Acupuncture Eases Joint Pain Caused by Aromatase Inhibitors

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After surgery, women diagnosed with hormone-receptor-positive breast cancer usually take hormonal therapy medicine to reduce the risk of the cancer coming back (recurrence). Hormonal therapy medicines work in two ways:

  • by lowering the amount of estrogen in the body
  • by blocking the action of estrogen on breast cancer cells

There are several types of hormonal therapy medicines. Tamoxifen, a selective estrogen receptor modulator (SERM), is one of the most well-known. Tamoxifen can be used to treat both premenopausal and postmenopausal women. Another type of hormonal therapy, the aromatase inhibitors:

  • Arimidex (chemical name: anastrozole)
  • Aromasin (chemical name: exemestane)
  • Femara (chemical name: letrozole)

have been shown to be more effective at reducing recurrence risk in postmenopausal women and are used more often than tamoxifen to treat women who’ve gone through menopause. Aromatase inhibitors aren’t commonly used to reduce recurrence risk in premenopausal women.

Both tamoxifen and aromatase inhibitors can cause side effects. Tamoxifen may cause hot flashes and increase the risk of blood clots and stroke. Aromatase inhibitors may cause muscle and joint aches and pains. Less common but more severe side effects of aromatase inhibitors are heart problems, osteoporosis, and broken bones. Research has shown that about 25% of women who are prescribed hormonal therapy to reduce the risk of recurrence after breast cancer surgery either don’t start taking the medicine or stop taking it early. In many cases, this is because of side effects.

If doctors can find a way to ease these side effects, more women might stick to their treatment plans.

A randomized study has found that acupuncture can relieve joint pain caused by aromatase inhibitors.

The research was presented on Dec. 7, 2017 at the 2017 San Antonio Breast Cancer Symposium. Read the abstract of “Randomized blinded sham- and waitlist-controlled trial of acupuncture for joint symptoms related to aromatase inhibitors in women with early stage breast cancer (S1200).”

“We know that it’s hard to get through [hormonal] therapy for 5 years,” said Dr. Dawn Hershman, leader of the Breast Cancer Program at the Herbert Irving Comprehensive Cancer Center at New York-Presbyterian/Columbia University Medical Center, who presented the research. Dr. Hershman also is a member of the Breastcancer.org Professional Advisory Board. “We and others have done studies that suggest that 50% of patients aren’t taking their medications or aren’t taking their medications regularly by the end of the 5 years. Probably the most common reason why people stop taking their medications is due to side effects. And the most common side effects with aromatase inhibitors are joint pains and joint stiffness.”

Earlier studies on acupuncture and joint pain have had mixed results. Because these studies were small (usually fewer than 40 women were included), were usually done at just one institution, and used different methodologies, Hershman and her colleagues decided to do a large trial that involved multiple locations around the country to definitively answer the question of whether acupuncture can help ease aromatase inhibitor-caused joint pain.

The study included 226 postmenopausal women who had been diagnosed with early-stage hormone-receptor-positive breast cancer. All the women had been taking an aromatase inhibitor for at least 30 days and all had a joint pain score that was 3 or higher on a 10-point scale.

The women were randomly assigned to one of three groups:

  • True acupuncture: 110 women were treated with standard traditional Chinese medicine acupuncture using traditional acupuncture needles inserted at acupuncture points on the body; the acupuncture treatment was tailored to each woman’s most painful joints. The women received two acupuncture sessions per week for 6 weeks and then one acupuncture session per week for 6 more weeks; each session lasted 30 to 45 minutes.
  • Sham acupuncture: 59 women were treated with sham acupuncture, which used thinner and shorter needles that were placed at non-acupuncture points on the body. The women received two sham acupuncture sessions per week for 6 weeks and then one sham acupuncture session per week for 6 more weeks; each session lasted 30 to 45 minutes.
  • Wait list: 57 women were told they were on a waiting list to receive true acupuncture after 24 weeks.

The sham acupuncture group and the wait list group were both considered control groups.

“We used two control groups,” Hershman explained. “One of the issues with sham is that it actually can have physiologic effects, even if it’s not in the acupoints. Those can be both positive and negative. Some people have pain with sham depending on how it’s given, without the benefits, and other people might have benefits because of the physiologic effects. It’s not a true placebo like it might be for a pill, so we also wanted to have a wait-list control group to look at the natural history, because over time when people are followed, in general, their symptoms should get a little bit better just from being monitored.”

The researchers measured the women’s joint pain scores using several methods five times during the study:

  • 6 weeks after the study started
  • 12 weeks after the study started
  • 16 weeks after the study started
  • 20 weeks after the study started
  • 24 weeks after the study started, when the women in the two acupuncture groups had received no acupuncture for 12 weeks

After 6 weeks, women receiving true acupuncture reported lower pain scores compared to women in the sham acupuncture and wait-list groups. This difference was significant, which means that it was likely due to the different in treatment and not just because of chance. The differences in pain scores remained statistically significant at 24 weeks, even though the women had stopped receiving acupuncture 12 weeks earlier.

The researchers also found that 58% of women receiving true acupuncture reported at least a two-point decrease in their pain score, compared to 31% of the women in the sham acupuncture group and 30% in the wait-list group.

“We found that at each of these time points [that pain was assessed], there was a benefit, both after the initial twice-a-week treatment and after the once-a-week treatment, but more importantly over time,” Hershman explained.

The only side effects from the acupuncture were mild bruising. About 47% of the women in the true acupuncture group and about 25% of women in the sham acupuncture group said they had mild bruising.

“We were very pleased to see acupuncture had durable beneficial effects with no significant side effects in a large, rigorous clinical trial,” said Hershman. “We hope that these data will not only encourage healthcare practitioners to discuss acupuncture as a complementary therapy for patients receiving aromatase inhibitors, but that they will also enhance payers’ willingness to reimburse these patients for acupuncture.”

In this study, 18 sessions of acupuncture over 6 months cost about $1,200, which worked out to be about $200 per month. Still, Hershman explained that in some areas, the cost can be as low as $50 per session. In some cases, acupuncturists will offer lower rates for group sessions.

Still, acupuncture is not covered by Medicare. Some insurance companies will cover a specified number of treatments.

Hershman said that she would absolutely recommend acupuncture to her patients suffering from joint pain.

“I would do anything that had minimal risk in order to keep a patient on their medication or stop them from suffering from side effects, so I think it’s completely reasonable to offer it,” she said. “I’d like to be able to offer it to people and have them have access to it. I recognize that a lot of women can’t pay those kinds of prices. So we really do hope that the advocacy community and the insurance companies will help these women get treatment that may help them get through their breast cancer treatments.”

For more information on acupuncture, including what to expect and practitioner requirements, visit the Breastcancer.org Acupuncture page.

Listen to a Breastcancer.org podcast with Dr. Hershman about this study.


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