce cancer-related pain. European Journal Of Cancer Care, 2017. 26(2).
8. Paley, C.A., M.I. Bennett, and M.I. Johnson, Acupuncture for cancer-induced bone pain? Evid Based Complement Alternat Med, 2011. 2011: p. 671043.
9. Ezzo, J., K. Streitberger, and A. Schneider, Cochrane systematic reviews examine P6 acupuncture-point stimulation for nausea and vomiting. Journal Of Alternative And Complementary Medicine (New York, N.Y.), 2006. 12(5): p. 489-495.
10. Wu, X., et al., Effectiveness of acupuncture and related therapies for palliative care of cancer: overview of systematic reviews. Scientific Reports, 2015. 5: p. 16776-16776.
11. Towler, P., A. Molassiotis, and S.G. Brearley, What is the evidence for the use of acupuncture as an intervention for symptom management in cancer supportive and palliative care: an integrative overview of reviews. Support Care Cancer, 2013. 21(10): p. 2913-23.
12. Filshie, J., et al., Acupuncture and self acupuncture for long term treatment of vasomotor symptoms in Cancer patients - audit and treatment algorithm. Acupuncture in Medicine, 2005. 23(4): p. 171-180.
13. Lee, M.S., et al., Acupuncture for treating hot flashes in breast cancer patients: a systematic review. Breast Cancer Research And Treatment, 2009. 115(3): p. 497-503.
14. Weihua, L. and G. Qing, Acupuncture for menopausal hot flashes. Clinical Journal Of Oncology Nursing, 2015. 19(2): p. 230-231.
15. Harding, C., A. Harris, and D. Chadwick, Auricular acupuncture: a novel treatment for vasomotor symptoms associated with luteinizing-hormone releasing hormone agonist treatment for prostate cancer. BJU International, 2009. 103(2): p. 186-190.
16. Walker, E.M., et al., Acupuncture versus venlafaxine for the management of vasomotor symptoms in patients with hormone receptor-positive breast cancer: a randomized controlled trial. Journal Of Clinical Oncology: Official Journal Of The American Society Of Clinical Oncology, 2010. 28(4): p. 634-640.
17. O'Sullivan, E.M. and I.J. Higginson, Clinical effectiveness and safety of acupuncture in the treatment of irradiation-induced xerostomia in patients with head and neck cancer: a systematic review. Acupuncture In Medicine: Journal Of The British Medical Acupuncture Society, 2010. 28(4): p. 191-199.
18. Zhuang, L., et al., The preventive and therapeutic effect of acupuncture for radiation-induced xerostomia in patients with head and neck cancer: a systematic review. Integrative Cancer Therapies, 2013. 12(3): p. 197-205.
19. Garcia, M.K., et al., Systematic review of acupuncture in cancer care: a synthesis of the evidence. Journal Of Clinical Oncology: Official Journal Of The American Society Of Clinical Oncology, 2013. 31(7): p. 952-960.
20. Ling, W.-M., et al., Effects of acupuncture and acupressure on cancer-related fatigue: a systematic review. Oncology Nursing Forum, 2014. 41(6): p. 581-592.
21. White, A., et al., Defining an adequate dose of acupuncture using a neurophysiological approach--a narrative review of the literature. Acupunct Med, 2008. 26(2): p. 111-20.
22. Ezzo, J., et al., Is acupuncture effective for the treatment of chronic pain? A systematic review. Pain, 2000. 86(3): p. 217-25.
23. Filshie, J. and J. Hester, Guidelines for providing acupuncture treatment for cancer patients - a peer-reviewed sample policy document. Acupuncture in Medicine, 2006. 24(4): p. 172-182.
24. AACP, AACP guidelines for safe practice. 2007: AACP Ltd.
Written by Carole A Paley; PhD
Carole has a background in sports science and sports medicine and then qualified as a physiotherapist in 1995. After specialising in musculoskeletal physiotherapy she became interested in pain and in particular the non-pharmacological treatment of pain and cancer pain. She has practiced acupuncture for over 15 years and is a member of the AACP. She received her PhD in 2013 after a programme of study entitled 'Acupuncture for Cancer Pain in Adults'. Since the start of her PhD she has published a number of journal articles, a Cochrane review and contributed to book chapters on the physiology of cancer pain and its treatment using acupuncture. Carole currently works at Airedale NHS Foundation Trust as Head of Research.