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Advances in the early detection of cancer and innovative treatments have propelled the number of cancer survivors on an upward trend over the last several decades.¹ In 2018, approximately 43.8 million cancer survivors were recorded globally within the previous five years.² In the US alone, as of January 2022, it is estimated that there were 18.1 million cancer survivors, representing approximately 5.4% of the population.³ Within this population, 69% of survivors had lived 5+ years since their diagnosis, 47% of survivors had lived 10+ years since their diagnosis, and 18% of survivors had lived 20+ years since their diagnosis.³ In the US, the number of cancer survivors is projected to increase by 24.4% to 22.5 million by 2032.³

This growing population of cancer survivors presents unique challenges for the clinician, as many patients experience long-term sequelae of cancer treatment, including, but not limited to, pain, stress, and insomnia.¹ A meta-analysis of surveys shows that the use of mind-body therapies by cancer survivors has been increasing over recent decades;⁴ these therapies may help patients manage symptoms and may also optimize health and enhance quality of life.^1,4-5 What does the medical literature suggest regarding two distinct modalities, acupuncture and meditation, for the amelioration of pain, stress, and insomnia as well as improved quality of life in cancer survivors?

Acupuncture & Chronic Pain

Cancer-related pain can be difficult to manage and can continue to occur after completion of cancer treatment.⁵ Acupuncture was recommended by the American Society of Clinical Oncology in practice guidelines for chronic pain in adult cancer survivors in 2018, based upon three systematic reviews, two with meta-analysis. More recent randomized controlled trials also demonstrate favorable benefits for acupuncture in reducing chronic pain related to cancer treatments like chemotherapy, hormonal therapy, radiotherapy, and surgery.⁵

A randomized clinical trial, identified in a Cochrane systematic review, studied 590 cancer patients with chronic neuropathic pain (radiation-induced proctitis and cystitis) who were treated with auricular acupuncture implants in test subjects; noninvasive seeds were used in the placebo group.^5,6 Study participants received acupuncture implants once a month for two months and then were assessed with pain measurement scales. At the end of the second month, the participants treated with acupuncture implants showed a significant decrease in pain intensity by 36% from baseline; there was almost no change in the placebo group. Participants in the acupuncture arm also demonstrated statistically significant shorter durations of pain symptoms as compared with the usual care arm.^5,6

Results from a large randomized clinical trial of 360 cancer survivor participants in 2021 suggest that two types of acupuncture may help reduce chronic pain in cancer survivors: electroacupuncture and auricular acupuncture.⁷ Study participants (70% female) had a prior cancer diagnosis but no current evidence of cancer and had reported musculoskeletal pain related to cancer for at least three months. For the 12-week study period, they were randomly assigned to one of two types of acupuncture or usual care for pain, which included pain medications, physical therapy, and steroids. Treatment involved 10 weekly sessions, and participants were then followed for an additional 16 weeks.⁷

In participants, electroacupuncture reduced pain severity by 1.9 points (97.5% CI, 1.4-2.4 points; P<0.001) on a pain intensity tool called the Brief Pain Inventory, and auricular acupuncture reduced the pain severity by 1.6 points (97.5% CI, 1.0-2.1 points; P<0.001), which represents a greater reduction than seen with the standard of care.⁷ Notably, in both acupuncture groups, the reduction in average pain severity persisted until week 24. Participants also reported improvements in physical function and quality of life, as well as reductions in analgesic use during the study period. It’s important to point out that a placebo group was not included in this trial, making it difficult to rule out the possibility that the pain improvements reported by those who received acupuncture were the result of a placebo effect.⁷

Meditation for Stress Reduction & Insomnia

A cancer diagnosis followed by treatment can be a significant source of stress for many individuals and often leads to sleep disturbances, depression, and anxiety.⁸ Studies suggest that mindfulness-based stress reduction (MBSR) has become a common intervention for cancer survivors.⁸ MBSR is an eight-week, group-based program developed by Professor Jon Kabat-Zinn at the University of Massachusetts Medical Center. This program consists of mindfulness meditation and yoga for improving the mindfulness of participants.

A 2017 systematic review of 13 studies conducted primarily in the US in Caucasian females found that in cancer patients, MBSR provided significant positive effects in psychological (perceived stress scale, mood states, depression scale, coping self-efficacy, etc.) or physiological outcome measures (cortisol sampling, heart rate, respiratory rate, and blood pressure) related to stress.⁸ The most common outcome measure was a mood disturbance score, which was utilized in four studies and was measured mainly by Profile of Mood States. It’s important to note that not all studies in this systematic review used a randomized controlled design; most had small sample sizes and had different outcome measures.⁸

Cancer survivors also commonly suffer from sleep disturbance, which can affect quality of life and cancer-related morbidity.⁹ In fact, among post-treatment cancer-related symptoms, sleep disturbance is the most common complaint among survivors.⁹ A nationwide survey in the US reported that 51% of long-term cancer survivors experience sleep disturbance, specifically insomnia, 20% experience poor sleep quality, and 28% use sleep medication.¹⁰ Cognitive behavioral therapy for insomnia (CBT-I) is considered best practice for sleep disturbance in adults with cancer and cancer survivors; however, this therapy may have limitations related to accessibility.¹⁰ This is just one reason clinicians and researchers have begun looking at the effectiveness of MBSR for stress reduction and insomnia.

A 2021 systematic review and meta-analysis of 10 studies suggests that MBSR may help cancer survivors improve sleep quality.⁹ The participants learned formal mindfulness meditation methods such as body scan, gentle Hatha yoga, sitting meditation, and walking meditation and informal meditation practices such as awareness of pleasant and unpleasant events, awareness of breathing, and deliberate awareness of routine activities and events (i.e., mindful eating). Daily home practice was recommended for a minimum of 45 minutes of formal meditation and 5-15 minutes of informal meditation daily.⁹

As a primary outcome, nine studies reported sleep quality measured using sleep-specific questionnaires.⁹ Results suggest that in adult cancer survivors aged 18 years or older (mean age 54-58 years, primarily female), an eight-week MBSR program improved sleep quality compared to usual care (CBT-I, psychoeducation, free-choice stress management techniques). The effect was small (SMD -0.29, 95% CI -0.55 to -0.04) but not insignificant; according to a guideline for interpreting the magnitude of the SMD, an SMD of 0.2 indicates a small difference, 0.5 indicates a medium difference, and 0.8 indicates a large difference. To confirm the efficacy and effectiveness of the MBSR on reducing sleep disturbance in cancer survivors, a more rigorous clinical trial measuring objective sleep parameters, using polysomnography and actigraphy, should be conducted.⁹

Functional Medicine Considerations

Functional medicine can play a much-needed role in cancer survivor care, emphasizing lifestyle-based therapies that address the pain and stress of this experience. Foundational functional medicine interventions for mind-body balance such as acupuncture and meditation are among the low-risk approaches that may help in survivorship quality of life. These low-risk therapeutic approaches may optimize a patient’s overall health and wellness during their survivorship journey.

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References

1. Viscuse PV, Price K, Millstine D, Bhagra A, Bauer B, Ruddy KJ. Integrative medicine in cancer survivors. Curr Opin Oncol. 2017;29(4):235-242. doi:1097/cco.0000000000000376
2. American Cancer Society. The Cancer Atlas: Cancer Survivorship. Published 2019. Accessed February 13, 2023. https://canceratlas.cancer.org/the-burden/cancer-survivorship/
3. National Cancer Institute: Division of Cancer Control & Population Sciences. Office of Cancer Survivorship: statistics and graphs. Updated November 17, 2022. Accessed February 13, 2023. https://cancercontrol.cancer.gov/ocs/statistics
4. Witt CM, Balneaves LG, Cardoso MJ, et al. A comprehensive definition for integrative oncology. J Natl Cancer Inst Monogr. 2017;2017(52). doi:1093/jncimonographs/lgx012
5. Lu W, Rosenthal DS. Oncology acupuncture for chronic pain in cancer survivors: a reflection on the American Society of Clinical Oncology Chronic Pain Guideline. Hematol Oncol Clin North Am. 2018;32(3):519-533. doi:1016/j.hoc.2018.01.009
6. Paley CA, Johnson MI, Tashani OA, Bagnall A-M. Acupuncture for cancer pain in adults. Cochrane Database Syst Rev. 2015;2015(10):CD007753. doi:1002/14651858.CD007753.pub3
7. Mao JJ, Liou KT, Baser RE, et al. Effectiveness of electroacupuncture or auricular acupuncture vs usual care for chronic musculoskeletal pain among cancer survivors: the PEACE Randomized Clinical Trial. JAMA Oncol. 2021;7(5):720-727. doi:1001/jamaoncol.2021.0310
8. Rush SE, Sharma M. Mindfulness-based stress reduction as a stress management intervention for cancer care: a systematic review. J Evid Based Complementary Altern Med. 2017;22(2):348-360. doi:1177/2156587216661467
9. Suh HW, Jeong HY, Hong S, et al. The mindfulness-based stress reduction program for improving sleep quality in cancer survivors: a systematic review and meta-analysis. Complement Ther Med. 2021;57:102667. doi:1016/j.ctim.2021.102667
10.  Strollo SE, Fallon EA, Gapstur SM, Smith TG. Cancer-related problems, sleep quality, and sleep disturbance among long-term cancer survivors at 9-years post diagnosis. Sleep Med. 2020;65:177-185. doi:10.1016/j.sleep.2019.10.008