BACKGROUND: Pain is one of the most common and problematic symptoms encountered by patients with cancer. Due to the multifactorial aetiology, pain management of these patients frequently requires multidisciplinary interventions including conventional support and specialty palliative care. Acupuncture has been identified as a possible adjunctive therapy for symptom management in cancer pain, and there is currently no systematic review focused solely on the evidence of acupuncture on cancer pain in palliative care.
OBJECTIVE: To critically analyse currently available publications regarding the use of acupuncture for pain management among patients with cancer in palliative care settings.
METHODS: Multiple academic databases were searched from inception to 29 October 2020. Randomised controlled trials involving acupuncture in palliative care for treatment of cancer-related pain were synthesised. Data were extracted by two independent reviewers, and methodological quality of each included study was assessed using the Oxford Centre for Evidence-Based Medicine (OCEBM) 2011 Levels of Evidence.
RESULTS: Five studies (n=189) were included in this systematic review. Results indicated a favourable effect of acupuncture on pain relief in palliative care for patients with cancer. According to OCEBM 2011 Levels of Evidence, they were level 2 in one case (20%), level 3 in two cases (40%) and level 4 in the remaining (40%). Low-level evidence adversely affects the reliability of findings.
CONCLUSIONS: Acupuncture may be an effective and safe treatment associated with pain reduction in the palliative care of patients with cancer. Further high-quality, adequately powered studies are needed in the future.
INTRODUCTION: Nausea and vomiting are common symptoms for patients with advanced cancer. While there is evidence for acupuncture point stimulation for treatment of these symptoms for patients having anticancer treatment, there is little for when they are not related to such treatment.
OBJECTIVE: To determine whether acupressure at the pericardium 6 site can help in the treatment of nausea and vomiting suffered by palliative care patients with advanced cancer.
MATERIALS AND METHODS: Double blind randomised controlled trial-active versus placebo acupressure wristbands. In-patients with advanced cancer in two specialist palliative care units who fitted either or both of the following criteria were approached: Nausea that was at least moderate; Vomiting daily on average for the prior 3 days.
RESULTS: 57 patients were randomised to have either active or placebo acupressure wristbands. There was no difference in any of the outcome measures between the two groups: change from baseline number of vomits; Visual Analogue Scale for 'did acupressure wristbands help you to feel better?'; total number of as needed doses of antiemetic medication; need for escalation of antiemetics.
CONCLUSIONS: In contrast to a previously published feasibility study, active acupressure wristbands were no better than placebo for specialist palliative care in-patients with advanced cancer and nausea and vomiting.
Background: Acupuncture is one of the fastest developing evidence bases in Complementary Medicine and is one of the leading therapies included within integrative health care. This narrative review includes two separate parts: the first is about evaluation of the current evidence status in reviews on acupuncture and the second examines and gives examples of available recommendations on acupuncture in treatment guidelines from health care experts and public health organizations recommending acupuncture as a viable treatment in patients in palliative care.
Methods: Electronic searches were performed in PubMed using the terms "acupuncture" + "palliative" and adding the term "safety" to find review articles documenting safety and evidence of effectiveness of acupuncture for treatment of symptoms in palliative care patients. Treatment guidelines that recommend use of acupuncture for symptom control in palliative care were found by searching through a database currently under construction by the lead author.
Results: Acupuncture shows emerging evidence for 17 indications in palliative care. Examples were found and presented of publications recommending acupuncture for treatment of symptoms for patients in palliative care from Government, public health, oncology, and medical expert sources. The most publications are in oncology, but other conditions were found and a number were found in pediatric care.
Conclusions: While the evidence for use of acupuncture to treat symptoms in palliative care patients is relatively weak, the evidence base is growing. Experts worldwide are also increasingly recommending acupuncture as a treatment for symptoms in palliative care. Since acupuncture is a safe, nonpharmacological treatment but with small, clinically significant effects, these recommended uses appear as pragmatic efforts to bridge the gap of treatment options available to this patient group.
Objectives: Existing evidence supports the use of certain Chinese medicine (CM) interventions for symptom management among palliative cancer patients. However, evidence-based service recommendations tailored to the local context are needed for CM planning and implementation. In response, we aimed to establish consensus on CM clinical service recommendations for cancer palliative care among Hong Kong experts. Methods: Seven CM interventions showing statistically significant favorable results in existing systematic reviews (SRs) and overviews of SRs were subjected to a GRADE-ADOLOPMENT-based 2-round Delphi survey. Twelve Hong Kong experts in cancer palliative care, including conventionally trained physicians, CM practitioners, and nurses (n = 4 from each category), were invited to participate. Use of the Evidence to Decision framework within the GRADE-ADOLOPMENT approach enabled experts to consider aspects of problem priority, benefits, harms, equity, acceptability, and feasibility when making CM recommendations in cancer palliative care.
Results: Three evidence-based CM interventions reached positive consensus as service recommendations, namely: (1) acupuncture for reducing fatigue among palliative cancer patients; (2) acupressure for reducing fatigue among palliative cancer patients; and (3) moxibustion for reducing nausea and vomiting among patients receiving chemotherapy. Median rating of recommendation ranged from 2.5 to 3.0 (interquartile range = 0.00-1.00) on a 4-point Likert-type scale, and the percentage agreement ranged from 83.4% to 91.7%.
Conclusions: The GRADE-ADOLOPMENT approach facilitates a consensus-based process of reaching 3 evidence-based CM recommendations for cancer palliative care. Future studies may develop tailored strategies to implement these recommendations in the Hong Kong health system.
Context: Nonpharmacological approaches are effective strategies for difficult to palliate breathlessness. Although acupuncture is effective for dyspnea in early-stage chronic obstructive pulmonary disease (COPD), little is known about its effects in patients with advanced (non)malignant diseases.
Objectives: The objective of this study was to identify and examine the evidence of acupuncture on breathlessness in advanced malignant and nonmalignant diseases.
Methods: Systematic literature review of randomized controlled trials of acupuncture and acupressure searched in five databases. Included were adult participants with at least 25% having advanced diseases such as cancer or COPD with severe breathlessness. Primary outcome was severity of dyspnea on Visual Analogue Scale or Borg Scale. Secondary outcomes included quality of life, function, and acceptability. Data were pooled using a random effects model of standardized mean differences.
Results: Twelve studies with 597 patients (347 COPD, 190 advanced cancer) were included. For breathlessness severity, significant differences were obtained in a meta-analysis (10 studies with 480 patients; standardized mean difference (SMD) = -1.77 [95% CI -3.05, -0.49; P = 0.007; I2 = 90%]) and in a subgroup analysis of using sham acupuncture control groups and a treatment duration of at least three weeks (6 studies with 302 patients; SMD = -2.53 [95% CI -4.07, -0.99; P = 0.001; I2 = 91%]). Exercise tolerance (6-minute walk test) improved significantly in the acupuncture group (6 studies with 287 patients; SMD = 0.93 [95% CI 0.27, 1.59; P = 0.006; I2 = 85%]). In four of six studies, quality of life improved in the acupuncture group.
Conclusion: Acupuncture improved breathlessness severity in patients with advanced diseases. The methodological heterogeneity, low power, and potential morphine-sparing effects of acupuncture as add-on should be further addressed in future trials.
INTRODUCTION: Almost all patients with end-of-life cancer experience cancer-related fatigue; however, there are only a few known effective coping methods.
OBJECTIVES: We will conduct a prospective, multi-center, single-blinded randomized controlled study to evaluate the efficacy of acupuncture for cancer-related fatigue in patients with end-of-life cancer.
METHODS: We will enroll 120 patients with cancer hospitalized in a palliative care unit or receiving consultation from a palliative care team in four hospitals. We will add acupuncture treatment; specifically, contact needle therapy (CNT), consisting of an intervention per week period to the usual care. The primary outcome measure will be the Cancer Fatigue Scale (CFS) score while the secondary outcome measures will be the Numerical Rating Scale (NRS) score for fatigue, pain, and salivary amylase levels.
CONCLUSION: We will evaluate the possibility of using acupuncture therapy, that is, CNT, in relieving fatigue sensation in patients with advanced cancer.
TRIAL REGISTRATION: UMIN000028304, registered on July 21st, 2017; https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000032401.
CONTEXT: Chinese medicine modalities, including acupuncture and Chinese herbal medicine (CHM), have been used as palliative interventions among cancer patients. More research should be conducted to confirm their effectiveness.
OBJECTIVES: To prioritize Chinese medicine clinical research questions for cancer palliative care.
METHODS: Twelve international experts, including physicians, Chinese medicine practitioners, nurses and clinical research methodologists (n=3 from each category) from Asia, North America, Australia and Europe participated in a two-round Delphi survey for prioritizing 29 research questions identified from existing systematic reviews. The experts were asked to i) rate clinical importance of answering the questions on a 9-point Likert scale; ii) provide qualitative comments on their ratings; and iii) suggest outcome measurement approaches.
RESULTS: Eight research priorities reached positive consensus after the two-round Delphi survey. Six of the priorities focused on acupuncture and related therapies; of which median ratings on importance ranged from 7.0 to 8.0 (interquartile range (IQR): 1.00 to 2.50), and the percentage agreement ranged from 75.0% to 91.7%. The remaining two priorities related to CHM; with median ratings ranged from 7.0 to 8.0 (IQR: 1.00 to 1.50), with percentage agreement ranged from 75.0% to 83.3%. Neither positive nor negative consensus was established among the remaining 21 questions.
CONCLUSION: The findings will inform rational allocation of scarce research funding for evaluating the effectiveness of Chinese medicine for cancer palliative care, especially on acupuncture and related therapies. Further research on herb safety and herb-drug interaction should be performed before conducting international trials on CHM.
OBJECTIVE: Studies suggest acupuncture improves cancer-related symptoms; however, it is unclear whether patient characteristics predict pain response. This study determined acupuncture's effect on cancer-related pain and identified variables associated with pain response.
METHODS: A retrospective chart review included adult patients with cancer referred to palliative medicine and received acupuncture for pain management. Paired t tests compared differences in pain scores from pre- to postacupuncture. Clinically meaningful pain improvement was defined as =2-point reduction in pain score. Logistic regression was used to evaluate associations between patient characteristics and pain improvement.
RESULTS: One hundred seventy acupuncture treatments from 68 individual patients were studied. Significant reductions in mean pain scores were observed after the first treatment (-1.9 ± 1.8; P < .001) and across all treatments (-1.7 ± 1.9; P < .001). Multivariable analysis demonstrated clinically meaningful pain improvement with higher baseline pain scores (odds ratio [OR]: 1.79, 95% confidence interval [CI]: 1.44-2.22; P < .001) and stage III/IV disease (OR: 3.23, 95% CI: 1.11-9.40; P < .001). There were significant improvements in anxiety, depression, drowsiness, dyspnea, fatigue, nausea, and well-being after the first treatment and across all treatments ( P < .001).
CONCLUSIONS: Acupuncture improved cancer-related pain and other symptoms. Those with higher baseline pain scores and advanced disease were more likely to achieve significant pain reduction. Improved depression and fatigue were closely related to pain reduction. Further studies are needed to confirm pain response variables, establish durability, and develop a personalized approach to acupuncture.
A 66-year-old female patient was diagnosed with hepatocellular carcinoma accompanied by neuropathic pain induced by a metastatic tumor that compromised root and spinal canal. Although her pain was relieved following medical treatment, breakthrough pain occurring 1-2 times a day was still distressing. Neuropathic pain in her right lower limb caused discomfort and irritability and decreased her quality of life. We had limited options to adjust her prescription drug regime, due to the side effect of these drugs. Although acupuncture therapy was only performed at her home once a week, the efficacy was outstanding. The patient did not report any further instances of breakthrough pain, and she did not require additional bolus morphine. She could comfortably live in her familiar surroundings with her family and did not require any emergency room visits or admission into the hospital during the last month of her life. She had excellent quality of life in the terminal period of her life, and could even participate in a family function during this time. The present case report suggests that acupuncture may have a role in treating neuropathic pain induced by bone metastasis in patients with advanced cancer across clinical and in-home settings.
Whilst acupuncture has the potential to impact on many aspects of health and well-being, including end-of-life care, there is little research regarding patients' experiences of its effects within the context of palliative care in hospice settings. The aim of this study was to address this gap, by exploring patients' experiences of acupuncture within this setting. In-depth, semi-structured interviews were conducted with a sample of eighteen patients who had received acupuncture as part of hospice care. Transcription of data, with thematic analysis, identified two overarching themes: (1) participant perceptions of the effects of acupuncture including pain control, improved physical and emotional health, spiritual well-being and awareness of health as a holistic phenomenon; and (2) factors which participants believed enabled acupuncture to have these effects including the quality of the practitioner relationship, engagement of participants in the process of their treatment and prior expectations that acupuncture could work. Acupuncture was found to be a highly acceptable, accessible and popular treatment with positive holistic effects reported across the domains of physical, mental and spiritual health and no serious adverse effects. By enabling awareness of the holistic nature of health and well-being, acupuncture was experienced as having the potential to contribute to a better death, an emergent theory that needs testing in further studies. In the meanwhile, the results of this study offer encouragement to hospices currently providing or considering investing in acupuncture provision.
The use of complementary and alternative medicine methods such as acupuncture in palliative care has increased over the past years. Well-planned trials are warranted to show its effectiveness in relieving distressing symptoms. The development of treatment schemes to be used in the trial for both acupuncture and medical symptom control is challenging, as both acupuncture and palliative care are highly individualized. Thus, standardized care plans of a randomized controlled trial will have difficulties in producing treatment results that compare to the clinical practice. As an alternative, treatment protocols for both acupuncture and medical symptom control of dyspnea, pruritus, hypersalivation, depression, anxiety, and xerostomia were designed with the input of experts. They are designed to provide sufficient symptom control and comparability for a three-arm, randomized controlled trial. Medical symptom control will be provided to all groups. The two control groups will be medical treatment and sham-laser acupuncture.
L'auteure définit la douleur cancéreuse, donne quelques bases pour comprendre cette douleur et dresse la classification des antalgiques impliqués dans le traitement de la douleur cancéreuse. Elle décrit ensuite la conduite pratique d'un traitement morphinique, d'un traitement des douleurs neuropathiques, d'un bloc nerveux et d'un traitement des douleurs des métastases osseuses. Enfin, elle évoque les thérapeutiques alternatives à la fin de la vie.
Ce chapitre est consacrée à la douleur et son traitement. En premier lieu, les auteurs traitent la physiopathologie de la douleur. En deuxième lieu, ils abordent les échelles d'évaluation. En troisième lieu, les auteurs décrivent le traitement antalgique de la douleur puis les techniques antalgiques en quatrième lieu. Viennent ensuite les pratiques alternatives telles que l'hypnose, l'auriculothérapie et l'acupuncture en fin de vie en cinquième, sixième et septième lieux respectivement.
Nouvelle édition de la "bible" des soins palliatifs, appellé couramment le "Lamau", du nom de la première directrice de publication de ce manuel, coordonné par Dominique Jacquemin et Didier de Broucker. Ce livre se veut un guide des soins palliatifs à dispenser aux personnes en fin de vie. Il donne un panorama des connaissances thérapeutiques, fait le point sur la rencontre et l'accompagnement humain, psychique et relationnel, et offre une contextualisation des soins palliatifs dans leur dimension sociale, sanitaire et politique.
La dyspnée est un symptôme fréquent chez les patients atteints de cancer. L'acupuncture permet-elle de réduire ce symptôme ? Un essai contrôlé randomisé comprenant 47 malades a été mis en place afin de tester l'efficacité de ce traitement.
L’auteur, spécialisé en thérapies complémentaires au St Christopher's Hospice (Londres), présente les bienfaits de ces thérapies sur les patients en phase terminale, à travers le témoignage de deux patients qui ont ressenti un soulagement temporaire mais significatif de leurs douleurs. En soins palliatifs, les thérapies complémentaires les plus fréquemment utilisées sont basées sur le toucher (massages, réflexologie…) ou le mental (relaxation, méditation, visualisation…). Par la détente qu’elles apportent, elles peuvent aider les patients à faire face physiquement et mentalement aux symptômes douloureux et aux situations stressantes liées à la fin de vie.
Nouvelle édition de la "bible" des soins palliatifs, appellé couramment le "Lamau", du nom de la première directrice de publication de ce manuel, coordonnée par Dominique Jacquemin et Didier de Brouek. Entièrement remaniée, cette troisième édition se veut en phase avec la nouvelle dynamique de formation en soins palliatifs (Diplômes Universitaires et Inter-Universitaires en soins palliatifs, formation continue, DESC douleur et soins palliatifs, etc. ...) et propose de faire un large point sur les connaissances thérapeutiques nécessaires à la prise en charge du patient en soins palliatifs, quelque soit son âge, sa pathologie et son lieu de soin. Son objectif consiste également à offrir des points de connaissances et d'appui concernant la dimension pluridisciplinaire des soins et de la connaissance du patient et de son entourage, avant d'envisager les questions ethiques transversales vis-à vis des évolutions législatives.
Il s'agit d'un commentaire sur le voyage d'étude sur le système médical en Chine ; il a duré deux semaines pour 20 professionnels de santé qui travaillent dans le domaine des soins palliatifs. Quatre thèmes sont présentés : attitude des chinois face à la mort, organisation des services de santé, prise en charge de la fin de vie et différents aspects de la médecine traditionnelle chinoise.