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This information is produced and provided by the National Cancer Institute (NCI). The information in this topic may have changed since it was written. For the most current information, contact the National Cancer Institute via the Internet web site at http://cancer.gov or call 1-800-4-CANCER.
This complementary and alternative medicine (CAM) information summary provides an overview of the use of acupuncture as a treatment for individuals with cancer or cancer-related disorders. The summary includes a brief history of acupuncture practice, a review of laboratory and animal studies, the results of clinical observations and trials, and possible side effects of acupuncture therapy. Information presented in some sections of the summary can also be found in tables located at the end of those sections.
This summary contains the following key information:
Many of the medical and scientific terms used in this summary are hypertext linked (at first use in each section) to the NCI Dictionary of Cancer Terms, which is oriented toward nonexperts. When a linked term is clicked, a definition will appear in a separate window.
Reference citations in some PDQ CAM information summaries may include links to external Web sites that are operated by individuals or organizations for the purpose of marketing or advocating the use of specific treatments or products. These reference citations are included for informational purposes only. Their inclusion should not be viewed as an endorsement of the content of the Web sites, or of any treatment or product, by the PDQ Cancer CAM Editorial Board or the National Cancer Institute.
Acupuncture, a complementary and alternative therapy used in cancer management,[1,2,3,4] has been used clinically to manage cancer-related symptoms, treat side effects induced by chemotherapy or radiation therapy, boost blood cell count, and enhance lymphocyte and natural killer (NK) cell activity. In cancer treatment, its primary use is symptom management; commonly treated symptoms are cancer pain,[4,5] chemotherapy-induced nausea and vomiting (N/V),[6,7] and other symptoms that affect a patient's quality of life, including weight loss, anxiety, depression, insomnia, poor appetite, xerostomia, hot flashes, peripheral neuropathy, and gastrointestinal symptoms (constipation and diarrhea).[8,9,10] Acupuncture is acceptable and safe for children.
More than 40 states and the District of Columbia have laws regulating acupuncture practice. The National Certification Commission for Acupuncture and Oriental Medicine offers national certification examinations for practitioners of acupuncture and traditional Chinese medicine (TCM) (www.nccaom.org); most, but not all, states require this certification. More than 50 schools and colleges of acupuncture and Oriental medicine operate in the United States, many of which offer master's-level programs and are accredited by or have been granted candidacy status by the Accreditation Commission for Acupuncture and Oriental Medicine (ACAOM). ACAOM standards for a master's-level degree require a 3-year program (approximately 2,000 hours of study) for acupuncture and a 4-year program for Oriental medicine, which includes acupuncture and herbal therapy (www.ACAOM.org). In recent years, some schools have begun to offer programs for Doctor of Acupuncture and Oriental Medicine with an additional 1,200 hours of clinical-based doctoral training. Some Western medical training, including the study of anatomy, physiology, and clean-needle technique is included in the curriculums of these schools. Postgraduate training programs in medical acupuncture for physicians also exist. In the United States, training to be a licensed acupuncturist is regulated according to individual state law. Because the educational and licensing requirements for acupuncture practice vary from state to state, one should inquire from each state board of acupuncture (or other relevant board) for particular information (www.nccaom.org). Third-party reimbursements also vary from state to state. Some insurance companies cover acupuncture or limited acupuncture treatment. Federal payers such as Medicare do not generally reimburse for acupuncture treatment.
Acupuncture has been practiced in China and other Asian countries for more than 4,000 years.[12,13,14] In China, acupuncture is part of a TCM system of traditional medical knowledge and is practiced along with other treatment modalities such as herbal medicine, tui na (massage and acupressure), mind/body exercise (e.g., qigong and tai chi), and dietary therapy.[15,16] In the United States, several different acupuncture styles are practiced in addition to TCM. These include Japanese acupuncture (e.g., meridian therapy), English acupuncture (e.g., five element or traditional acupuncture), French acupuncture (e.g., French energetic acupuncture), Korean acupuncture (e.g., constitutional acupuncture), and American medical acupuncture. Most of these are derived from ancient Chinese medical philosophy and practices. All are based on the view that the human body must be perceived and treated as a whole and as part of nature; health is the result of harmony among bodily functions and between the body and nature, and disease occurs when this harmony is disrupted. TCM therapeutic interventions, including acupuncture are used to restore the state of harmony.
Acupuncture is closely associated with Chinese meridian theory. According to this theory, there are 12 primary meridians, or channels, and eight additional meridians, each following a particular directional course along the body. A vital energy known as qi flows through these meridians and participates in the homeostatic regulation of various bodily functions. Along the meridians are approximately 360 points that serve as both pathognomonic signs of disorder and as loci for acupuncture treatments.[14,17] When the normal flow of energy over a meridian is obstructed (e.g., as a result of tissue injury or a tumor), pain or other symptoms result. Chinese medicine proposes that the purpose of acupuncture therapy is to normalize energy flow, thereby relieving the symptoms by stimulating specific sites (acupuncture points) on the meridians. In acupuncture treatment, stainless steel needles, usually ranging from 0.22 mm to 0.25 mm in diameter, are inserted into relevant acupuncture points to stimulate the affected meridians. A needling sensation known as de qi sensation occurs, in which the patient may feel heaviness, numbness, or tingling during an acupuncture treatment. Length and frequency of treatment vary according to the condition being treated. Chronic conditions usually require a longer treatment period. Typically, two or three sessions per week are required initially and may decrease to once a week after several weeks of treatment. Needles are typically left in place for 15 to 30 minutes after insertion, and their effects may be augmented with manual or electrical stimulation and/or heat (e.g., moxibustion or heat lamps).
Classical techniques of acupuncture include needling, moxibustion, and cupping. Acupressure, using fingers or mechanical devices to apply pressure on acupuncture points is based on the same principles as acupuncture. Moxibustion is a method in which an herb (Artemisia vulgaris) is burned above the skin or on an acupuncture point for the purpose of warming it to alleviate symptoms. Cupping promotes blood circulation and stimulates acupuncture points by creating a vacuum or negative pressure on the surface of the skin. During the past several decades, various new auxiliary devices have been developed. Acupuncture devices such as electroacupuncture (EA) machines and heat lamps are commonly used to enhance the effects of acupuncture.
In addition to classical acupuncture techniques, other techniques have been developed and are sometimes used in cancer management. These include trigger point acupuncture, laser acupuncture, acupuncture point injection, and techniques focusing on particular regions of the body: auricular acupuncture, scalp acupuncture, face acupuncture, hand acupuncture, nose acupuncture, and foot acupuncture. Of these, auricular acupuncture is the most commonly used.
In clinical practice, most acupuncturists in the United States follow the traditional theories and principles of Chinese medicine. However, there are other schools of acupuncture practice, including medical acupuncture, which have different theories regarding meridians and acupuncture point locations.
Although acupuncture has been practiced for millennia, it has come under scientific investigation only recently. In 1976, the U.S. Food and Drug Administration (FDA) classified acupuncture needles as investigational devices (Class III) (www.fda.gov), resulting in a number of research studies on the effectiveness and safety of acupuncture. In November 1994, the Office of Alternative Medicine (the predecessor of the National Center for Complementary and Alternative Medicine) at the National Institutes of Health (NIH) sponsored an NIH-FDA workshop on the status of acupuncture needle usage. Two years later, the FDA reclassified acupuncture needles as medical devices (Class II) without, however, giving specific indications for their use. In 1997, NIH held a Consensus Development Conference on Acupuncture to evaluate its safety and efficacy. The 12-member panel concluded that promising research results showing the efficacy of acupuncture in certain conditions have emerged and that further research is likely to uncover additional areas in which acupuncture intervention will be useful. The panel stated that "there is clear evidence that needle acupuncture treatment is effective for postoperative and chemotherapy N/V." It also stated that there are "a number of other pain-related conditions for which acupuncture may be effective as an adjunct therapy, an acceptable alternative, or as part of a comprehensive treatment program," and it agreed that further research is likely to uncover additional areas in which acupuncture intervention will be useful.
These actions by the FDA and NIH have resulted in the establishment of a number of active programs of research into the mechanisms and efficacy of acupuncture, much of which is, or is potentially, relevant to cancer management. To date, the most extensively investigated aspect of these mechanisms has been the effect of acupuncture on pain management. The NIH Consensus Panel concluded that "acupuncture can cause multiple biological responses," local and distal, "mediated mainly by sensory neurons…within the central nervous system." Acupuncture "may also activate the hypothalamus and the pituitary gland, resulting in a broad spectrum of systemic effects," including "alterations in peptides, hormones and neurotransmitters and the regulation of blood flow." Recent studies show the effect of acupuncture on chronic inflammatory pain.[21,22] Evidence suggests that acupuncture operates through the autonomic nervous system to balance the sympathetic and parasympathetic systems and suggests that the anti-inflammatory effects of acupuncture are mediated by its electrophysiologic effects on neurotransmitters, cytokines, and neuropeptides.[1,22,23,24,25,26,27,28,29,30,31] Many studies provide evidence that opioid peptides are released during acupuncture and that acupuncture analgesia is mediated by the endogenous opioid system.[32,33]
Laboratory and animal cancer studies exploring the mechanisms of acupuncture have focused mainly on the activation and modulation of the immune system. Acupuncture treatment points are located by using standard anatomic landmarks and comparative anatomy. EA is the most commonly used treatment intervention; a few studies have used moxibustion. These studies show that acupuncture may boost animal immune function by enhancing NK cell and lymphocyte activity.[34,35,36] According to one animal study, acupuncture may be a useful adjuvant for suppressing chemotherapy-induced emesis.
Although several studies published in China examined the effect of acupuncture on the human immune system,[8,29,32,38,39,40,41] most cancer-related human clinical studies of acupuncture evaluated its effect on patient quality of life. These investigations mainly focused on cancer symptoms or cancer treatment–related symptoms, predominantly cancer pain [10,23,42,43,44,45,46] and chemotherapy-induced N/V.[25,27,47,48,49,50,51,52,53,54,55] Studies have also been done on the effect of acupuncture on radiation -induced xerostomia (dry mouth), proctitis, dysphonia, weight loss, cough, thoracodynia, hemoptysis, fever, esophageal obstruction, poor appetite, night sweats, hot flashes in women and men, dizziness, fatigue, anxiety, and depression in cancer patients.[8,9,10,57,58,59,60] The evidence from most of these clinical studies is inconclusive, despite their positive results; either poor research design or incompletely described methodologic procedures limit their value. There is controversy about the most appropriate control for acupuncture, which also limits the interpretability of the results of clinical trials. The positive results of the studies on chemotherapy-induced N/V, which benefit from scientifically sound research designs, are the most convincing.
The generally accepted history of acupuncture /moxibustion (known as zhen jiu) is part of traditional Chinese medicine (TCM), an indigenous, coherent system of medicine that has been practiced in China for thousands of years. The history of acupuncture/moxibustion in China can be traced back archeologically at least 4,000 years, when bian (stone needles) were in use. During the long history of recorded practice, acupuncture has been applied to many disorders. The earliest written medical text, the ancient classic Huang Di Nei Jing (Yellow Emperor's Inner Classic, second century BC), records nine types of needles and their therapeutic functions.
The dissemination of acupuncture and TCM to other regions dates back centuries: first to Korea and Japan and then to other Asian countries. The use of acupuncture in Europe was documented in the middle of the 16th century. The relatively brief history of acupuncture in the United States can be traced back about 200 years, when Dr. Franklin Bache published a report in the North American Medical and Surgical Journal on his use of acupuncture to treat lower back pain. However, until the 1970s, when U.S.–Chinese diplomatic ties were resumed, the practice of acupuncture in this country was mainly limited to Chinatowns.
For centuries, Chinese acupuncturists treated cancer symptomatically. Ancient literature and acupuncture textbooks classify cancer as a Zheng syndrome or blood stasis condition and document acupuncture treatment principles and methods.[5,6,7] Since the development of modern conventional medicine, acupuncture has primarily been used clinically as an adjunct to conventional cancer treatment.
At least seven animal studies investigating the effects of acupuncture in cancer or cancer-related conditions have been reported in the scientific literature.[1,2,3,4,5] Two of the studies were conducted in China, one of which was published in Chinese with an English abstract. One study was conducted in Japan, one in Sweden, and one in the United States. Four of the studies were ex vivo laboratory investigations using blood samples or tissues; [1,2,3,5] the remaining study was an animal behavioral study testing the effect of acupuncture on chemotherapy -induced nausea and vomiting. 
The four ex vivo studies suggested that acupuncture is useful in anticancer therapy either by actively stimulating immune activity or by preventing chemotherapy suppression of immune activity.
In a study involving normal rats, electroacupuncture (EA) (1 Hz, 5–20 V, 1-millisecond pulse width, 2 hours) applied at the point Tsu-Sanli (S36) for 2 hours daily on 3 consecutive days enhanced the cytotoxicity of splenic natural killer (NK) cells compared with a stimulation of a nonacupuncture control point in the abdominal muscle.
Another study found that NK cell activity and T-lymphocyte transformation rate were increased in a mouse model of transplanted mammary cancer compared with a control (P < .05) after eight sessions of acupuncture and moxibustion.
A study involving tumor -bearing mice (sarcoma S180) using moxibustion to warm the acupuncture point Guanyuan (CV4) once a day for 10 days found significantly increased production of erythrocytes, compared with a nontreatment control.
The fourth ex vivo study used a rat model to investigate the effect of EA on nerve growth factor (NGF), which is associated with polycystic ovary syndrome (PCOS). Women with PCOS have an increased risk of endometrial cancer and other diseases. Repeated EA treatments (12 treatments administered over 30 days) in PCO rats significantly lowered the concentrations of NGF in the ovaries, compared with untreated PCO rats.
A study of cyclophosphamide -induced emesis in a ferret behavioral model used acupuncture as an adjunct therapy in treating the emetic side effects of chemotherapy. EA at 100 Hz, 1.5 V, for 10 minutes in combination with subeffective doses of antiemetics such as ondansetron (0.04 mg/kg), droperidol (0.25 mg/kg), and metoclopramide (2.24 mg/kg) significantly reduced the total number of emetic episodes by 52%, 36%, and 73%, respectively (P < .01), in this ferret model.
A rat model has been established by injecting AT-3.1 prostate cancer cells into the tibia of the adult male Copenhagen rat, which closely mimics prostate cancer-induced bone cancer pain. The cancer-caused pain was treated with 10 Hz EA for 30 minutes a day at acupuncture point gallbladder 30 (GB30) from days 14 to 18 after cancer-cell injection. For sham control, EA needles were inserted into GB30 without stimulation. Thermal hyperalgesia, a decrease in paw withdrawal latency to a noxious thermal stimulus, and mechanical hyperalgesia, a decrease in paw withdrawal pressure threshold, were measured at baseline and 20 minutes after EA. EA significantly attenuated the hyperalgesia compared with sham control. Moreover, the EA inhibited up-regulation of preprodynorphin mRNA and dynorphin as well as interleukin-1beta (IL-1beta) and its mRNA compared with sham control. Intrathecal injection of antiserum against dynorphin A (1–17) and IL-1 receptor antagonist significantly inhibited the cancer-induced hyperalgesia. These data suggests that EA alleviates bone cancer pain at least in part by suppressing spinal dynorphin and IL-1beta expression.[7,8]
Another cutaneous cancer pain model has been established by injecting B16-BL6 melanoma cells into the plantar region of one hind paw of C57BL/6 mice. A single EA treatment showed significant analgesia on day 8 but not on day 20. EA treatments once every other day starting on day 8 showed analgesia at day 20, but EA starting on day 16 did not. The results indicate that EA exerts antihyperalgesic effects on early stage but not on late stage cutaneous cancer pain. These animal studies support the clinical use of EA in the treatment of cancer pain.
The findings of these studies suggest that acupuncture may be effective in treating cancer-related symptoms and cancer treatment–related disorders and that acupuncture may be able to activate immune functions [1,2,3] and regulate the autonomic nervous system.[4,5] Only one study reported a decrease in tumor volume in animals treated with acupuncture compared with control animals; however, the scientific value of this report is limited because of insufficient information about the research methodology.
Effect of Acupuncture on Immune Function
At least seven human studies have evaluated the effect of acupuncture on immune system function in patients with cancer.[1,2,3,4,5,6,7] These studies were all conducted in China. Five were reported in English,[1,2,3,6,7] and two were reported in Chinese with English abstracts.[4,5]
Four randomized controlled trials,[1,2,4,5] a nonrandomized clinical study, and two case series [6,7] found that acupuncture enhanced or regulated immune function.
The first randomized controlled trial found that acupuncture treatment enhanced platelet count and prevented leukocyte decrease after radiation therapy or chemotherapy, in comparison with the control group.
A second study involved a group of 40 postoperative cancer patients, 20 of whom received daily acupuncture treatment and 20 of whom served as a control group. After 3 days, leukocyte phagocytosis was enhanced in the treated group, compared with the baseline measurement (P < .01); no such enhancement was observed in the control group.
A third study observed the effect of acupuncture on interleukin-2 (IL-2) and natural killer (NK) cell activity in the peripheral blood of patients with malignant tumors. The patients were divided into an acupuncture treatment group (n = 25), which received 30 minutes of acupuncture daily for 10 days, and a nonacupuncture control group (n = 20). The data showed that IL-2 level and NK cell activity were significantly increased in the acupuncture group, compared with the control group (P < .01).
A fourth study observed the effect of acupuncture on T-lymphocyte subsets (CD3 +, CD4 +, and CD8 +), soluble IL-2 receptor (SIL-2R), and beta-endorphin (beta-EP) in the peripheral blood of patients with malignant tumors. The data showed that acupuncture treatment increased the proportion of the CD3 + and CD4 + T-lymphocyte subsets, the CD4 +/CD8 + ratio (P < .01), and the level of beta-EP. It decreased the level of SIL-2R (P < .01). The investigators suggested that the anticancer effect of acupuncture may be mediated via the mechanism of immunomodulation. 
The nonrandomized clinical study showed that microwave acupuncture (MAT), a newly developed technique in which a specially designed device attached to a normally inserted acupuncture needle is used to deliver microwave radiation to a given point, enhanced the immunologic function of cancer patients. Although there was an increase in white blood cell count in the MAT group, the change was not significantly different from that seen in the control group under drug treatment.
In a clinical case series, 28 cancer patients who were treated with electroacupuncture (EA) while undergoing chemotherapy experienced no declines in T cells (CD3 +, CD4 +, CD8 +) or in NK cell activity, both of which are usually suppressed by chemotherapy. Similar findings were reported in a study comparing EA to the control in patients receiving chemotherapy for breast, colorectal cancer, and non-Hodgkin lymphoma.
In another clinical case series, 48 patients with leukopenia —including two cancer patients—who were treated with manual acupuncture experienced improvements in leukocyte count, intracutaneous phytohemagglutinin (PHA), and immunoglobulin (IgG, IgA, and IgM) levels after 14 daily acupuncture treatments, compared with their pretreatment levels.
Effect of Acupuncture on Cancer Pain
Seven clinical studies of acupuncture as a treatment for cancer-related pain have been reported in the English language (refer to Table 1 at the end of this section).[9,10,11,12,13,14,15] Three studies were randomized controlled clinical trials, with two studies conducted in China and one in France.[10,14,15] Four studies were case series, with one each from England, France, Hong Kong, and the United States.[9,11,12,13]
One randomized trial compared classical Chinese acupuncture, acupuncture point injection with freeze-dried human transfer factor, and conventional analgesic treatment in patients with gastric cancer pain. The investigators reported an equivalent analgesic effect among the three groups observed after 2 months of treatment; however, the conventionally treated group experienced significantly superior analgesia compared with both acupuncture treatment groups during the first 10 days of treatment. The researchers reported that the patients in both acupuncture treatment groups also experienced improved quality of life and a decrease in the side effects of chemotherapy, in addition to analgesia.
A nonrandomized, single-arm, observational clinical study evaluated the effect of auricular acupuncture in 20 cancer patients who were still experiencing pain after treatment with analgesics. While patients continued their analgesic medication, auricular acupuncture needles were embedded in ear acupuncture points, chosen according to clinical symptoms and electrodermal response, and were left in place until they fell out. In some cases, the needles remained in place for 35 days, while in others they fell out after 5 days. Pain intensity was measured by a nurse on the Visual Analog Scale (VAS) on day 0 and day 60, and the data were analyzed using a t test. The results showed that pain intensity decreased or remained stable after auricular acupuncture in all patients, with a significant average pain intensity decrease of 33 mm (P < .001). The same investigators later reported a larger (n = 90) randomized, blinded, controlled trial in which cancer pain intensity was significantly decreased (by 36%) in an auricular acupuncture treatment group, in comparison with control groups (acupuncture at placebo points or auricular seeds placed at placebo points) after 2 months of treatment (P < .001).
In a case series involving 183 cancer patients who were treated with acupuncture for cancer-related pain, 52% were significantly helped (P value not stated). Multiple treatments at intervals of 1 to 4 weeks were nearly always necessary for significant and long-term pain control.
In another case series, 29 patients with malignant tumors who developed pain received EA treatment.. All experienced various degrees of pain relief, and 25 out of 29 were able to either reduce or eliminate their analgesic requirements following multiple EA treatments.
A third case series produced similar results. After auricular EA treatment, five patients with cancer pain reported improvements.
Although most of these studies were positive and demonstrated the effectiveness of acupuncture in cancer pain control, the findings have limited significance because of methodologic weaknesses such as small sample sizes, an absence of patient blinding to treatment in most cases, varying acupuncture treatment regimens, a lack of standard outcome measurements, and an absence of adequate randomization. Further investigations into the effects of acupuncture on cancer pain using rigorous scientific methodology are warranted.
Effect of Acupuncture on Cancer Treatment–related Side Effects
Five studies published in English have addressed the use of acupuncture for pain related to cancer treatment, mostly postsurgical pain (refer to Table 2 at the end of this section). A randomized clinical trial evaluated the effect of various combinations of auricular acupuncture, Chinese herbs, and epidural morphine to relieve postoperative pain in 16 patients with liver cancer. The study design was complicated and had a very small sample size (n = 2 per group). On the basis of the VAS (0–100 mm), all of the combination treatment groups experienced better analgesia than did the placebo -treated control group.
A nonrandomized study investigated the effect of acupuncture in postoperative pain management and arm movement in breast cancer patients after surgical excision of the cancer and axillary lymph node dissection. Forty-eight patients were treated with acupuncture on the third, fifth, and seventh days after surgery and on the day of patient discharge. Compared with a control group of 32 patients who had the same surgery but did not receive acupuncture treatment, the acupuncture group had significant pain relief during arm movement on the fifth and seventh days following surgery and at the time of discharge. The range of arm motion also increased significantly in the treatment group, compared with the control group, during the postoperative period (P < .001). The authors concluded that acupuncture point selection based on the state of the patient and obtaining a needling "de qi" sensation were important in achieving an effective acupuncture treatment. A small retrospective case review of acupuncture for chemotherapy-induced peripheral neuropathy in 18 patients showed benefit with reduced symptoms in 82%.
Arthralgias and myalgias from aromatase inhibitors
A randomized, blinded study comparing true acupuncture with sham acupuncture for aromatase-related joint symptoms enrolled 51 patients, 38 of whom were evaluable. True acupuncture was significantly more effective than sham acupuncture, as measured by Brief Pain Inventory-Short Form scores in relieving joint symptoms.
Nausea and vomiting
Chemotherapy-induced nausea and vomiting
Of all the investigated effects of acupuncture on cancer-related or chemotherapy-related symptoms and disorders, the positive effect of acupuncture on chemotherapy-induced nausea and vomiting (N/V) is the most convincing, as demonstrated by the consistency of the results of a variety of clinical study types, including randomized clinical trials (RCTs), nonrandomized trials, prospective consecutive case series, and retrospective studies (refer to Table 3 at the end of this section). Consistent with the findings from clinical studies of acupuncture on N/V due to other causes such as postoperative N/V and morning sickness, these studies showed acupuncture to be effective in the treatment of chemotherapy-induced N/V. A well-documented example is discussed below.
A systematic review of the effect of acupuncture on N/V describes five clinical trials of chemotherapy-induced N/V, conducted by different investigators on different groups of patients and using different forms of acupuncture point stimulation. All five trials yielded positive results. These consistent results support the claim that acupuncture is useful for treating chemotherapy-induced N/V. More recently, the efficacy of acupuncture point stimulation for chemotherapy-induced N/V has been reviewed, suggesting that acupuncture is more effective for acute vomiting than for acute or chronic nausea.
A number of clinical studies of the effect of acupuncture on chemotherapy-induced N/V have been reported.[24,25,26,27,28,29,30,31,32,33,34,35,36]
A randomized placebo-controlled clinical trial investigated the effect of EA on chemotherapy-induced emesis in 104 patients with breast cancer who were undergoing a highly emetogenic chemotherapy regimen.  The patients were randomly assigned to receive low-frequency EA at classic antiemetic acupuncture points once daily for 5 days (n = 37), minimal needling at control points with mock EA on the same schedule (n = 33), or no adjunct needling (n = 34). All patients received concurrent antiemetic drugs (prochlorperazine, lorazepam, and diphenhydramine) and high-dose chemotherapy (cyclophosphamide, cisplatin, and carmustine). The main outcome measures were the total number of emesis episodes and the proportion of emesis-free days occurring during the 5-day study period. The data revealed fewer emesis episodes in the EA treatment group than in the minimal needling and drug-only control groups (P < .001), although differences among the groups were not significant during the 9-day follow-up period (P = .18). These findings are consistent with results reported by other investigators.[24,25,27,28,30,31,34] However, another published study showed that acupuncture had no additional effect on the prevention of acute N/V in patients receiving high-dose chemotherapy combined with ondansetron. One RCT of acupuncture and vitamin B6 versus acupuncture or vitamin B6 intramuscular injection alone for N/V in women with ovarian cancer undergoing highly emetogenic chemotherapy, found a statistically significant benefit of both vitamin B6 and acupuncture. Results also showed that acupuncture alone, compared with vitamin B6, had a greater benefit in reducing the frequency of emesis. One study suggested decreased delayed nausea from acupressure at point p6 compared with sham acupressure. One study involving 34 patients with gynecologic cancer suggested that the acupressure applied to P6 acupuncture point with wristbands may be effective in reducing chemotherapy-related nausea and may decrease the antiemetic use after chemotherapy.
Radiation-induced nausea and vomiting
Acupuncture has also been used to relieve radiation-induced nausea and vomiting. In one randomized study, patients who were randomly assigned to receive either verum or sham acupuncture experienced fewer episodes of nausea and vomiting than did those who received standard care.
Some studies have reported that acupuncture may be effective in reducing vasomotor symptoms among postmenopausal women with breast cancer and prostate cancer patients on androgen-deprivation therapy.[43,44,45,46,47,48,49] One study randomly assigned 55 patients to acupuncture versus venlafaxine for management of vasomotor symptoms in women with hormone receptor–positive breast cancer. Acupuncture was just as effective as venlafaxine and caused fewer adverse effects.
A phase I pilot study evaluated the effect of acupuncture on tamoxifen -induced menopause symptoms. Fifteen patients with breast cancer who were taking tamoxifen were treated with acupuncture weekly for 3 months. The Greene Menopause Index was used for outcome assessments at baseline before treatment and at 1, 3, and 6 months. The results showed that anxiety, depression, and somatic and vasomotor symptoms, but not libido, were significantly improved in comparison with the baseline (P < .001).
An uncontrolled prospective case series of 50 women on tamoxifen for early breast cancer evaluated women receiving eight treatments of traditional acupuncture weekly. Mean frequency of vasomotor symptoms dropped by 49.8% (P < .0001) at the end of treatment. Seven domains of the Women's Health Questionnaire showed statistically significant improvement.
A retrospective evaluation of 194 patients with predominantly breast or prostate cancer and experiencing vasomotor symptoms found long-term relief of vasomotor symptoms associated with acupuncture and self-acupuncture. The authors suggested that overall treatment dose may be more important than point location, but favored SP6. A small RCT of EA compared with hormone therapy in women with breast cancer suggested a prolonged effect of EA on hot flushes after 24 months. Seven of 19 women initially randomly assigned to EA had 2.1 flushes in 24 hours compared with a baseline of 9.6 flushes in 24 hours. In a prospective randomized study of 84 breast cancer patients on tamoxifen treated with acupuncture versus placebo, acupuncture showed a reduction of hot flashes in both the treatment and the control arms, but there was no difference between true acupuncture and sham acupuncture. The findings from these studies are summarized in Table 4 below.
In a randomized controlled trial, 47 cancer patients with moderate to severe fatigue were randomly assigned to one of three groups. One group received six 20-minute sessions of acupuncture (n = 15); one group was instructed to use acupressure (n = 16); and the third group, the sham acupressure group (n = 16), was taught to apply pressure in three points unrelated to true acupressure. All three groups continued with the same techniques for 2 weeks. The study concluded that acupuncture was a more effective method than acupressure or sham acupressure.
In a follow-up study, 302 breast cancer patients were randomly assigned to a 6-week course of either daily acupuncture or usual care enhanced by educational booklets on managing fatigue. Acupuncture significantly reduced fatigue and improved quality of life over that of the "enhanced usual care" group.
A number of clinical studies have investigated the effect of acupuncture for the treatment and prevention of xerostomia in nasopharyngeal carcinoma and head and neck cancer patients.
Acupuncture was associated with a decrease in the onset of symptoms and an increased saliva flow in two randomized studies that compared acupuncture with standard care for preventing xerostomia in patients undergoing radiation therapy.[56,57]
Compared with standard care, acupuncture significantly improved xerostomia symptoms in patients who experienced the condition following radiation therapy.[58,59]
Two phase III randomized controlled studies, one for prevention, and one for treatment of radiation-induced xerostomia revealed increases in salivary flow rates following real and sham (superficial needling 1 or 2 cm away from acupuncture points) acupuncture, although differences between groups were not significant.[60,61] It also reported improvements in quality of life after acupuncture treatment, but there were no significant differences between the groups.
One study examined long-term effects of acupuncture on xerostomia. Patients who received real acupuncture were followed for 6 months and up to 3 years. Compared with baseline, significant differences in salivary flow rates were seen in patients 6 months after acupuncture treatment. At 3 years, patients who received additional acupuncture exhibited greater saliva flow rates than patients who did not continue acupuncture treatment.
There is one ongoing phase III clinical trial evaluating the effect of acupuncture for treatment (NCT01141231) of xerostomia in head and neck cancer patients. Information about ongoing clinical trials is available from the NCI Web site.
The findings from these studies are summarized in Table 5 below.
Other Treatment-related Side Effects
Many studies have reported on the effects of acupuncture on cancer or other cancer treatment–related symptoms, including weight loss, cough, hemoptysis, fever, anxiety, depression, xerostomia, proctitis, dysphonia, esophageal obstruction, hiccups, and postoperative lymphedema.[1,9,44,72,73,74,75,76,77,78] These studies were from China,[1,56,73,74,75] Japan, England, Italy, Sweden, and the United States.[9,19,54,72,77] The findings from these studies are summarized in Table 6 below.
In a randomized clinical trial, 76 patients with various types of cancer, including 38 with esophageal cancer, 24 with gastric cancer, and 14 with lung cancer, were randomly assigned to two groups (n = 38 per group). The treatment group received acupuncture in combination with radiation therapy or chemotherapy, and the control group was treated with radiation therapy or chemotherapy alone. The data showed that the patients in the acupuncture group gained significantly more body weight than patients in the control group (P < .001). The acupuncture group also showed greater improvement than the controls in the symptoms of cough, thoracodynia, hemoptysis, and fever for patients with lung cancer and the symptoms of chest pain, mucus vomiting, and difficulty in swallowing for patients with esophageal cancer. In addition, the acupuncture group suffered fewer side effects (poor appetite, N/V, dizziness, or fatigue) from radiation therapy or chemotherapy than the control group. However, no statistical analysis was performed on these data. An RCT of 138 patients treated with acupuncture plus massage versus usual care showed decreased pain (P = .05) and a decrease in depressive mood (P = .003) in postoperative cancer patients.
A retrospective survey study involved patients of an oncology clinic who were offered acupuncture treatment for potential palliation of symptoms. Among 89 patients treated with acupuncture, 79 responded to a telephone questionnaire survey. The data indicated that the major reasons for referral included pain (53%), xerostomia (32%), hot flashes (6%), and nausea/loss of appetite (6%). Sixty percent of the patients showed at least 30% improvement in their symptoms, and about one-third had no change in the severity of symptoms. Patients were not questioned regarding acupuncture treatment expectations.
Current Clinical Trials
Check NCI's list of cancer clinical trials for cancer CAM clinical trials on acupuncture therapy, acupuncture-like transcutaneous electrical nerve stimulation, electroacupuncture therapy and acupressure therapy that are actively enrolling patients.
General information about clinical trials is also available from the NCI Web site.
Serious adverse effects of acupuncture are rare. Reported accidents and infections appear to be related to violations of sterile procedure, negligence of the practitioner, or both.[1,2] A systematic review of case reports on the safety of acupuncture, involving 98 papers published in the English language from 22 countries during the period from 1965 to 1999, found only 202 incidents. The number of incidents appeared to decline as training standards and licensure requirements were enhanced. Among the 118 (60%) reported incidents involving infection, 94 (80%) involved hepatitis, occurring mainly in the late 1970s and early 1980s. Very few hepatitis or other infections associated with acupuncture have been reported since 1988, when widespread use of disposable needles was introduced and national certification requirements for clean-needle techniques were developed and enforced as an acupuncture licensure requirement.[3,4] Because cancer patients who are undergoing chemotherapy or radiation therapy are immunocompromised, precautions must be taken and strict clean-needle techniques must be applied when acupuncture treatment is given.
Minor adverse effects of acupuncture, such as pain at needling sites, hematoma, tiredness, lightheadedness, drowsiness, and localized skin irritation, have been reported.[6,7,8,9,10] These minor adverse effects can be minimized by appropriate patient management, including local pressing and massage at the needling site after treatment.[11,12] Acupuncture in children has not been studied extensively. However, adverse effects appear to be rare and limited to the same effects as observed in adults.[13,14]
It is noteworthy that almost all reported clinical studies on the effects of acupuncture on cancer or cancer therapy –related symptoms focus on symptom management rather than the disease itself. Investigations into the effects of acupuncture on chemotherapy -induced nausea and vomiting, many of which were randomized and well-controlled, produced the most convincing findings. Although a considerable number of favorable clinical acupuncture studies have been reported, most were case studies, clinical observations, or nonrandomized and poorly controlled clinical trials. In many studies, methodologic flaws in clinical study design hampered rigorous scientific efforts to evaluate the effects of acupuncture. Although pain relief is the most clinically common use of acupuncture, only a few studies on cancer pain are well-controlled or have sample sizes large enough to support their findings.
Separate levels of evidence scores are assigned to qualifying human studies on the basis of statistical strength of the study design and scientific strength of the treatment outcomes (i.e., endpoints) measured. The resulting two scores are then combined to produce an overall score. For additional information about levels of evidence analysis, refer to Levels of Evidence for Human Studies of Cancer Complementary and Alternative Medicine.
The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.
Editorial changes were made to this summary.
This summary is written and maintained by the PDQ Cancer Complementary and Alternative Medicine Editorial Board, which is editorially independent of NCI. The summary reflects an independent review of the literature and does not represent a policy statement of NCI or NIH. More information about summary policies and the role of the PDQ Editorial Boards in maintaining the PDQ summaries can be found on the About This PDQ Summary and PDQ NCI's Comprehensive Cancer Database pages.
Purpose of This Summary
This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about the use of acupuncture in the treatment of people with cancer. It is intended as a resource to inform and assist clinicians who care for cancer patients. It does not provide formal guidelines or recommendations for making health care decisions.
Reviewers and Updates
This summary is reviewed regularly and updated as necessary by the PDQ Cancer Complementary and Alternative Medicine Editorial Board, which is editorially independent of the National Cancer Institute (NCI). The summary reflects an independent review of the literature and does not represent a policy statement of NCI or the National Institutes of Health (NIH).
Board members review recently published articles each month to determine whether an article should:
Changes to the summaries are made through a consensus process in which Board members evaluate the strength of the evidence in the published articles and determine how the article should be included in the summary.
The lead reviewers for Acupuncture are:
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Levels of Evidence
Some of the reference citations in this summary are accompanied by a level-of-evidence designation. These designations are intended to help readers assess the strength of the evidence supporting the use of specific interventions or approaches. The PDQ Cancer Complementary and Alternative Medicine Editorial Board uses a formal evidence ranking system in developing its level-of-evidence designations.
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The preferred citation for this PDQ summary is:
National Cancer Institute: PDQ® Acupuncture. Bethesda, MD: National Cancer Institute. Date last modified <MM/DD/YYYY>. Available at: http://www.cancer.gov/cancertopics/pdq/cam/acupuncture/healthprofessional. Accessed <MM/DD/YYYY>.
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Last Revised: 2014-10-07
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