Battlefield acupuncture for chronic musculoskeletal pain in cancer survivors: a novel care delivery model for oncology acupuncture.

Introduction: Battlefield Acupuncture (BFA), a standardized auricular acupuncture protocol, is widely used for pain in the military but is not well-studied in oncology. This study examined cancer survivors who received BFA for pain. Methods: This is a secondary analysis of a randomized trial that compared the effectiveness of BFA and electroacupuncture vs. usual care for chronic musculoskeletal pain in cancer survivors. This study focused on participants randomized to BFA. Participants received 10 weekly treatments. Needles were placed until one of these stop conditions were satisfied: ten needles were administered; pain severity decreased to ≤1 out of 10; patient declined further needling, or vasovagal reaction was observed. Pain severity was assessed using Brief Pain Inventory. Responders were those with ≥30% pain severity reduction. We examined pain location, BFA stop reason, and pain reduction of participants during the first session. We also examined which factors predicted responder status after the first session (week 1) or the full treatment (week 12). Results: Among 143 randomized to BFA, most common pain locations were lower back (30.8%) and knee/leg (18.2%). Of 138 who initiated treatment, 41 (30.0%) received ten needles; 81 (59.1%) achieved pain ≤1; 14 (10.2%) declined further needling; and 1 (0.7%) had vasovagal reaction. BFA reduced pain severity by 2.9 points (95% CI 2.6 to 3.2) after the first session (P < 0.001). After adjusting for baseline pain severity, responders at week 1 were 2.5 times more likely to be responders at week 12, compared to those who were non-responders at week 1 (AOR 2.5, 95% CI 1.02 to 6.11, P = 0.04). Among those who achieved pain ≤1, 74% were responders at week 12, a higher proportion compared to the proportion of responders among those who received ten needles (39.5%), those who declined further needling (50%), and those with vasovagal reaction (0.0%) (P = 0.001). Those with pain in proximal joints had a higher proportion of responders at week 12, compared to those with pain in distal joints (64.2% vs. 20%, P = 0.008). Conclusion: Specific factors may predict the likelihood of achieving meaningful pain reduction from BFA. Understanding these predictors could inform precision pain management and acupuncture delivery models.

Acupuncture vs Massage for Pain in Patients Living With Advanced Cancer: The IMPACT Randomized Clinical Trial.

Importance: Pain is challenging for patients with advanced cancer. While recent guidelines recommend acupuncture and massage for cancer pain, their comparative effectiveness is unknown. Objective: To compare the effects of acupuncture and massage on musculoskeletal pain among patients with advanced cancer. Design, Setting, and Participants: A multicenter pragmatic randomized clinical trial was conducted at US cancer care centers consisting of a northeastern comprehensive cancer center and a southeastern cancer institute from September 19, 2019, through February 23, 2022. The principal investigator and study statisticians were blinded to treatment assignments. The duration of follow-up was 26 weeks. Intention-to-treat analyses were performed (linear mixed models). Participants included patients with advanced cancer with moderate to severe pain and clinician-estimated life expectancy of 6 months or more. Patient recruitment strategy was multipronged (eg, patient database queries, mailings, referrals, community outreach). Eligible patients had English or Spanish as their first language, were older than 18 years, and had a Karnofsky score greater than or equal to 60 (range, 0-100; higher scores indicating less functional impairment). Interventions: Weekly acupuncture or massage for 10 weeks with monthly booster sessions up to 26 weeks. Main Outcomes and Measures: The primary end point was the change in worst pain intensity score from baseline to 26 weeks. The secondary outcomes included fatigue, insomnia, and quality of life. The Brief Pain Inventory (range, 0-10; higher numbers indicate worse pain intensity or interference) was used to measure the primary outcome. The secondary outcomes included fatigue, insomnia, and quality of life. Results: A total of 298 participants were enrolled (mean [SD] age, 58.7 [14.1] years, 200 [67.1%] were women, 33 [11.1%] Black, 220 [74.1%] White, 46 [15.4%] Hispanic, and 78.5% with solid tumors). The mean (SD) baseline worst pain score was 6.9 (1.5). During 26 weeks, acupuncture reduced the worst pain score, with a mean change of -2.53 (95% CI, -2.92 to -2.15) points, and massage reduced the Brief Pain Inventory worst pain score, with a mean change of -3.01 (95% CI, -3.38 to -2.63) points; the between-group difference was not significant (-0.48; 95% CI, -0.98 to 0.03; P = .07). Both treatments also improved fatigue, insomnia, and quality of life without significant between-group differences. Adverse events were mild and included bruising (6.5% of patients receiving acupuncture) and transient soreness (15.1% patients receiving massage). Conclusions and Relevance: In this randomized clinical trial among patients with advanced cancer, both acupuncture and massage were associated with pain reduction and improved fatigue, insomnia, and quality of life over 26 weeks; however, there was no significant different between the treatments. More research is needed to evaluate how best to integrate these approaches into pain treatment to optimize symptom management for the growing population of people living with advanced cancer. Trial Registration: ClinicalTrials.gov Identifier: NCT04095234.

Comparing sleep measures in cancer survivors: Self-reported sleep diary versus objective wearable sleep tracker.

Purpose: Cancer survivors are increasingly using wearable fitness trackers, but it's unclear if they match traditional self-reported sleep diaries. We aimed to compare sleep data from Fitbit and the Consensus Sleep Diary (CSD) in this group. Methods: We analyzed data from two randomized clinical trials, using both CSD and Fitbit to collect sleep outcomes: total sleep time (TST), wake time after sleep onset (WASO), number of awakenings (NWAK), time in bed (TIB) and sleep efficiency (SE). Insomnia severity was measured by Insomnia Severity Index (ISI). We used the Wilcoxon Singed Ranks Test, Spearman's rank correlation coefficients, and the Mann-Whitney Test to compare sleep outcomes and assess their ability to distinguish insomnia severity levels between CSD and Fitbit data. Results: Among 62 participants, compared to CSD, Fitbit recorded longer TST by an average of 14.6 (SD = 84.9) minutes, longer WASO by an average of 28.7 (SD = 40.5) minutes, more NWAK by an average of 16.7 (SD = 6.6) times per night, and higher SE by an average of 7.1% (SD = 14.4); but shorter TIB by an average of 24.4 (SD = 71.5) minutes. All the differences were statistically significant (all p < 0.05), except for TST (p = 0.38). Moderate correlations were found for TST (r = 0.41, p = 0.001) and TIB (r = 0.44, p < 0.001). Compared to no/mild insomnia group, participants with clinical insomnia reported more NWAK (p = 0.009) and lower SE (p = 0.029) as measured by CSD, but Fitbit outcomes didn't. Conclusions: TST was the only similar outcome between Fitbit and CSD. Our study highlights the advantages, disadvantages, and clinical utilization of sleep trackers in oncology.

SIO-ASCO guideline on integrative medicine for cancer pain management: implications for racial and ethnic pain disparities.

Racial and ethnic disparities in pain management pose major challenges to equitable cancer care delivery. These disparities are driven by complex interactions between patient-, provider-, and system-related factors that resist reductionistic solutions and require innovative, holistic approaches. On September 19, 2022, the Society for Integrative Oncology and the American Society of Clinical Oncology published a joint guideline to provide evidence-based recommendations on integrative medicine for cancer pain management. Integrative medicine, which combines conventional treatments with complementary modalities from cultures and traditions around the world, are uniquely equipped to resonate with diverse cancer populations and fill existing gaps in pain management. Although some complementary modalities, such as music therapy and yoga, lack sufficient evidence to make a specific recommendation, other modalities, such as acupuncture, massage, and hypnosis, demonstrated an intermediate level of evidence, resulting in moderate strength recommendations for their use in cancer pain management. However, several factors may hinder real-world implementation of the Society for Integrative Oncology and the American Society of Clinical Oncology guideline and must be addressed to ensure equitable pain management for all communities. These barriers include, but are not limited to, the lack of insurance coverage for many complementary therapies, the limited diversity and availability of complementary therapy providers, the negative social norms surrounding complementary therapies, the underrepresentation of racial and ethnic subgroups in the clinical research of complementary therapies, and the paucity of culturally attuned interventions tailored to diverse individuals. This commentary examines both the challenges and the opportunities for addressing racial and ethnic disparities in cancer pain management through integrative medicine.

Telehealth-Based Music Therapy Versus Cognitive Behavioral Therapy for Anxiety in Cancer Survivors: Rationale and Protocol for a Comparative Effectiveness Trial.

BACKGROUND: Cancer survivors represent one of the fastest growing populations in the United States. Unfortunately, nearly 1 in 3 survivors experience anxiety symptoms as a long-term consequence of cancer and its treatment. Characterized by restlessness, muscle tension, and worry, anxiety worsens the quality of life; impairs daily functioning; and is associated with poor sleep, depressed mood, and fatigue. Although pharmacological treatment options are available, polypharmacy has become a growing concern for cancer survivors. Music therapy (MT) and cognitive behavioral therapy (CBT) are evidence-based, nonpharmacological treatments that have demonstrated effectiveness in treating anxiety symptoms in cancer populations and can be adapted for remote delivery to increase access to mental health treatments. However, the comparative effectiveness of these 2 interventions delivered via telehealth is unknown. OBJECTIVE: The aims of the Music Therapy Versus Cognitive Behavioral Therapy for Cancer-related Anxiety (MELODY) study are to determine the comparative effectiveness of telehealth-based MT versus telehealth-based CBT for anxiety and comorbid symptoms in cancer survivors and to identify patient-level factors associated with greater anxiety symptom reduction for MT and CBT. METHODS: The MELODY study is a 2-arm, parallel-group randomized clinical trial that aims to compare the effectiveness of MT versus CBT for anxiety and comorbid symptoms. The trial will enroll 300 English- or Spanish-speaking survivors of any cancer type or stage who have experienced anxiety symptoms for at least 1 month. Participants will receive 7 weekly sessions of MT or CBT delivered remotely via Zoom (Zoom Video Communications, Inc) over 7 weeks. Validated instruments to assess anxiety (primary outcome), comorbid symptoms (fatigue, depression, insomnia, pain, and cognitive dysfunction), and health-related quality of life will be administered at baseline and at weeks 4, 8 (end of treatment), 16, and 26. Semistructured interviews will be conducted at week 8 with a subsample of 60 participants (30 per treatment arm) to understand individual experiences with the treatment sessions and their impact. RESULTS: The first study participant was enrolled in February 2022. As of January 2023, 151 participants have been enrolled. The trial is expected to be completed by September 2024. CONCLUSIONS: This study is the first and largest randomized clinical trial to compare the short- and long-term effectiveness of remotely delivered MT and CBT for anxiety in cancer survivors. Limitations include the lack of usual care or placebo control groups and the lack of formal diagnostic assessments for psychiatric disorders among trial participants. The study findings will help guide treatment decisions for 2 evidence-based, scalable, and accessible interventions to promote mental well-being during cancer survivorship. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/46281.

Effect of acupuncture versus usual care on sleep quality in cancer survivors with chronic pain: Secondary analysis of a randomized clinical trial.

BACKGROUND: Chronic pain negatively affects sleep; it is unclear whether pain relief from acupuncture contributes to sleep quality improvements in cancer survivors. This study aimed to evaluate the effect of acupuncture versus usual care on sleep quality among cancer survivors with comorbid sleep disturbance and chronic musculoskeletal pain. METHODS: Sleep outcome data from the Personalized Electroacupuncture Versus Auricular Acupuncture Comparative Effectiveness (PEACE) randomized clinical trial were analyzed. Electroacupuncture or auricular acupuncture was compared with usual care for sleep quality improvement over 10 weeks of treatment among cancer survivors with clinically significant sleep disturbance and chronic musculoskeletal pain at baseline. Sleep quality was measured with the Pittsburgh Sleep Quality Index (PSQI) global score. RESULTS: Among 268 participants (mean [standard deviation (SD)] age, 61.4 [12.6] years; 191 women [71.3%]; mean [SD] baseline PSQI global score, 10.3 [3.3] points), electroacupuncture and auricular acupuncture resulted in greater reductions in the PSQI global score from baseline to 10 weeks in comparison with usual care: 1.42 points (95% confidence interval [CI], 0.45-2.38; p = .004) and 1.59 points (95% CI, 0.62-2.55; p = .001), respectively. The improvement in sleep quality for the acupuncture groups was sustained for 24 weeks from randomization. Furthermore, a greater proportion of patients in the electroacupuncture and auricular acupuncture groups had clinically meaningful improvement in sleep quality compared to the usual care group (41.0% and 42.9% vs. 21.4%; p = .044). CONCLUSIONS: Among cancer survivors with comorbid sleep disturbance and chronic pain, electroacupuncture and auricular acupuncture produced a clinically relevant and persistent improvement in sleep quality. These findings suggest that acupuncture may be an evidence-based nonpharmacologic intervention to improve sleep health for cancer survivors with pain. PLAIN LANGUAGE SUMMARY: This study analyzed the sleep quality data from a published randomized clinical trial that evaluated the effect of electroacupuncture or auricular acupuncture versus usual care on pain relief among people who survived cancer. This analysis included a prespecified subgroup of 268 participants with co-occurring sleep disturbance and chronic musculoskeletal pain at baseline and found that patients who used acupuncture for pain relief demonstrated greater improvements in sleep quality compared with patients who received usual care. Sleep quality improvement by acupuncture was sustained after the treatment ended.

Addressing cancer-related fatigue through sleep: A secondary analysis of a randomized trial comparing acupuncture and cognitive behavioral therapy for insomnia.

Background: Fatigue is a troublesome symptom in cancer survivors that often results from disrupted sleep. We sought to assess whether two insomnia-focused non-pharmacological interventions are also effective for improving fatigue. Methods: We analyzed data from a randomized clinical trial comparing cognitive behavioral therapy for insomnia (CBT-I) versus acupuncture for insomnia among cancer survivors. Participants were 109 patients who reported insomnia and moderate or worse fatigue. Interventions were delivered over eight weeks. Fatigue was evaluated at baseline, week 8, and week 20 using the Multidimensional Fatigue Symptom Inventory-Short Form (MFSI-SF). We used both mediation analysis and t-tests to explore the extent to which fatigue reduction was attributable to insomnia response. Results: Compared to baseline, both CBT-I and acupuncture produced significant reductions in total MFSI-SF scores at week 8 (-17.1 points; 95% confidence interval [CI]: -21.1 to -13.1, and -13.2 points; 95% CI: -17.2 to -9.2, respectively, all p<0.001) and week 20 (-14.6 points; 95% CI: -18.6 to -10.6, and -14.2 points; 95% CI: -18.1 to -10.3. respectively, all p<0.001), with no significant between-group differences. MFSI-SF total scores at week 8 were significantly associated with sleep improvements in both CBT-I and acupuncture groups (p<0.001 and p=0.011, respectively). Insomnia responders demonstrated significantly greater improvements in mean MFSI-SF total scores compared with non-responders in the CBT-I group (p=0.016) but not in the acupuncture group. Conclusion: CBT-I and acupuncture produced similar, clinically meaningful, and durable fatigue reductions in cancer survivors with insomnia, primarily through improvements in sleep. Acupuncture may also reduce fatigue through additional pathways.

Music Therapy for Pain in Black and White Cancer Patients: A Retrospective Study.

CONTEXT: Racial pain disparities present challenges to cancer symptom management. Music therapy has demonstrated benefits for pain and is a promising treatment option for diverse populations due to music's multicultural presence. However, Black cancer patients are under-represented in music therapy trials. OBJECTIVES: This study compared pain severity, treatment approaches, and responses to music therapy between Black and white cancer patients. The findings will be used to generate hypotheses for future music therapy research to address racial disparities in pain management. METHODS: We conducted a retrospective program evaluation of Black and white patients who received music therapy at an NCI-Designated Comprehensive Cancer Center. We used the Edmonton Symptom Assessment Scale (ESAS) to assess pain. We abstracted opioid use, music therapy referral reasons, and treatment approaches from the electronic health record. RESULTS: Among 358 patients, 18% were Black, 42% reported moderate-to-severe pain, and 47% received opioids. Black patients reported higher baseline pain than white patients, but similar proportions of Black and white patients received opioids. Greater proportions of Black patients received music therapy referrals for pain (73% vs. 56%, P = 0.04) and engaged in active techniques (92% vs. 82%, P = 0.04). Black and white patients reported clinically meaningful pain reduction of similar magnitude after music therapy. Black patients discussed spirituality more commonly during music therapy, whereas white patients focused on family bonds. CONCLUSION: Black and white patients reported clinically meaningful pain reduction through varying music therapy approaches. Our findings may help inform cultural adaptations of music therapy to address racial pain disparities in oncology.

Comparison of Depressive Symptom Outcomes in Hospitalized Adult Cancer Patients Receiving Music Therapy or Massage Therapy.

CONTEXT: Depressive symptoms are prevalent and associated with greater healthcare utilization among hospitalized adults with cancer. Music therapy and massage therapy are available at many National Cancer Institute (NCI)-Designated Cancer Centers and recommended by the American Society of Clinical Oncology for depressive symptoms, but a paucity of studies have compared these two therapies. OBJECTIVES: We conducted a retrospective, multi-method program evaluation of single, first-time music therapy and massage therapy sessions delivered to hospitalized adults with cancer. METHODS: The study was conducted at an NCI-Designated Comprehensive Cancer Center between February 2018 and October 2019. We assessed depressive symptoms with the Edmonton Symptom Assessment Scale (ESAS) depression item. We also invited patients to provide free-text comments describing their treatment experience. RESULTS: Among 1764 patients (61.2% women, 72.7% white), 350 received music therapy and 1414 received massage therapy; music therapy was associated with a 0.4 point greater reduction (95% 0.3 to 0.6, P < 0.001) in the ESAS depression score relative to massage therapy. When analyses were restricted to the 452 (25.6%) patients with moderate-to-severe depressive symptoms (ESAS score ≥ 4), music therapy was associated with a 1.2 point greater reduction (95% CI 0.7 to 1.7, P < 0.001) relative to massage therapy, a clinically meaningful difference. In free-text comments, music therapy was described as energizing, uplifting, and evocative, whereas massage therapy was described as calming and relaxing. CONCLUSION: Among hospitalized adult cancer patients, both music therapy and massage therapy were associated with reduced depressive symptoms, but music therapy was associated with a greater reduction than massage therapy.

Acupuncture versus cognitive behavioral therapy for pain among cancer survivors with insomnia: an exploratory analysis of a randomized clinical trial.

Pain and insomnia often co-occur and impair the quality of life in cancer survivors. This study evaluated the effect of acupuncture versus cognitive behavioral therapy for insomnia (CBT-I) on pain severity among cancer survivors with comorbid pain and insomnia. Using data from the CHOICE trial that compared acupuncture versus CBT-I for insomnia among cancer survivors, we analyzed the effect of interventions on pain outcomes in 70 patients with moderate to severe baseline pain. Interventions were delivered over eight weeks. We assessed average pain severity (primary outcome) and pain interference at baseline, week 8, and week 20. We further defined insomnia and pain responders as patients who achieved clinically meaningful improvement in insomnia and pain outcomes, respectively, at week 8. We found that compared with baseline, the between-group difference (-1.0, 95% CI -1.8 to -0.2) was statistically significant favoring acupuncture for reduced pain severity at week 8 (-1.4, 95% CI -2.0 to -0.8) relative to CBT-I (-0.4, 95% CI-1.0 to 0.2). Responder analysis showed that 1) with acupuncture, insomnia responders reported significantly greater pain reduction from baseline to week 4, compared with insomnia non-responders (-1.5, 95% CI -2.7 to -0.3); 2) with CBT-I, pain responders reported significantly greater insomnia reduction at week 8, compared with pain non-responders (-4.7, 95% CI -8.7 to -1.0). These findings suggest that among cancer survivors with comorbid pain and insomnia, acupuncture led to rapid pain reductions, which contributed to a decrease in insomnia, whereas CBT-I had a delayed effect on pain, possibly achieved by insomnia improvement.

Metabolic requirements of NK cells during the acute response against retroviral infection.

Natural killer (NK) cells are important early responders against viral infections. Changes in metabolism are crucial to fuel NK cell responses, and altered metabolism is linked to NK cell dysfunction in obesity and cancer. However, very little is known about the metabolic requirements of NK cells during acute retroviral infection and their importance for antiviral immunity. Here, using the Friend retrovirus mouse model, we show that following infection NK cells increase nutrient uptake, including amino acids and iron, and reprogram their metabolic machinery by increasing glycolysis and mitochondrial metabolism. Specific deletion of the amino acid transporter Slc7a5 has only discrete effects on NK cells, but iron deficiency profoundly impaires NK cell antiviral functions, leading to increased viral loads. Our study thus shows the requirement of nutrients and metabolism for the antiviral activity of NK cells, and has important implications for viral infections associated with altered iron levels such as HIV and SARS-CoV-2.

Addressing Psychosocial Stressors through a Community-Academic Partnership between a Museum and a Federally Qualified Health Center: A Qualitative Study.

Psychosocial stressors are prevalent and linked to worse health outcomes, but are less frequently addressed than physically apparent medical conditions at primary care visits. Through a community-academic partnership between an art museum and a federally qualified health center, we developed an innovative museum-based intervention and evaluated its feasibility and acceptability among diverse, underserved patients and its perceived effects on psychosocial stressors. Guided by experiential learning and constructivist approaches, the intervention consisted of a single, three-hour session that incorporated group discussions and interactive components, including art-viewing, sketching, and object-handling. We used post-intervention focus groups to elicit feedback qualitatively. From July 2017 to January 2018, 25 patients participated. Focus groups revealed that the intervention exhibited therapeutic qualities, fostered self-reflection, catalyzed social connectivity, and functioned as a gateway to community resources. These findings can guide future research and development of community-based interventions to target the growing burden of psychosocial stressors among the underserved.

Virtual Mind-Body Programming for Patients With Cancer During the COVID-19 Pandemic: Qualitative Study.

BACKGROUND: Patients with cancer are particularly vulnerable to stress and anxiety during the COVID-19 pandemic. Social distancing is critical for patients with cancer; however, it can also reduce their access to psychosocial coping resources. OBJECTIVE: The aim of this study was to explore patient experiences to generate a model of how virtual mind-body programs can support the psychosocial well-being of patients with cancer. METHODS: We conducted a qualitative study among patients (aged ≥18 years) who participated in a virtual mind-body program offered by a National Cancer Institute-designated Comprehensive Cancer Center during the COVID-19 pandemic. The program consisted of mind-body group therapy sessions of fitness, yoga, tai chi, dance therapy, music therapy, and meditation. Live integrative medicine clinicians held each session via Zoom videoconferencing for 30-45 minutes. In semistructured phone interviews (n=30), patients were asked about their overall impressions and perceptions of the benefits of the sessions, including impacts on stress and anxiety. Interviews were analyzed using grounded theory. RESULTS: Among the 30 participants (average age 64.5 years, SD 9.36, range 40-80, 29 female), three major themes were identified relating to experiences in the virtual mind-body program: (1) the sessions helped the patients maintain structured routines and motivated them to adhere to healthy behaviors; (2) the sessions enhanced coping with COVID-19-related-stressors, allowing patients to "refocus" and "re-energize"; and (3) the sessions allowed patients to connect, fostering social relationships during a time of isolation. These themes informed the constructs of a novel behavioral-psychological-social coping model for patients with cancer. CONCLUSIONS: Virtual mind-body programming supported patients with cancer during the COVID-19 pandemic through a behavioral-psychological-social coping model by enhancing psychological coping for external stressors, supporting adherence to motivation and health behaviors, and increasing social connection and camaraderie. These programs have potential to address the behavioral, psychological, and social challenges faced by patients with cancer during and beyond the COVID-19 pandemic. The constructs of the conceptual model proposed in this study can inform future interventions to support isolated patients with cancer. Further clinical trials are needed to confirm the specific benefits of virtual mind-body programming for the psychosocial well-being and healthy behaviors of patients with cancer.

Effects of acupuncture versus cognitive behavioral therapy on brain-derived neurotrophic factor in cancer survivors with insomnia: an exploratory analysis.

INTRODUCTION: Decreased brain-derived neurotrophic factor (BDNF) is associated with poor sleep. This study examined the effects of acupuncture versus cognitive behavioral therapy for insomnia (CBT-I) on serum BDNF and sleep outcomes in cancer survivors with insomnia. METHODS: This was an exploratory analysis of a randomized clinical trial (n = 160) comparing acupuncture versus CBT-I for cancer survivors with insomnia. Interventions were delivered over 8 weeks. Outcomes were assessed at baseline and week 8. Serum BDNF was evaluated with enzyme-linked immunosorbent assay (ELISA). Sleep was evaluated with the insomnia severity index and consensus sleep diary. Pearson correlations between BDNF and sleep outcomes were calculated. Data analysis was limited to 87 survivors who provided serum samples. RESULTS: Among 87 survivors, the mean age was 61.9 (SD: 11.4) years, 51.7% were women, and 24.1% were non-White. Mean serum BDNF did not significantly increase in acupuncture (n = 50) or CBT-I (n = 37) groups. When analysis was restricted to patients with low baseline BDNF (i.e. levels below the sample median of 47.1 ng/mL), the acupuncture group (n = 22) demonstrated a significant 7.2 ng/mL increase in mean serum BDNF (P = 0.03), whereas the CBT-I group (n = 21) demonstrated a non-significant 2.9 ng/mL increase (P = 0.28). Serum BDNF was not significantly correlated with sleep outcomes (all P > 0.05). CONCLUSION: Among cancer survivors with insomnia and low baseline BDNF, acupuncture significantly increased serum BDNF levels; however, the clinical significance of this finding requires further investigation.Trial registration no. NCT02356575 (ClinicalTrials.gov).

Effectiveness of Electroacupuncture or Auricular Acupuncture vs Usual Care for Chronic Musculoskeletal Pain Among Cancer Survivors: The PEACE Randomized Clinical Trial.

IMPORTANCE: The opioid crisis creates challenges for cancer pain management. Acupuncture confers clinical benefits for chronic nonmalignant pain, but its effectiveness in cancer survivors remains uncertain. OBJECTIVE: To determine the effectiveness of electroacupuncture or auricular acupuncture for chronic musculoskeletal pain in cancer survivors. DESIGN, SETTING, AND PARTICIPANTS: The Personalized Electroacupuncture vs Auricular Acupuncture Comparative Effectiveness (PEACE) trial is a randomized clinical trial that was conducted from March 2017 to October 2019 (follow-up completed April 2020) across an urban academic cancer center and 5 suburban sites in New York and New Jersey. Study statisticians were blinded to treatment assignments. The 360 adults included in the study had a prior cancer diagnosis but no current evidence of disease, reported musculoskeletal pain for at least 3 months, and self-reported pain intensity on the Brief Pain Inventory (BPI) ranging from 0 (no pain) to 10 (worst pain imaginable). INTERVENTIONS: Patients were randomized 2:2:1 to electroacupuncture (n = 145), auricular acupuncture (n = 143), or usual care (n = 72). Intervention groups received 10 weekly sessions of electroacupuncture or auricular acupuncture. Ten acupuncture sessions were offered to the usual care group from weeks 12 through 24. MAIN OUTCOMES AND MEASURES: The primary outcome was change in average pain severity score on the BPI from baseline to week 12. Using a gatekeeping multiple-comparison procedure, electroacupuncture and auricular acupuncture were compared with usual care using a linear mixed model. Noninferiority of auricular acupuncture to electroacupuncture was tested if both interventions were superior to usual care. RESULTS: Among 360 cancer survivors (mean [SD] age, 62.1 [12.7] years; mean [SD] baseline BPI score, 5.2 [1.7] points; 251 [69.7%] women; and 88 [24.4%] non-White), 340 (94.4%) completed the primary end point. Compared with usual care, electroacupuncture reduced pain severity by 1.9 points (97.5% CI, 1.4-2.4 points; P < .001) and auricular acupuncture reduced by 1.6 points (97.5% CI, 1.0-2.1 points; P < .001) from baseline to week 12. Noninferiority of auricular acupuncture to electroacupuncture was not demonstrated. Adverse events were mild; 15 of 143 (10.5%) patients receiving auricular acupuncture and 1 of 145 (0.7%) patients receiving electroacupuncture discontinued treatments due to adverse events (P < .001). CONCLUSIONS AND RELEVANCE: In this randomized clinical trial among cancer survivors with chronic musculoskeletal pain, electroacupuncture and auricular acupuncture produced greater pain reduction than usual care. However, auricular acupuncture did not demonstrate noninferiority to electroacupuncture, and patients receiving it had more adverse events. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02979574.

Herbal Topical Analgesic for Pain Management: Perspectives from Cancer Patients.

OBJECTIVE: Herbs and natural products are increasingly used by cancer patients for pain management, but few studies have examined their integration within conventional cancer care. This study describes the characteristics, experiences, and perspectives of cancer patients who were prescribed an herbal topical analgesic for pain management. DESIGN AND SETTING: Program evaluation of a pilot herbal dispensary at a National Cancer Institute-designated comprehensive cancer center. SUBJECTS: Cancer patients who were prescribed the Tibetree Pain-Relieving Plaster (PRP) by an integrative medicine physician. METHODS: Sociodemographic and clinical characteristics of patients were abstracted from medical records. Semistructured phone interviews were conducted 1-2 weeks after PRP prescription to evaluate patient experiences with using PRP for pain. Interviews were analyzed through thematic content analysis. RESULTS: From February 2019 to February 2020, 50 patients were prescribed PRP. Median age (range) was 63 years (21-86), 37 patients (74%) were female, 14 (28%) were non-White, and 38 (76%) were using oral analgesics. During interviews, the majority of patients reported that the PRP improved pain and health-related outcomes, was convenient to use, and addressed pain management needs that were not fulfilled by oral analgesics. However, a few patients described adverse experiences with PRP, including skin irritation. CONCLUSIONS: Understanding patient experiences and perspectives is a critical step toward evidence-based integration of herbs and natural products into cancer pain management. Findings from this program evaluation will inform the design of a randomized clinical trial on the efficacy and safety of PRP for pain in patients with cancer.

Multi-stakeholder perspectives on managing insomnia in cancer survivors: recommendations to reduce barriers and translate patient-centered research into practice.

PURPOSE: Insomnia is a debilitating symptom experienced by nearly 60% of cancer survivors. Building on our prior research showing the clinical benefit of cognitive behavioral therapy for insomnia (CBT-I) and acupuncture, we organized a workshop of patient advocates and clinician stakeholders to understand the barriers and develop recommendations for the dissemination and implementation of these interventions. METHODS: Participants completed a pre-workshop survey assessing their experiences with insomnia and barriers to insomnia treatment and participated in a workshop facilitated by professionals and patient experts. Responses from the survey were tabulated and the discussions from the workshop were content-analyzed to extract relevant factors that may influence dissemination and implementation. RESULTS: Multidisciplinary and stakeholder workshop participants (N = 51) identified barriers and proposed solutions and future recommendations for dissemination and implementation of evidence-based interventions to improve sleep health in cancer survivors. Barriers were identified in four categories: patient (e.g., knowledge, time, cost), clinician (e.g., education, time, capacity), institutional (e.g., space, insurance reimbursement, referrals), and societal (e.g., lack of prioritization for sleep issues). Based on these categories, we made six recommendations for dissemination and implementation of research findings to improve clinical sleep management in oncology. CONCLUSION: Dissemination and implementation efforts are necessary to translate research into clinical practice to improve patient care. IMPLICATIONS FOR CANCER SURVIVORS: Sleep needs to be prioritized in cancer care, but patient, provider, and institutional/societal barriers remain. Dedicated effort and resources at each of these levels are needed to help millions of people affected by cancer manage their insomnia and improve their quality of life.

Fear of analgesic side effects predicts preference for acupuncture: a cross-sectional study of cancer patients with pain in the USA.

PURPOSE: Approximately one in two cancer patients globally are under-treated for pain. Opioids and other analgesics represent the mainstay of cancer pain management; however, barriers to their use are well-documented. We evaluated whether acupuncture would be a preferable treatment option among cancer patients with attitudinal barriers to pharmacological pain management. METHODS: We conducted a cross-sectional survey of cancer patients at a tertiary urban cancer center and eleven suburban/rural hospitals in the Northeastern United States. We assessed attitudinal barriers to pharmacological pain management with the Barriers Questionnaire (BQ-13). The BQ-13 consists of two subscales: pain management beliefs and analgesic side effects. We also asked patients whether they prefer acupuncture, analgesics, or have no preference between these two modalities for pain management. Covariates included sociodemographics, clinical characteristics, and attitudes/beliefs about acupuncture. We used logistic regression to examine the association between attitudinal barriers and acupuncture preference. RESULTS: Among 628 patients, 197 (31.4%) preferred acupuncture for pain management, 146 (23.3%) preferred analgesics, and 285 (45.4%) had no preference. The highest reported attitudinal barriers were fear of addiction and fear of analgesic-associated constipation and nausea. Adjusting for covariates, we found that attitudinal barriers related to fear of analgesic side effects were significantly associated with acupuncture preference (adjusted odds ratio [AOR] 1.45, 95% confidence interval [CI] 1.17-1.81), but barriers related to pain management beliefs were not (AOR 1.17, 95% CI 0.91-1.51). Attitudes/beliefs about acupuncture (i.e., greater expected benefits, fewer perceived barriers, and more positive social norms) and female gender also predicted acupuncture preference, whereas race and educational status did not. CONCLUSION: Acupuncture may be a preferable treatment option among cancer patients at risk of inadequately controlled pain due to fear of analgesic side effects. Evidence-based integration of acupuncture and analgesics, guided by patient treatment preferences, represents an essential aspect of patient-centered care and has potential to address unmet cancer pain management needs.