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P-163 Using acupuncture to treat hot flashes and night sweating for patients with breast cancer

Authors:

Abstract

Background Hot flashes and night sweating are a common disruptive clinical problem that affects nearly two-thirds of all breast cancer survivors. Adjuvant hormonal therapies are an essential part of the treatment regimen for early breast cancer, and are used to prevent recurrence. However, hot flashes and night sweating are the most frequently occurring side effects of these interventions. Aim To assess the effectiveness of acupuncture in breast cancer related hot flashes and sweating. Methods A 44 year -old woman with a diagnosis of breast cancer had been suffering from intractable hot flashes and night sweating for the past two years. She had tried all other measures but these had very little or no effects on her symptoms. The subject received acupuncture treatment once a week for eight weeks, and the needles were stimulated manually every 10 min during each sessions. In all the treatment sessions, acupuncture points were stimulated manually and the needles were left in situ for 30 mins. Subjective measurement of vasomotor symptoms used Visual Analogue Scale (VAS). Results A noticeable reduction in hot flashes and night sweating were observed after six sessions of treatment, which had a huge impact on her sleep pattern and psychological wellbeing. By the end of eight weeks of treatment the subject reported a significant reduction in both her vasomotor and associated symptoms such as palpitations, anxiety, irritability and headaches. Conclusion It would appear that eight sessions of acupuncture treatment had been shown to be effective in reducing vasomotor symptoms, especially for breast cancer patients who are seeking nonpharmacological therapies.
Acupuncture in Physiotherapy, Volume 28, Number 1, Spring 2016, 9398
CASE REPORT
Acupuncture for cancer-related hot flashes and
night sweating in a 44-year-old woman with
breast cancer
V. Ramasamy
John Taylor Hospice, Birmingham, UK
Abstract
The aim of this study was to assess the effect of acupuncture treatment for cancer-related
hot flashes and night sweating. The subject was a 44-year-old woman with a diagnosis of
breast cancer who had suffered from intractable hot flashes and night sweating for the past
2 years. Other measures failed to improve her symptoms, but she responded to a course of
acupuncture treatment. The subject’s hot flashes and sweating decreased from 9/10 to 2/10,
as measured on a visual analogue scale. There was also an improvement in her quality of
sleep and overall sense of well-being. Acupuncture may have potential as a treatment
modality since the current therapeutic options for hot flashes and night sweating are limited,
especially for patients with hormone-sensitive carcinoma.
Keywords: acupuncture, breast cancer, hot flashes, night sweating.
Introduction
Sweating is the natural way of lowering body
temperature. This is achieved because sweat
results in heat loss through the skin. In patients
with cancer, sweating may be caused by an
infection, a tumour or cancer treatment.
A hot flash is defined as a sudden onset of
heat in the upper trunk that spreads to the arms
and face, often with subsequent sweating and
then a chill. A combination of hot flashes and
sweating is frequently the result of vasomotor
symptoms, and may occur during the day and
also at night (Kronenberg 1990). The severity
and frequency of hot flashes vary from person
to person, and these can be extreme in patients
with breast or prostate cancer who are under-
going anticancer therapy (Filshie 2005).
Early research by Carpenter et al. (1998) dem-
onstrated that hot flashes are a common and
Correspondence: Visweswaran Ramasamy, John Taylor
Hospice, 76 Grange Road, Erdington, Birmingham
B24 0DF, UK (e--mail: vnramasamy@gmail.com).
disruptive clinical problem that affects nearly
two-thirds of all breast cancer survivors. These
individuals experience hot flashes and sweating
more frequently than women undergoing a
natural menopause, and cancer-related flashes
may be more severe, distressing and of greater
duration (Carpenter et al. 2002).
Hot flashes and night sweating may be
accompanied by a range of physical sensations,
including sweating, flashing or redness, palpita-
tions, dizziness, feelings of suffocation, nausea,
tingling sensations in the hands, and chills
before or after the flash. Associated emotional
symptoms may include anxiety, feelings of
panic, irritation, annoyance and frustration, and
even suicidal ideation. Night sweating disturbs
sleep patterns, leading to fatigue and irritability
(Miller 2004).
Adjuvant hormonal therapies such as tamox-
ifen are an essential part of the treatment
regimen for early breast cancer, and are used to
prevent recurrence. However, Hunter et al.
(2004) mentioned that hot flashes and night
© 2016 Acupuncture Association of Chartered Physiotherapist 93
Cancer-related hot flashes and night sweating
sweating are the most frequently occurring side
effects of these interventions, with up to 80% of
women taking tamoxifen reporting these as
troublesome. Many patients do not wish to expe-
rience further side effects of pharmacological
preparations during their cancer treatment. For
these women, complementary and alternative
medicine approaches may offer an alternative
(Hunter et al. 2004). Preliminary studies suggest
that acupuncture may reduce hot flashes and
night sweating in breast cancer survivors, and
have fewer side effects than conventional phar-
macological therapies (Hervik et al. 2009;
Walker et al. 2010).
Mechanism of action
The specific pathophysiology of acupuncture for
hot flashes remains a mystery, although several
hypotheses exist. Acupuncture is known to
stimulate neuropeptide synthesis, which controls
bodily functions such as cardiovascular physiol-
ogy and hormonal secretions (Omura 1975). This
is believed to activate peripheral nerve endings,
muscles and also connective tissue. The
stimulation of the nerves produces affer-ent
signals, which increase, for example, central β-
endorphins and serotonin, and probably also
activate receptors (Guo et al. 2008; Moazzami et
al. 2010). Using functional magnetic resonance
imaging, Hui et al. (2010) demonstrated that acu-
puncture decreased activity in the amygdala and
hypothalamus. Calcitonin gene-related peptide
(CGRP) is a neuropeptide that is released into the
circulatory system during a hot flash (Wyon et al.
2000). Acupuncture stimulation causes the release
of ß--endorphin, which has an inhibitory effect on
CGRP. A study by Wyon et al. (1995) showed that
urinary excretion of CGRP was reduced following
acupuncture. It is possible that neuronal activity in
the hypothalamus is elevated during hot flashes,
and acupuncture may reduce this, perhaps
mediated by increased ß-endorphin release and
decreased noradrenaline activity.
Case report
Background
The present subject was a 44-year-old woman
with a diagnosis of breast cancer. She had been
suffering from intractable hot flashes and night
sweating for the past 2 years, and this had had a
severe impact on her quality of life (QoL). Her
sweating was very bad, especially when she tried
to sleep. She needed to change her bedclothes
several times a night, which had an effect on her
sleep and QoL. The subject’s poor sleep pattern
impacted on her energy level during the day,
leading to fatigue. The hot flashes made her feel
uncomfortable when socializing with friends,
and increased her anxiety level every time she
experienced them. She had tried all other
measures, i.e. medications, using a fan,
maintaining ambient room temperature, wearing
cotton clothing, avoiding caffeine-related drinks,
relaxation and listening to music, but these had
had very little or no effect on her sweating.
Having previously worked as a librarian, she had
quit her job because of the increasing side effects
of her cancer treatment.
Clinical impression
The subject was alert and appeared well.
Based on the subjective history and objective
findings, the vasomotor symptoms that she
was experiencing were directly linked to her
breast cancer diagnosis. Medical assessment
ruled out any infection or pyrexia as a cause of
sweating. She had begun to have vasomotor
symptoms following breast cancer treatment.
The subject described her experience of a hot
flash as “a sudden warmth all over the body
and then accompanied by a feeling of skin
peeling from inside”. During hot flashes, she
experienced associated symptoms such as
palpitation, anxiety, irritability and headaches.
Treatment
Prior to acupuncture treatment, precautions were
taken and contraindications were checked. The
subject’s left arm was not needled because of
axillary clearance. She was given an informa-
tion leaflet that explained acupuncture treatment
and possible adverse reactions to it. Written
informed consent was gained once all the infor-
mation had been provided (AACP 2012).
The acupuncture points that were selected
are listed in Table 1. The majority of the points
94 © 2016 Acupuncture Association of Chartered Physiotherapist
Table 1. Acupuncture points selected: (LI) Large Intestine;
(PC) Pericardium; (TE) Triple Energizer; (HT) Heart; (LR)
Liver; (SP) Spleen; (ST) Stomach; and (KI) Kidney
Size of needle
Depth of
Acupuncture point
(mm)
needling (cun)
De Qi
LI4 (right)
0.18×25
0.4
Yes
PC6 (right)
0.18×25
0.4
Yes
PC8 (right)
0.18×25
0.4
Yes
TE5 (right)
0.18×25
0.4
Yes
HT6 (right)
0.18×25
0.4
Yes
HT7 (right)
0.18×25
0.4
Yes
HT8 (right)
0.18×25
0.4
Yes
LI11 (right)
0.25×40
0.5
Yes
LR2 (bilateral)
0.18×25
0.4
Yes
SP9 (bilateral)
0.25×50
1.2
Yes
SP6 (bilateral)
0.25×40
0.7
Yes
ST36 (bilateral)
0.25×50
1.3
Yes
KI3 (bilateral)
0.18×25
0.4
Yes
KI6 (bilateral)
0.18×25
0.4
Yes
KI7 (bilateral)
0.18×25
0.4
Yes
used corresponded to those employed in the
largest trial of acupuncture for hot flashes
(Borud et al. (2009). In all treatment sessions,
the acupuncture points were stimulated manu-
ally, and the needles were left in situ for 30
min. The subject received treatment once a
week, and the needles were stimulated
manually every 10 min during each session in
order to improve the therapeutic effects. The
depth of needling was dependent on whether
De Qi was elicited. The needles used were all
sterile and made of stainless steel (Classic
Plus, HMD Europe Ltd, Chipping Norton,
Oxfordshire,UK).
The subject did not notice any changes in her
symptoms until three sessions of treatment had
been completed, after which the frequency and
severity of her hot flashes and night sweating
reduced slightly. A noticeable reduction in
vasomotor symptoms was observed after six
sessions of treatment, which had a huge impact
on her sleep pattern and psychological well-
being. By the end of 8 weeks of acupuncture
treatment, the subject reported a significant
reduction in both her vasomotor and associated
symptoms, including palpitation, anxiety,
irritability and headaches. Her hot flashes and
sweating decreased from 9/10 to 2/10, as
measured on a visual analogue scale (VAS).
Discussion
A significant reduction in the present subject’s
hot flashes and night sweating was brought
V. Ramasamy
about by 8 weeks of acupuncture treatment.
Prior to this, she had reported between three
and four hot flashes every hour, and from four
to six incidents of sweating every night.
Following the completion of her treatment, she
reported that she now only experienced a mild
damp feeling two or three times a day, and that
her palpitations and feelings of irritability had
considerably improved. Similarly, her night-
time sweating had reduced considerably to
only one or two incidents a night, and since
these were less intense, she could manage the
problem without changing her nightclothes.
The hot flashes had lessened significantly fol-
lowing acupuncture, and the distress caused by
these had decreased even more. The outcomes
of the acupuncture treatment are detailed in
Table 2.
Current treatment options for hot flashes in
patients with breast cancer include pharma-
cological agents, especially selective serotonin
reuptake inhibitors (e.g. venlafaxine and
parox-etine), but these have adverse side
effects and are considered to be undesirable
options for most women (Loprinzi et al. 1998;
Nelson et al. 2006). Hormone replacement
therapy reduces hot flashes in women by 90
95%, compared to 1050% with placebo
treatment (Carpenter et al. 2007), and may
improve QoL (Fahlén et al. 2011), but it also
increases the risk of breast cancer (MWSC
2003) and probably that of a recurrence of this
form of cancer (Holmberg et al. 2008).
This situation has led to an increasing demand
for alternative treatments for hot flashes and
night sweating. Although there has been no
clearly defined treatment for hot flashes in
patients with breast cancer for whom oestrogen
replacement is contraindicated (Studdard 1999),
alternatives are available. One modality that has
only been investigated to a limited extent is
acupuncture (Towlerton et al. 1999), possibly
because the conclusions of many trials of are not
robust enough and are generally inconsistent.
Nevertheless, acupuncture has been shown to be
effective for postmenopausal hot flashes, and
clinical experience suggests that it is an effective
alternative treatment for reducing hot flashes
and night sweating, especially for patients with
© 2016 Acupuncture Association of Chartered Physiotherapist 95
Cancer-related hot flashes and night sweating
Table 2. Treatment outcomes: (LI) Large Intestine; (PC) Pericardium; (HT) Heart; (SP) Spleen; (ST) Stomach; (KI) Kidney; (LR)
Liver; and (TE) Triple Energizer
Treatment session
(week)
Number of hot flashes
Number of night sweats
1
34 every hour, with warmth all over
46 every night; the subject needed to
the body and then a feeling of skin
change her clothes several times
peeling from inside
2
34 every hour, with warmth all over
46 every night; the subject needed to
the body and then a feeling of skin
change her nightclothes several times
peeling from inside
3
34 every hour, with warmth all over
46 every night; the subject needed to
the body and then a feeling of skin
change her nightclothes several times
peeling from inside
4
34 hot flashes every 23 h; a slight
46 every night, but with less intensity;
reduction in warmth and feeling of
the subject needed to change her
skin peeling from inside
nightclothes at times
5
34 hot flashes every 23 h with less
34 every night, but with less intensity;
intensity; no warmth or feeling of
the subject managed her sweating
skin peeling from inside
without any need for a change of
nightclothes
6
46 hot flashes in a day with less
34 every night but with less intensity;
intensity; no warmth or feeling of
the subject managed sweating without
skin peeling from inside*
any need for a change of nightclothes
7
23 hot flashes in a day with less
12 mild ones every night; quality of
intensity; no warmth or feeling of
sleep had improved
skin peeling from inside
8
0; only a damp feeling two or three
12 mild ones every night; overall sense
times a day without any hot flashes
of well--being had improved
*The subject experienced palpitation, anxiety, irritability and headaches at the time of the hot flashes. These associated symptoms began to lessen from
week 6 onwards, and a considerable reduction was reported at the end of 8 weeks of treatment.
breast cancer who are seeking non-
pharmacological therapies.
There is good evidence that acupuncture can
be effective in the treatment of breast-cancer-
related hot flashes and night sweating. For
example, Walker et al. (2010) demonstrated that
12 weeks of acupuncture is as effective as ven-
lafaxine in managing vasomotor symptoms in
patients with breast cancer. In addition to this,
the above authors demonstrated that hot flashes
remained at low levels in the acupuncture group
2 weeks after treatment, whereas the venlafaxine
group had experienced significant increases in
hot flashes by this time. Positive results were
maintained in the acupuncture group 12 weeks
after treatment ended. The acupuncture group
had the additional benefits of an improvement in
their energy levels, and a sense of well-being
without any adverse effects. On the other hand,
the venlafaxine group experienced side effects
such as nausea, dry mouth, dizziness and anxiety.
Similarly, De Valois et al. (2010) explored the
use of traditional acupuncture to manage tamoxifen
related hot flashes and night sweating in women
with early breast cancer. Furthermore, they
extended the focus of their study to measure
physical and emotional well-being using the
Women’s Health Questionnaire (WHQ), and the
Hot Flashes and Night Sweats Questionnaire.
Acupuncture treatment was given on a weekly
basis for 8 weeks, and its effects were monitored
for up to 30 weeks after treatment. In contrast to
Walker et al. (2010), De Valois et al. (2010)
reported that a number of participants did not
adhere to the weekly acupuncture schedule, and
had treatments beyond the allocated 8-week period
because leaving gaps between sessions. This could
have influences both short and long-term
96 © 2016 Acupuncture Association of Chartered Physiotherapist
outcomes of the study. Nevertheless, the present
subject reported improvements in her physical
and emotional well-being, as well as reductions
in hot flashes and night sweating.
The VAS was used as a subjective outcome
measure in the present case study. On reflec-
tion, it might have been beneficial to use more-
-measurable markers (e.g. the WHQ) of the
frequency and intensity of hot flashes and
night sweating, and health-related QoL. The
WHQ subscales focus on aspects of emotional
and physical health, such as depression, sleep
problems, anxiety and somatic symptoms.
Establishing the optimum dose, frequency and
duration of acupuncture is an outstanding issue
with regard to this form of treatment. It might
be worthwhile extending the present subject’s
treatment to determine whether her hot flashes
and night sweating could be further reduced.
Conclusions
It would appear that eight sessions of acupunc-
ture treatment had a very good effect on the
present subject’s hot flashes and night
sweating. The symptoms associated with hot
flashes and night sweating reduced
considerably, and this improved her QoL.
Acupuncture has a good safety profile and a
low incidence of side effects, and is a low-risk
form of non-pharmacological treatment. On
the basis of the present single case study, it is
possible that acupuncture may be an accept-
able treatment option in the management of
hot flashes and night sweating in patients with
breast cancer.
Acknowledgements
I would like to thank the subject for consenting
to the publication this case study. I would also
like to thank Mr Roger Wheelwright, a
prostate cancer nurse specialist, for his advice
and sup-port during this process.
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98 © 2016 Acupuncture Association of Chartered Physiotherapist
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