Exploring acupuncture in integrative oncology
Clinical guidelines recently published by American Society of Oncology set out the current recommendations for using acupuncture in cancer pain and anxiety. European countries are likely to follow suit in producing clinical guidelines for integrating complementary approaches with conventional medical treatments.
We asked four different people for their views and experiences of integrative oncology – a patient, a physician running a private integrated practice, an NHS pain consultant and a BAcC member working in the NHS.
But first, let’s turn to one of our interviewees, Dr Nina Fuller-Shavel, for a definition:
Integrative oncology is a person-centred branch of healthcare that aims to rationally synthesise the best of conventional medicine with evidence-informed nutrition and lifestyle medicine, psycho-emotional wellbeing, and complementary medicine to support better quality of life and whole person resilience, minimise the side effects of treatment and improve clinical outcomes.
The patient
I was diagnosed with early stage breast cancer in August 2022, I subsequently had four operations including a mastectomy, three months of weekly chemotherapy, six months of a biological drug treatment and am now on a long term drug Tamoxifen.
Initially there was no mention of complementary therapies, I was provided with leaflets on services offered by Macmillan but my meetings with surgeons and oncologists revolved around the medical interventions and my prognosis.
At the start of the journey I had hoped that I would be able to undertake one small operation and recover quickly. What I hadn’t prepared for was the marathon ahead. Every time I had an operation I was keen to get back to work but the reality over time was that my recovery was taking longer – and yet I wasn’t provided with any guidance on how to manage the cumulative impact. I was progressively more tired, less resilient and finding it harder to physically ‘bounce back’ and once I started chemo the fatigue was quite significant.
During chemo I experienced a range of side effects including digestive issues, joint ache, neuropathy, mouth ulcers and nosebleeds. I also had neck problems, exacerbated because I chose to wear a cold cap during chemo to prevent hair loss – it was however heavy and tight on my head which impacted on my neck.
Not long after starting chemo several friends suggested acupuncture. I found a fantastic acupuncturist – he took time to understand my medical history, a bit about me and my family (he started treating my partner as well) and asked about the emotional impact of the experience within his initial and regular conversations with me.
I realised early in my cancer treatment that there would be no single person having an overview of my treatment plan – I would meet multiple surgeons, oncologists, nurses, and at times they provided differing options. The impact of a lack of a consistent professional with an overview of my situation cannot be underestimated. Whilst I had a named nurse on several occasions she made judgements and statements that were not helpful or were inaccurate and I lost trust in her fairly early on.
Meeting my acupuncturist every fortnight during chemo meant that I had a consistent person I could talk to about the impact of the whole experience on my body. He spent time addressing differing symptoms, and I would notice the impact immediately from the acupuncture treatment.
Straight after an acupuncture session I would feel lighter, less tense and more positive. My digestive system would also function better and the neuropathy symptoms were reduced. I felt a greater energy within my body, and I felt as though the treatment was an act of care in the middle of a brutal treatment plan.
During chemo I was also offered a free acupuncture session at Macmillan. That was also helpful, however you can only book one appointment at a time and it would take six weeks to get an appointment. This meant that really the sessions were tasters into the benefits of acupuncture but couldn’t be relied on to help with the cancer treatment. I felt fortunate to be able to pay for acupuncture treatments – often the financial impact of cancer means you have limited means to access complementary therapies on a regular basis.
Due to the side effects of Tamoxifen including frequent hot flushes, fatigue, joint pain, nausea I have now been referred by my oncologist for medical acupuncture which is organised via Macmillan. I now see acupuncture as a ’tool’ that I need to apply as part of my recovery and would recommend it to anyone undertaking chemotherapy or other cancer treatments.
The Medical Director & Head of Integrative Cancer Care: Dr Nina Fuller-Shavel
I am an integrative medicine physician, scientist, and educator with over a decade’s experience in integrative healthcare. In addition to my clinical role at the [privately run] Synthesis Clinic, I co-chair the BSIO (British Society for Integrative Oncology) Education Committee.
Most recently, I was one of the co-authors of the SIO-ASCO guideline on integrative oncology care of symptoms of anxiety and depression in adults with cancer. I am also the co-founder and director of Oncio CIC, an innovative non-profit aimed at providing high quality app-based resources for people with cancer and healthcare professionals.
Why is an integrative approach needed?
The UK is struggling under the burden of cancer care with one in two of us estimated to receive a cancer diagnosis at some point in our lifetime, and our cancer outcomes are also unfortunately some of the worst in Europe across multiple cancer types. We have no formal cancer survivorship programmes, leaving a significant symptom burden in the community that primary care may not be well-equipped to manage and an unmitigated risk for important post-treatment complications, for example increased cardiovascular disease risk.
Our care for people with advanced disease, while good at ‘firefighting’, is often inadequate in providing patients with a good quality of life. If we would like to support better clinical outcomes and quality of life for people impacted by cancer, an integrative approach delivered by a multidisciplinary team is essential. Available evidence shows that integrative oncology care can improve symptom control and quality of life and may impact survival.
What do you think the role of acupuncture is in this area?
We need to offer more options for our patients struggling with the oncology polypharmacy and symptoms that do not have adequate medical management options, and acupuncture is a very important modality in this setting.
Acupuncture has been recommended in guidelines for chemotherapy-induced nausea and vomiting, aromatase inhibitor-induced arthralgia (AIA), general cancer-related and musculoskeletal pain in people affected by cancer, and anxiety symptoms in people with breast cancer post-treatment, with a low strength of recommendation for surgical pain and chemotherapy-induced peripheral neuropathy (CIPN).
Beyond the current guidelines and impact on overall quality of life, there is building evidence for the benefit of acupuncture in cancer-related menopausal symptoms, insomnia, fatigue, and other symptoms, and relieving side effects of medications, for example opiate-induced constipation. With so many benefits to offer, acupuncture is an important modality to incorporate within the overall integrative cancer care plan.
How would you like to see acupuncture develop within oncology in the next five years?
I would like to see acupuncture offered at every cancer care centre across the charity, private and NHS sectors in the UK within the next five years, with robust evaluation of patient-reported outcomes. The weight of evidence on how acupuncture can support patients impacted by cancer throughout the care continuum is already substantial – as highlighted by multiple guidelines – and continues to grow with several pivotal trial results awaited in the next few years.
Within the five-year timeframe it would be important to put appropriate evidence into practice consistently and to focus on implementation and real-world evaluation. Eventually I would like to see acupuncture being embedded as a part of the full integrative cancer care package delivered by a multidisciplinary team, rather than being used simply as an adjunct to conventional medicine.
The NHS chronic pain consultant: Dr Deepak Ravindran
I am a consultant working full time in a secondary care pain service in the NHS primarily focusing on chronic pain management. I get referrals from oncology and palliative care colleagues looking for advice and suitability around interventions for their cancer patients and those at the end of life for palliative or potentially medication sparing interventions.
In cancer survivors especially I have been struck by the fact that their referrals to the outpatient pain clinic are mostly for an alternative to strong opioids. There has never been any significant discussion around other integrative/complementary or non-pharmacological approaches at any point of time. Given the emerging evidence based around the use of integrative approaches, I have often felt that there is tremendous opportunity to improve the care of cancer survivors.
Those in the palliative care setting often have access to more integrative approaches either because of my palliative care colleagues looking for adjuvants to medication or the presence of various charities in the Hospice who raise awareness and promote the use of other integrative techniques.
Why is an integrative approach needed?
An integrative approach in my mind should be the necessary standard of care rather than this artificial division between conventional medicine and complementary/alternative therapies.
Within oncology – and especially in cancer survivors – evidence that is possibly acceptable for funding at a population level does not necessarily lead to successful outcomes in an individual. Drugs that may offer some benefit at a population level may not be tolerated or give benefit in selected patients. In such circumstances it is important to utilise a variety of other non-pharmacological approaches, and sometimes a judicious and well planned combination of integrated approaches can give greater benefit than just the drugs alone.
What do you think the role of acupuncture is in this area?
I routinely recommend acupuncture for those cancer survivors that are referred to my chronic pain clinic for further advice.
Within oncology, I’m aware of the studies that provide benefit in terms of aromatase inhibitor induced joint pains. There is also some evidence that is emerging regarding its role in symptom management and improving quality of life in patients with chemotherapy or post-surgery related pain and other symptoms. No doubt further research will be required but this is a safe integrative approach that can be combined with other techniques with minimal interactions.
With the right training and skills, I believe acupuncture can be safely deployed as a part of an integrative approach within oncology. The SIO have produced guidelines suggesting where acupuncture could play a larger role and therefore I think it is a modality that should be supported and funded.
How would you like to see acupuncture develop within oncology in the next five years?
Clinically, I know that specialist cancer centres do often have links with charities/services that provide acupuncture for their patients. I would like to see various integrative approaches including mind-body practices and acupuncture become routinely available to all NHS centres that offer cancer care. As a consultant working in a secondary care pain service, I can confirm that we are seeing increasing numbers of cancer survivors being referred to us with cancer or chemotherapy related widespread aches and pains. I would be of the opinion that acupuncture and other integrative approaches should also be made available to specialists in pain services across the NHS as well.
The NHS acupuncturist & BAcC member: Mandy Brass
I am the lead acupuncturist at Dimbleby Cancer Care, an integrative department within the Cancer Centre of Guy’s NHS Foundation Trust in London, providing complementary therapies and psychological support. We provide three acupuncture clinics: a seated group clinic, a one-to-one clinic and a NADA ear acupuncture hot flushes clinic.
All patients are initially referred by a healthcare professional within the hospital; this is most commonly their cancer nurse specialist, but can be from any department, including oncologists, physiotherapists or psychologists. Equally, I am able to refer on to other healthcare professionals where necessary. All patients receive treatment once a week for six weeks – but I am mostly not able to extend this due to the sheer weight of demand for our services.
Tell us how you as an acupuncturist have carved out your position in this field? Any advice for others following this path?
I have been an acupuncturist for twenty-three years but only began working in the palliative care world twelve years ago. I started as a volunteer acupuncturist in a hospice, which is where I first gained experience of group work with complex patients with life-limiting conditions. Seven years ago I took on a position to set up a group acupuncture clinic in Dimbleby Cancer Care and the role has evolved from a one-year renewable contract to a permanent position within the wider complementary therapy team.
My advice for others is conflicted. On the one hand, volunteering is, without a doubt, the way I was able to move into this field. I have talented volunteers working in the service because currently, there is no funding for additional acupuncture roles. I am frustrated that other healthcare professionals are paid whilst gaining valuable experience, but as acupuncturists, we are unable to get this public sector experience without volunteering. However, NHS resources are unlikely to change in the near future, so volunteering will continue to be the primary way to gain experience.
Why is an integrative approach needed?
Patients are more likely to complete treatment, with fewer side effects and better quality of life.
From the patients’ perspective – many of whom have experienced lengthy, scary or life-changing treatments – they are often interested in accessing acupuncture or other complementary therapies, but are nervous about sourcing a practitioner who may not understand their cancer journey or any potential contraindications. They would like to know which therapy is best suited for them and their individual set of symptoms. An integrated setting provides the patient with confidence and trust that their treatment will be safe, effective and individualised in the context of their cancer journey.
Acupuncture can additionally aid recovery beyond alleviating symptoms. Patients have gone through a process where their bodies have required life-saving interventions accompanied by potentially challenging side effects. Acupuncture allows patients to see their symptoms as an imbalance and to re-engage with their own healing. It restores their faith in their body’s ability to work for them rather than against them. It is, after all, their body that is responding to the needles, and improving symptoms. This process can be a catalyst for change and for restoring positivity, in mind, body and spirit.
Case example
Jane – not the patient’s real name – was recently diagnosed with ovarian cancer and was terrified of starting chemotherapy, missing her first appointment. She was fast-tracked to the psycho-oncology team, who referred her to acupuncture. I calmed her mind, cleared heart-fire, nourished her kidneys and reassured her we would be able to continue supporting her during her first few cycles of chemotherapy. She attended her next chemotherapy appointment and with our combined support, completed all further treatment.
How would you like to see acupuncture develop within oncology in the next five years?
I would like to see every cancer centre in the country have an integrative oncology department including acupuncture and complementary therapies. Where patients access our services, I think they reduce the burden on other healthcare professionals, reduce medication usage and ultimately save the NHS money. Convincing those providing the funding is the challenge!
If you have views on and/or experience in the field of integrative oncology, you can share them in Acu.
