Acupuncture’s Role in the Integrative Medical Care of Cancer Patients

1. Acupuncture’s Role in the Integrative Medical Careof Cancer Patients Adam Schreiber, MAOM, Dipl. OM, R.Ac.

2. A Brief History of Acupuncture • Acupuncture is one branch of a complete system of medicine known as Oriental Medicine, which has developed over the course of thousands of years. • Theories underlying traditional Oriental Medicine are largely based on observing the natural world. • Oldest written medical information ~ 168 BCE

3. Most important text – Yellow Emperor’s Canon of Internal Medicine – (300-100 BCE) • Historically, people learn by being part of a lineage of practitioners - leads to the practice of many different styles. • Western/Biomedicine comes to China in the early 1900s. Begins long process of Westernizing traditional Chinese medicine.

4. 1950s - Mao Zedong has leading medical people standardize and Westernize traditional medicine. Becomes known as “TCM” (Traditional Chinese Medicine) – taught today in many Western acupuncture schools. • In China today, many hospitals are integrated – Biomedicine/Western & Traditional medicine in the same hospital. • Standard practice in Chinese TCM hospitals for cancer patients to receive Biomedical and traditional medicine (includes herbs) treatment simultaneously.

5. The Holistic Nature of Oriental Medicine • Oriental medicine takes all aspects of a person’s health into account. • Able to treat patient as a whole – body, mind, spirit (especially important for cancer patients). • Aims to treat the root causes of disease, while also addressing the symptoms. • Pattern oriented – try to ID the overall pattern of disharmony in the body which is causing disease.

6. The Theoretical Foundations of Acupuncture

7. The Human Body • Acupuncture theory sees the body as a microcosmic representation of the universe (e.g. meridians of the body are analogous to the waterways of the earth). • Organs of the body are considered more for their functions than for their structure.

8. The Concept of Qi • Translated as “life energy” or “vital energy”, a dynamic construct. • OM defines Qi by the function it performs in the body. Qi is responsible for all physiological functioning in the body. • Qi is derived from three main sources: air we breathe, food we eat, & inherited. • Qi flows through the body via channels, or meridians, that correspond to particular organs or organ systems.

9. Qi

10. The Concept of Blood • Different than Western idea of blood – though there is overlap. Also defined functionally. • Blood nourishes the body, moistens body tissues. • Blood contains the Shen, or spirit, which corresponds roughly to the psyche. • Blood and qi perform many of the same functions, yet are interdependent.

11. Meridians & Acupoints • Meridians are pathways which qi follows as it flows around the body. • Analogous to, but not the same as, circulatory, lymphatic, and nervous systems. • 12 regular meridians, named for internal organs. • Meridians contain 365 acupuncture points. • Points have Chinese names which often relate to their function or location. • Acupoints are discrete and specific sites through which the Qi of the organs communicates with the surface of the body.

12. Stomach Meridian Graphics reprinted with permission Copyright 2002-2005 Yin Yang House – all rights reserved http://www.yinyanghouse.com/

13. Small Intestine Meridian Graphics reprinted with permission Copyright 2002-2005 Yin Yang House – all rights reserved http://www.yinyanghouse.com/

14. Organ Systems • Each organ system associated with different levels of influence - physical, energetic, mental, emotional. Mind-body continuum. • Again, organs seen more for their functions than for their physical structure. • Example - we say in Chinese medicine that the “Spleen” keeps blood within the blood vessels. The “Spleen” also transforms food into qi that the body can use (i.e. digestion and assimilation). • OM organs  Biomedical organs.

15. Causes of Disease • Generally disease is caused by dysfunction in flow of qi and/or blood in the body. • Three causes of disease: 1) External causes of disease: • Six Exogenous Factors 2) Internal causes of disease: • Seven Emotions 3) Other causes of disease: • Miscellaneous

16. Exogenous Factors • Environmental conditions behave the same way in the body as they do in nature. • Wind • Dryness • Heat • Cold • Dampness • Summer-heat

17. Endogenous Factors • Excessiveor prolonged emotions lead to a variety of distortions in the movement and function of Qi, which can eventually result in pathology: - Anger - Pensiveness - Joy - Shock - Sadness - Worry - Fear

18. Miscellaneous Factors • Genetic Predisposition – Constitutional issues • Improper diet – includes overeating, eating the wrong foods, poor eating habits • Overwork – physical and/or mental • Trauma • Parasites

19. Diagnosis • Goal is to locate and describe a pattern of disharmony. • Based on the “4 Examinations” 1) Asking 2) Looking 3) Listening 4) Palpating

20. Tongue Diagnosis • Observe color, coating, size, shape, moisture. Organs mapped on tongue surface. • Pulse Diagnosis: • Assess: rate, quality, strength. Different positions correspond to internal organs.

21. Treatments • Only sterile, single-use needles. • May have mild discomfort with needles, but generally well tolerated. • Treatments are usually very relaxing. • Treatment course depends on nature of disease, cancer patients may need ongoing treatment. • Simultaneously treat the symptoms while addressing the root cause and/or the constitution of the patient.

23. Biomedical Theories of How Acupuncture Works • “Gate Control theory” – acupuncture stimulates nerve fibers which signal for inhibition of pain. • “Endorphin theory” – stimulates release of endorphins, serotonin, norepinephrine and ACTH – all implicated in pain relief. • “Connective Tissue theory” – acupuncture creates changes in connective tissue which impact the body at the cellular level via mechanotransduction.1 1. Langevin HM, Churchill DM, Cipolla MJ. Mechanical signaling through connective tissue: a mechanism for the therapeutic effect of acupuncture. FASEB J. 2001;15:2275-2282.

24. Acupuncture and the Integrative Treatment of Cancer

25. Pathology of Cancer in OM • Any/all of the 3 causes of disease are implicated. • Four common patterns of disharmony: • Phlegm accumulation • Heat/Fire Toxins • Qi & Blood Deficiency • Qi & Blood Stagnation

26. How Can Acupuncture Help Cancer Patients? • It is safe to use acupuncture concurrently with Biomedical cancer treatments. It will not interfere with pharmaceutical/radiation treatment. • Generally used as supportive treatment, to help alleviate side effects of Biomedical treatments. • Literature review of cancer-related acupuncture research – Cohen and colleagues.2 2. Cohen AJ, Menter A, Hale, L. Acupuncture: Role in Comprehensive Cancer Care – A Primer for the Oncologist and Review of Literature. Integr Cancer Ther. 2005 Jun;4(2):131-43.

27. Cancer-Related Acupuncture Research • MSKCC – Integrative Medicine – leader in research • Antiemetic effects – well documented, 1997 NIH consensus statement3 • Pain Control • Fatigue • Breathlessness • Mood Disorders, QOL Issues • Xerostomia • Flushing (Breast and Prostate cancers) 3. Acupuncture. NIH Consensus Statement. 1997;15(5):1-34

28. Pain Control • 48 patients with axillary pain after axillary node dissection for breast cancer – acupuncture group showed significantly more complete arm abduction and less pain than control group.4 • Alimi and colleagues – cancer patients w/stable analgesic treatment with neuropathic pain – 90 patients, auricular acupuncture – 36% still had reduced pain intensity at two months.5 4. He JP, Friedrich M, Ertan AK, Muller K, Schmidt W. Pain-relief and movement improvement by acupuncture after ablation and axillary lymphadenectomy in patients with mammary cancer. Clin Exp Obstet Gynecol. 1999;26:81-84. 5. Alimi D, Rubino C, Pichard-Leandri E, Fermand-Brule S, Dubreuil-Lemaire M-L, Hill C. Analgesic effect of auricular acupuncture for cancer pain: a randomized, blinded, controlled trial. J Clin Oncol. 2003;21:4120-4126.

29. Fatigue • Phase II pilot study (MSKCC) – post-chemotherapy fatigue – mean improvement was 31.1%.6 • Breathlessness • Open Pilot - Filshie and colleagues – 20 patients with cancer-related breathlessness – 14 reported marked symptomatic benefit with commensurate physiological changes.7 6. Vickers AJ, Straus DJ, Fearon B, Cassileth BR. Acupuncture for post-chemotherapy fatigue: a phase II study. J Clin Oncol. 2004;22:1731-1735. 7. Filshie J, Penn K, Ashley S, Davis CL. Acupuncture for the relief of cancer-related breathlessness. Palliat Med. 1996;10:145-150.

30. Immune Effects • Studies not specific to cancer, but have shown: • Increases in CD3+, CD4+ lymphocytes and CD8+ cells.8 • Increases in B lymphocytes & NK cell activity. • Modulation of B and T cells that favors antibody production.9 • 8. Spiegel D, Stroud P, Fyfe A. Complementary medicine. West J Med. 1998;168:241-247. • 9. Petti F, Bangrazi A, Liquori A, Reale G, Ippoliti F. Effects of acupuncture on immune response related • to opioid-like peptides. J Tradit Chin Med. 1998;18(1):55-63.

31. Current Clinical Trials • Head and neck pain related to head and neck cancer surgery – Phase III (MSKCC) • Hot flashes from breast cancer – Phase III (MSKCC) • Reducing symptoms in advanced colorectal cancer – Phase I (Univ. of Pittsburgh Med. Center) Source: http://nccam.nih.gov/clinicaltrials/acupuncture.htm

32. Research Conclusions “As for oncologists in the community or in academic centers, in light of our current understanding of acupuncture and its efficacy, it seems reasonable to suggest its use for patients with difficult-to-control chemotherapy-induced side effects such as pain, fatigue, nausea and vomiting, xerostomia and mood disorders. There may be additional benefits to patients in terms of quality of life, hot flashes, peripheral neuropathy, alopecia, neutropenia, anorexia, constipation and spiritual connection, but these have not yet been well documented in the literature.” (Cohen, Menter, Hale, p. 141)

33. Other Reasons to Refer for Acupuncture Treatment • Any of the following: • Digestive complaints • Bowel and/or Urinary problems • Depression, anxiety • Other pain issues • General immune support – low blood counts

34. Further Information • Websites: • www.yinyanghouse.com (general info) • www.acupuncturetoday.com (general) • www.acubriefs.com (acupuncture research) • www.mskcc.org/mskcc/html/1979.cfm • ww.medicalacupuncture.org • www.nccam.nih.gov/clinicaltrials

35. References • Langevin HM, Churchill DM, Cipolla MJ. Mechanical signaling through connective tissue: a mechanism for the therapeutic effect of acupuncture. FASEB J. 2001;15:2275-2282. • Cohen AJ, Menter A, Hale, L. Acupuncture: Role in Comprehensive Cancer Care – A Primer for the Oncologist and Review of Literature. Integr Cancer Ther. 2005 Jun;4(2):131-43. • He JP, Friedrich M, Ertan AK, Muller K, Schmidt W. Pain-relief and movement improvement by acupuncture after ablation and axillary lymphadenectomy in patients with mammary cancer. Clin Exp Obstet Gynecol. 1999;26:81-84. • Alimi D, Rubino C, Pichard-Leandri E, Fermand-Brule S, Dubreuil-Lemaire M-L, Hill C. Analgesic effect of auricular acupuncture for cancer pain: a randomized, blinded, controlled trial. J Clin Oncol. 2003;21:4120-4126. • Vickers AJ, Straus DJ, Fearon B, Cassileth BR. Acupuncture for post-chemotherapy fatigue: a phase II study. J Clin Oncol. 2004;22:1731-1735. • Filshie J, Penn K, Ashley S, Davis CL. Acupuncture for the relief of cancer-related breathlessness. Palliat Med. 1996;10:145-150. • Spiegel D, Stroud P, Fyfe A. Complementary medicine. West J Med. 1998;168:241-247. • Petti F, Bangrazi A, Liquori A, Reale G, Ippoliti F. Effects of acupuncture on immune response related to opioid-like peptides. J Tradit Chin Med. 1998;18(1):55-63.