Stimulated by Zhu et al 2026.[1]
From a previous blog that is worth revisiting.
EA – electroacupuncture
QoL – quality of life
HRQoL – health-related quality of life
IF – impact factor
RCT – randomised controlled trial
HBV – hepatitis B virus
HDV – hepatitis D virus
FACT-Ga – functional assessment of cancer therapy – gastric
TOI – trial outcome index
DFS – disease free survival– key to acronyms
This paper has been sitting in my ‘Recent’ folder on Zotero for a few months. It was initially published as an accepted manuscript, so I waited for it to be properly presented as a page set journal article before highlighting it here. It is published in the Journal of the National Cancer Institute or JNCI (IF 7.2), where ‘National’ refers to the US of course.
It is a moderately large (n=222) open 3-arm RCT of EA for supportive care of patients following surgery for gastric cancer (T2 and T3) and undergoing neoadjuvant chemotherapy. It was based at 11 hospitals in the region of Guangzhou, the capital of the Guangdong province. I have mentioned Guangzhou here before (see Acupuncture in PMD, Acupuncture for perimenopausal GAD, and Acupuncture for MMT reduction 2024, or simply put Pearl River in the search box).
Gastric cancer is the 5th most common cancer globally and is particularly common in East Asia.[2] Mongolia is an extreme outlier with double the incidence of China. This is thought to be related to the near universal prevalence of Helicobactor pylori infection and extremely high salt intake. Despite this, gastric cancer is not the most common cancer in Mongolia, that dubious honour goes to liver cancer, which is related to the very high prevalence of HBV plus HDV infection.
The trial I am highlighting has the acronym EAGER, but the journal editors clearly did not want that in the title – perhaps because of the ER at the end, which presumably comes from the last 2 letters of cancer.
There were 2 EA groups that were distinguished only by EA session frequency. Somewhat confusingly they were named the high frequency and low frequency EA groups, but the frequency in both arms was 2Hz, ie low! I would have preferred them to name the groups high session frequency and low session frequency… but they didn’t.
EA was applied across PC6 and ST36 on each side (at least, that is according to my reading of the methods). Additional points were presumably stimulated manually. They included SP4, GV20, and Yintang. Back-shu points were chosen on an individual basis.
The high session frequency group had 3 treatments in the first week and 2 treatments a week for the next 2 weeks of each chemotherapy cycle making a total of 21 treatments over the first 3 cycles. The low session frequency group had 1 treatment a week for the 3 weeks of each chemotherapy cycle and a total of 9 treatments over the first 3 cycles. The third arm of this trial received usual care only but were offered acupuncture at the low session frequency rate after the end of cycle 3.
The primary outcome for this trial was taken from the FACT-Ga questionnaire. The FACT-Ga includes 5 subscales, including physical well-being, social and family well-being, emotional well-being, functional well-being, and the gastric cancer subscale. The FACT-Ga TOI for this trial consisted of the physical well-being, functional well-being, and the gastric cancer subscales. The primary outcome was described as the difference between the groups of the trajectory of the FACT-Ga TOI; however, whilst trajectory implies the direction of a missile, they actually compared the AUC and average of the FACT-Ga TOI.
The EA groups were both highly significantly improved on HRQoL compared with the usual care group. there was no difference between the high session frequency and the low session frequency EA groups on any outcomes.
DFS is always measured in trials on cancer patients, so whilst this was not mentioned as an outcome in the protocol, it was reported. The 3-year DFS in the EA groups was ~80% compared with ~50% in the usual care groups. That is a substantial difference, but the trial was not designed or powered for this outcome, so it must be interpreted with caution. One commentator, in a letter to the journal, suggested the need for sham controls and that expectation may have played a part in the improved DFS.[3] Whilst I acknowledge the problems of open trials and subjective outcomes, here we are talking about mortality, which, correct me if I’m wrong, is far from a subjective outcome. It is probably the most objective outcome you can have in healthcare. With objective outcomes, blinding does not appear to be important (see Blinding where is the bias – it’s a real corker), presumably because you cannot think yourself (for example) to stay alive by expectation alone. But if you can, why not bring it on.
References
1 Zhu Y-J, Chang X-S, Wu X-Y, et al. Electro-acupuncture for quality of life during adjuvant chemotherapy in gastric cancer: a randomized trial. J Natl Cancer Inst. 2025;djaf309. doi: 10.1093/jnci/djaf309
2 Bray F, Laversanne M, Sung H, et al. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2024;74:229–63. doi: 10.3322/caac.21834
3 Sun M, Zang D, Chen J. Re: Electro-acupuncture for quality of life during adjuvant chemotherapy in gastric cancer: a randomized trial. J Natl Cancer Inst. 2026;djag012. doi: 10.1093/jnci/djag012
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