Inspired by Shen et al 2024.[1]
EA – electroacupuncture
MA – manual acupuncture
CINV – chemotherapy-induced nausea and vomiting
HEC – highly emetogenic chemotherapy
5-HT – 5-hydroxytryptamine (serotonin)
NK – neurokinin
VAS – visual analogue scale– key to acronyms
This trial in JCO (IF 42.1) immediately caught my attention because of the topic and the name of the first author. The last time I saw such a study was over 20 years ago in JAMA (IF 63.1) when the first author was also a Shen – Joannie Shen from the Nation Institute of Health, Bethesda (at the time of her study).[2] Jacky invited her to speak at a BMAS Scientific meeting in Bournemouth in 2001.
This paper comes from China and is a multicentre study (6 centres). 239 women with breast cancer due to undergo HEC were randomised to either real or sham EA every day for 4 days starting 1-2 hours prior to chemotherapy and then each subsequent morning.
MA was performed at LI4, PC6, and ST36 on both sides. EA was applied from PC6 to ST36 at 2Hz and less than 10mA. The intensity was increased after 15 minutes based on the patient’s tolerance. The sham version was superficial off-point needling without stimulation but with EA leads attached.
Both groups received standard triple therapy for prophylaxis of CINV consisting of dexamethasone, a 5-HT3 receptor antagonist, and an NK1 receptor antagonist.
The primary outcome was the proportion of patients achieving complete protection from CINV within 120 hours of receiving HEC. Complete protection was defined as no vomiting, no need for rescue treatment, and no significant nausea. No significant nausea was defined as VAS nausea of <25mm, and no nausea was defined as VAS nausea of <5mm.
85% of patients in the real EA group and 90% in the sham group completed all 4 days of treatment. Patients were included in the full analysis set if they had completed at least one treatment with EA or sham EA and had received triple anti-emetic therapy.
The proportion of patients achieving complete protection within 120 hours of HEC was 52.9% in the real EA group and 34.5% in the sham EA group (p=0.004). One of the secondary outcomes was called ‘total control’, and that was the same as complete protection but with no nausea rather than no significant nausea. The proportion of patients achieving total control within 120 hours of HEC was 13.4% in the real EA group and 4.3% in the sham EA group (p=0.014).
Looking at the difference in percentage achieving ‘complete protection’ (>50%) compared with those achieving ‘total control’ (<15%) despite 3 antiemetics and daily EA, it seems clear that the majority of patients still experience some symptoms of nausea following HEC. Having said that, a threefold increase in patients who experience no symptoms following HEC by adding daily EA is impressive, as in a ~60% increase in those with an insignificant degree of nausea.
It is a relatively simple protocol and has now been featured in 2 very high impact journals. I wonder whether the oncology world will take notice.
References
1 Shen G, Ren D, Zhao F, et al. Effect of Adding Electroacupuncture to Standard Triple Antiemetic Therapy on Chemotherapy-Induced Nausea and Vomiting: A Randomized Controlled Clinical Trial. J Clin Oncol. 2024;JCO2400099. doi: 10.1200/JCO.24.00099
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
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