Inspired by Zhu et al 2021.
QoL – quality of lifekey to acronyms
HRQoL – health related quality of life
EA – electroacupuncture
MA – manual acupuncture
AEs – adverse events
ITT – intention to treat (analysis)
PP – per protocol (analysis)
This is a relatively small (n=66) pilot study with 3 parallel arms. It has some familiar features as well as some novel ones and is well reported.
The study aimed to assess the impact of EA at two different ‘doses’ versus a standard care control on the decline in HRQoL associated with adjuvant chemotherapy in patients with gastric or gastroesophageal cancer. The study was conducted in seven hospitals in China, but there was also some involvement of a prominent researcher from a famous cancer centre in the US.
The doses of EA differed in terms of the frequency and number of sessions. The high dose group received 21 sessions over 3 chemotherapy cycles and the low dose group received 9 sessions ie 1 session per week during each cycle.
I was interested to observe that treatment was performed throughout the cycle of chemotherapy, and there was no mention of monitoring neutrophil counts during this process from a safety perspective, although treatment-related AEs were measured and compared as an outcome.
A variety of parameters were measured to meet inclusion criteria, and these included a neutrophil count of at least 1.5×109/L and a platelet count of at least 100×109/L. These are useful limits to observe in clinical practice in this patient population.
The treatment protocol involved a rather familiar combination of EA at ST36 and PC6, as well as MA to GV20, Yintang, SP4, and selected Back-shu points.
I first came across this EA combination in a trial by Joannie Shen and colleagues that was published in JAMA 21 years ago. I met Joannie when she spoke at a BMAS meeting in Bournemouth in the following year. This trial was using EA to treat nausea related to high dose chemotherapy in women with breast cancer. Again, it was a study with 3 parallel arms, and 2 ‘doses’ of acupuncture. In this trial the doses differed in terms of intensity of the treatment, with EA compared with minimal needling at real APs (LU7 and GB34) plus sham EA. The third group received medication alone. Treatment was given daily for the first 5 days. EA proved to be better than minimal needling which was better than medication alone for emesis episodes during the 5 days of treatment, but there was no significant difference during the 9-day follow-up period.
Given the similarity of the treatment protocols, I was surprised to see Shen et al (2000) was not cited in the current paper. Of course, there were a lot of differences too.
So, what happened to HRQoL in this group of gastric cancer patients? EA at both treatment frequency doses appeared to reduce the expected fall in HRQoL in the 3 different outcome scores used, but the reductions were non-significant trends in the ITT analysis, probably due to the limited statistical power of the study. The results just reached statistical significance in the PP analysis in 2 out of 3 of the outcomes.
There were 2 interesting secondary outcomes in this pilot study. First was that the low dose of treatment frequency appeared to be similar to the high dose in most outcomes but there was a trend favouring the low dose in the second and third cycles of chemotherapy as measured by one of the symptom scores.
The second one was a significant reduction in the rate of more severe (grade 3–4) leucopenia and neutropenia in the EA groups. I guess that is a good thing given what I mentioned before about treatment being performed throughout the chemotherapy cycle.
1 Zhu Y-J, Wu X-Y, Wang W, et al. Acupuncture for Quality of Life in Gastric Cancer Patients Undergoing Adjuvant Chemotherapy. J Pain Symptom Manage 2021;:S0885-3924(21)00528-5. doi:10.1016/j.jpainsymman.2021.09.009
2 Shen J, Wenger N, Glaspy J, et al. Electroacupuncture for control of myeloablative chemotherapy-induced emesis: A randomized controlled trial. JAMA 2000;284:2755–61. doi:10.1001/jama.284.21.2755