Practical Ways to Incorporate Acupuncture Into Clinical Practice

Robert H. Carlson, MBA


March 28, 2018

With the national crisis of opioid abuse focusing attention on nonpharmaceutical pain relief, new data on acupuncture has oncologists taking a deeper look at this complementary therapy.

Most recently, another phase 3 trial, Southwest Oncology Group (SWOG) S1200, has shown that acupuncture is a viable alternative to medication to relieve symptoms related to cancer and cancer treatment—in this case, joint pain associated with aromatase inhibitors.[1] However, a lack of awareness about advances in acupuncture research is one reason some oncologists do not prescribe it for patients.

"Today, there are enough well conducted phase 3 trials of acupuncture showing benefits for multiple symptoms—not just arthralgias, but also fatigue and hot flashes—and physicians are starting to realize that this is an actual therapy we can offer to patients to help them," said Julie Nangia, MD, an assistant professor and director of the Breast Cancer Prevention and High Risk Clinic at Baylor College of Medicine.

Physicians are starting to realize that acupuncture is an actual therapy.

Nangia, who does prescribes acupuncture for some of her patients, was asked to comment on the obstacles that might keep others from prescribing, and how clinicians can learn more as well as find suitable acupuncturists. She said that besides the question of whether is it really helpful and safe—"which is being answered by the phase 3 trials now in the literature"—another obstacle to physician referral is finding a good acupuncturist.

Nangia said that a social worker at Baylor keeps a list of complementary medicine practitioners who have been vetted, so physicians have a handout they can give patients. "Complementary medicine" refers to health and wellness therapies that have typically not been part of conventional Western medicine but which complement conventional medicine.

"Each center has to compile its own list of acupuncturists they want to refer to, and it takes time to build a list like that, but acupuncture is one more supportive care service we should be offering our patients," Nangia said.

Many leading cancer centers have already taken note. Jun J. Mao, MD, chief of the Integrative Medicine Service at Memorial Sloan Kettering Cancer Center (MSKCC) and a licensed acupuncturist, and colleagues recently performed a systematic review of 45 National Cancer Institute-designated comprehensive cancer center websites and found that 89% of those websites in 2016 provided information about acupuncture, among other integrative medicine modalities—up from 59% in 2009, a 30% increase.[2]

S1200 Details

In the S1200 study, presented at the 2017 San Antonio Breast Cancer Symposium (SABCS) and reported by Medscape Medical News, acupuncture significantly reduced joint pain related to aromatase inhibitor (AI) therapy in postmenopausal women with early-stage breast cancer compared with placebo (sham acupuncture) or no treatment.

In the study, conducted at nine large community practices and two academic centers, 58% of the 110 patients who received true acupuncture twice a week for 6 weeks experienced a statistically significant reduction in the "worst pain" score, compared with 31% for the 59 patients who received sham acupuncture and 30% for 57 who received no treatment.

Finding an Acupuncture Provider

Oncologists interested in finding an acupuncturist for their patients can start by looking in their own institutions, said Dawn Hershman, MD, a professor of medicine and epidemiology and leader of the Breast Cancer Program at the Herbert Irving Comprehensive Cancer Center at Columbia University, and senior author of the S1200 study.

"Many of the larger community sites participating in S1200 have a provider affiliated with the center or even on staff as part of their survivorship program," Hershman said.

S1200 used 11 study sites and required each to have two acupuncturists available.

"And sometimes you get the best ideas from listening to patients; they tell you what they have done to improve their symptoms, and you think maybe you should test that," Hershman said. "That's how this acupuncture study came about."

Mao, at MSKCC, also said that oncologists can ask whether their cancer patients use acupuncture for pain as a way of locating acupuncturists in the area. "Many patients are using acupuncture without telling their doctor," he said.

When considering an acupuncturist, Mao advised asking what training they have undergone, and then have a face-to-face meeting. Mao requires community acupuncturists to take the MSKCC online course. He said there are now more than 400 community acupuncturists taking the course.[3]

"Acupuncturists don't necessarily know the nuances of taking care of the psychosocial [and] physical complexity of cancer patients, such as low blood count. We address safety and psychosocial complexity," Mao said.

The online "Acupuncture for the Cancer Patient" course is a 17-hour program that prepares licensed acupuncturists to safely care for cancer patients experiencing treatment symptoms and side effects. The course is open to licensed or certified acupuncturists.

Related MSKCC online courses are "Fundamentals of Oncology Acupuncture," "Advances in Oncology Acupuncture: Clinical Research and Side Effect Management," and "Acupuncture Trialists' Collaboration."

And the MSKCC online course "Integrative Oncology for Physicians" for general family practice physicians, hospitalists, and other physicians provides an overview of how integrative modalities, including acupuncture, can support treatment and recovery for their patients.

Adam Schreiber, a licensed acupuncturist who has worked with cancer patients at the University of Pennsylvania's Abramson Cancer Center and is now in private practice in Philadelphia, said that when he is contacted by an oncologist about acupuncture, he stresses the safety record.

"I reassure the oncologist that acupuncture will not interfere with any other treatment at the cancer center," Schreiber said. "That's often a stumbling block with oncologists: They hesitate to refer a patient largely because they don't understand acupuncture well. But in fact, the vast majority of patients can receive acupuncture treatment during cancer therapy, including radiation therapy."

Schreiber said he also takes pains not to conflate acupuncture with Chinese herbal medicine, which he says is not always safe.

Acupuncture will not interfere with any other treatment at the cancer center.

Schreiber said that acupuncturists in Pennsylvania are licensed through the state board of medicine, and acupuncturists can become board-certified through the National Certification Commission for Acupuncture and Oriental Medicine.

"A physician might not have time for that level of investigation, but those are resources available," he said.

Barriers to Patient Use

Mao coauthored a 2016 survey of breast cancer survivors asking about barriers to acupuncture use.[3] The survey, presented at the 13th International Conference of the Society for Integrative Oncology by Ting Bao, MD, also an MSKCC oncologist, found that the most common barrier among patients was lack of awareness—that doctors and nurses did not mention that acupuncture is available and can be helpful (42%).

The second most common barrier, was no insurance coverage (25%), followed by cost (22%), difficulty finding a qualified acupuncturist (18%), and time constraints (17%).

Of note, only 7% of patients surveyed reported perceiving acupuncture as a painful procedure as a barrier.

Insurance Issues

Adam Schreiber said financial constraints are the major obstacle to patients using acupuncture. "There's a better chance that insurance doesn't cover acupuncture than that it does," he said. "The situation is improving, and coverage is better in some states than in others."

Schreiber's fee is $150 for the initial visit, with an extensive interview and treatment, and afterward is $90 per visit, which he says is typical for Philadelphia area.

Often the patients take it upon themselves to find an acupuncturist, and the oncologist gets the reference from patients.

Alan Shaw, a licensed acupuncturist on staff at St. Luke's in Boise, Idaho, was one of the two staff acupuncturists who treated the participants in the S1200 study of aromatase inhibitor-related joint pain. Nine years ago when he started in Boise, only 10%-15% of patients had coverage, whereas today it's 40%-45%. If a patient's insurance does not cover acupuncture, he encourages them to contact their insurer and ask them to start coverage, because that might spark an interest.

Some insurers will pay for acupuncture for some or all of the treatment if a physician writes the prescription. Some people have health flex plans; they have an account that they can use toward such treatment. But other insurers haven't paid for it.

"We feel there is now sufficient evidence to support insurance coverage of acupuncture for aromatase inhibitor arthralgia," Hershman said at SABCS. "We hope when the manuscript is published, people will be able to persuade their insurance companies—to provide evidence that it's worth paying for. You would hope that if you present insurance companies with high-level evidence, they would support it. They support a lot of other interventions that are much more expensive with much less of a benefit."


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