The use of acupuncture in symptom management in palliative care

Acupuncture has an increasing role in the palliation of both painful and non-painful symptoms in cancer patients. Acupuncture can help both acute pain peri-operatively and chronic cancer related pain states.

Despite the remarkable advances in the pharmacological management of cancer pain, approximately 10% of patients on active treatment have pain that is refractory to the appropriate use of analgesics and coanalgesics. In late stage disease, this figure can rise to over 50%. Side-effects of analgesics and coanalgesics often contribute to lack of compliance with medication.

An orthodox Western diagnosis is essential prior to treatment including history, clinical examination and special investigations. Pain can be due to the cancer itself, which can give bone pain, nerve pain, pain due to soft tissue infiltration, myofascial pain, visceral pain etc. The pain may also be due to treatment (e.g. post-surgical syndromes such as post-head and neck dissection, post-mastectomy and axillary dissection pain, post-amputation pain, etc.). The pain is sometimes due to irradiation damage (e.g. of the brachial or lumbosacral plexus, or radiation myelopathy). The pain may also be completely unrelated to the cancer. Herpes zoster, for example, is not uncommon in immunocompromised patients. Sequential objective rating of pain scores and the Hospital Anxiety and Depression (HAD) score are desirable to monitor pain management progress. It is important in every case of pain to take an adequate pain history, including the onset, frequency, temporal nature, exacerbating and relieving features, nature of the pain, radiation patterns, etc., and sleep interference prior to clinical examination in order to make a differential and then a definitive diagnosis. Several further investigations may be necessary. Some patients have several pains that may or may not be cancer related and each one will ideally need to be diagnosed prior to treatment.

Neuropathic pain is, perhaps, the most difficult to treat in cancer patients and a purist approach to treatment is not always possible. Not infrequently, a combination of drug and non-drug methods is required and the least complicated regimen should be sought for each patient.

Prior to choosing any form of treatment, the comparative risks should be balanced against the potential benefit.

A clinical approach to the management of pain will be described, including segmental points, trigger points and strong traditional acupuncture points. Examples of clinical situations that can be particularly helped by acupuncture will be given and a brief outline of treatment options for patients with multiple symptoms in addition to pain including nausea and vomiting, advanced cancer related breathlessness, ulcers and xerostomia.

Contraindications and side-effects will also be discussed. Acupuncture not only has the potential for alleviating troublesome symptoms, but it could, in some cases, be risky and can mask disease progression. As a result of this, acupuncture in palliative care should be either given by or at least closely supervised by a physician/pain specialist knowledgeable about the clinical staging and current treatment of their patients.

The hierarchy of evidence supporting the practice of acupuncture for palliative care will be briefly described. However, it reveals a lack of high-quality evidence to support the practice on the whole. While this is also true for many conventional treatments in palliative care, due to recruitment difficulties and high rates of attrition, etc., this needs to be urgently addressed. Some of the factors which limit research in this area will be discussed and promising conditions suggested for study once these obstacles are overcome!