Acupuncture, massage equally effective for cancer pain

In patients with advanced cancer, both acupuncture and massage prove beneficial in reducing pain and fatigue, as well as improving insomnia symptoms and quality of life, as shown in the IMPACT trial.

Over 26 weeks of treatment, acupuncture reduced the worst pain score by a mean of 2.53 points (95 percent confidence interval [CI], −2.92 to −2.15) while massage lowered the Brief Pain Inventory worst pain score by a mean of 3.01 points (95 percent CI, −3.38 to −2.63). The between-group difference was not significant (−0.48; 95% CI, −0.98 to 0.03; p=0.07). [JAMA Netw Open  2023;6:e2342482]

More than half of the patients had a clinical response to treatment by week 26 (acupuncture: 55.2 percent, 95 percent CI, 46.0–64.0; massage: 65.9 percent, 95 percent CI, 57–74).

Both treatments also improved fatigue, insomnia, and quality of life, with the effect sizes being similar between the two treatment groups.

As for safety, adverse events were mild and included bruising (6.5 percent of patients receiving acupuncture) and transient soreness (15.1 percent of patients receiving massage).

“The findings contribute to current guidelines for cancer pain management by demonstrating the long-term comparative effectiveness of two nonpharmacologic therapies in the growing population of patients living with advanced cancer,” the investigators said. [J Clin Oncol 2022;40:3998-4024; J Natl Cancer Inst 2022;114:1476-1483]

Multifaceted benefits

IMPACT comprised 298 patients with advanced cancer (mean age 58.7 years, 67.1 percent women, 78.5 percent had solid tumours), with the mean time since diagnosis being 5.6 years. The most common cancer types were haematologic (21.5 percent), breast (19.8 percent), gynaecologic (14.4 percent), and gastrointestinal (11.7 percent). The mean score for worst pain severity was 6.9, with pain having been present for a mean of 3.8 years. At baseline, 98 patients (32.9 percent) were receiving opioids.

“In patients with advanced cancer, pharmacotherapy is often the mainstay of pain management. However, polypharmacy is a growing concern in this population due to adverse effects and drug–drug interactions,” the investigators stated. [Lancet Oncol 2015;16:e333-e341; Oncologist 2022;27:e580-e588]

“In this trial, acupuncture and massage not only reduced pain but also improved comorbid fatigue and insomnia symptoms, underscoring the multifaceted benefits that integrative modalities can offer for this population,” they added.

The investigators also stressed that interventions were provided in addition to pharmacotherapy for some patients. Hence, “the data should not be interpreted as drugs should be replaced by acupuncture or massage, but that these nonpharmacologic interventions can improve pain and symptom control while potentially reducing medication use.”

As alternative therapies, both acupuncture and massage are widely used and becoming more common in cancer treatment centres. Some payors, such as Medicare in the US, currently only covers acupuncture for chronic low back pain but not massage for pain management. Given that advanced cancer patients often experience pain in multiple areas due to their condition and cancer treatment, expanding Medicare coverage to include other pain locations and massage therapy is important to ensure equitable and effective pain management for cancer patients. [J Natl Cancer Inst Monogr 2017;2017:lgx004; J Altern Complement Med 2021;27:1011-1013; J Gen Intern Med 2021;36:527-529]

In addition, more training should be provided to acupuncturists and massage therapists to ensure they are equipped to treat patients with advanced cancer safely and effectively. The investigators called for more work to determine the optimal integration of these nonpharmaceutical treatments into existing pain management strategies to create patient-centred, efficient, and effective care.