Acupuncture is associated with significant, long-term reduction in joint pain for postmenopausal women with early breast cancer who experience aromatase inhibitor (AI)–related arthralgias, new research shows.
In a multicenter study with more than 200 participants, results showed that for patients who received a 12-week acupuncture intervention, joint pain was reduced for up to 52 weeks compared with patients who received sham acupuncture or were in a wait-list control group.
These results highlight the durability of an acupuncture intervention, the investigators note.
"It's reassuring that the effects can be maintained without continuous need for treatments," lead author Dawn L. Hershman, MD, professor of medicine and epidemiology, Columbia University Medical Center, New York City, told Medscape Medical News.
Hershman added that clinicians should "offer this as an option for patients on AI therapy who complain of significant joint pain and to advocate for payers to cover the costs."
The findings were published online November 11 in JAMA Network Open.
AIs, which prevent an enzyme in fat tissue (aromatase) from changing other hormones into estrogen, are used to treat hormone-sensitive breast cancer. About 80% of breast cancers are estrogen-receptor positive.
For more than 50% of patients, arthralgias and stiffness contribute to nonadherence to therapy.
In the previous Southwest Oncology Group (SWOG) S1200 study, true acupuncture was compared with sham acupuncture and being in a wait-list control group (WC). Results showed that true acupuncture was associated with a statistically significant reduction in joint pain related to AIs at 6 weeks among women with early-stage breast cancer. Subsequent systemic reviews and meta-analyses confirmed this effect.
However, the duration of the acupuncture benefit after treatment has been uncertain. Previous acupuncture trials suggested that treatment effects persist for up to 12 months, but most studies were "shorter, smaller, and [at a] single institution," Hershman noted.
"It's important to know that a 12-week intervention had effects on joint pain that lasted for up to a year," she said. "This has policy implications in terms of funding, as payers have a rationale for funding 12 weeks of treatment."
The current analysis included 52-week results from the SWOG trial.
The 11-center study included 226 postmenopausal women (87.7% White; mean age, 60.7 years) with early-stage (I–III) breast cancer who were taking an AI. All had a score of 3 or higher on the 10-point Brief Pain Inventory Worst Pain (BPI-WP) scale, in which higher scores represent worse symptoms (mean baseline score, 6.7)
Researchers randomly assigned the participants to true acupuncture (n = 110), sham acupuncture (n = 59), WC, or usual care (n = 57). Although sham acupuncture has the advantage of blinding, it may have some physiologic effects that have a bearing on the effect size. WC was included in the trial because of this possibility. Lack of blinding in the usual-care group could influence pain reporting, Hershman said.
Both true and sham acupuncture involved 30- to 45-minute sessions twice a week for 6 weeks, followed by one session a week for 6 additional weeks. For true acupuncture, needles were inserted at traditional depths and angles. The sham protocol targeted non-acupuncture points with thin, short needles that were inserted superficially.
The WC group received no acupuncture during the initial 24 weeks. At that point, all study participants received vouchers for 10 true acupuncture sessions.
The primary endpoint was the 52-week assessment of BPI-WP. Both baseline and 52-week BPI-WP scores were available for analysis in 82.7% of participants assigned to true acupuncture, 89.8% to the sham treatment, and 82.5% to WC.
Compared with baseline, the BPI-WP was 2.72 points lower at 52 weeks in the true acupuncture group, 1.46 points lower in the sham acupuncture group, and 1.55 points lower in the WC group.
The differences in adjusted mean BPI-WP scores was 1.08 points (95% CI, 0.24 – 1.91 points) between the true and sham acupuncture groups (P = .01) and 0.99 points (95% CI, 0.12 – 1.86 points) between the true acupuncture and WC groups (P = .03).
"We showed that after a 12-week intervention, there was a continued reduction of mean worst pain score of about 1 point between true and sham [acupuncture] and between true and weight-list control," said Hershman.
She noted that most studies consider this difference between mean scores to be clinically "meaningful." However, pain is subjective, and there's no accepted definition of meaningful improvement in pain, the investigators write. They add that assessment of pain control strategies can be challenging.
The pain reduction at 52 weeks with acupuncture was "fairly similar" to what the researchers observed at 6 weeks, Hershman reported.
The only adverse event among patients receiving acupuncture was "a minimal amount of grade 1 bruising," she said.
Hershman said the exact mechanisms by which acupuncture reduces joint pain is unclear, although there are several theories. The "most simplistic" of these is that the intervention releases neurotransmitters; but it could also be that it stimulates the vagal-adrenal axis or reduces inflammation.
The intervention is appealing to some patients because of the generally limited adverse effects compared with medications, she noted. However, it is not covered by many insurance plans. For Medicare beneficiaries, acupuncture is covered only for low back pain. Hershman said the average price can vary but ranges from $75 to $150 per session.
Answers a Main Question
Commenting for Medscape Medical News, Robert Bonakdar MD, director of pain management, Scripps Center for Integrative Medicine, La Jolla, California, said the study was "very well done" and helps answer a main question remaining from previous trials: How long does the benefit of acupuncture last for patients with AI-related joint pain?
"Acupuncture in this setting demonstrates benefit from an initial 12-week trial which persisted at 1 year, which his similar to trials of other painful conditions," said Bonakdar, who was not involved with the current research.
He noted that the follow-up was much longer than that for many medications routinely used for this condition.
"Hopefully, this trial will provide confidence both for clinicians and patients to seek out this well-tolerated treatment," Bonakdar said.
The study was supported by the National Center for Complementary and Integrative Health of the National Institutes of Health and the Office of Research on Women's Health. Hershman and Bonakdar have reported no relevant financial relationships.
JAMA Netw Open. Published online November 11, 2022. Full article
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Image 1: Columbia University Medical Center
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Cite this: Acupuncture Linked to Reduced Joint Pain for Up to a Year - Medscape - Nov 16, 2022.