Feasibility trial of electroacupuncture for aromatase inhibitor--related arthralgia in breast cancer survivors

Global research trends of acupuncture therapy on cancer pain: A bibliometric and visualized study

Background

The number of publications on acupuncture for cancer pain is increasing rapidly with an upward tendency. Considering that no bibliometric articles related to this topic have been published yet. It is necessary to evaluate the global scientific output of research in this field, and shed light on the direction of clinical cancer pain management in the future.

Methods

Research publications regarding acupuncture on cancer pain from inception to 2022 were downloaded from the Web of Science Core Collection. Bibliometric analyses were performed using CiteSpace software, the bibliometrix R package, and VOSviewer software. Network maps were generated to assess the collaborations between different countries, institutions, authors, and keywords. And clusters map was generated to evaluate reference.

Results

A total of 790 articles related to acupuncture therapy for cancer pain were identified. We observe that the number of publications is gradually increasing over time. China and the United States were the main contributors. Mem Sloan Kettering Canc Ctr (38 papers) and Beijing Univ Chinese Med (28 papers) contributed the most publications, becoming the leading contributors in this field. Although J Clin Oncol (28 articles) ranked ninth in terms of publication volume, it was the journal with the most citations and the highest number of IF (50.717) and H-index (494) at the same time. MAO J from Mem Sloan Kettering Canc Ctr was the most prolific author (23 articles). The main hot topics included matters related to acupuncture (239 times), pain (199 times), management (139 times), quality of life (107 times), electroacupuncture (100 times), and breast cancer (82 times).

Conclusion

Our bibliometric analysis provides a comprehensive overview of the development of acupuncture for cancer pain, enabling relevant authors and research teams to identify the current research status in this field. At the same time, acupuncture for breast cancer (BC) pain, aromatase inhibitor-induced arthralgia (AIA), and chemotherapy-induced peripheral neuropathy (CIPN) may soon become prospective focus.

Addressing cancer-related fatigue through sleep: A secondary analysis of a randomized trial comparing acupuncture and cognitive behavioral therapy for insomnia

Background

Fatigue is a troublesome symptom in cancer survivors that often results from disrupted sleep. We sought to assess whether two insomnia-focused non-pharmacological interventions are also effective for improving fatigue.

Methods

We analyzed data from a randomized clinical trial comparing cognitive behavioral therapy for insomnia (CBT-I) versus acupuncture for insomnia among cancer survivors. Participants were 109 patients who reported insomnia and moderate or worse fatigue. Interventions were delivered over eight weeks. Fatigue was evaluated at baseline, week 8, and week 20 using the Multidimensional Fatigue Symptom Inventory-Short Form (MFSI-SF). We used both mediation analysis and t-tests to explore the extent to which fatigue reduction was attributable to insomnia response.

Results

Compared to baseline, both CBT-I and acupuncture produced significant reductions in total MFSI-SF scores at week 8 (-17.1 points; 95% confidence interval [CI]: -21.1 to -13.1, and -13.2 points; 95% CI: -17.2 to -9.2, respectively, all p<0.001) and week 20 (-14.6 points; 95% CI: -18.6 to -10.6, and -14.2 points; 95% CI: -18.1 to -10.3. respectively, all p<0.001), with no significant between-group differences. MFSI-SF total scores at week 8 were significantly associated with sleep improvements in both CBT-I and acupuncture groups (p<0.001 and p=0.011, respectively). Insomnia responders demonstrated significantly greater improvements in mean MFSI-SF total scores compared with non-responders in the CBT-I group (p=0.016) but not in the acupuncture group.

Conclusion

CBT-I and acupuncture produced similar, clinically meaningful, and durable fatigue reductions in cancer survivors with insomnia, primarily through improvements in sleep. Acupuncture may also reduce fatigue through additional pathways.

Effects of Acupuncture on Breast Cancer Patients Taking Aromatase Inhibitors

Although acupuncture has been used in clinical practice for thousands of years, it remains a controversial treatment option to help alleviate pain in cancer patients. In this study, we analyzed published material on randomized trials of acupuncture from MEDLINE published up until July 31, 2018, to assess its effects on pain experienced by cancer patients. Revman 5.0 software was used to conduct meta-analysis with pain score as the index. The results of nine randomized controlled trials involving 592 patients were analyzed and showed that acupuncture can relieve the pain caused by aromatase inhibitors. Weighted mean difference of worst pain and pain severity was -3.03, 95% CI (-3.90,-2.16) and -2.69, 95% CI (-4.08,-1.30), respectively ( $P<0.01$ ). This led us to conclude that acupuncture has pain relieving effects against pain caused by aromatase inhibitors.

Acupuncture versus massage for pain in patients living with advanced cancer: a protocol for the IMPACT randomised clinical trial

INTRODUCTION

Pain, comorbid fatigue and sleep disturbances are common and distressing symptoms for patients with advanced cancer, negatively impacting their quality of life. Clinical guidelines recommend non-pharmacological interventions, including acupuncture and massage, for pain management in adult patients with cancer in adjunct to conventional care. However, high-quality evidence about the comparative effectiveness and long-term durability of these therapies for symptom management is limited.

METHODS AND ANALYSIS

We describe the design of a two-arm, parallel group, multicentre randomised controlled trial that investigates the use of acupuncture versus massage for musculoskeletal pain among 300 patients with diverse types of advanced cancer. The primary aim is to evaluate the long-term effectiveness (26 weeks from randomisation) of acupuncture vs massage for pain (primary outcome) and comorbid symptoms (fatigue, sleep disturbance and quality of life). The secondary aim is to identify patient-level demographic characteristics (eg, sex, race, age), clinical factors (eg, insomnia, pain severity) and psychological attributes that are associated with a greater reduction in pain for either acupuncture or massage. Patients will receive weekly acupuncture or massage treatments for 10 weeks, followed by monthly booster sessions up to 26 weeks. The primary endpoint will be the change in worst pain intensity score from baseline to 26 weeks. We will collect validated patient-reported outcomes at multiple time points over 26 weeks.

ETHICS AND DISSEMINATION

The Institutional Review Board at Memorial Sloan Kettering Cancer Center in New York approved this protocol. Results will be disseminated via peer-reviewed scientific journals and conference presentations. Our findings will help patients and healthcare providers make informed decisions about incorporating non-pharmacological treatments to manage pain for patients with advanced cancer.

TRIAL REGISTRATION NUMBER

NCT04095234.

Prophylactic Acupuncture Treatment During Chemotherapy in Patients With Breast Cancer: Results of a Qualitative Study Nested in a Randomized Pragmatic Trial

Background:

In a randomized controlled trial, compared with standard care alone in breast cancer, acupuncture as a prophylactic treatment did not show better quality of life or fewer side effects of chemotherapy (NCT01727362 [clinicaltrials.gov]). The aim of the qualitative part of this mixed methods study was to better understand the subjective perspectives of the patients regarding quality of life during chemotherapy and the perceived effects of acupuncture.

Methods:

In a nested retrospective qualitative study, semi-structured telephone interviews were conducted with 5 responders and 5 non-responders (defined by the outcome of the primary parameter FACT-B) who were randomly selected from both study arms. The interviews were digitally recorded, pseudonymized, transcribed, and then deductively and inductively analyzed according to Qualitative Content Analysis using MAXQDA^® software.

Results:

A total of 20 patients were included in the qualitative part of the study. In both groups, most women stated that their quality of life was surprisingly better than what they had expected before starting the chemotherapy. All patients of the acupuncture group experienced the acupuncture treatments as relaxing and beneficial, mentioning a friendly setting, and empathic attitude of the therapist. Most of these patients stated that the acupuncture treatment reduced chemotherapy-induced side effects. The patients reported that acupuncture was supportive for coping with the disease in a salutogenic way. For all patients, finding strategies to cope with life-threatening cancer and the side effects of chemotherapy was essential, for example, keeping a positive attitude toward life, selecting social contacts, and staying active as much as possible.

Conclusions:

Patients in the acupuncture group reported positive effects on psychological and physical well-being after receiving the study intervention. For all patients, having coping strategies for cancer seemed to be more important than reducing side effects. Therefore, further studies should focus more on coping strategies and reducing acute side effects.

The Therapeutic Effects of Acupuncture and Electroacupuncture on Cancer-related Symptoms and Side-Effects

In addition to cancer-related death, malignant progression also leads to a series of symptoms and side-effects, which would detrimentally affect cancer patients' the quality of life, adversely influence their adherence to treatments, and, therefore, negatively affect their long-term survival. Acupuncture and electroacupuncture (EA), as two classic treatment methods in traditional Chinese medicine, have been widely employed to cure various diseases. Recently, the clinical application of acupuncture and EA in cancer patients has received great attention. In this review, we summarized the clinical application of acupuncture and EA in alleviating the cancer symptoms, reducing the cancer treatment-related side-effects, and relieving the cancer pain. The symptoms and side-effects discussed in this review include fatigue, insomnia, chemotherapy-associated dyspepsia syndrome (CADS), pain, xerostomia, and anxiety and depression. The underlying mechanisms of the therapeutic effects of acupuncture and EA might be related to the regulation of the mitochondrial function, coordination of the activity of the nervous system, adjustment of the production of neurotransmitters, and alleviation of the immune responses. In conclusion, acupuncture and EA have been proved to be beneficial for cancer patients. More research, however, is required to clarify the potential mechanisms behind acupuncture and EA for widespread adoption in clinical application.

Effect of complementary and alternative medicine interventions on cancer related pain among breast cancer patients: A systematic review

OBJECTIVE

This systematic review aimed to evaluate the efficacy of CAM interventions for cancer-related pain in breast cancer patients.

METHODS

Databases (PubMed, Scopus, Web of Science, and EMBASE) were searched from January 1, 2000, up to April 31, 2019, using the keywords: Complementary and alternative medicine therapies and cancer related pain. Standard tools were used to evaluate the quality of the studies included.

RESULTS

Of the 3742 articles found, 46 articles comprising 3685 participants entered the final phase. Our results indicate that interventions including acupuncture/acupressure, tai chi/qi gong, hypnosis, meditation, music therapy, yoga, massage, reflexology, and Reiki improve cancer-related pain in breast cancer patients. However, aromatherapy had no effect on the same.

CONCLUSIONS

Despite the positive effect of various CAM interventions in reducing cancer-related pain, necessary precautions should be adopted to use them alongside other treatments to control cancer pain in the clinical setting.

Prophylactic acupuncture treatment during chemotherapy with breast cancer: a randomized pragmatic trial with a retrospective nested qualitative study

PURPOSE

This study investigated the effect of additional prophylactic acupuncture during chemotherapy on quality of life and side effects compared to standard treatment alone in breast cancer patients.

METHODS

In a pragmatic trial, newly diagnosed breast cancer patients were randomized to additional acupuncture treatments over 6 months or standard care alone (control group). The primary outcome was the disease-specific quality of life (FACT-B). Twenty qualitative semi-structured interviews were conducted with ten patients from each group regarding their subjective experiences.

RESULTS

A total of 150 women (mean age 51.0 (SD 10.0) years) were randomized. For the primary endpoint, FACT-B total score after 6 months, no statistically significant difference was found between groups (acupuncture: 103.5 (95%, CI 88.8 to 107.2); control (101.4 (- 97.5 to 105.4); difference 2.0 (- 3.4 to 7.5) p = 0.458)). Qualitative content analyses showed that patients in the acupuncture group described positive effects on psychological and physical well-being. For both patient groups, coping strategies were more important than reducing side effects.

CONCLUSIONS

Breast cancer patients receiving prophylactic acupuncture during chemotherapy did not show better quality of life in the questionnaires in contrast to the reported positive effects in the qualitative interviews. Coping strategies for cancer appear to be important.

TRIAL REGISTRATION

clinicaltrials.gov; NCT01727362. Prospectively registered 11 July 2012; https://clinicaltrials.gov/ct2/show/NCT01727362 . The manuscript adheres to CONSORT guidelines.

Acupuncture for cancer pain: protocol for a pilot pragmatic randomised controlled trial

INTRODUCTION

Although acupuncture has been recommended for alleviating cancer pain by clinical guidelines, the level of the supporting evidence needs to be improved. A pragmatic randomised controlled trial (pRCT) in a hospital setting would provide real-world assessments of the overall clinical effects of acupuncture. This pilot trial aims to explore the feasibility and provide data for sample size calculations for a pRCT evaluating the effectiveness of acupuncture as an adjunctive therapy to routine medical care for cancer pain.

METHODS AND ANALYSIS

Thirty patients with cancer admitted to the oncology department with moderate or severe pain will be recruited. Participants will be randomised at a ratio of 1:1 to the adjunctive acupuncture group or a control group which receives routine pain management without acupuncture. The standardised section of the acupuncture protocol will be developed based on the results of reviews of the literature, recommendations in clinical guidelines and interviews with clinical experts. The acupuncturist will be allowed to tailor the protocol according to the individual situation of each participant. Primary outcomes relevant to the feasibility of conducting a fully powered trial include: numbers and proportions of participants recruited, screened, consented and randomised; numbers and reasons for withdrawals and dropouts; numbers and types of adverse events; feasibility of implementing the trial procedures; evaluation of the comprehensiveness and ease-of-use of the case report form. Secondary outcomes are clinical measurements of the effectiveness of the treatment that are intended for use in the full-scale trial. Analysis of feasibility will be descriptive and pain intensity measures will be analysed using mixed-effects regression.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Institutional Ethics Committee of Guangdong Provincial Hospital of Chinese Medicine (approval no: Z2017-184-01) and RMIT University Human Research Ethics Committee (reference no: 21361). Results will be disseminated in a peer-reviewed journal, and trial participants will be informed via email and/or phone calls.

TRIAL REGISTRATION NUMBER

ChiCTR1800017023.

Joint pain and falls among women with breast cancer on aromatase inhibitors

PURPOSE

Arthralgia is common among women with breast cancer on adjuvant aromatase inhibitor (AI) therapy. Pain is associated with falls in the general population; however, little is known about the relationship between arthralgia and falls among AI users. Our objective was to determine whether joint pain severity and interference predict future falls.

METHODS

We conducted a prospective cohort study of postmenopausal women with stage I-III estrogen receptor-positive breast cancer who were prescribed a third-generation AI. Arthralgia symptoms were measured at baseline using a modified version of the Brief Pain Inventory. Fall occurrence was obtained at 24-month follow-up.

RESULTS

Among 667 participants (median age 63 years, interquartile range 57-69 years), 232 (35%, 95% CI 31 to 39%) reported falls 12-24 months after baseline. Among women who fell, 65 (28%) reported seeking medical assistance. After controlling for multiple fall risk factors, we found significant non-linear associations between baseline joint pain severity and risk of falls (p = 0.001). Women with joint pain severity scores ≥ 4 had a more than twofold increase in fall risk compared to those without pain (41% vs. 20%). We observed a similar relationship for pain interference and fall risk (p < 0.001). Fewer than half of participants reported having been asked about falls in the past 12 months by their primary care physician (44%) or oncologist (36%).

CONCLUSION

Joint pain increases the risk of falls among women with breast cancer on adjuvant AI therapy. Health care providers should evaluate and manage arthralgia symptoms and implement fall-prevention strategies for those who are at increased risk.

Pain and Menopause Symptoms of Breast Cancer Patients with Adjuvant Hormonal Therapy in Korea: Secondary Analysis

Objective:

The purpose of this study was to describe the prevalence and levels of pain and menopause symptoms of breast cancer patients with adjuvant hormonal therapy (HT).

Methods:

A cross-sectional survey design was used. Secondary analysis was used from the primary data collected in 2013 from a total of 110 breast cancer patients receiving HT for more than 3 months, using questionnaires of the Korean version of brief pain inventory and the menopause rating scale.

Results:

Mean age of the participants was 53.56. Most (88.2%) of the participants reported to have pain and almost (95.5%) of them reported to have menopause symptoms. More pain was reported in participants with aromatase inhibitor (AI) than those with tamoxifen. Adherence to HT showed a significant difference according to the rate of feeling increased pain (P = 0.001). Among the menopause symptoms, fatigue was the most common symptom (97.3%). Sweating/flush was significantly higher in tamoxifen group (P < 0.005), and joint and muscle complaints were higher in AI group (P < 005).

Conclusions:

The results of the study show that the prevalence and levels of pain and menopause symptoms among breast cancer patients receiving HT were high. Thus, oncology professionals need to provide appropriate interventions to relieve pain and menopause symptom to improve adherence to HT.

Interventions for the Treatment of Aromatase Inhibitor-Associated Arthralgia in Breast Cancer Survivors: A Systematic Review and Meta-analysis

BACKGROUND

Aromatase inhibitors (AIs) have been established as successful adjuvant therapy for breast cancer survivors. Unfortunately, nearly half of women taking AIs report joint pain, AI-associated arthralgia (AIA). Aromatase inhibitor-associated arthralgia often results in noncompliance, which could lead to cancer recurrence.

OBJECTIVE

The purpose of this study was to identify current pain management of AIA and to evaluate the study quality and effects of interventions.

METHODS

Nineteen articles published from 2000 to August 2015 were identified using PubMed, CINAHL, PsycINFO, Web of Science, and additional records. Study quality was evaluated by the Quality Assessment Tool for Quantitative Studies. Meta-analysis was used to obtain effect sizes of interventions on pain and subgroups.

RESULTS

Five types of interventions emerged: pharmacological approaches, acupuncture, nutritional supplementation, relaxation techniques, and physical exercise. Six studies were strong, 8 were moderate, and 5 were weak in quality. The overall effect size of the interventions on pain was large; pharmacological approaches, acupuncture, and relaxation techniques showed moderate to large effects on pain, whereas nutritional supplementation and physical exercise had no significant effects on it.

CONCLUSION

The evidence was based on a body of research with moderate study quality. Although the overall effect of interventions is large, further investigation into the influence of nutrition and physical exercise is needed to better discern their potential for pain management.

IMPLICATION FOR PRACTICE

Oncology nurses may be able to implement such validated interventions as pain management modalities to mitigate the symptoms so that breast cancer survivors remain compliant with AIA therapy.

Reliability of the NICMAN Scale: An Instrument to Assess the Quality of Acupuncture Administered in Clinical Trials

BACKGROUND

The aim of this study was to examine the reliability of a scale to assess the methodological quality of acupuncture administered in clinical research.

METHODS

We invited 36 acupuncture researchers and postgraduate students to participate in the study. Firstly, participants rated two articles using the scale. Following this initial stage, modifications were made to scale items and the exercise was repeated. Interrater reliability was assessed for individual items using the Fleiss kappa statistic, whilst the overall scale used the intraclass correlation coefficient statistic. A threshold agreement of ≥0.61 was acceptable.

RESULTS

We received 26 responses and a 72% response rate. The first phase of testing found moderate reliability with intraclass correlation coefficients of 0.46 and 0.55 for the articles. The interrater reliability of the scales varied between and within the researchers (0.35, 0.60) and was more consistent with the postgraduate students (0.54, 0.54). Five items on the scale scored below the threshold and were revised for further testing. In this phase the intraclass correlation coefficient demonstrated variability between articles but improved to achieve reliability above the agreed threshold.

CONCLUSION

This study provides evidence of the reliability of the NICMAN scale although improvements to a small number of items remain.

Traditional Chinese Medicine Bionic Tiger Bone Powder for the Treatment of AI-Associated Musculoskeletal Symptoms

Background. Aromatase inhibitors (AIs) are used for adjuvant therapy of breast cancer; however AIMSS (AI-Associated Musculoskeletal Symptoms) can negatively affect quality of life and compliance. Most patients in China moved to TCM (traditional Chinese medicine) for help. TB (tiger bone) is used to treat bone disease, whose main ingredients are calcium and collagen. The objective of this study was to evaluate whether the TB prevented AIMSS in postmenopausal women with ER/PR+ breast cancer. Methods. We conducted a randomized, blind, controlled study of comparing TB versus placebo for 12 weeks in postmenopausal women with breast cancer who have taken AI for less than a month. Patients completed the M-BPI, VAS, and FACT-B at baseline, 6 weeks, and 12 weeks. M-BPI and VAS were used as the primary outcomes. FACT-B was used as the secondary outcome. Serum E₂ and FSH were tested every 6 weeks. Results. Of 70 evaluable cases, 8 of 35 patients (22.9%) developed new or worsening point symptoms in TB group, compared to 21 of 35 (60%) in placebo group (P < 0.001). We also found differences between 2 groups in average pain (2 to 5.6), worst pain (3.9 to 8), pain interference severity (1.9 to 5.3), stiffness (2.4 to 6.9), and joint symptom interference (1.8 to 5.7), all P < 0.001; similar findings were seen in VAS value (3 to 6.6) at the end of intervention. HRQoL measured by FACT-B (P < 0.05) was improved. No change of serum estradiol and FSH between two groups. Conclusions. TB appeared to be effective and safe in the prevention of AIMSS. This trial is registered with ChiCTR-IPR-15007081.

Expectancy in real and sham electroacupuncture: does believing make it so?

BACKGROUND

The large placebo effect observed in prior acupuncture trials presents a substantial challenge for interpretation of the efficacy of acupuncture. We sought to evaluate the relationship between response expectancy, a key component of the placebo effect over time, and treatment outcome in real and sham electroacupuncture (EA).

METHODS

We analyzed data from a randomized controlled trial of EA and sham acupuncture (SA) for joint pain attributable to aromatase inhibitors among women with breast cancer. Responders were identified using the Patient Global Impression of Change instrument at Week 8 (end of intervention). The Acupuncture Expectancy Scale (AES) was used to measure expectancy four times during the trial. Linear mixed-effects models were used to evaluate the association between expectancy and treatment response.

RESULTS

In the wait list control group, AES remained unchanged over treatment. In the SA group, Baseline AES was significantly higher in responders than nonresponders (15.5 vs 12.1, P = .005) and AES did not change over time. In the EA group, Baseline AES scores did not differ between responders and nonresponders (14.8 vs 15.3, P = .64); however, AES increased in responders compared with nonresponders over time (P = .004 for responder and time interaction term) with significant difference at the end of trial for responders versus nonresponders (16.2 vs 11.7, P = .004).

CONCLUSIONS

Baseline higher response expectancy predicts treatment response in SA, but not in EA. Divergent mechanisms may exist for how SA and EA influence pain outcomes, and patients with low expectancy may do better with EA than SA.

Acupuncture for symptom management in cancer care: an update

In a previous systematic review of the worldwide literature of randomized controlled trials (RCTs) involving needle insertion into acupuncture points for symptom management in cancer patients, we identified only one high-quality RCT that was deemed to have a low risk of bias. Medline, Embase, CINAHL, Cochrane (all databases), Scopus, and PubMed were searched from inception through December 2011 with no language limits applied. A total of 41 RCTs met all inclusion criteria and were rated. In the current review, we examined 18 trials published since our last report. The purpose of this update was to emphasize important recent findings and discuss how concerns such as blinding, separating non-specific placebo effects from specific needling effects, determining biologic mechanisms and dosing parameters, evaluating determinants of response such as expectation, controlling for sources of bias, and the lack of standardization in treatment and study methods may affect the interpretation of study results.

Acupuncture for Neoplasms: An Update from the PubMed Database

Background: The therapeutic mainstays of cancer remain surgery, radiotherapy, and chemotherapy. However, radiotherapy and chemotherapy are often associated with serious side-effects, such as nausea and vomiting. Acupuncture has been used widely to treat disorders in clinical practice for at least 3000 years. According to the National Institutes of Health (NIH) Consensus Statement, chemotherapy-induced nausea and vomiting are suitable for acupuncture intervention. Objectives: The goal of this review is to analyze the applications of acupuncture for treating cancer and to look ahead at the potential advantages of acupuncture for patients with cancer. Materials and Methods: The PubMed database was searched for articles on acupuncture therapy and neoplasms. The different distributions of scientific papers were analyzed preliminarily. Results: The articles found showed that acupuncture was used to address various symptoms related to different types of cancer. Conclusions: The results of clinical trials in acupuncture have provided important clues in oncologic practice. The evidence suggests that acupuncture is a safe and effective therapy for managing cancer and treatment-related symptoms, such as nausea and vomiting and fatigue caused by chemotherapy. As more evidence emerges, the potential advantages of acupuncture in tumor treatment will eventually be clear.

Do attitudes and beliefs regarding complementary and alternative medicine impact its use among patients with cancer? A cross-sectional survey

BACKGROUND

Complementary and alternative medicine (CAM) incorporates treatments used by cancer survivors in an attempt to improve their quality of life. Although population studies have identified factors associated with its use, to the best of the authors knowledge, assessment of why patients use CAM or the barriers against its use have not been examined to date.

METHODS

The authors conducted a cross-sectional survey study in the thoracic, breast, and gastrointestinal medical oncology clinics at an academic cancer center. Clinical and demographic variables were collected by self-report and chart abstraction. Attitudes and beliefs were measured using the validated Attitudes and Beliefs about CAM (ABCAM) instrument. This instrument divides attitudes and beliefs into 3 domains: expected benefits, perceived barriers, and subjective norms.

RESULTS

Among 969 participants (response rate, 82.7%) surveyed between June 2010 and September 2011, patient age ≤65 years, female sex, and college education were associated with a significantly greater expected benefit from CAM (P<.0001 for all). Nonwhite patients reported more perceived barriers to CAM use compared with white patients (P<.0001), but had a similar degree of expected benefit (P = .76). In a multivariate logistic regression analysis, all domains of the ABCAM instrument were found to be significantly associated with CAM use (P<.01 for all) among patients with cancer. Attitudes and beliefs regarding CAM explained much more variance in CAM use than clinical and demographic variables alone.

CONCLUSIONS

Attitudes and beliefs varied by key clinical and demographic characteristics, and predicted CAM use. By developing CAM programs based upon attitudes and beliefs, barriers among underserved patient populations may be removed and more patient centered care may be provided.

Acupuncture for treating aromatase inhibitor-related arthralgia in breast cancer: a systematic review and meta-analysis

PURPOSE

Acupuncture has been used as a complementary medical treatment for arthralgia and other types of pain. The objective of this review is to assess the effectiveness of acupuncture in the treatment of arthralgia in patients with breast cancer who were treated with aromatase inhibitors (AIs).

METHODS

A literature search was performed, without language restrictions, of 10 databases from their inception through February 2014. The literature reviewed included randomized clinical trials (RCTs) and clinical trials that compared real versus sham acupuncture for the treatment of AI-related musculoskeletal symptoms (AIMSS). The methodologic quality of these trials was assessed by using the modified Jadad Quality Scale. Meta-analytic software (RevMan 5.0) was used to analyze the data.

RESULTS

Five To compare the effects of real versus sham acupuncture, five RCTs were assessed by meta-analysis and quality analysis. Three of the RCTs reported favorable effects with regard to use of acupuncture in reducing pain and joint-related symptoms, while the other two RCTs did not. The meta-analysis showed trends toward reduced pain and stiffness in patients given acupuncture compared with those who received sham treatment (n=82; pain, mean difference: -2.07 [95% confidence interval (CI), -4.72 to 0.57]; p=0.12; stiffness, mean difference: -86.10 [95% CI, -249.11 to 76.92]; p=0.30), although these differences were not statistically significant.

CONCLUSIONS

Acupuncture has been reported as a safe and promising treatment for AIMSS, but the present analysis indicated that the effects were not statistically significant. Other outcome measurements, such as imaging studies, would be worth including in future studies to further confirm the efficacy of acupuncture in AIMSS.

Breast cancer pain management - a review of current & novel therapies

Breast cancer is one of the most prevalent cancers amongst women in the world. Unfortunately, even after adequate treatment, some patients experience severe pain either due to disease progression or due to treatment related side effects. The persistent pain causes a negative physical and psychosocial impact on patients' lives. Current rational pain management is patient-centred and requires a thorough psychological assessment. Usually adequate analgesia is achieved by adopting the WHO's three step analgesic ladder. As the disease progresses, the pain experienced by the patient also increases. This necessitates the administration of opioids and adjuvant analgesics to the breast cancer patients experiencing severe pain. However, opioid use is associated with intolerable side effects like constipation, nausea, vomiting, fear of dependence, and tolerance. Concomitant medications are required to combat these unacceptable side effects. Adjuvant analgesics need to be added to provide adequate and satisfactory analgesia. These factors worsen the psychological state of patients and deteriorate their quality of life. Hence, there is a need to develop therapeutic modalities to provide adequate analgesia with minimum side effects. This review article focuses on the current treatments available for cancer pain management, their limitations, and novel targets and non-pharmacological measures under investigation which have the potential to produce a radical change in pain management measures for the breast cancer patients.

A randomised trial of electro-acupuncture for arthralgia related to aromatase inhibitor use

BACKGROUND

Arthralgia is a common and debilitating side-effect experienced by breast cancer patients receiving aromatase inhibitors (AIs) and often results in premature drug discontinuation.

METHODS

We conducted a randomised controlled trial of electro-acupuncture (EA) as compared to waitlist control (WLC) and sham acupuncture (SA) in postmenopausal women with breast cancer who self-reported arthralgia attributable to AIs. Acupuncturists performed 10 EA/SA treatments over 8 weeks using a manualised protocol with 2 Hz electro-stimulation delivered by a TENS unit. Acupuncturists administered SA using Streitberger (non-penetrating) needles at non-traditional acupuncture points without electro-stimulation. The primary end-point was pain severity by Brief Pain Inventory (BPI) between EA and WLC at Week 8; durability of response at Week 12 and comparison of EA to SA were secondary aims.

FINDINGS

Of the 67 randomly assigned patients, mean reduction in pain severity was greater in the EA group than in the WLC group at Week 8 (-2.2 versus -0.2, p=0.0004) and at Week 12 (-2.4 versus -0.2, p<0.0001). Pain-related interference measured by BPI also improved in the EA group compared to the WLC group at both Week 8 (-2.0 versus 0.2, p=0.0006) and Week 12 (-2.1 versus -0.1, p=0.0034). SA produced a magnitude of change in pain severity and pain-related interference at Week 8 (-2.3, -1.5 respectively) and Week 12 (-1.7, -1.3 respectively) similar to that of EA. Participants in both EA and SA groups reported few minor adverse events.

INTERPRETATIONS

Compared to usual care, EA produced clinically important and durable improvement in arthralgia related to AIs in breast cancer patients, and SA had a similar effect. Both EA and SA were safe.

Aromatase inhibitor associated musculoskeletal symptoms are associated with reduced physical activity among breast cancer survivors

Physical activity (PA) has numerous health benefits for breast cancer survivors. Recent data suggest that some breast cancer survivors treated with aromatase inhibitors may experience aromatase inhibitor associated musculoskeletal symptoms. It is unknown whether aromatase inhibitor associated musculoskeletal symptoms are associated with reduced PA and what other risk factors are associated with such PA reductions. We conducted a cross-sectional study at a large university-based breast cancer clinic among breast cancer survivors prescribed an aromatase inhibitor. At routine follow-up, we surveyed participants about aromatase inhibitor associated musculoskeletal symptoms, as well as pre-aromatase inhibitor, and current, PA levels. Among 300 participants, 90 (30%) reported a reduction of PA since the initiation of aromatase inhibitor therapy. Those with aromatase inhibitor associated musculoskeletal symptoms were more likely to report decreased PA (62% versus 38%, p = 0.001) compared with those without aromatase inhibitor associated musculoskeletal symptoms. In multivariate analyses, aromatase inhibitor associated musculoskeletal symptoms (odds ratio [OR] = 2.29 [95% confidence interval [CI]: 1.36-3.86]), and body mass index (OR = 1.06 [95% CI: 1.02-1.12]) were associated with reductions in PA. In subgroup analysis among breast cancer survivors with aromatase inhibitor associated musculoskeletal symptoms, self-reported lower extremity joint pain (OR = 1.23 [95% CI: 1.00-1.50]) and impaired lower extremity physical function (OR = 1.07 [95% CI: 1.01-1.14]) were associated with reductions in PA. Breast cancer survivors with aromatase inhibitor associated musculoskeletal symptoms were more likely to report reductions in PA since initiating aromatase inhibitor therapy compared with those without aromatase inhibitor associated musculoskeletal symptoms. Our findings suggest that tailored interventions targeting lower extremity functional limitations are needed to enable breast cancer survivors with aromatase inhibitor associated musculoskeletal symptoms to participate in PA.

Joint pain severity predicts premature discontinuation of aromatase inhibitors in breast cancer survivors

Background

Premature discontinuation of aromatase inhibitors (AIs) in breast cancer survivors compromises treatment outcomes. We aimed to evaluate whether patient-reported joint pain predicts premature discontinuation of AIs.

Methods

We conducted a retrospective cohort study of postmenopausal women with breast cancer on AIs who had completed a survey about their symptom experience on AIs with specific measurements of joint pain. The primary outcome was premature discontinuation of AIs, defined as stopping the medication prior to the end of prescribed therapy. Multivariate Cox regression modeling was used to identify predictors of premature discontinuation.

Results

Among 437 patients who met eligibility criteria, 47 (11%) prematurely discontinued AIs an average of 29 months after initiation of therapy. In multivariate analyses, patient-reported worst joint pain score of 4 or greater on the Brief Pain Inventory (BPI) (Hazard Ratio [HR] 2.09, 95% Confidence Interval [CI] 1.14-3.80, P = 0.016) and prior use of tamoxifen (HR 2.01, 95% CI 1.09-3.70, P = 0.026) were significant predictors of premature discontinuation of AIs. The most common reason for premature discontinuation was joint pain (57%) followed by other therapy-related side effects (30%). While providers documented joint pain in charts for 82% of patients with clinically important pain, no quantitative pain assessments were noted, and only 43% provided any plan for pain evaluation or management.

Conclusion

Worst joint pain of 4 or greater on the BPI predicts premature discontinuation of AI therapy. Clinicians should monitor pain severity with quantitative assessments and provide timely management to promote optimal adherence to AIs.

Herbal medicine and acupuncture for breast cancer palliative care and adjuvant therapy

Breast cancer is a life-threatening disease among women worldwide with annual rates of reported incidence and death increasing alarmingly. Chemotherapy is a recommended and effective treatment option for breast cancer; however, the narrow therapeutic indices and varied side effects of currently approved drugs present major hurdles in increasing its effectiveness. An increasing number of literature evidence indicate that complementary and alternative medicine (CAM) used in treatment-related symptom control and alleviation of side effects plays an important role in increasing survival rate and quality of life in breast cancer patients. This review focuses on the use of herbal medicines and acupuncture in palliative care and as adjuvants in the treatment of breast cancer. Herbal medicinal treatments, the correlation of clinical use with demonstrated in vitro and in vivo mechanisms of action, and the use of certain acupoints in acupuncture are summarized. The aim of this review is to facilitate an understanding of the current practice and usefulness of herbal medicine and acupuncture as adjuvants in breast cancer therapy.

Phase II study of glucosamine with chondroitin on aromatase inhibitor-associated joint symptoms in women with breast cancer

PURPOSE

Many women with hormone receptor-positive breast cancer discontinue effective aromatase inhibitor (AI) treatment due to joint symptoms.

METHODS

We conducted a single-arm, open-label, phase II study evaluating glucosamine-sulfate (1,500 mg/day) + chondroitin-sulfate (1,200 mg/day) for 24 weeks to treat joint pain/stiffness in postmenopausal women with early stage breast cancer who developed moderate-to-severe joint pain after initiating AIs. The primary endpoint was improvement in pain/stiffness at week 24 assessed by the Outcome Measure in Rheumatology Clinical Trials and Osteoarthritis Research Society International (OMERACT-OARSI) criteria. Secondary endpoints assessed changes in pain, stiffness, and function using the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) Index for hips/knees and the Modified Score for the Assessment and Quantification of Chronic Rheumatoid Affections of the Hands (M-SACRAH) for hands/wrists. The Brief Pain Inventory (BPI) assessed pain interference, severity, and worst pain.

RESULTS

Of 53 patients enrolled, 39 were evaluable at week 24. From baseline to week 24, 46 % of patients improved according to OMERACT-OARSI criteria. At week 24, there were improvements (all P < 0.05) in pain and function as assessed by WOMAC and M-SACRAH, and in pain interference, severity, and worst pain as assessed by BPI. Estradiol levels did not change from baseline. The most commonly reported side effects were headache (28 %), dyspepsia (15 %), and nausea (17 %).

CONCLUSIONS

In this single-arm study, 24 weeks of glucosamine/chondroitin resulted in moderate improvements in AI-induced arthralgias, with minimal side effects, and no changes in estradiol levels. These results suggest a need to evaluate efficacy in a placebo-controlled trial.

Managing the side effects of oral aromatase inhibitors

SUMMARY Aromatase inhibitors (AIs) are increasingly being used to treat postmenopausal estrogen receptor-positive breast cancer. In the short term they enhance or induce menopausal symptoms that compromise AI adherence, while in the long-term they adversely affect bone and probably also cardiovascular health, although this is mainly when compared to tamoxifen, which is cardioprotective. The distinct decrease in estrogen levels following AI administration is believed to be the main reason for the emergence of these side effects, although exact mechanisms remain to be elucidated. As such, management strategies to meet these AI-induced toxicities are still mainly symptomatic. In this review, current treatment options and promising new modalities under research will be discussed.

Sexual problems, communication patterns, and depressive symptoms in couples coping with metastatic breast cancer

BACKGROUND

The treatment of breast cancer tends to result in physical side effects (e.g., vaginal dryness, stomatitis, and atrophy) that can cause sexual problems. Although studies of early-stage breast cancer have demonstrated that sexual problems are associated with increased depressive symptoms for both patients and their partners, comparatively little is known about these associations in metastatic breast cancer (MBC) and how patients and partners cope together with sexual problems. We examined the links between sexual problems, depressive symptoms, and two types of spousal communication patterns (mutual constructive and demand-withdraw) in 191 couples in which the patient was initiating treatment for MBC.

METHODS

Patients and partners separately completed paper-and-pencil surveys.

RESULTS

Multilevel models indicated that high levels of sexual problems were significantly associated with more depressive symptoms only for patients who reported low levels of mutual constructive communication (p < 0.01) and high levels of demand-withdraw communication (p < 0.0001). In contrast, for partners, greater sexual problems were associated with more depressive symptoms regardless of the communication pattern reported. These associations remained significant when we controlled for patients' reports of average pain and functional and physical well-being and couples' dyadic adjustment.

CONCLUSIONS

Sexual problems were associated with depressive symptoms for both MBC patients and their partners. The way in which patients and partners talk with one another about cancer-related problems seems to influence this association for patients. MBC patients may benefit from programs that teach couples how to minimize demand-withdraw communication and instead openly and constructively discuss sexual issues and concerns.

Individualization of treatment strategies

This section focuses on different aspects of the individualization of hormone treatment in breast cancer. This includes tumor-related biological factors such as expression of hormone receptors, HER-2, and Ki-67; host-related factors such as CYP2D6 or body mass index, and risk and/or development of specific toxicities and treatment adherence. The best predictor of response to hormonal interventions is the expression of hormone receptors, in particular, estrogen receptors. Treatment adherence and compliance are key factors and strategies aiming to identify and intervene when patients are at risk of abandoning treatment. Currently, routine assessment of CYP2D6 is not recommended to guide tamoxifen treatment. Likewise, there are no criteria regarding bone mass density, lipid profile, or arthralgias to recommend one class of agent versus another. Aromatase inhibitors should not be administered to patients who are pre- or perimenopausal.

Aromatase inhibitor-associated bone and musculoskeletal effects: new evidence defining etiology and strategies for management

Aromatase inhibitors are widely used as adjuvant therapy in postmenopausal women with hormone receptor-positive breast cancer. While the agents are associated with slightly improved survival outcomes when compared to tamoxifen alone, bone and musculoskeletal side effects are substantial and often lead to discontinuation of therapy. Ideally, the symptoms should be prevented or adequately treated. This review will focus on bone and musculoskeletal side effects of aromatase inhibitors, including osteoporosis, fractures, and arthralgias. Recent advances have been made in identifying potential mechanisms underlying these effects. Adequate management of symptoms may enhance patient adherence to therapy, thereby improving breast cancer-related outcomes.

Aromatase inhibitor-induced loss of grip strength is body mass index dependent: hypothesis-generating findings for its pathogenesis

BACKGROUND

Our preliminary results showed that tenosynovial changes and decrease in grip strength are associated with the aromatase inhibitor-induced musculoskeletal syndrome (AIMSS). Here, we report the final results and assess the relationship between grip strength and body mass index (BMI).

PATIENTS AND METHODS

We conducted a prospective study including postmenopausal early breast cancer patients receiving either an aromatase inhibitor (AI) or tamoxifen. Primary end point was change from baseline in tenosynovial abnormalities. Secondary end points were changes from baseline in morning stiffness, intra-articular fluid and grip strength and its association with BMI.

RESULTS

After 6 months of therapy, 74% [95% confidence interval (CI) 51% to 89%] of AI-treated patients had worsened tenosynovial abnormalities, 56% (95% CI 34% to 75%) had increased intra-articular fluid, and 22% (95% CI 9% to 45%) had increased morning stiffness. Grip strength decreased 8% for the left hand (95% CI 2% to 21%) and 11% for the right (95% CI 4% to 17%). Regression analysis suggested that grip strength decreased more for subjects with high or with low BMI.

CONCLUSIONS

AIMSS is characterized by tenosynovial changes, intra-articular fluid and morning stiffness. We hypothesize that the quadratic association between BMI and loss of grip strength reflects AI-induced changes on the endocrine control of the growth hormone insulin-like growth factor-I pathway.

Uncovering the expectancy effect: the validation of the acupuncture expectancy scale

PURPOSE

Research suggests that expectancy may modulate the response to medical interventions, including acupuncture. However, the paucity of validated tools to measure expectancy limits rigorous evaluation. We sought to validate a previously developed Acupuncture Expectancy Scale (AES) as an instrument to measure patients' expected responses to acupuncture.

PURPOSE

Participants were patients with stage I to III cancers seen in outpatient medical and radiation oncology clinics. They were drawn from three study cohorts that included 404 participants. We examined the reliability, validity, and responsiveness of the AES.

RESULTS

The scores on the AES had internal consistency (Cronbach's alpha coefficient) of 0.95 and test-retest reliability of 0.62 over 4 weeks without acupuncture treatment. Those who had previously used acupuncture had higher AES scores compared to those who were acupuncture naive (12.4 vs 9.5, P = .002). AES scores were higher in those who reported willingness to participate in an acupuncture trial compared to those who did not want to participate in an acupuncture trial (11.5 vs 8.1, P < .001). Patients who enrolled in a pilot trial of acupuncture had higher AES scores than the general outpatient population (13.0 vs 9.8, P = .02), and expectancy increased during the course of acupuncture treatment (13.0 to 16.5, P < .017).

CONCLUSION

The AES is reliable and valid, and scores appear to increase during or after prior therapy. Incorporation of AES in clinical trials and outcome studies can evaluate the role of expectancy on acupuncture outcomes.

Musculoskeletal adverse events associated with adjuvant aromatase inhibitors

Musculoskeletal symptoms including arthralgia and myalgia occur frequently in aging women, particularly during the transition to menopause, when plasma estrogens precipitously decline. In postmenopausal women (PMW) with breast cancer, third-generation aromatase inhibitors (AIs) as adjuvant hormonal therapy have proven to be more effective, and to have a more predictable side effect profile, than tamoxifen. However, AIs further reduce plasma estrogens in PMW, exacerbating musculoskeletal symptoms. Clinical trial data have shown significantly higher incidences of arthralgia and myalgia with AIs compared with women on tamoxifen or placebo. Symptoms may be severe enough to significantly affect quality of life; musculoskeletal symptoms are a frequent reason for discontinuing therapy. In many cases, symptoms can be effectively managed with oral analgesics or other strategies. Early recognition and effective management of musculoskeletal symptoms can help maximize treatment compliance, enabling patients to derive optimal benefit from therapy in terms of preventing recurrence.

Aromatase inhibitor-induced arthralgia in early breast cancer: what do we know and how can we find out more?

Aromatase inhibitors (AIs) are a standard of care for the adjuvant treatment of hormone responsive early carcinoma of the breast as demonstrated in a number of large international phase III randomised trials. Arthralgia was a somewhat unexpected side effect of this class of agents and has proven to be potentially problematic in clinical practice. Although rates of up 35% have been reported in the randomised trials, the figure has been much higher in subsequent case series. There is concern that these symptoms are significant and may affect compliance and thus the overall efficacy of treatment. It is therefore extremely important that we evaluate this syndrome with a view to gaining more information regarding its clinical features and possible aetiological mechanism. The potential aetiological mechanisms and evidence for aromatase inhibitor-induced arthralgia (AIA) are reviewed in this article. Looking forward, it is now important that prospective clinical trials are well designed to evaluate this syndrome and potential therapeutic strategies to circumvent it. Radiological imaging and biochemical analyses may help our understanding of AIA and these are discussed.

Patterns and risk factors associated with aromatase inhibitor-related arthralgia among breast cancer survivors

BACKGROUND

Arthralgia is common in postmenopausal breast cancer survivors (BCS) who are receiving aromatase inhibitors (AIs). The objective of this study was to evaluate the perceived onset, characteristics, and risk factors for AI-related arthralgia (AIA).

METHODS

In a cross-sectional survey of postmenopausal BCS who were receiving adjuvant AI therapy at a university-based oncology clinic, patient-reported attribution of AIs as a cause of joint pain was used as the primary outcome. Multivariate logistic regression analyses were performed to evaluate risk factors.

RESULTS

Among 300 survey respondents, 139 (47%) attributed AI as a cause of their current arthralgia. Of those patients, 74% recognized the onset of AIA within 3 months of starting medication, and 67% rated joint pain as moderate or severe in the previous 7 days. In multivariate logistic regression analyses, the time since last menstrual period (LMP) was the only significant predictor of AIA. Controlling for covariates, the women who had their LMP within 5 years had the highest probability of reporting AIA (73%), whereas those who had their LMP > or =10 years previously had the lowest probability of reporting AIA (35%; adjusted odds radio, 3.39; 95% confidence interval, 1.21-9.44; P = .02). Wrists/hands, ankles/feet, elbows, and knees appeared to be associated more strongly with AI-related symptoms than non-AI-related joint symptoms (all P < .01).

CONCLUSIONS

AIA was common, began within the first 3 months of therapy in most patients, and appeared to be related inversely to the length of time since cessation of menstrual function. These findings suggest that estrogen withdrawal may play a role in the mechanism of this disorder.