The ASCO Post’s Integrative Oncology series is intended to facilitate the availability of evidence-based information on integrative and complementary therapies commonly used by patients with cancer. In this installment, authors Jun J. Mao, MD, MSCE, and Jyothirmai Gubili, MS, present a case study and discuss the evidence concerning the role of acupuncture in managing hot flashes in patients with breast cancer.
Jun J. Mao, MD, MSCE, is the Laurance S. Rockefeller Chair in Integrative Medicine, and Chief, Integrative Medicine Service, at Memorial Sloan Kettering Cancer Center, in New York. Dr. Mao joined Memorial Sloan Kettering Cancer Center in 2016, succeeding Barrie R. Cassileth, MS, PhD. Jyothirmai Gubili, MS, is the editor for the Integrative Medicine Service at Memorial Sloan Kettering Cancer Center in New York.
Editor’s note: Dr. Cassileth is retired from Memorial Sloan Kettering Cancer Center and living in Los Angeles. She will continue to contribute to Integrative Oncology in The ASCO Post on an occasional basis.
Mary is a 49-year-old woman diagnosed with stage II estrogen receptor–positive cancer 2 years ago. She has finished surgery, chemotherapy, and radiotherapy and is currently on tamoxifen. Chemotherapy put her into premature menopause, and since then, she has been having frequent hot flashes, 8 to10 times during the day. The hot flashes are worst at night and wake her up three to four times, where she finds the sheet soaked in sweat. She tried venlafaxine for a few weeks; however, she did not like the fact that it decreased her libido and so stopped taking the drug. She asks you, “Women in my support group told me to try acupuncture. What do you think?”
An integral component of Traditional Chinese Medicine, acupuncture originated more than 2,000 years ago. Practitioners utilize needles, sometimes with electricity (electroacupuncture) to enhance the therapeutic effect, on one or more predetermined points on the body.
Current evidence on [acupuncture’s] ability to alleviate hot flashes and improve quality of life is also encouraging, but larger, rigorous clinical trials are needed to garner conclusive data.— Jun J. Mao, MD, MSCE, and Jyothirmai Gubili, MS
The role of acupuncture in relieving symptoms associated with cancer and its treatments has been investigated in many studies, and results support its utility in alleviating pain, postoperative and chemotherapy-induced nausea and vomiting, xerostomia, and chemotherapy-induced peripheral neuropathy. These findings have led to more than 60% of National Cancer Institute (NCI)-designated comprehensive cancer centers recommending acupuncture for managing cancer symptoms.1 Growing evidence suggests that acupuncture also has value in controlling hot flashes, a problematic symptom that negatively impacts quality of life. This article will focus on studies involving breast cancer patients and survivors, a population prone to severe, longer-lasting hot flashes compared with healthy postmenopausal women.2
Physiology of Hot Flashes and Treatments
Hot flashes, also referred to as hot flushes, are characterized by periods of a sudden, intense feeling of warmth that begins at the chest and radiates to the neck and face, accompanied by flushing, sweating, and heart palpitations; the duration varies from several seconds to minutes.3 Although hot flashes can occur anytime during a 24-hour period, those occurring at night tend to be the most bothersome, because they disrupt sleep.4
In a study of cognitive behavioral treatment for chronic insomnia involving breast cancer survivors, nights with hot flashes had a significantly greater wake time, decreased stage II sleep, and a longer rapid eye movement latency compared with nights without hot flashes.5 Sleep deprivation negatively impacts daytime functioning and also elevates pain, fatigue, depression, and anxiety levels, significantly impairing quality of life.6,7
The etiology of hot flashes is not well understood, but contributing factors in breast cancer survivors include the age at diagnosis, premature menopause due to chemotherapy and surgery, and estrogen deficiency resulting from the use of tamoxifen and aromatase inhibitors.8
Hormone-replacement therapy, once considered a treatment option, was found to increase the risk of cancer recurrence in a trial of women with previous breast cancer; the study was terminated prematurely following this finding.9 This treatment has since been contraindicated. Nonhormonal, pharmacologic agents in current use, such as venlafaxine, gabapentin, citalopram, and clonidine confer benefits but are associated with adverse effects, including dizziness, headaches, and drowsiness.10
Acupuncture in the Literature
A few studies of acupuncture for hot flashes have yielded promising results,11 but they are not definitive in terms of efficacy. A 2015 systematic review including eight randomized trials of breast cancer patients also reported that acupuncture resulted in significant improvement in hot flashes compared with baseline. However, the evidence was deemed insufficient to arrive at any conclusions because the studies were methodologically flawed.12
But in a recent randomized trial, in which 190 breast cancer patients were assigned to manual acupuncture or enhanced self-care, acupuncture was reported to have beneficial effects. It not only reduced hot flash scores at the end of the trial, but at both the 3-month and 6-month follow-up visits. Acupuncture also significantly improved quality of life compared with the control group.13
Noteworthy are findings from a 2015 randomized controlled trial in which 120 breast cancer survivors experiencing hot flashes were randomized to receive electroacupuncture, sham acupuncture, gabapentin, or placebo for 8 weeks. Data indicate that the effects of electroacupuncture were comparable to those of gabapentin and durable, with fewer adverse effects. Although the effect size of electroacupuncture was small compared with sham treatment at week 8, it increased considerably at week 24, suggesting that electroacupuncture may produce longer-lasting physiologic effects.14 Furthermore, electroacupuncture was also reported in a recent study to be comparable to gabapentin in improving sleep in breast cancer survivors experiencing hot flashes.15 Although its mechanism of action is not completely understood, studies have demonstrated that electroacupuncture mediates its effects via endorphins and other central neuropeptides, offering a physiologic basis for alleviating hot flashes.16
Acupuncture treatments are generally safe when administered by licensed practitioners and tend to be well tolerated by most patients. Minor adverse events such as bleeding, hematoma, dizziness, and pain have been reported; pneumothorax and local infections are rare events.17,18
It is predicted that the number of breast cancer survivors in the United States will approach 6 million by the year 2020.19 This estimate underscores the importance of identifying effective interventions of symptom control. And increasingly, patients desire natural alternatives to avoid the unwanted adverse effects associated with prescription medications in current use.20 As one of the extensively studied complementary therapies, acupuncture has been documented to be valuable in the oncology setting for symptom control.
Current evidence on its ability to alleviate hot flashes and improve quality of life is also encouraging, but larger, rigorous clinical trials are needed to garner conclusive data. Until then, for patients experiencing bothersome symptoms who are not amenable to medications, oncologists or nurses can recommend a course of 6 to 10 acupuncture treatments for symptom relief. A final important note for patients with cancer considering acupuncture is to seek credentialed practitioners who have training or experience in working with this population. ■
Disclosure: Dr. Mao and Ms. Gubili reported no potential conflicts of interest.
1. Brauer JA, El Sehamy A, Metz JM, et al: Complementary and alternative medicine and supportive care at leading cancer centers: A systematic analysis of websites. J Altern Complement Med 16:183-186, 2010.
8. Bordeleau L, Pritchard KI, Loprinzi CL, et al: Multicenter, randomized, cross-over clinical trial of venlafaxine versus gabapentin for the management of hot flashes in breast cancer survivors. J Clin Oncol 28:5147-5152, 2010.
9. Holmberg L, Anderson H; HABITS steering and data monitoring committees: HABITS (hormonal replacement therapy after breast cancer—is it safe?), a randomised comparison: Trial stopped. Lancet 363:453-455, 2004.
10. Johns C, Seav SM, Dominick SA, et al: Informing hot flash treatment decisions for breast cancer survivors: A systematic review of randomized trials comparing active interventions. Breast Cancer Res Treat 156:415-426, 2016.
13. Lesi G, Razzini G, Musti MA, et al: Acupuncture as an integrative approach for the treatment of hot flashes in women with breast cancer: A prospective multicenter randomized controlled trial (AcCliMaT). J Clin Oncol 34:1795-1802, 2016.
15. Garland SN, Xie SX, Li Q, et al: Comparative effectiveness of electro-acupuncture versus gabapentin for sleep disturbances in breast cancer survivors with hot flashes: A randomized trial. Menopause. November 21, 2016 (early release online).