Acupuncture: could it become everyday practice in oncology?
Identifieur interne : 000880 ( Pmc/Corpus ); précédent : 000879; suivant : 000881Acupuncture: could it become everyday practice in oncology?
Auteurs : Aneta Kilian-Kita ; Mirosława Puskulluoglu ; Kamil Konopka ; Krzysztof KrzemienieckiSource :
- Contemporary Oncology [ 1428-2526 ] ; 2016.
Abstract
Acupuncture is a complementary and alternative medical treatment (CAM) which is increasingly used in the care of cancer patients. Traditionally derived from Chinese medicine, nowadays it is becoming a part of evidence-based oncology. The use of acupuncture in these patients has been recommended by the American Cancer Society (ACS) for the treatment of side effects associated with conventional cancer therapy and cancer-related ailments. A growing body of evidence supports the use of acupuncture in the treatment of cancer-induced pain and chemotherapy-related nausea and vomiting. Also other indications, such as xerostomia, fatigue, hot flashes, anxiety and peripheral neuropathy, are being constantly evaluated. This article summarizes the most important discoveries related to the possible usefulness of this method in contemporary oncology. Emphasis is placed on the results of randomized controlled trials with an adequate level of evidence. However, explanation of the mechanisms responsible for these effects requires confirmation in further studies with an adequate level of evidence. In future, acupuncture may become an interesting and valuable addition to conventional medicine.
Url:
DOI: 10.5114/wo.2016.60065
PubMed: 27358589
PubMed Central: 4925730
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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Acupuncture: could it become everyday practice in oncology?</title><author><name sortKey="Kilian Kita, Aneta" sort="Kilian Kita, Aneta" uniqKey="Kilian Kita A" first="Aneta" last="Kilian-Kita">Aneta Kilian-Kita</name></author><author><name sortKey="Puskulluoglu, Miroslawa" sort="Puskulluoglu, Miroslawa" uniqKey="Puskulluoglu M" first="Mirosława" last="Puskulluoglu">Mirosława Puskulluoglu</name></author><author><name sortKey="Konopka, Kamil" sort="Konopka, Kamil" uniqKey="Konopka K" first="Kamil" last="Konopka">Kamil Konopka</name></author><author><name sortKey="Krzemieniecki, Krzysztof" sort="Krzemieniecki, Krzysztof" uniqKey="Krzemieniecki K" first="Krzysztof" last="Krzemieniecki">Krzysztof Krzemieniecki</name></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">27358589</idno><idno type="pmc">4925730</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4925730</idno><idno type="RBID">PMC:4925730</idno><idno type="doi">10.5114/wo.2016.60065</idno><date when="2016">2016</date><idno type="wicri:Area/Pmc/Corpus">000880</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000880</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Acupuncture: could it become everyday practice in oncology?</title><author><name sortKey="Kilian Kita, Aneta" sort="Kilian Kita, Aneta" uniqKey="Kilian Kita A" first="Aneta" last="Kilian-Kita">Aneta Kilian-Kita</name></author><author><name sortKey="Puskulluoglu, Miroslawa" sort="Puskulluoglu, Miroslawa" uniqKey="Puskulluoglu M" first="Mirosława" last="Puskulluoglu">Mirosława Puskulluoglu</name></author><author><name sortKey="Konopka, Kamil" sort="Konopka, Kamil" uniqKey="Konopka K" first="Kamil" last="Konopka">Kamil Konopka</name></author><author><name sortKey="Krzemieniecki, Krzysztof" sort="Krzemieniecki, Krzysztof" uniqKey="Krzemieniecki K" first="Krzysztof" last="Krzemieniecki">Krzysztof Krzemieniecki</name></author></analytic><series><title level="j">Contemporary Oncology</title><idno type="ISSN">1428-2526</idno><idno type="eISSN">1897-4309</idno><imprint><date when="2016">2016</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p>Acupuncture is a complementary and alternative medical treatment (CAM) which is increasingly used in the care of cancer patients. Traditionally derived from Chinese medicine, nowadays it is becoming a part of evidence-based oncology. The use of acupuncture in these patients has been recommended by the American Cancer Society (ACS) for the treatment of side effects associated with conventional cancer therapy and cancer-related ailments. A growing body of evidence supports the use of acupuncture in the treatment of cancer-induced pain and chemotherapy-related nausea and vomiting. Also other indications, such as xerostomia, fatigue, hot flashes, anxiety and peripheral neuropathy, are being constantly evaluated. This article summarizes the most important discoveries related to the possible usefulness of this method in contemporary oncology. Emphasis is placed on the results of randomized controlled trials with an adequate level of evidence. However, explanation of the mechanisms responsible for these effects requires confirmation in further studies with an adequate level of evidence. In future, acupuncture may become an interesting and valuable addition to conventional medicine.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Molassiotis, A" uniqKey="Molassiotis A">A Molassiotis</name></author><author><name sortKey="Fernadez Ortega, P" uniqKey="Fernadez Ortega P">P Fernadez-Ortega</name></author><author><name sortKey="Pud, D" uniqKey="Pud D">D Pud</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Hok, J" uniqKey="Hok J">J Hök</name></author><author><name sortKey="Tishelman, C" uniqKey="Tishelman C">C Tishelman</name></author><author><name sortKey="Ploner, A" uniqKey="Ploner A">A Ploner</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="White, A" uniqKey="White A">A White</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Streitberger, K" uniqKey="Streitberger K">K Streitberger</name></author><author><name 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<front><journal-meta><journal-id journal-id-type="nlm-ta">Contemp Oncol (Pozn)</journal-id><journal-id journal-id-type="iso-abbrev">Contemp Oncol (Pozn)</journal-id><journal-id journal-id-type="publisher-id">WO</journal-id><journal-title-group><journal-title>Contemporary Oncology</journal-title></journal-title-group><issn pub-type="ppub">1428-2526</issn><issn pub-type="epub">1897-4309</issn><publisher><publisher-name>Termedia Publishing House</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">27358589</article-id><article-id pub-id-type="pmc">4925730</article-id><article-id pub-id-type="publisher-id">27624</article-id><article-id pub-id-type="doi">10.5114/wo.2016.60065</article-id><article-categories><subj-group subj-group-type="heading"><subject>Review Paper</subject></subj-group></article-categories><title-group><article-title>Acupuncture: could it become everyday practice in oncology?</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Kilian-Kita</surname><given-names>Aneta</given-names></name></contrib><contrib contrib-type="author" corresp="yes"><name><surname>Puskulluoglu</surname><given-names>Mirosława</given-names></name></contrib><contrib contrib-type="author"><name><surname>Konopka</surname><given-names>Kamil</given-names></name></contrib><contrib contrib-type="author"><name><surname>Krzemieniecki</surname><given-names>Krzysztof</given-names></name></contrib></contrib-group><aff>Department of Clinical Oncology, University Hospital in Krakow, Krakow, Poland</aff><author-notes><corresp id="cor1"><bold>Address for correspondence: Mirosława Puskulluoglu</bold>, Department of Clinical Oncology, University Hospital in Krakow, Śniadeckich 10, 31-501 Krakow, Poland. e-mail: <email xlink:href="mircoll@wp.pl">mircoll@wp.pl</email></corresp></author-notes><pub-date pub-type="epub"><day>14</day><month>6</month><year>2016</year></pub-date><pub-date pub-type="ppub"><year>2016</year></pub-date><volume>20</volume><issue>2</issue><fpage>119</fpage><lpage>123</lpage><history><date date-type="received"><day>16</day><month>3</month><year>2014</year></date><date date-type="accepted"><day>16</day><month>7</month><year>2014</year></date></history><permissions><copyright-statement>Copyright © 2016 Termedia</copyright-statement><copyright-year>2016</copyright-year><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by-nc-sa/4.0/"><license-p>This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International (CC BY-NC-SA 4.0) License, allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material, provided the original work is properly cited and states its license.</license-p></license></permissions><abstract><p>Acupuncture is a complementary and alternative medical treatment (CAM) which is increasingly used in the care of cancer patients. Traditionally derived from Chinese medicine, nowadays it is becoming a part of evidence-based oncology. The use of acupuncture in these patients has been recommended by the American Cancer Society (ACS) for the treatment of side effects associated with conventional cancer therapy and cancer-related ailments. A growing body of evidence supports the use of acupuncture in the treatment of cancer-induced pain and chemotherapy-related nausea and vomiting. Also other indications, such as xerostomia, fatigue, hot flashes, anxiety and peripheral neuropathy, are being constantly evaluated. This article summarizes the most important discoveries related to the possible usefulness of this method in contemporary oncology. Emphasis is placed on the results of randomized controlled trials with an adequate level of evidence. However, explanation of the mechanisms responsible for these effects requires confirmation in further studies with an adequate level of evidence. In future, acupuncture may become an interesting and valuable addition to conventional medicine.</p></abstract><kwd-group><kwd>acupuncture</kwd><kwd>cancer</kwd><kwd>complementary and alternative treatment</kwd><kwd>side effects</kwd><kwd>supportive treatment</kwd></kwd-group></article-meta></front><body><sec sec-type="intro" id="S0001"><title>Introduction</title><p>Complementary and alternative medical treatment (CAM) has gained significant interest in recent years [<xref rid="CIT0001" ref-type="bibr">1</xref>]. Although the list of CAM has changed over the years, the Office of Alternative Medicine (established at the National Institutes of Health [NIH] in the USA) nowadays recognizes five major categories [<xref rid="CIT0002" ref-type="bibr">2</xref>]. Acupuncture, belonging to the Manipulative Therapies category, due to its low cost, safety (considering all possible contraindications) and the minimal number of side effects is gaining popularity among patients [<xref rid="CIT0003" ref-type="bibr">3</xref>]. Acupuncture has repeatedly been reported to be useful in oncological practice in alleviating side effects of anti-tumor treatment. Numerous clinical trials of acupuncture indicate its potential role in fighting the following ailments: nausea and chemotherapy-induced vomiting, pain, xerostomia, vasomotor symptoms, neutropenia, fatigue, anxiety, insomnia, lymphoedema after mastectomy, and peripheral neuropathy [<xref rid="CIT0004" ref-type="bibr">4</xref>–<xref rid="CIT0016" ref-type="bibr">16</xref>]. A sudden increase in the number of studies on acupuncture in oncology was first noted in 1997, when at the NIH conference a consensus was reached on the use of acupuncture, which was then acknowledged as a useful medical procedure [<xref rid="CIT0017" ref-type="bibr">17</xref>]. This article reviews the literature concerning the referred studies.</p></sec><sec id="S0002"><title>What is acupuncture?</title><p>Acupuncture is a method of treatment that has its origins in Traditional Chinese Medicine and is based on over 4,000 years of empirical evidence. The technique involves the insertion of thin needles into specific locations (energy points) on the patient's body along energy pathways or meridians. According to Chinese philosophy, the hypothetical substance Qi (vital energy) flows in the human body along the meridians, and blockage of Qi leads to a particular ailment [<xref rid="CIT0018" ref-type="bibr">18</xref>]. There are 12 main and 8 extra meridians. All the main meridians consist of internal channels connected with the 12 body organs and the external channels spreading symmetrically on the skin surface. The literature describes around 360 energy points located on the external parts of the meridians. Acupuncture is considered to cure diseases by stimulating particular acupoints and removing blockage of Qi [<xref rid="CIT0019" ref-type="bibr">19</xref>]. <xref ref-type="fig" rid="F0001">Figures 1</xref>–<xref ref-type="fig" rid="F0003">3</xref> present acupuncture meridian pathways.</p><fig id="F0001" position="float"><label>Fig. 1</label><caption><p>The course of main meridians on the anterior surface of the body</p></caption><graphic xlink:href="WO-20-27624-g001"></graphic></fig><fig id="F0002" position="float"><label>Fig. 2</label><caption><p>The course of main meridians on the posterior surface of the body</p></caption><graphic xlink:href="WO-20-27624-g002"></graphic></fig><fig id="F0003" position="float"><label>Fig. 3</label><caption><p>The course of main meridians on the lateral surface of the body</p></caption><graphic xlink:href="WO-20-27624-g003"></graphic></fig><p>Although acupuncture has been studied extensively in both animal and human models, little is known about its mechanisms that could explain acupuncture's therapeutic qualities. <xref ref-type="table" rid="T0001">Table 1</xref> shows suggested mechanisms of acupuncture. This treatment method has been the focus of increased interest, which has resulted in a growing number of studies.
</p><table-wrap id="T0001" position="float"><label>Table 1</label><caption><p>Possible mechanisms of action of acupuncture</p></caption><table frame="hsides" rules="groups"><thead><tr><th align="left" rowspan="1" colspan="1">Possible mechanisms of action of acupuncture</th><th align="left" rowspan="1" colspan="1">Effects</th><th align="center" rowspan="1" colspan="1">References</th></tr></thead><tbody><tr><td align="left" rowspan="1" colspan="1"><bold>Local inflammatory response</bold><list list-type="bullet"><list-item><p>Histamine</p></list-item><list-item><p>Prostaglandins</p></list-item><list-item><p>Chemokines</p></list-item></list></td><td align="left" rowspan="1" colspan="1"><break></break><list list-type="bullet"><list-item><p>increasing permeability and dilatation of the capillaries</p></list-item><list-item><p>promotion of blood flow to the site</p></list-item><list-item><p>initiation of the migration of phagocytes and signaling them to increase production of various mediators</p></list-item></list></td><td align="center" rowspan="1" colspan="1">[<xref rid="CIT0020" ref-type="bibr">20</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Cytokines</bold><list list-type="bullet"><list-item><p>decreased expression of IL-6, βNGF and TIMP-1</p></list-item><list-item><p>reducing proinflammatory cytokines IL-1, IL-6, TNF-α through activation of CB2 receptors</p></list-item></list></td><td align="left" rowspan="1" colspan="1"><break></break><list list-type="bullet"><list-item><p>anti-inflammatory effect</p></list-item><list-item><p>antinociceptive effect on inflammatory pain</p></list-item></list></td><td align="center" rowspan="1" colspan="1">[<xref rid="CIT0021" ref-type="bibr">21</xref>, <xref rid="CIT0022" ref-type="bibr">22</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>ANS</bold><list list-type="bullet"><list-item><p>increasing synchronization between the two branches of the ANS and improvement of HRV</p></list-item></list></td><td align="left" rowspan="1" colspan="1"><break></break><list list-type="bullet"><list-item><p>mediating global physiological regulation</p></list-item></list></td><td align="center" rowspan="1" colspan="1">[<xref rid="CIT0023" ref-type="bibr">23</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Stem cells</bold><list list-type="bullet"><list-item><p>increasing levels of non-differentiated progenitor of stem cells CD133+ and CD34– cell in the serum of patients after spinal cord injury</p></list-item><list-item><p>promotion of proliferation and differentiation of neural stem cells, up-regulation of the growth factors and the expression of VEGF mRNA in the rats ischemic brain</p></list-item></list></td><td align="left" rowspan="1" colspan="1"><break></break><list list-type="bullet"><list-item><p>spinal cord stem cell mobilization</p></list-item><list-item><p>protection cerebral injuries after ischemia and promotion nerve regeneration</p></list-item></list></td><td align="center" rowspan="1" colspan="1">[<xref rid="CIT0024" ref-type="bibr">24</xref>]</td></tr></tbody></table><table-wrap-foot><fn><p>IL – interleukin; NGF – nerve growth factor; TIMP-1 – tissue inhibitors of metalloproteinase-1; CB2 – cannabinoid receptor 2; ANS – autonomic nervous system; HRV – heart rate variability; CD – cluster of differentiation; VEGF – vascular endothelial growth factor</p></fn></table-wrap-foot></table-wrap></sec><sec id="S0003"><title>Acupuncture as supportive treatment</title><p>Chemotherapy agents are considered to be medications with the most severe side effects, which in many cases may force the patient to abandon therapy. Because of that, proper alleviation of side effects is most crucial. Acupuncture should not be seen as a replacement for modern medicines, but rather an adjunct with a low level of procedure-related complications that may enhance efficacy and in some cases allow the dosage of other drugs to be reduced. Acupuncture as part of supportive treatment in oncology has been tested for numerous indications. The strongest evidence from a randomized controlled trial (RCT) with low risk of bias supports the use of acupuncture for control of nausea and vomiting related to chemotherapy [<xref rid="CIT0025" ref-type="bibr">25</xref>]. This indication seems to be very important, as the high emetogenicity of many cytostatic agents is hard to control even with three-drug therapy [<xref rid="CIT0026" ref-type="bibr">26</xref>]. Despite many RCTs on treatment of other chemotherapy-induced side effects, the level of evidence is not yet satisfactory, but considering its relative safety, acupuncture may be useful in everyday practice. Descriptions of these clinical trials on the effectiveness of acupuncture in minimizing cancer treatment-related side effects are summarized in <xref ref-type="table" rid="T0002">Table 2</xref>.
</p><table-wrap id="T0002" position="float"><label>Table 2</label><caption><p>Possible mechanisms of action of acupuncture and its effectiveness in the treatment of various types of ailments related to cancer therapy</p></caption><table frame="hsides" rules="groups"><thead><tr><th align="left" rowspan="1" colspan="1">Condition</th><th align="left" rowspan="1" colspan="1">Possible molecular mechanisms of action</th><th align="left" rowspan="1" colspan="1">Clinical trials</th><th align="center" rowspan="1" colspan="1">References</th></tr></thead><tbody><tr><td colspan="4" align="center" rowspan="1"><bold>Randomized control trials</bold></td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Nausea and chemotherapy-induced vomiting</bold></td><td align="left" rowspan="1" colspan="1">Multiple mechanisms<list list-type="bullet"><list-item><p>influences the endogenous opioid system and changes the serotonin transmission</p></list-item><list-item><p>has effects on the gastric myoelectrical activity</p></list-item><list-item><p>increases vagal modulation</p></list-item><list-item><p>influences the cerebellar vestibular activities</p></list-item></list></td><td align="left" rowspan="1" colspan="1">RCT:<list list-type="bullet"><list-item><p>acupuncture significantly reduced the number of episodes of emesis between three groups: electroacupuncture, minimal needling and pharmacotherapy alone (median number of episodes, 5, 10, and 15, respectively; <italic>p</italic> < 0.001)</p></list-item></list></td><td align="left" rowspan="1" colspan="1">[<xref rid="CIT0026" ref-type="bibr">26</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Cancer pain</bold></td><td align="left" rowspan="1" colspan="1">Opioid peptides<list list-type="bullet"><list-item><p>increased concentration level observed in the serum and brain tissue after acupuncture</p></list-item></list><break></break>Neuromodulation<list list-type="bullet"><list-item><p>activity modulation of the human brain areas (activated in acute or chronic pain) during acupuncture in neuroimaging (fMRI, PET, EEG)</p></list-item></list></td><td align="left" rowspan="1" colspan="1">Meta-analysis of RCTs:<list list-type="bullet"><list-item><p>acupuncture did not make a better effect than drug therapy (<italic>n</italic> = 886; RR 1.12; 95% CI: 0.98 to 1.28; <italic>p</italic> = 0.09)</p></list-item><list-item><p>combination therapy (acupuncture with drug therapy) was more effective than drug therapy alone (<italic>n</italic> = 437; RR 1.36; 95% CI: 1.13–1.64; <italic>p</italic> = 0.003)</p></list-item></list></td><td align="left" rowspan="1" colspan="1">[<xref rid="CIT0007" ref-type="bibr">7</xref>, <xref rid="CIT0008" ref-type="bibr">8</xref>, <xref rid="CIT0027" ref-type="bibr">27</xref>–<xref rid="CIT0031" ref-type="bibr">31</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Chemotherapy-induced leucopoenia</bold></td><td align="left" rowspan="1" colspan="1">Multiple mechanisms<list list-type="bullet"><list-item><p>promotes the release of WBC from bone marrow</p></list-item><list-item><p>prolonging the life of WBC</p></list-item><list-item><p>increases the activity of CSFs</p></list-item><list-item><p>promotes the proliferation of haemopoietic stem cells</p></list-item><list-item><p>reduces haemopoietic stem cells damage by chemotherapy</p></list-item><list-item><p>improves microcirculation</p></list-item></list></td><td align="left" rowspan="1" colspan="1">Meta-analysis of RCTs from China:<list list-type="bullet"><list-item><p>acupuncture was effective in increasing WBC level</p></list-item><list-item><p>mean difference in the WBC level was 1221 WBC/µl (95% CI: 636–1807, <italic>p</italic> < 0.0001)</p></list-item></list>Pilot study from USA:<break></break>Significant increase in the median leukocyte value for baseline value after acupuncture (<italic>p</italic> = 0.046):<list list-type="bullet"><list-item><p>8600 WBC/µl, 95% CI: 4800–12000 in the test group</p></list-item><list-item><p>4400 WBC/µl, 95% CI: 2300–10000 in the control group</p></list-item></list>Decrease in the frequency of occurrence of severe leucopoenia (<italic>p</italic> = 0.02):<list list-type="bullet"><list-item><p>30% in the test group</p></list-item><list-item><p>90% in the control group</p></list-item></list></td><td align="left" rowspan="1" colspan="1">[<xref rid="CIT0011" ref-type="bibr">11</xref>, <xref rid="CIT0032" ref-type="bibr">32</xref>–<xref rid="CIT0034" ref-type="bibr">34</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>AI-induced arthralgias</bold></td><td align="left" rowspan="1" colspan="1">Multiple mechanisms<list list-type="bullet"><list-item><p>increases the opioid peptides level</p></list-item><list-item><p>improves blood flow</p></list-item></list></td><td align="left" rowspan="1" colspan="1">RCT:<break></break>Significant difference between the test group and the control group at 6 weeks of treatment was observed in:<list list-type="bullet"><list-item><p>the mean BPI-SF worst pain scores (on the scale from 0–10, 10 being the most intense pain; 3.0 vs. 5.5; <italic>p</italic> < 0.001)</p></list-item><list-item><p>pain severity (2.6 vs. 4.5; <italic>p</italic> = 0.003)</p></list-item><list-item><p>pain-related interference (2.5 vs. 4.5; <italic>p</italic> = 0.002)</p></list-item></list></td><td align="left" rowspan="1" colspan="1">[<xref rid="CIT0035" ref-type="bibr">35</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Radiation-induced xerostomia</bold></td><td align="left" rowspan="1" colspan="1">Neural transmission:<list list-type="bullet"><list-item><p>bilateral activation of the brain function area in fMRI that is responsible for salivary production</p></list-item></list>CGRP:<list list-type="bullet"><list-item><p>increase the release of CGRP, which positively affects the salivary flow rates</p></list-item></list></td><td align="left" rowspan="1" colspan="1">RCT:<break></break>In the acupuncture group as compared to the control group was observed:<list list-type="bullet"><list-item><p>significant reduction in dry mouth symptoms measured by means of the VAS (<italic>p</italic> < 0.05)</p></list-item><list-item><p>increase in unstimulated and stimulated salivary flow and production (<italic>p</italic> < 0.001)</p></list-item></list></td><td align="left" rowspan="1" colspan="1">[<xref rid="CIT0009" ref-type="bibr">9</xref>, <xref rid="CIT0036" ref-type="bibr">36</xref>, <xref rid="CIT0037" ref-type="bibr">37</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Hot flushes</bold></td><td align="left" rowspan="1" colspan="1">Neuromodulation<list list-type="bullet"><list-item><p>increases endorphin release and decrease noradrenalin and serotonin activity in the central nervous system (make thermoregulation more stable)</p></list-item></list>CGRP<list list-type="bullet"><list-item><p>direct effect on the release of vasodilator – CGRP in peripheral nerve endings</p></list-item></list></td><td align="left" rowspan="1" colspan="1">RCT:<break></break>Significant reduction of hot flushes and sleep disturbances was observed in:<list list-type="bullet"><list-item><p>16 patients (52%) of the test group</p></list-item><list-item><p>7 patients (24%) of the control group.</p></list-item><list-item><p>effect was obtained after the second acupuncture session and lasted for the next 12 weeks after treatment</p></list-item></list></td><td align="left" rowspan="1" colspan="1">[<xref rid="CIT0038" ref-type="bibr">38</xref>, <xref rid="CIT0039" ref-type="bibr">39</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Anxiety-like behaviour and stress</bold></td><td align="left" rowspan="1" colspan="1">NPY and CRF<list list-type="bullet"><list-item><p>increases NPY mRNA levels and reduces CRF mRNA levels in the amygdala of rats after acupuncture</p></list-item></list></td><td align="left" rowspan="1" colspan="1">Randomized controlled experimental study:<list list-type="bullet"><list-item><p>after 10 acupuncture sessions patients with generalized anxiety disorders demonstrated significantly reduced anxiety (85.7%) following compared to a placebo group</p></list-item></list></td><td align="left" rowspan="1" colspan="1">[<xref rid="CIT0013" ref-type="bibr">13</xref>, <xref rid="CIT0040" ref-type="bibr">40</xref>, <xref rid="CIT0041" ref-type="bibr">41</xref>]</td></tr><tr><td colspan="4" align="center" rowspan="1"><bold>Non RCT studies</bold></td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Chemotherapy-induced peripheral neuropathy</bold></td><td align="left" rowspan="1" colspan="1">Purinergetic signaling<list list-type="bullet"><list-item><p>stimulating purinergic signals (increase in the release of adenine nucleotides and adenosine from skin keratinocytes) and neurotransmission in the central and peripheral nervous system</p></list-item></list></td><td align="left" rowspan="1" colspan="1">Pilot study:<list list-type="bullet"><list-item><p>acupuncture treatment for 6 weeks was effective in 82% (<italic>n</italic> = 14) of patients</p></list-item></list></td><td align="left" rowspan="1" colspan="1">[<xref rid="CIT0016" ref-type="bibr">16</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Cancer-related fatigue</bold></td><td align="left" rowspan="1" colspan="1"><list list-type="bullet"><list-item><p>multicomponent</p></list-item></list></td><td align="left" rowspan="1" colspan="1">Prospective, clinical study:<list list-type="bullet"><list-item><p>significant improvement after 2 weeks of treatment was observed with regard to: general fatigue (<italic>p</italic> < 0.001), physical fatigue (<italic>p</italic> = 0.016), activity (<italic>p</italic> = 0.004) and motivation (<italic>p</italic> = 0.024), and lasted for 2 weeks after the end of the intervention</p></list-item></list></td><td align="left" rowspan="1" colspan="1">[<xref rid="CIT0012" ref-type="bibr">12</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>CRT-induced dysphagia</bold></td><td align="left" rowspan="1" colspan="1">Multiple mechanisms<list list-type="bullet"><list-item><p>increase the saliva production</p></list-item><list-item><p>restore swallowing reflex</p></list-item><list-item><p>inhibition the fibrosis process</p></list-item></list></td><td align="left" rowspan="1" colspan="1">Case series study:<list list-type="bullet"><list-item><p>The treatment was effective in: 9/10 patients (90%) of the test group (subjective improvement in the swallowing function, decrease in dry mouth symptoms, pain and fatigue level)</p></list-item><list-item><p>in 6/7 patients (86%) it was possible to remove the PEG tube (a median time of 114 days from the last CRT session and acupuncture treatment, the range from 49 to 368 days)</p></list-item></list></td><td align="left" rowspan="1" colspan="1">[<xref rid="CIT0042" ref-type="bibr">42</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Hiccup</bold></td><td align="left" rowspan="1" colspan="1">Modulation of the hiccup reflex arc<list list-type="bullet"><list-item><p>locally: changing blood perfusion, activating the autonomic nervous system, regulating inflammatory mediators</p></list-item><list-item><p>centrally: influences the hiccup center by modulating the secretion of neurotransmitters and neurohormones (endogenous opioids, norepinephrine, serotonin, substance P)</p></list-item></list></td><td align="left" rowspan="1" colspan="1">Case series study:After 1–3 courses of treatment (over a 1–7-day period) was observed:<list list-type="bullet"><list-item><p>complete symptom relief in 13 patients (81%, <italic>p</italic> < 0.0001);</p></list-item><list-item><p>partial symptom relief in 3 patients (18.8%)</p></list-item><list-item><p>substantial improvement in discomfort (<italic>p</italic> < 0.0001), fatigue (<italic>p</italic> = 0.0078) and anxiety (<italic>p</italic> < 0.0001)</p></list-item></list></td><td align="left" rowspan="1" colspan="1">[<xref rid="CIT0043" ref-type="bibr">43</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Lymphoedema</bold></td><td align="left" rowspan="1" colspan="1"><list list-type="bullet"><list-item><p>unclear</p></list-item></list></td><td align="left" rowspan="1" colspan="1">Pilot study:<break></break>After 4 weeks of treatment, 30% reduction of oedema in comparison to the baseline results was observed in 4/9 patients (44.5%)</td><td align="left" rowspan="1" colspan="1">[<xref rid="CIT0015" ref-type="bibr">15</xref>]</td></tr></tbody></table><table-wrap-foot><fn><p>RCTs – randomized controlled trials; fMRI – functional magnetic resonance imaging; RR – relative risk; PET – positron emission tomography; EEG – electroencephalography; NPY – neuropeptide Y; CRF – corticotropin-releasing factor; CGRP – calcitonin gene-related peptide; VAS – visual analogue score; CRT – chemoradiation therapy; PEG – percutaneous endoscopic gastrostomy; AI – aromatase inhibitors; BPI-SF – the Brief Pain Inventory – Short Form; WBC – white blood cells; CSFs – colony-stimulating factors</p></fn></table-wrap-foot></table-wrap></sec><sec id="S0004"><title>Level of evidence issue</title><p>A recently published systemic review stated that other indications, such as pain, xerostomia, vasomotor symptoms, fatigue, mood disorders, and insomnia, were not evaluated in RCTs with an appropriate level of evidence [<xref rid="CIT0044" ref-type="bibr">44</xref>]. One of the major problems with the reviewed studies is their poor methodological quality, mostly difficulty with blinding and a low number of subjects. Also the optimal design of such studies (acupuncture vs placebo, acupuncture vs sham acupuncture) has not been established yet [<xref rid="CIT0045" ref-type="bibr">45</xref>]. In spite of satisfactory results in most of these studies, further research on a larger group of patients is necessary.</p></sec><sec id="S0005"><title>Summary</title><p>In an oncological setting, acupuncture is still being constantly reviewed. Nevertheless, the present available evidence suggests that acupuncture may become a safe, low-cost and efficient form of complementary therapy in modern oncology. The potential role of acupuncture has been found in alleviation of various symptoms, but the data from the majority of clinical studies on acupuncture are heterogeneous. The incomplete description of procedural methodology and insufficient patient groups limit their value. Thus, further research on a larger scale on the potential use of acupuncture in contemporary oncology is required. 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