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Supportive Care in Cancer

, Volume 18, Issue 11, pp 1487–1490 | Cite as

The safety of acupuncture in children and adolescents with cancer therapy-related thrombocytopenia

  • Elena J. Ladas
  • Diane Rooney
  • Katherine Taromina
  • Deborah H. Ndao
  • Kara M. Kelly
Short Communication

Abstract

Purpose

Acupuncture is frequently used to manage the side effects associated with cancer therapy. In acupuncture practice, the presence of thrombocytopenia is a relative contraindication to acupuncture use among patients with cancer. However, the safety of acupuncture in patients with cancer treatment-related thrombocytopenia has not been previously investigated.

Methods

Medical records of 32 patients receiving acupuncture at an academic medical center with an established acupuncture program during treatment for cancer or during stem cell transplantation were reviewed.

Results

Of 237 acupuncture sessions, 20%, 8%, and 19% of the sessions were administered to patients with severe, moderate, and mild thrombocytopenia, respectively. No bleeding side effects were observed.

Conclusions

This retrospective case series provides descriptive data on the safety of acupuncture using Japanese J-type Seirin needles, with mild manual stimulation administered at 0.5-cun depth in patients with cancer with and without thrombocytopenia. Prospective trials are needed to confirm these initial observations.

Keywords

Thrombocytopenia Acupuncture Complementary/alternative therapies Pediatric and adolescents 

Background

Traditional Chinese Medicine (TCM) incorporates several modalities including acupuncture, Chinese herbal remedies, dietary interventions, qi gong (breathing and movements techniques), and tui na (Chinese massage) to ease the side effects associated with cancer therapies [1]. Acupuncture is the most commonly used TCM modality in the western hemisphere for the relief or prevention of pain and other health conditions [2]. Acupuncture is defined as the insertion of thin, sterile, FDA-approved disposable needles on specific acupuncture points (acupoints) located along energy channels on the body providing pathways for qi to flow freely [3]. According to TCM theory, qi is the vital substance that pervades the body and provides the necessary elements for optimal physiological function. Acupuncturists can manipulate qi via acupoints to achieve a clinical effect.

Children and adolescents with cancer use TCM to manage a variety of therapy-related toxicities [4, 5]. A NIH consensus panel reported that acupuncture is effective for the treatment of nausea among adults with cancer [2]. Individuals with cancer seek out repeated acupuncture treatments, suggesting a perceived benefit [4]. Several small studies suggest that acupuncture may improve immune response, reduce pain, and manage a variety of therapy-induced symptoms; however, well-designed trials investigating outcomes and safety are still needed [1].

Thrombocytopenia is a frequent side effect of many chemotherapy agents and is associated with an elevated risk of prolonged bleeding. Published guidelines state that acupuncture is contraindicated in patients with platelets below 50,000/μL to avoid the potential risk of prolonged bleeding [6]. As a result, patients are routinely denied access to acupuncture, a potentially beneficial adjunctive treatment for the side effects of conventional anti-cancer therapy. According to TCM practice principles, thrombocytopenia would be approached as a blood regulating treatment, and administration of acupuncture would be indicated [3]. Case reports have suggested that acupuncture is safe in the setting of thrombocytopenia [7, 8]; however, no clinical studies have investigated its safety in the setting of thrombocytopenia.

Given the popularity and suggested efficacy of acupuncture in patients undergoing cancer therapy, the development of evidence-based guidelines is important. As part of a program initiative to develop guidelines for the provision of acupuncture to children and adolescents with cancer, a retrospective descriptive analysis of the experience with acupuncture in the oncology and stem cell transplant population in children and adolescents with and without thrombocytopenia was undertaken.

Methods

After institutional review board approval, medical charts were reviewed from patients who received treatment with acupuncture through the Integrative Therapies Program for Children with Cancer (ITPCC) at Columbia University Medical Center during the period from July 2006 to June 2007. In accordance with ITPCC policy and procedures, physician’s consent was obtained prior to every acupuncture session, and the platelet count was recorded. An ITPCC-licensed acupuncturist conducted a comprehensive TCM intake, which included tongue and pulse diagnosis and patient complaints. Acusites were then selected and needled as per TCM diagnosis guidelines, using practitioner discretion. Varying depths, stimulations, retention time, and amplitudes at the acusites were treated according to TCM treatment theory. All of the patients were needled with Seirin type # 1 and 3 disposable needles (0.16- and 0.20-mm diameter (40 and 36 gauge) and 15-, 30-, or 40-mm length; SEIRIN-America; Weymouth, MA). Treatment details and TCM diagnosis were documented in the medical charts.

Patient demographics (gender, date of birth, race), malignant or non-malignant diagnoses, medical treatment protocol, phase of therapy, and location of treatment (inpatient or outpatient) were collected. Details of the acupuncture treatments were also abstracted from the medical charts. The chief complaints, reasons for requesting acupuncture, TCM diagnosis (pulse and tongue assessment), acupoint selection, number of needles per acupuncture treatment, and the number of repeat TCM visits requested by the patient were recorded. Clinical conditions (uremia) and administration of medications (corticosteroids or low molecular weight heparin (LMWH)) that could increase the risk of bleeding with an acupuncture treatment were also collected.

Acute side effects were collected and charted by the licensed acupuncturist at the time of treatment. Acute side effects were defined as a side effect that occurred during or immediately after removal of needle. These included hematoma, pain, nausea, fainting, dizziness, vomiting, headache, anxiety, and localized skin irritation.

Results

The records of all 32 patients who received treatment with acupuncture during the period from July 2006 to June 2007 were reviewed. The demographics are presented in Table 1. The median age of participants was 17 years (range 2–22 years). There were equal numbers of males and females, and the ethnic/racial distribution was comparable to our urban patient population. Cancer diagnoses included leukemia/lymphoma (eight), solid tumors (13), and brain tumors (five). Six patients were receiving a stem cell transplant for treatment of a malignant or non-malignant diagnosis. The majority (21) was receiving active anti-cancer treatment, six had completed stem cell transplantation, and five patients were in the surveillance phase after completion of therapy.
Table 1

Demographics of the patient population receiving acupuncture treatments

Age

 Mean Age (years)

15.7

 Median (years)

17 (2–22)

Gender

 Male

16

 Female

16

Race

 

 Caucasian

13

 Black, non-Hispanic

3

 Hispanic

10

 Asian

4

 Other

2

Diagnosis

 Brain tumor

5

 Solid tumor

13

 Leukemia/lymphoma

8

 Stem cell transplant

6

All acupuncture treatments were administered by two acupuncturists. The total number of acupuncture sessions administered was 237. Of these, 151 (64%) of sessions were administered in the outpatient setting and 86 (36%) sessions were in the inpatient setting. Patients requested treatment with acupuncture for symptom management; 93 (39%) of the sessions treated multiple symptoms. Gastrointestinal symptoms including nausea/vomiting, constipation, diarrhea, or low appetite were the most common reason for the acupuncture request (24% of the total number of side effects treated). Neurologic symptoms (dizziness, leg weakness, brain trauma, depression, anxiety/stress, or seizure prevention) were associated with 22% of acupuncture sessions, whereas pain management accounted for 16% of acupuncture session requests. Less frequently, acupuncture was requested for symptoms relating to constitutional symptoms (night sweats, fever, insomnia, fatigue; 14%), pulmonary (13%), lymphatic (5%), or other (6%) therapy-related side effects.

Patients were categorized into four groups according to their platelet count at the time of the acupuncture session; less than or equal to 20,000/μL (severe thrombocytopenia), 21,000–50,000/μL (moderate thrombocytopenia), 51,000–100,000/μL (mild thrombocytopenia), and greater than 100,000/μL (normal; Table 2). Of the sessions, 20% were administered to patients with severe thrombocytopenia, 8% with moderate thrombocytopenia, 19% with mild thrombocytopenia, and 53% with normal platelet counts.
Table 2

Distribution of acupuncture treatments during severe, moderate, and mild and no thrombocytopenia

Thrombocytopenia

Acupuncture treatments (N = 237)

Plateletsa (µL)

No. of needlesa

20 µL and below (severe)

48

7 (1–17)

10 (2–17)

21–50 µL (moderate)

18

35.5 (24–49)

11 (3–18)

51–100 µL (mild)

46

74.5 (52–99)

9 (2–19)

Greater than 100 µL

125

202 (101–534)

10 (1–28)

aMedian values and ranges per session are reported

The median number of sessions of acupuncture per patient was 3 (1–48). The median number (range) of needles used per treatment in patients with severe, moderate, mild, and normal were 10 (2–17), 11 (3–18), 9 (2–19), and 10 (1–28), respectively (Table 2). Of the 237 sessions, 49 (21%) sessions were associated with LMWH use and 45 (19%) of the sessions were associated with the use of corticosteroids on the same day of treatment as acupuncture. No sessions were administered in patients with a blood urea nitrogen value associated with platelet dysfunction (greater than 50 mg/dl).

No acute side effects were reported during any of the acupuncture sessions. Following one session, a small hematoma was reported in one patient by the nurse practitioner during the week following acupuncture treatment; however, the location of the hematoma was not at a site that received treatment with an acupuncture needle.

Discussion

We present preliminary evidence suggesting that acupuncture can be safely administered to children and adolescents undergoing cancer therapy, without an increase in the rate of bleeding or adverse events, even in the 28% of patients who received acupuncture with platelet counts below the reported guideline lower limit of 50,000/µL.

The safety of acupuncture in patients not at especially high risk for bleeding complications has been evaluated in several previously published studies [9, 10, 11] In a prospective survey that included 31,882 acupuncture sessions, bleeding or hematoma formation were reported to be the most common side effect (310 per 10,000 acupuncture sessions); however, after adjusting for potential reporting errors, this decreased to 190 per 10,000 [10]. Yamashita et al. suggested that bleeding maybe associated with mode of needle manipulation [11]. This group reported that the incidence of bleeding was 0.64% and 3.37% for manual and electroacupuncture stimulation, respectively. A review of clinical trials investigating acupuncture reported that hematomas occurred in 1.04% of treatment sessions [12]. The incidence of bleeding and hematoma formation has not been reported in any of the pediatric trials of acupuncture [12].

The low incidence of hematoma formation and bleeding observed in this retrospective case series may be related to the experience of our practitioners, as both were licensed with more than 5 years of experience in the administration of acupuncture to both children and adults. Japanese J-type Seirin needles were used for all acupuncture treatments; these have a silicone coating and a slightly blunt tip compared to most acupuncture needles, which may be associated with decreased risk for bleeding in the setting of thrombocytopenia. Additionally, needle insertion did not exceed 0.5-cun depth, and mild manual stimulation was applied to obtain de qi sensation. Aggressive forms of needle manipulation including trigger-point fasciculation were not used by our practitioners.

This study was limited by being a retrospective evaluation of adverse effects of acupuncture. Minor bruising or pain occurring more than 24 h after treatment with acupuncture may have remained unreported, particularly in children who were treated as outpatients and did not return to the medical center within the week. Prospective studies with standardized questionnaires and data collection protocols will minimize this variability.

In summary, this review provides preliminary evidence that acupuncture, as administered as part of this study, is safe in children and adolescents with cancer receiving treatment at an academic cancer center with an established acupuncture program. It is unknown if these preliminary results can be attributed to the use of acupuncture with other types of acupuncture needles, techniques, or depth. Our study also suggests that acupuncture may be safe even in the setting of platelet counts below 50,000/μL. Large prospective studies are now needed to ensure accurate and thorough documentation of acute and delayed side effects of acupuncture therapy, thereby allowing the development of evidence-based guidelines for administration of acupuncture among patients with cancer.

Notes

Acknowledgments

This research study was supported in part by the Tamarind Foundation and Origins Natural Resources. We would like to acknowledge Alexa Weitzman for her assistance with data collection and management.

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Copyright information

© Springer-Verlag 2010

Authors and Affiliations

  • Elena J. Ladas
    • 1
  • Diane Rooney
    • 1
  • Katherine Taromina
    • 1
  • Deborah H. Ndao
    • 1
  • Kara M. Kelly
    • 1
    • 2
  1. 1.Division of Pediatric Oncology, Department of PediatricsColumbia University Medical CenterNew YorkUSA
  2. 2.Division of Pediatric OncologyColumbia University Medical CenterNew YorkUSA

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