Aromatase inhibitors, joint pain and acupuncture 2022

Inspired by Hershman et al JAMA Network Open 2022.[1]

AI – aromatase inhibitor
BPI – brief pain inventory
BPI-WP – brief pain inventory worst pain

key to acronyms

When this paper popped up on my searches, I was surprised to find that I had not written about AI-related joint pain since the JAMA paper by the same group in 2018.[2] The blog I wrote at the time focussed on a discussion of the clinical relevance of the measured effect of real acupuncture over sham and waiting list. I assumed that it would have been the JAMA editors insisting on this, but it turned out to be the authors themselves that had taken the 2-point change from baseline on the BPI measured by Farrar et al (2001) and applied it to the difference in group means.[3] You can read more detail in the blog post from 2018. I was interested to see that Mao & Farrar wrote to JAMA making the same point some 4 months after my blog was published.[4]

The current paper is very similar in size, design, and interventions to the JAMA paper from 2018, but with a dramatically longer follow-up, and indeed, the primary outcome was set at 52 weeks as opposed to 6 weeks in the 2018 paper.

Manual acupuncture was applied to general body points, ear points, and regional points based on the affected joints. Manual stimulation of the needles was applied twice during a 20-to-25-minute treatment session. Treatments were twice a week for the first 6 weeks and weekly thereafter for 6 weeks, making a total of 18 sessions over 12 weeks. The final follow-up was 40 weeks later, ie 1 year from the start of the trial.

The results were good, with persisting benefits of real acupuncture over sham and waiting list throughout the follow-up period. The difference between groups was about 1 point on the BPI-WP, but the mean change from baseline in the real acupuncture group was over 2.5 points, which is clearly a clinically relevant improvement. I note that there is no discussion of clinically relevant change in this paper, but that is fine, we can determine that for ourselves from the graphical results.

The real importance of this research is that for the first time we have a clear indication that the benefits of acupuncture can persist for at least a year. Combine this with a positive recommendation from the recent SIO/ASCO guidelines and it seems that acupuncture should be the first line choice for AI-related joint pain.

Personally, I prefer to use EA, as has been done in the past for this indication.[5] One reason for doing this is to optimise dose and maximise the general effects of acupuncture, thereby attempting to treat the other common side-effects of hot flushes and fatigue as well as the AI-related joint pain.

  1. Hershman DL, Unger JM, Greenlee H, et al. Comparison of Acupuncture vs Sham Acupuncture or Waiting List Control in the Treatment of Aromatase Inhibitor-Related Joint Pain: A Randomized Clinical Trial. JAMA Netw Open 2022;5:e2241720. doi:10.1001/jamanetworkopen.2022.41720
  2. Hershman DL, Unger JM, Greenlee H, et al. Effect of Acupuncture vs Sham Acupuncture or Waitlist Control on Joint Pain Related to Aromatase Inhibitors Among Women With Early-Stage Breast Cancer: A Randomized Clinical Trial. JAMA 2018;320:167–76. doi:10.1001/jama.2018.8907
  3. Farrar JT, Young JP, LaMoreaux L, et al. Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain 2001;94:149–58. doi:10.1016/S0304-3959(01)00349-9
  4. Mao JJ, Farrar JT. Acupuncture for Aromatase Inhibitor-Related Joint Pain Among Breast Cancer Patients. JAMA 2018;320:2269–70. doi:10.1001/jama.2018.16736
  5. Mao JJ, Xie SX, Farrar JT, et al. A randomised trial of electro-acupuncture for arthralgia related to aromatase inhibitor use. Eur J Cancer Oxf Engl 1990 2014;50:267–76. doi:10.1016/j.ejca.2013.09.022

Declaration of interests MC