Acupuncture/Electroacupuncture

To scrutinize the evidence of using acupoint stimulation (APS) by any modality on managing adverse events related to anticancer therapies in patients with breast cancer

English databases searched were PubMed, Cochrane library, Embase, the Cumulative Index to Nursing and Allied Health, and PsycINFO.

Chinese databases searched were CNKI, CEPS, and WanFang as well as manual searching.

Search keywords were medical terms of breast cancer (e.g., breast neoplasm, breast carcinoma, breast tumor) combined separately with at least one of the following: acupuncture, acupressure, auricular acupuncture, ear acupuncture, acupuncture points, electroacupuncture, acupoint, transcutaneous electric nerve stimulation,  moxibustion.

Studies were included if they

• Were in English or Chinese language.
• Reported on adults diagnosed with breast cancer at any stage and undergoing treatments such as surgery, radiotherapy, chemotherapy, hormonal therapy, or palliative treatment and experiencing treatment-induced adverse events.
• Utilized an intervention that involved stimulation of acupuncture points by any modality.
• Had at least one clinically related outcome variable, as well as condition-specific outcomes or generic health status outcomes.

Studies were excluded if they were

• Animal studies.
• Case reports and anecdotal evidence.
• Qualitative studies or descriptive surveys.
• Reports available only in abstract form.
• Trials that included diagnosis other than breast cancer unless separate data was available for the breast cancer group.

Initial review involved 843 titles and abstracts and 51 full-text articles. Of those, 26 studies were included in the report.

Study evaluation began with two independent reviewers using a modified Jadad scale, assessing 3 aspects: randomization procedure (2 points); dropout and withdrawal discussion (1 point); and blinding (2 points). Studies were classified as high quality if they attained a score of 3 or higher.

Evaluated literature included 18 randomized controlled trials (RCTs) and eight controlled clinical trials published between 1999 and 2008. Nine trials included conventional acupuncture, 6 included electroacupuncture, 5 included drug injection in acupoints, 3 included self-acupressure, and 3 included acupoint stimulation by wristbands or acumagnet. Eighteen were in English, and 8 were in Chinese.

• The total sample size was 1,548.
• Age range across across studies was 28–76 years.
• Five studies reported the participant’s body mass index, which ranged from 23.1 to 28.8.
• Information on participants’ education, background of acupuncturists, symptom distress before management, and measurement tool reliability was reported in too few studies to provide a meaningful summary.

Nine of the 26 studies were rated as high quality. Adverse effects (outcomes) of the APS included vasomotor syndrome, chemotherapy-induced nausea and vomiting (CINV), post-mastectomy pain, joint symptoms, lymphedema, leukopenia, and adverse events.

Eleven studies investigated CINV and APS with acupoints P6 and ST36. Ten of the CINV studies reported APS significantly improved emesis caused by breast cancer therapy.

The most common outcome evaluated by APS in the studies was CINV. APS was noted to be effective in reducing acute emesis caused by breast cancer therapy. Authors reported that APS is beneficial in the management of CINV, especially in the acute phase.

Healthcare providers should consider using APS as an option for the management of CINV.

• FINAL NUMBER STUDIES INCLUDED = 22 in qualitative synthesis (six studies of CINV) and five in meta-analysis
• TOTAL PATIENTS INCLUDED IN REVIEW = 2,459
• SAMPLE RANGE ACROSS STUDIES: 51–480 patients
• KEY SAMPLE CHARACTERISTICS: Various cancer types

PHASE OF CARE: Active antitumor treatment (for CINV trials)

All studies favored pharmacopuncture over the control group, but outcome measures varied. Five out of six studies reported response rates as an outcome measure. Two studies calculated response rate using emesis episodes. One study (26) used two outcome measures, the total number of emesis episodes in 21 days and the proportion of emesis-free days in the same period.

The level of evidence was not strong enough to draw any conclusions. There was a careful suggestion that pharmacopuncture may help alleviate cancer-related pain, CINV, and other symptoms such as ileus, hiccups, fever, quality of life, and gastrointestinal disturbances.

The findings of this meta-analysis should be interpreted with consideration of its limitations. Additional rigorously designed and conducted studies are required.

To review existing research on the use of acupuncture and acupressure in the management of nausea and vomiting in order to provide nurses the information required to assist their patients receiving chemotherapy and experiencing chemotherapy-induced nausea and vomiting (CINV)

Databases searched were described as scientific and internet sources, Institutes of Health Consensus statement, and federal regulations.

Search keywords included acupuncture and acupressure in combination with chemotherapy-induced nausea and vomiting.

Numerous studies tested the effectiveness of acupressure, acupuncture, and the combination. Few focused on acupressure alone for managing CINV.

A total of five studies were found, representing a total of 409 patients.

Very few studies were found, but, overall, results indicated improvement in nausea and vomiting, supporting the use of acupressure and acupuncture of the treatment of CINV. Acupuncture and acupressure were found to be safe and effective for the relief of CINV in combination with current antiemetic drugs.

The sample sizes were small in the studies; therefore, determining applicability to various practice settings and populations is difficult.

Database searched was MEDLINE (1966-Dec 2003).

Search keywords were acupuncture, alternative medicine, electroacupuncture, moxibustion, “injections, intramuscular”, “Medicine, Traditional Chinese”, acupressure, transcutaneous electrical nerve stimulation (TENS), and TENS. These were combined with nausea, vomiting, emesis, antiemetic therapy, and antineoplastic agents/adverse effects.

Studies were included in the review if they

• Were randomized.
• Involved patients receiving chemotherapy.
• Included an intervention that stimulated acupuncture points.
• Reported on nausea or vomiting as outcomes.

Studies were excluded from the review if they had a high possibility of bias.

In all, 14 studies were identified and reviewed.

In the nine studies that evaluated acute vomiting management via acupuncture-point stimulation, acute vomiting was reduced but nausea severity was not.

In the seven studies that assessed acute nausea via acupressure, acute nausea severity was reduced.

Three studies that evaluated delayed vomiting did not support the intervention.

In the five studies using acupuncture-point stimulation, the intervention did not reduce delayed vomiting.

The pooled results of 11 studies using acupuncture-point stimulation plus antiemetics for chemotherapy-induced nausea and vomiting (CINV) showed significant reduction in acute vomiting and marginal statistical significance for reducing acute nausea.

Electroacupuncture provided protective effects for acute vomiting, but acupuncture did not. Acupressure was effective for acute nausea in patients using “state-of-the-art” antiemetics. However, placebo effects may have influenced results.

To evaluate the effectiveness of acupuncture for symptom control in patients with cancer.

Databases searched were MEDLINE, EMBASE, CINAHL, Cochrane Collaboration, Scopus, and PubMed through December 2011.

Search keywords were acupuncture, electroacupuncture, moxibustion, Chinese medicine, Asian medicine, and keywords that included cancer and cancer symptoms.

Studies were included in the review if they

• Were randomized, clinical trials (RCTs)
• Involved acupuncture with needle insertion
• Compared acupuncture to control, placebo, or sham acupuncture.

Studies were excluded from the review if they

• Compared two active acupuncture forms, acupressure, or other interventions similar to acupuncture that did not involve needle insertion
• Did not measure the effect of acupuncture on symptoms
• Were considered gray literature (i.e., not generally accessible).

In total, 3,494 references were retrieved and evaluated according to the Cochrane Handbook for Systematic Reviews of Interventions.

• The final number of studies included was 41.
• The authors did not provide the sample range across studies, total number of patients, disease types, or characteristics.

Studies addressed potential management of the following symptoms:

• Pain:  Eleven RCTs met the criteria for analysis. No large trials reported positive results or were of good quality.
• Chemotherapy-Induced Nausea and Vomiting (CINV):  Eleven RCTs met the criteria for analysis. One large study with a low risk of bias showed between-group effect sizes for acupuncture versus sham (0.80) and for acupuncture versus usual care (1.10).
• Fatigue:  Three RCTs met the criteria for analysis. All had high risks of bias, and two had negative outcomes.
• Hot Flashes:  Seven RCTs met the criteria for analysis. None had a low risk of bias.
• Anxiety or Depression:  Five of the six RCTs analyzed showed positive results. All five had high risks of bias.
• Sleep:  Three RCTs met the criteria for analysis, and all three reported positive outcomes and had high risks of bias.

The strongest evidence that the study produced showed that acupuncture may be effective for the management of CINV. The study did not show acupuncture to be efficacious in the treatment of other symptoms.

The studies included were of low quality.

Available evidence, which was limited, did not support the claim that acupuncture is effective in alleviating various adverse symptoms in adults with cancer. Additional research is needed to determine the efficacy. The findings of this analysis suggested that patients with uncontrolled CINV may be appropriate candidates for acupuncture referral. For the treatment of other symptoms, the efficacy is undetermined.

MEDLINE was searched for the 14 medical conditions for which the National Institutes of Health Acupuncture Consensus Development Panel (NIHCDP) concluded acupuncture was effective or could be useful. The two conditions in which acupuncture was found to be effective are the treatment of chemotherapy-induced nausea and vomiting (CINV) and postoperative nausea and vomiting. The remaining 12 conditions reviewed in the article were the effect of acupuncture on pain and the treatment of other conditions (e.g., addiction, stroke rehabilitation, and asthma).

Three of the studies reviewed examined the effect of P6 acupuncture on CINV. Although the chemotherapy agents were variable and various carcinomas were studied, strong evidence supported the use of acupuncture for greater antiemetic effect than antiemetics alone.

Evidence supports the use of acupuncture in the treatment of CINV and postoperative nausea and vomiting.

• Databases searched were MEDLINE and CINAHL (1990-2002).
• Search keywords were nausea, vomiting, chemotherapy and neoplasm, assessment, management, complementary therapies, pharmacological, and nonpharmacological.
• Studies were included in the review if they included primary research, literature reviews, opinion articles, and information leaflets/booklets.
• Studies were excluded if they involved anticipatory nausea and vomiting associated with chemotherapy, because the authors felt that symptoms with a psychological basis should be addressed in a separate paper.

• Nonpharmacologic management interventions were reviewed with the intention that they do not replace standard antiemetic therapies but, rather, are adjuncts to improve quality of life (QOL).
• Intervention articles were reviewed for progressive muscle relaxation, guided imagery, self-hypnosis, acupressure/acupuncture, transcutaneous electrical nerve stimulation, biofeedback, cognitive distraction, and music therapy.

Support for the use of nonpharmacologic interventions for the treatment of chemotherapy-induced nausea and vomiting (CINV) was weak.

Many studies were flawed because of small sample sizes and confounding variables (e.g., stage of disease, various chemotherapy regimens, culture, patient compliance).

Preliminary available evidence suggests positive benefits through nonpharmacologic techniques; however, larger randomized trials are needed to demonstrate the exact benefits, including economic.

 To identify the evidence in scientific literature related to nonpharmacologic interventions for the treatment of chemotherapy-induced nausea and vomiting (CINV)

Databases searched were Cochrane, PubMed, Latin American and Caribbean Health Sciences Literature (LILACSO), and Brazilian Nursing Database (BDENF).

Search keywords were nausea, vomiting, chemotherapy, nursing care, cursing care protocols for cancer chemotherapy, and chemotherapy induced nausea and vomiting.

Studies were included in the review if they

• Addressed nonpharmacological interventions for nausea and vomiting.
• Were completed within the past 10 years (1998–2008).
• Were conducted in English or Spanish.

• An initial set of 111 articles were identified. Of these, 102 were related to pharmacological management and were eliminated. A final sample of nine studies was included in the review.
• The authors developed an instrument to analyze the literature related to method, journal type, and author.
• The articles were published in English (78%), Portuguese (11%), and Spanish (11%).
• The majority of the articles (67%) were written by physicians in collaboration with psychologists and pharmacists.

• Across the nine studies, a total sample of 1,635 patients were studied.
• The majority of studies involved the use acupuncture, acupressure, or electroacupuncture (5 trials and 1 meta-analysis).
• Studies involved patients receiving highly emetogenic chemotherapy or those with refractory CINV.

• One of the studies involved patient dietary education and adherence to antiemetic therapy in which patients reported a better sense of security with the provision of written information.
• One study, which had 16 participants, found hypnosis to be effective in reducing anticipatory CINV.
• One randomized, controlled trial of 62 patients using a yoga program showed no decrease in frequency or intensity of CINV with the intervention.
• Findings among studies of acupuncture and acupressure had mixed results, with most showing no significant difference in symptoms with the intervention.
• The meta-analysis showed a reduction in the proportion of patients with acute vomiting but not in the severity of nausea.
• Electrical stimulation did not improve results.

This review demonstrated no substantial effects among the interventions included. Findings regarding the use of acupuncture, acupressure, and electroacupuncture were mixed. Most studies using acupuncture and acupressure involved use of the p6 point on the wrist.

This review included a limited number of studies.

The evidence does not demonstrate significant effect of these interventions for CINV. However, these interventions may be useful as adjuncts to pharmacologic treatment. Nonpharmacologic interventions appear to be most effective in the prevention of acute vomiting rather than symptoms of nausea.

• FINAL NUMBER STUDIES INCLUDED = 21
• TOTAL PATIENTS INCLUDED IN REVIEW = 1,713
• KEY SAMPLE CHARACTERISTICS: Patients were aged 6–80 years and were recruited from inpatient settings and outpatient clinics. The average sample size was 81 patients. The studies focused on a variety of malignancies including breast cancer, lung cancer, leukemia, gastrointestinal cancer, and (in one study) pediatric cancer.

PHASE OF CARE: Active antitumor treatment
 
APPLICATIONS: Pediatrics and elder care

• Effective rate of AT with acute CINV: 44.44%–93.33% intervention group; 15%–91.67% control group
• Effective rate of AT with delayed CINV: 62.96%–100% intervention group; 25%–100% control group
• Studies comparing antiemetics versus antiemetics plus AT found the intervention group more effective. Intervention group: 54.62%–100%; control group 34.38%–100%
• Four studies investigated the effect of auricular acupressure on either acute or delayed CINV. There was no concordance of results. Some studies showed more improvement in acute, some in delayed, and some showed no difference.
• Three studies that included information about the performance statuses of patients using the Karnofsky Performance Status (KPS) index demonstrated a favorable effect on KPS scores in the intervention group compared to the control group.
• Twenty studies did not monitor patient compliance with the intervention, and the length of pressing acupuncture points varied from 30 seconds to 5 minutes.

This review was a helpful starting point to spur more research on the use of AT for the management of CINV. There was significant heterogeneity among the trials, but there appeared to be encouraging results for the use of AT to justify additional research. To better answer the question about AT's benefit, well-designed, randomized, controlled trials will be needed. From the information presented, it appears that AT may have a role in the management of delayed CINV, which can be challenging to manage and very troublesome for patients.

The investigators were only able to evaluate English and Chinese studies, which may have prevented the review of other studies such as Korean trials.

Encouraging results were identified about the adjunct use of AT for CINV, but this review demonstrated the need for well-designed trials incorporating AT with antiemetic regimens for acute and delayed CINV. The trials need to incorporate standard AT points, standard pressing length at each point, and a standard CINV assessment scale. Patient compliance also should be assessed and documented.

To evaluate the use of electroacupuncture in preventing anthracycline-based chemotherapy-related nausea and vomiting (CINV) refractory to combination 5-HT₃-antagonist and dexamethasone

Patients received electroacupuncture in addition to standard antiemetic prophylaxis. Acupuncture was started 10 minutes prior to start of chemotherapy infusion and then continued for an additional 20 minutes. The P6 acupuncture point was used, a second needle was inserted at a different point, and electrical stimulation was delivered. 

• The study consisted of 27 patients with breast cancer.
• All patients were receiving their second cycles of doxorubicin and cyclophosphamide; cyclophosphamide, doxorubicin, and prednisone; or doxorubicin only.
• Patients were defined as having refractory emesis (defined as vomiting three or more times, 24-48 hours after cycle one).
• Patients received standard antemetic prophylaxis.

This was a prospective trial.

• Patients completed a questionnaire assessing their attitudes toward acupuncture. 
• Patients recorded frequency of vomiting in diaries.
• A trained doctor interviewed patients via telephone 24-48 hours after chemotherapy to grade nausea and vomiting using the National Cancer Institute Common Toxicity Criteria (NCI-CTC).

• Ten patients (37%) reported no vomiting after the second cycle of chemotherapy with the addition of electroacupuncture.
• The majority of patients (96%) reported significantly less nausea and vomiting, but one patient experienced increased vomiting after electroacupuncture.
• Overall, mean emetic episodes decreased from 7 to 3 after the intervention (p < 0.0001).
• NCI grade of vomiting decreased significantly (p = 0.0120).
• The number of patients reporting grade 3-4 vomiting dropped from 14 prior to the electroacupuncture to 5 after the electroacupuncture.
• NCI grade of nausea improved as well after the intervention (p < 0.0001).
• Most patients (93%) reported that they thought that electroacupuncture was an acceptable procedure and helpful in reducing emesis.

• All patients participated in the intervention group; no control group was provided.
• Two subjects complained of severe headaches after the electroacupuncture, lasting for several days; otherwise it was well-tolerated.
• The intervention was delivered by trained acupuncturists.

To study the effectiveness of acupuncture and acupressure in reducing chemotherapy-induced nausea

Patients were treated for one cycle of chemotherapy with acupuncture and acupressure at point P6 and for one cycle at a close sham point. Participants were randomized to acupuncture at P6 or at a close nonacupuncture point, and it was delivered by one of two physicians with training and experience in acupuncture. Participants wore acupressure bands for 72 hours at the same points on both arms and could wear them for an additional four days if needed. The bands were covered with a mull bandage to blind the staff. Participants completed diaries for seven days, documenting intensity (on a 0-6 rating scale), frequency, and duration of nausea and vomiting; additional antiemetics taken; and, on day 7, rate the effectiveness of side effects or impairment by acupuncture or acupressure. Patients completed the Morrow Assessment of Nausea and Emesis (MANE). Oncology staff checked that the diaries were completed accurately, standard antiemetics regimens were followed, and if any adverse reactions related to acupuncture occurred.

• The study consisted of 28 patients receiving moderately emetogenic chemotherapy (MEC) or highly emetogenic chemotherapy (HEC).
• Patients were eligible for the study if they
  • Were 18-75 years old.
  • Were scheduled to receive MEC or HEC and standard antiemesis additional medication for rescue predefined for two cycles of chemotherapy.
  • Had a Karnofsky index of 50%.
• Patients were excluded from the study if they had
  • Received chemotherapy within the last three months.
  • Experienced anticipatory nausea and vomiting, cerebral metastasis, chronic ileus or subileus, or lymphedema in arms.
  • Prior knowledge of acupressure points.

The study was conducted by the hematology and gastroenterology departments of a large university hospital in Germany.

This was a randomized, crossover pilot study.

• The MANE, shortened version, was used to measure nausea.
• Patients recorded the Intensity, frequency, and duration of nausea in patient diaries.

• No difference was found between combined acupuncture and acupressure at the P6 point and at the sham point.
• The study was stopped early because of recruitment problems and low incidence of nausea and vomiting in the sham group.
• Half of the participants reported an irradiating feeling, which is a sign of effective acupuncture.

• The sample size was small.
• Incidence of nausea was low in the sham group.
• No acupuncture control group was included.
• No control was included for type of cancer or chemotherapy regimen.
• The sham point may have been too close to P6 or the needle was too deep.

To compare the efficacy of ondansetron versus acupuncture in the prevention of delayed chemotherapy-induced nausea and vomiting (CINV)

Patients were randomized to receive acupuncture (applied to wrists) or ondansetron (8 mg IV for 30 minutes) before chemotherapy. Acupuncture also was applied the day after chemotherapy. All patients received dexamethasone at 5 mg orally twice per day for three days following chemotherapy. Ondansetron at 4 mg was administered orally every 12 hours for vomiting. During subsequent chemotherapy infusions, patients received the other intervention in a crossover design. Data on CINV were collected for five days after the administration of chemotherapy, and quality-of-life data were collected on the seventh day following chemotherapy.

• N = 70
• AVERAGE AGE = 51.6 years
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: Patients with gynecologic cancers receiving similar chemotherapy regimens of carboplatin and paclitaxel and similar premedications before chemotherapy
• OTHER KEY SAMPLE CHARACTERISTICS: Exclusion criteria included vomiting or use of antiemetics within 24 hours, abdominal or pelvic radiation within 48 hours prior to or during the study, evidence of brain metastasis, bowel obstructions, or other serious concurrent conditions.

• SITE: Not stated  
• SETTING TYPE: Not specified    
• LOCATION: Bangkok, Thailand

• PHASE OF CARE: Active antitumor treatment
• APPLICATIONS: Elder care

Randomized, crossover study

• Patients self-reported the severity of nausea, incidents of emesis, and required doses of oral ondansetron.  
• Functional Assessment of Cancer Therapy–General (FACT-G)

Patients in the intervention group had a higher rate of complete response for delayed CINV (p = 0.02), less delayed nausea (p = 0.004), lower nausea scores (p < 0.001), and fewer doses of additional ondansetron (p = 0.002). Fewer patients reported adverse side effects when receiving acupuncture. Forty patients reported that they preferred acupuncture to ondansetron.

Acupuncture was effective in the prevention of delayed CINV and nausea. Patients receiving acupuncture also required fewer doses of ondansetron during the delayed phase of CINV.

• Small sample (< 100)
• Risk of bias (no control group)
• Findings not generalizable

Although additional research with a larger and more diverse sample is needed, the use of acupuncture to manage CINV could represent an effective nursing intervention for patients receiving platinum-based chemotherapy.

To compare the effectiveness of electroacupuncture, minimal needling and mock electrical stimulation, or antiemetic medications alone in controlling emesis among patients undergoing highly emetogenic chemotherapy

Participants were randomly assigned to one of three groups.

• Low-frequency electroacupuncture at classic antiemetic acupuncture points once daily for five days
• Minimal needling at control points with mock electrostimulation once daily for five days
• No adjunct needling

• The study consisted of 104 patients.
• The mean age was 46 years with a range of 18–62 years.
• All participants were women with histologically proven resected breast cancer undergoing myeloablative chemotherapy, Karnofsky scores of 80 or more (on a 0–100 scale), and life expectancy of at least six months. All participants were appropriate candidates for bone marrow transplantation.
• Patients were excluded from the study if they had brain metastases, cardiac pacemakers, life-threatening concurrent nonmalignant conditions, or active skin infections over the proposed treatment area.

Participants were from an inpatient unit at a tertiary hospital with a comprehensive cancer center. Patients were recruited from oncology clinics.

The study design was random, without stratification.

Investigators recorded the total number of emetic episodes during the five-day study period and the proportion of emesis-free days across the treatment groups.

• The electroacupuncture group had significantly fewer emesis episodes than the minimal needling group or the pharmacotherapy group alone (p < 0.001).
• The minimal needling group had significantly fewer episodes of emesis than the pharmacotherapy group alone (p = 0.01).
• The electroacupuncture group had a greater proportion of emesis-free days than the other groups (p < 0.001).
• No significant difference existed between the groups over days 6–14.

• Homogeneity of sample (standard chemotherapy and supportive care) helped to increase the precision in measurement; however, generalizability is limited.
• The study did not include 5-HT₃ antagonists or corticosteroids.
• Training is required for electroacupuncture and minimal needling. The two investigators administered the procedure (training completed with 3–20 years of experience).
• Time commitment was 30 minutes a day for five days.
• This was a grant-funded project. 

• The beneficial effect of electroacupuncture may be related to attention and clinician-patient interaction.
• Minimal needling led to a reduction in emesis, which could have been a placebo effect.
• Electroacupuncture has been thought to modulate serotonin, substance P, and endogenous opioids (similar to drugs that are available now).

To investigate the effects of acupuncture on nausea, vomiting, pain, sleep quality, and anxiety in patients who were hospitalized or undergoing chemotherapy

Acupuncture was given for three days. On the day of hospitalization and after three days, study assessments were completed. Chemotherapy-induced nausea and vomiting (CINV) was not measured in patients receiving chemotherapy for the first time.

• N = 45
• MEAN AGE = 50.5 years (SD = 13.3 years)
• MALES: 60%, FEMALES: 40%
• KEY DISEASE CHARACTERISTICS: Multiple tumor types; 71% were receiving palliative chemotherapy; 29% were receiving adjuvant chemotherapy
• OTHER KEY SAMPLE CHARACTERISTICS: 70% received primary school or less education

• SITE: Single site    
• SETTING TYPE: Inpatient    
• LOCATION: Turkey

• PHASE OF CARE: Multiple phases of care
• APPLICATIONS: Palliative care

• Quasi-experimental

• Visual Analog Scale (VAS) for pain
• Insomnia Severity Index (ISI)
• Nausea and vomiting were measured according to oral intake and graded on a 0–4 scale.
• Beck Anxiety Inventory (BAI)

The sign test was used to show the pre- and post-treatment significance of differences, and these were shown for all symptoms (p < 0.001). However, the pretreatment score for insomnia was equal to one before and after treatment, and a larger proportion of patients did not improve (57.8%) than improved (42.2%) in terms of sleep quality. In other symptoms, the percentage that improved was similar to the percentage that did not improve. The intervention group appeared to have the greatest number of patients whose nausea improved.

Acupuncture may be a useful adjunctive therapy for the management of pain, CINV, anxiety, and insomnia in hospitalized patients receiving chemotherapy. The design of this study limits the strength of its findings.

• Small sample (< 100)
• Risk of bias (no control group)
• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Unintended interventions or applicable interventions not described that would influence results
• Other limitations/explanation: No information was provided regarding the use of other interventions such as medications for any of the symptoms examined. Baseline symptom levels were not reported in all cases.

Acupuncture is a complementary therapy that may be beneficial as an adjunct treatment for symptom management in patients with cancer. This individual study has multiple limitations, and additional evidence is needed to evaluate the effectiveness of acupuncture.

To investigate the effects of transcutaneous electrical acupoint stimulation (TEAS) on chemotherapy-induced nausea and vomiting (CINV)

Patients receiving chemotherapy via an infusion to transcatheter arterial chemoembolization were randomized to an active or placebo acupuncture group. Prior to chemotherapy, all patients received IV palonosetron. Patients received acupuncture 1–2 hours before chemotherapy, and more just after chemotherapy. Acupuncture was continued twice daily for six days. In the sham acupuncture group, electrodes were placed on the same acupoints for the same length of time and frequency, but no electrical stimulation was given. Severity and frequency of nausea and vomiting were recorded in patient diaries daily. P6, L14, and ST36 acupoints were used.

• N = 142   
• MEAN AGE = 56.5 years
• AGE RANGE = 30–77
• MALES: 68.3%, FEMALES: 41.7%
• CURRENT TREATMENT: Chemotherapy
• KEY DISEASE CHARACTERISTICS: Primary or metastatic liver cancer
• OTHER KEY SAMPLE CHARACTERISTICS: All were on cisplatin-based regimens.

• SITE: Single site   
• SETTING TYPE: Not specified    
• LOCATION: China

PHASE OF CARE: Active antitumor treatment

Double-blind, sham-controlled, randomized, controlled trial

• Visual analog scale (VAS) 0–10 for anorexia
• MD Anderson Symptoms Inventory

No significant differences in CINV existed between groups. Anorexia was lower in the active acupuncture group from the second day onward (p < 0.0002).

Electroacupuncture was not shown to have an effect on CINV but appeared to have benefit for reducing anorexia.

• Measurement/methods not well described
• Of daily CINV scoring, values used in analysis were not described.

Electroacupuncture was not effective in reducing CINV in this study but appeared to have a positive effect on appetite. Additional research is needed to determine any potential role of acupuncture for anorexia in patients with cancer.

To evaluate transcutaneous electroacupuncture (TEA) on chemotherapy-induced nausea and vomiting (CINV) as well as serotonin and dopamine levels among patients with cancer

• N = 72
• AGE = Not stated
• MALES: 60% (43), FEMALES: 40% (29)
• KEY DISEASE CHARACTERISTICS: Not stated
• OTHER KEY SAMPLE CHARACTERISTICS: All were naïve to chemotherapy or received only moderate to highly emetogenic chemotherapy; scheduled to receive moderate or highly emetogenic chemotherapy (cisplatin > 50 mg/m², cyclophosphamide > 1,500 mg/m², or carmustine > 250 mg/m²)

• SITE: Single site
• SETTING TYPE: Inpatient
• LOCATION: Zhejiang Provincial Hospital of Traditional Chinese Medicine

• PHASE OF CARE: Active antitumor treatment

Randomized, controlled trial

• Nausea and vomiting: Patients recorded the date and time of emesis or retching, the degree of nausea (none, mild, moderate, or severe), and the use of rescue medications (name, dose, and time) in a diary.
• Serotonin and dopamine
• Safety measures: Vital signs, 12-lead electrocardiogram (EKG), blood tests (white blood cell count, aspartate transaminase, alanine transaminase, and creatinine clearance), and urinalysis

Vomiting was significantly improved in the treatment group compared to the control group at 48 hours only (p = 0.046). No difference was noted at 24 hours (p = 0.9) or 72 hours (p = 0.68). Nausea was significantly better for the treatment group than the control group at 48 hours (p = 0.001) and 72 hours (p = 0.025) but not at 24 hours. Serotonin and dopamine were not different at baseline but were significantly reduced in the treatment group when compared to the control group at 48 hours (p = 0.03) and 72 hours (p = 0.02). No safety issues were noted in any patients. Laboratory results and EKG tests were normal.

Transcutaneous electroacupuncture was effective at improving delayed nausea and vomiting and had no significant safety issues.

• Small sample (< 100)
• Other limitations/explanation: Sample characteristics were not adequately reported, and no differences between the groups were noted. The authors did not report if any subjects withdrew from the study.

The needleless system of transcutaneous electroacupuncture made administration easy and compliance rates high.

4,900 references were identified that were published between January 1, 1990 and December 31, 2013. 203 articles were included in the final review although only 174 were referenced. Grades used and reported here were A: recommended, high certainty of benefit, B: recommended, high certainty of moderate to substantial benefit, D: recommends against use, moderate to high certainty of no net benefit, and H: recommends against use, moderate to high certainty that harms outweigh benefits.

Interventions for specific symptoms that had strong recommendations for or against use were:

• Anxiety: Music therapy during RT and chemotherapy sessions, meditation, and yoga for patients undergoing therapy (B-level recommendation)
• Depression: Mindfulness-based stress reduction for patients undergoing radiotherapy, relaxation, and yoga (level A recommendation); massage and music therapy (level B)
• Fatigue: Energy conservation (level B)
• CINV: Acupressure and electroacupuncture in addition to antiemetics (B level)
• Neuropathy: Acetyl L carnitine was not recommended because of harm (H level).
• Radiodermatitis: Aloe vera and hyaluronic acid cream were not recommended as standard therapy because of lack of effect (D level).

It appears that only specific types of interventions were included, and there are numerous types of integrative or complementary interventions that were not considered in this review. The findings considered were limited to women with breast cancer. Quality rating of evidence was not discussed individually.

These guidelines provided an evidence-based evaluation of various integrative therapies in women with breast cancer. This set of interventions is not all-inclusive; however, it does provide some guidance to clinicians and others regarding evidence strength in these areas as assessed by this specific study group.