Inspired by Chan et al 2022.
EA – electroacupuncturekey to acronyms
MA – manual acupuncture
CIPN – chemotherapy-induced peripheral neuropathy
AiM – Acupuncture in Medicine
FACT/GOG-Ntx – Functional Assessment of Chronic illness Therapy (Gynecologic Oncology Group) Neurotoxicity subscale
MSKCC – Memorial Sloan Kettering Cancer Center
This week we stay on the topic of colorectal cancer and examine the role of EA in mitigating the neural toxicity caused by oxaliplatin.
This is a relatively small trial (n=60) from Hong Kong and it is published in Acupuncture in Medicine. I think we (AiM) were the first to publish a paper on acupuncture in CIPN – a case series back in 2006. There has been quite a lot of research since, but no really definitive large clinical trials demonstrating efficacy. I have a category for CIPN on this blog and this will make the 7th entry.
In general, the data has a positive trend, although there are some questions regarding efficacy over sham and cost effectiveness.[3,4] We have seen recently (BMAS Blog: Acupuncture for CIPN 2022) that significant changes can be measured in sensory nerve action potential amplitude following a course of acupuncture, yet in the same study a minority of the subjective outcomes demonstrated significant change compared to a no treatment control.
I am getting the impression that our outcome measures may not be adequately capturing the improvements in the condition, and I see that the adequacy of outcome assessment has already been questioned in CIPN. Having said that, a relatively large pragmatic trial from the UK was clearly positive.
This paper may be the first to focus on a single tumour type and chemotherapeutic agent. EA plus MA was performed weekly for 12 weeks and the control group received the same protocol using the Streitberger non-penetrating needles. They do not say how the EA was connected, but images in an appendix show ST36 to LR3 on each side and SP6 to SP6 in the legs, and LI4 to PC6 in each arm. Other points used were LI11 and the extra points in the web spaces of the hands (Baxie) and feet (Bafeng).
There were no real differences between groups, although the authors did put a positive spin on one or two p values that scraped below 0.05 out of over 100 calculated. The primary outcome (FACT/GOG-Ntx) is an 11-item scale with a maximum score of 44 (higher scores equate to worse symptoms of neuropathy). The baseline was around 40 in both groups and the trend favoured the sham group rather than the real acupuncture group. I’m afraid I did not pick that up on proofreading the paper prior to publication because I was unfamiliar with the outcome measure – oops! Anyway, the numerous measurements may prove useful to other researchers planning what outcomes to use in subsequent research.
Well, that may seem a little unsatisfactory, but the good news is that there is a much larger (n=250) trial underway at MSKCC looking at the use of EA in the treatment of pain related to CIPN. We will have to wait a while though, as recruitment is not due to finish until 2025.
Having reviewed a couple of the validation papers for the FACT/GOG-Ntx,[9,10] I see that they each use an opposite system in terms of the direction of symptoms with the numerical score. At face value, higher numbers are associated with worse symptoms, but I guess this can easily be reversed. This obviously has implications in terms of interpretation of the paper I have highlighted; however, whichever way the trend of benefit applies, the trial was clearly underpowered, so we will still have to wait for bigger and better ones.
1 Chan K, Lui L, Lam Y, et al. Efficacy and safety of electroacupuncture for oxaliplatin-induced peripheral neuropathy in colorectal cancer patients: a single-blinded, randomized, sham-controlled trial. Acupunct Med 2022;:9645284221125420. doi:10.1177/09645284221125421
2 Wong R, Sagar S. Acupuncture treatment for chemotherapy-induced peripheral neuropathy–a case series. Acupunct Med 2006;24:87–91. doi:10.1136/aim.24.2.87
3 Pei L-X, Yi Y, Guo J, et al. The effectiveness and safety of acupuncture/electroacupuncture for chemotherapy-induced peripheral neuropathy: a systematic review and meta-analysis. Acupunct Med 2022;:9645284221076512. doi:10.1177/09645284221076512
4 Molassiotis A, Dawkins B, Longo R, et al. Economic evaluation alongside a randomised controlled trial to assess the effectiveness and cost-effectiveness of acupuncture in the management of chemotherapy-induced peripheral neuropathy. Acupunct Med 2021;39:41–52. doi:10.1177/0964528420920285
5 Friedemann T, Kark E, Cao N, et al. Acupuncture improves chemotherapy-induced neuropathy explored by neurophysiological and clinical outcomes – The randomized, controlled, cross-over ACUCIN trial. Phytomedicine 2022;104:154294. doi:10.1016/j.phymed.2022.154294
6 Molassiotis A, Cheng HL, Lopez V, et al. Are we mis-estimating chemotherapy-induced peripheral neuropathy? Analysis of assessment methodologies from a prospective, multinational, longitudinal cohort study of patients receiving neurotoxic chemotherapy. BMC Cancer 2019;19:132. doi:10.1186/s12885-019-5302-4
7 Stringer J, Ryder WD, Mackereth PA, et al. A randomised, pragmatic clinical trial of ACUpuncture plus standard care versus standard care alone FOr Chemotherapy Induced peripheral Neuropathy (ACUFOCIN). Eur J Oncol Nurs 2022;60:102171. doi:10.1016/j.ejon.2022.102171
8 Memorial Sloan Kettering Cancer Center. A Randomized Phase III Clinical Trial of Acupuncture for Chemotherapy-induced Peripheral Neuropathy Treatment (ACT). 2022. https://clinicaltrials.gov/ct2/show/NCT04917796 (accessed 9 Nov 2022).
9 Calhoun EA, Welshman EE, Chang C-H, et al. Psychometric evaluation of the Functional Assessment of Cancer Therapy/Gynecologic Oncology Group-Neurotoxicity (Fact/GOG-Ntx) questionnaire for patients receiving systemic chemotherapy. Int J Gynecol Cancer Off J Int Gynecol Cancer Soc 2003;13:741–8. doi:10.1111/j.1525-1438.2003.13603.x
10 Huang HQ, Brady MF, Cella D, et al. Validation and reduction of FACT/GOG-Ntx subscale for platinum/paclitaxel-induced neurologic symptoms: a gynecologic oncology group study. Int J Gynecol Cancer Off J Int Gynecol Cancer Soc 2007;17:387–93. doi:10.1111/j.1525-1438.2007.00794.x
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