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154]

 Original Article

Acupuncture for hot flashes in women with

breast cancer: A systematic review
ABSTRACT Yu-Pei Chen,
Background: Acupuncture is applied worldwide in treating hot flashes (HFs), which may be a common complication experienced Tong Liu,
by women with breast cancer (BC). Although researches associated with the effect of acupuncture for HFs have been done by many Yuan-Yuan Peng,
people, there is a lack of comprehensive evaluation of the effect of this therapy. Yan-Ping Wang,
Huan Chen1,
Objective: The aim of this systematic review is to assess the effectiveness of acupuncture for HFs in women with BC.
Yi-Fan Fan,
Methods: Seven databases (Cochrane Central Register of Controlled Trials, Embase, PubMed, Web of Science, Chinese National Li Zhang
Knowledge Infrastructure Database, Chinese Biomedical Literature Database, and Wan Fang Database) were searched from their
inceptions to June 2015 without language restrictions. Randomized controlled trials (RCTs) were aggregated to evaluate the therapeutic School of
Acupuncture-
effect of acupuncture for HFs in women with BC.
Moxibustion and
Results: Twelve RCTs were identified at last, and all of the studies agreed on the potential therapeutic effect of acupuncture for HFs Tuina, Beijing
in women with BC. However, three trials showed significant difference compared with the controls. One research demonstrated an University of Chinese
encouraging trend, and six did not find any difference between acupuncture and controls. Another two trials got a negative result Medicine,
Beijing 100029,
compared with hormone therapy. The meta‑analysis indicated a difference in the number of HFs after treatment and during follow‑up 1
Acupuncture
compared with the controls. Three trials reported Kupperman index scores, and meta‑analysis showed significant difference between Department of Jiangsu
acupuncture and controls after treatment and during follow‑up. Province Hospital,
Nanjing 210000, China
Conclusion: Acupuncture seems to be an effective therapy for HFs in women with BC; however, there was insufficient evidence to
support the efficacy of acupuncture. However, the results should be interpreted cautiously, because of the poor quality and small For correspondence:
number of included studies. Prof. Li Zhang,
School of
Acupuncture-
KEY WORDS: Acupuncture, breast cancer, hot flashes, systematic review Moxibustion and
Tuina, Beijing
University of Chinese
Medicine, No. 11
INTRODUCTION meaningful effects of soy phytoestrogens,[18‑20] red of North Third-ring
clover,[21,22] or black cohosh[23‑25] for HFs. Vitamin E East Road, Chaoyang
Hot flashes (HFs) are described as episodic only produces a small positive effect for HFs.[26,27] District,
Beijing 100029, China.
sensations of heat, intense sweating, flashing Thus, clinicians and patients begin to focus their E‑mail: zhangli1572@
affecting the face and chest, and always attention on complementary and alternative sina.com
accompanied by palpitations and anxiety. [1‑3] therapies to find a new way to harmonize
This symptom may last for 3–10 min and usually this manifestation. Acupuncture, though the
occurs with varying frequency.[4,5] Some patients mechanism is still unclear, has been reported
even experience HFs hourly or daily, and almost
as a supporting and palliative care for HFs in
two‑thirds of the patients report that HFs
cancer patients.[28‑30] Actually, there have been
decrease their quality‑of‑life.[6‑8] HFs are common
some reviews analyzing the therapeutic effect of
and detrimental adverse effects in women with
breast cancer (BC). Any reason that can cause rapid acupuncture for HFs in patients with BC,[31,32] but
estrogen withdrawal could have an influence on the no positive conclusions are available. Our review
Access this article online
onset or worsening of HFs in women with BC, such aims at making an update.
Website: www.cancerjournal.net
as cancer therapies (oophorectomy, chemotherapy, DOI: 10.4103/0973-1482.172716
This is an open access article distributed under the terms of the Creative Commons
and endocrine therapies), menopausal status.[9‑13] Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix,
PMID: ***
It is understood that 65% BC survivors experience tweak, and build upon the work non‑commercially, as long as the author is credited Quick Response Code:

HFs due to the treatment of BC.[14‑17] Up to now, and the new creations are licensed under the identical terms.
many randomized trials do not show any clinically For reprints contact: reprints@medknow.com

Cite this article as: Chen YP, Liu T, Peng YY, Wang YP, Chen H, Fan YF, et al. Acupuncture for hot flashes in women with
breast cancer: A systematic review. J Can Res Ther 2016;12:535-42.

© 2016 Journal of Cancer Research and Therapeutics | Published by Wolters Kluwer - Medknow 535
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Chen, et al.: Acupuncture for breast cancer

METHODS Data extraction, quality and validity assessment

Data sources
Trials were searched using seven databases (Cochrane Central
Register of Controlled Trials, Embase, PubMed, Web of Science,
Chinese National Knowledge Infrastructure Database, Chinese
Biomedical Literature Database, and Wan Fang Database) from
their inceptions to June 2015. Search terms used were as
follows: “Acupuncture” or “electro‑acupuncture” or “needle” or
“acupuncture point” or “acupoint” or “acupuncture treatment”
or “acupuncture therapy” or “meridian” and “BC” or “breast
carcinoma” or “breast tumor,” and “HFs” or “hot flushes.”
Hardcopies of all articles were obtained manually and read
fully.
Study selection
(1) Only randomized controlled trials (RCTs) labeled the
intervention “acupuncture,” such as traditional acupuncture,
electro‑acupuncture, ear‑acupuncture, self‑acupuncture, and
injection acupuncture were included in this systematic review.
Observational, cohort, case–control, case series, qualitative
studies, uncontrolled trials, and laboratory studies were
excluded. (2) Patients who accepted acupuncture as the main
treatment or an adjunct to other treatment for HFs (if the
control group also received the same concomitant treatment
as the acupuncture group) were employed. (3) The control
could be sham acupuncture (SA), nonacupoint acupuncture,
relaxation, or some other ways (such as Western medicine).
Dissertations and abstracts were also included. (4) Trials were
included only when the outcome measurement is relevant to
HFs in women with BC. The primary outcome was the number
or frequency of HFs after treatment and during follow‑up, and
the second outcome could be improvement of the quality‑of‑life
measured by validated scores such as Kupperman index (KI). (5)
It was ineligible if only immunological or biological parameters
were estimated. Language restrictions were not imposed. The
selection process is listed in Figure 1.
Records identified
through database
Additional records
identified through
searches n = 246
other sources n = 4
(included duplicates)
All articles were read by two independent reviewers (Chen and
Peng), and data from the articles were validated and extracted
based on the predefined criteria. No language limitations were
exerted. The risk of bias was assessed using the assessment tool
for “risk of bias” from the Cochrane Handbook for Systematic
Reviews of Interventions.[33] The following characteristics
were assessed: (1) Was the allocation sequence adequately
generated? (2) Was the allocation adequately concealed?
(3) Was knowledge of the allocated interventions adequately
presented during the study? (4) Were incomplete outcome data
adequately addressed? (5) Were the study reports have selective
outcome reporting? (6) Was the study free of other problems
that could put it at a risk of bias? Our review used “L, U, and
H” as keys for the judgments: “Low” (L) indicated a low risk of
bias, “unclear” (U) indicated that a risk of bias was uncertain,
and “high” (H) indicated a high risk of bias. Given that blinding
therapists to the use of acupuncture is out of question, the
patient and assessor blinding were assessed separately.
Disagreements were resolved by the third reviewer (Liu).
Data analysis
Outcome data were summarized using risk ratio with 95%
confidence intervals (95% CI) for binary outcomes or mean
difference (MD) with 95% CI for continuous outcomes.
RevMan 5.0.20 software (Cochrane Database of Systematic
Reviews) was used for data analyses. Meta‑analysis was
used if the trials had good homogeneity, which was assessed
by examining I2 (an index that describes the percentage of
variation across the studies that is due to heterogeneity rather
than chance) on study design, participants, interventions,
control, and outcome measures. Funnel plot analysis was done
to determine publication bias if feasible.
RESULTS
Literature search
One hundred forty‑nine hits have generated with the search
methods and 12 articles[34‑45] met our inclusion criteria. The key
data of the included RCTs are listed in Tables 1 and 2.

122 papers Description of studies

excluded Four papers
(n = 5) excluded Participants
Second screen (abstract Six hundred seventy‑two women with BC were involved in 12
and full-text articles)
assessed for eligibility
prospective RCTs. In nine [34‑37,39,40,43‑45] trials, the mean age is
n = 124 52-62 years. One[42] study did not mention the mean age and
the age gap in another two[38,41] studies was a little big, ranging
Reasons for exclusions:
from 30 to 77. The sample size was ranged from 20 to 94. The
Full-text articles • duplicated publication (n = 4) reason of HFs did not clearly described in the included RCTs,
assessed for inclusion • not clinical trials (n = 3)
criteria n = 25 • outcome not relevant (n = 2) except participants in four[34,38,39,44] trials were complaining HFs
• exposure not relevant (n = 1)
• specific participants (n = 3) because of the use of tamoxifen.

RCTS included finally Interventions and controls

n = 12
Inter ventions included manual acupuncture and
Figure 1: Flow chart of report selection process electro‑acupuncture while controls varied considerably.

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Chen, et al.: Acupuncture for breast cancer

Table 1: Summary of the randomized controlled clinical trials

Study Number of Age Intervention Acu-points Intervention Outcome Results Adverse
patients (years) and controls treatment frequency/ measures events
duration
Hervik 59 MA: 53.6 MA vs SA LIV3, GB20, LU7, De-qi, 30 min, Number of A significant difference NO
et al.[34] SA: 52.3 KI3, SP6, REN4, 2 times weekly for HFs of day was found in the number
P7, LIV8 the first 5 weeks, and night, KI at day and night in MA
1 time weekly for the group, and a further
following 5 weeks reduction in the next
12 weeks while SA group
had a smaller reduction
only at day time. MA
reduced KI and SA didn’t
Deng 72 MA: 55 MA vs SA GB20, Du14, De-qi, 20 min, Number of There was reduction in Slight or
et al.[35] SA: 56 BL13, PC7, HT6, 2 times weekly for HFs per day both the two groups, but bleeding or
KI7, ST36, SP6, 4 weeks there was no significant bruising at
Ear shen men, Ear difference the needle
sympathetic point site
Frisk 45 EA: 56.5 EA vs HT BL15, 23 and 32, De-qi, 30 min, 2 times Number of Significant reduction was NO
et al.[36] HT: 53.4 GV20, HT7, PC6, weekly for first HFs at day found in both groups.
LR3, SP6, SP9 2 week and 1 time and night, KI HT is better than EA
weekly for 10 weeks
Frisk 45 EA: 54.1 EA vs HT BL15, BL23 and De-qi, 30min, PGWB, WHQ Significant difference was NR
et al.[37] HT: 53.4 32, GV20, HT7, 2 times weekly for found in both groups, and
PC6, LR3, SP6, first 2 week and HT is better than EA
SP9 1 time weekly for
10 weeks
Walker 50 35-77 MA vs BL23, KI3, SP6, De-qi, twice a week HFD, Both groups exhibited NO
et al.[38] Venlafaxine DU14, GB20, for the first 4 weeks MenQQL, significant decreases in
LR9, LIV3, DU 20, and once a week for SF-12, all the outcome measures
ST36, REN6, PC7, the next 8 weeks BDI-PC, except for SF-12: Physical
and HT7 NCICTCS but no significant
interactions. MA group had
no side effects while 18
incidences in the control
Liljegren 84 58 MA vs SA LI4, HT6, LR3, P6 De-qi, 20 min, twice Frequency Both groups reported NO
et al.[39] and KI7.b a week or 5 weeks and intensity improvement regarding
of HFs severity and frequencies in
HFs and sweating but no
statistical difference was
found between the groups.
MA was better than SA
regarding the severity of
sweating at night (P=0.03)
Bokmad 94 MA: 60 MA vs SA HC6, KI3, SP6 De-qi, 20 min, once Mean VAS Acupuncture is better Five mild,
et al.[40] SA: 62 vs NT and LR3 a week for 5 weeks score of HFs than SA and NT temporary
NT: 62 side effects
Nedstrand 38 30-64 EA vs BL15, BL23, BL32, De-qi, 30 min, Number of Both the 2 groups had NR
et al.[41] applied GV20, HT7, PC6, 2 times weekly for HFs at day significant reduction in the
relaxation LR3, SP6, SP9 the first 2 weeks and night, KI number of HFs and KI.
and once a week for There is no comparison
10 weeks between groups
Davies 20 NR TA vs NR Total 4 sessions Numbers of No significant difference NR
et al.[42] minimal HFs, VAS, was found, but there is an
acupuncture FACT-ES tool encouraging trend
BaoT 47 MA: 61 RA vs SA CV4, CV6, CV12, 20 min, eight HFRDI, Hot Patients benefit from NR
et al.[43] LI4, MH6, GB34, weekly acupuncture flash weekly both RA and SA, with
ST36, KI3, BL65 severity no significant difference
score, Hot between groups
flash weekly
frequency
Hervik 80 TA: 51.3 TA vs SA NR NR KI scores Acupuncture seems to NR
et al.[44] SA: 50.2 have a positive effect,
with no significant effect
2 years later

Contd...

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Table 1: Contd..
Study Number of Age Intervention Acu-points Intervention Outcome Results Adverse
patients (years) and controls treatment frequency/ measures events
duration
Nedstrand 38 53 EA vs AR BL15, 23 and 32, De Qui, 30 min, number of Changes were similar, Few side
et al.[45] HT7, SP6 and 9, twice a week for the hot flushes but no differences effect
LR3, PC6, and first two weeks, once per day, appeared in two groups
GV20 a week for 10 weeks KI,VAS,
Mood Scale
and SCL
VAS=Visual analog scale, MA=Manual acupuncture, TA=Traditional acupuncture, SA=Sham acupuncture, EA=Electro-acupuncture, KI=Kupperman index, HT=Hormone
therapy, NS=Not significant, NR=Not reported, NT=Not treatment, WHQ=Women’s health questionnaire, PGWB=Psychological and general well-being index,
HFD=Hot flash diary, MenQQL=Menopause specific quality of life questionnaire, SF-12=Short Form 12-Item survey, BDI-PC=Beck depression inventory-primary care,
NCICTC=National cancer institute common toxicity criteria, HFRDI=Hot flash-related daily interference scale, SCL=Symptom checklist

Table 2: Risk of bias assessment for the included studies

Study Adequate sequence Allocation Blinding of patients, Incomplete Selective Other
generation concealment personnel, and outcome outcome outcome sources
assessor data reporting of bias
Hervik et al.[34] Unclear A sealed envelope Patients and investigator Low Low Low
Deng et al.[35] A computer system A computer system Patients and outcome assessor Low Low Low
Frisk et al.[36] Computer‑generated High Unclear Low Low Low
Frisk et al.[37] Computer‑generated High Unclear Low Low Low
Walker et al.[38] Unclear High Unclear Low Low Low
Liljegren et al.[39] Unclear Patients identifier Patients Low Low Low
Bokmad et al.[40] Unclear A sealed envelope Patients and investigator Low Low Low
Nedstrand et al.[41] Unclear A sealed envelope Unclear Low Low Low
Davies et al.[42] Unclear Unclear Unclear Unclear Unclear Low
Bao T et al.[43] Randomization software Unclear Patients and investigator Low Low Low
Hervik et al.[44] Unclear A sealed envelope Patients and investigator Low Low Low
Nedstrand et al.[45] Unclear A sealed envelopes Patients and investigator Low Low Low

Seven[34,35,39,40,42‑44] trials applied SA, [34,35,39,40,44] of which five were Adverse events

applied on nonacupoints away from the real, while one[43] used
the middle point between two real acupoints and another
one[42] without detailed information. Among the seven SA
groups, three[34,40,44] used superficial insert, three[35,39,43] applied
no penetration with special needle, and another trial[42] gave
no information about this. Two[36,37] trials adopt hormone
therapy (HT) and one[38] employed medication (venlafaxine).
Two[41,45] studies made applied relaxation, which consisted of
progressive relaxation, release‑only relaxation, cue‑controlled
relaxation, differential relaxation, rapid relaxation, application
training, and maintenance program as the control.
Two[35,45] trials reported slight bleeding or bruising at the needle
site. A total of 14 (15%) participants with fatigue, pruritus, and
nausea were reported in one[40] trial.
Quality evaluation of the randomized controlled trials
Adequate sequence generation
In 12 studies, four [35,36,37,43] claimed the methods of
randomization clearly, namely computer‑generated
randomization table while eight[34,38‑42,44,45] did not clearly
described how the random adequate sequences were
generated.

Outcomes Allocated concealment

Six[34‑36,41,42,45] RCTs reported number of HFs a day as the primary
outcome and four[34,36,41,45] of them reported KI at the same time.
One[44] trial just reported KI scores. Frequency or intensity/
severity of HFs was revealed in two[39,43] RCTs.
All of the RCTs show therapeutic effect of acupuncture.
However, of the six[34,35,39,40,43,44] trials comparing acupuncture
with SA, only two[34,40] get significant difference between
intervention and control groups, other four[35,39,43,44] reach
no statistical significance. Two[36,37] studies indicate negative
difference for acupuncture comparing with HT. Acupuncture
group appears to be equivalent to drug therapy (venlafaxine).[38]
As to applied relaxation, no statistic compare could be seen
in two[41,45] articles.
Only seven [34,35,39,40,41,44,45] trials reported the allocated
concealment method clearly. Hervik and Mjåland[44] used a
sealed envelope technique and Deng et al.[35] achieved the
concealment by cancer central of the trial. Five[36‑38,43] had no
specific statement and the other one[42] without concealing.
Blinding methods
One[39] trial performed blinding just for patients while another
six[34,35,40,43‑45] for the patients and investigator or outcome
assessor. It is unclear in the other articles.
Incomplete outcome data and selective outcome reporting
Only one [42] trial was found unclear on the risk of the
incomplete outcome data and selective outcome reporting.

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Other sources of bias
The trials were with no other sources of bias.
Estimate Effects of randomized controlled trials
Data were not available in two[38,42] trials, so nine[34,36,37,39‑41,43‑45]
trials were included for analysis. For 1[35] trial that was a
cross‑over design, we just chose the data before cross‑over.
Improvement of number or frequency of hot flashes
Six[34‑37,39,41] trials reported the number or frequency of HFs
after treatment, and meta‑analysis indicated that acupuncture
was superior to controls [MD, −1.52, 95% CI: −2.47–−0.58,
P = 0.002, Figure 2]. Five[34,36,37,39,41] trials reported the number
or frequency of HFs during follow‑up, and meta‑analysis
showed that acupuncture was better than controls [MD, −1.32,
95% CI: −2.19–−0.46, P = 0.003, Figure 3]. Two[36,37] trials were
not included in this meta‑analysis because interquartile range
was used in the result analysis, and the sample was too small
to convert into MD.
Improvement of quality‑of‑life
Three[34,41,44] trials reported KI scores, and meta‑analysis showed
significant difference between acupuncture and controls after
treatment [MD, −3.34, 95% CI: −3.60 − 3.07, P < 0.00001,
Figure 4] and during follow‑up [MD, −2.55, 95% CI: −2.77–
−2.34, P < 0.00001, Figure 5].
One [40] trial found a significant positive effect on sleep
in the acupuncture group compared with the SA and

Figure 2: Number of hot flashes after treatment

Figure 3: Number of hot flashes during follow-up

Figure 4: Improvement of Kupperman index after treatment

Figure 5: Improvement of Kupperman index during follow-up

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Chen, et al.: Acupuncture for breast cancer
no‑treatment groups after treatment. One[37] trial reached an
equivalent effect between acupuncture and HT in term with
health‑related quality‑of‑life and sleep. One[45] trial found no
difference between acupuncture and applied relaxation on
psychological well‑being and mood.
A funnel plot analysis is not eligible due to the insufficient
number.
DISCUSSION
This systematic review identifies very few rigorous RCTs testing
the effectiveness of acupuncture for HFs in women with BC. Of
the 12 RCTs, all of them agree on the effect of acupuncture to
improve HFs symptoms. Three[34,38,40] trials showed significant
difference compared with the controls, one[42] research just
demonstrated an encouraging trend, and six[35,39,41,43‑45] did
not find any difference between acupuncture and controls.
Another two[36,37] trials got a negative result compared with HT.
Our analysis gets positive results in terms with the number
of HFs and KI scores on the time after treatment and during
follow‑up in women with BC.
Compared with the most recent review by Frisk et al.,[46]
we found that acupuncture might be an effective way in
reducing the number of HFs and improving the quality‑of‑life
in women with BC. Hence, many methods were used to
assess the therapeutic effectiveness of HFs in women
with BC, but most of reviews used frequency of HFs as the
measurement.[31,47,48] Unlike them, number of HFs and KI of
women with BC were extracted to analyze in this review.
Number of HFs would measure the acupuncture effect the
same as the frequency of HFs and KI was established in
clinical practice which would indicate the quality of women’s
life from a multidimensional view including physiological,
psychological, and social aspects.[49] Hence, the improvement
of HFs in women with BC can be well‑evaluated from the
angle of number of HFs and KI.
Considering the limitations and side effects of conventional
therapies, HFs are proved to be different to manipulate in
women with BC.[17] In addition, the majority of the reasons
should be responsible for HFs in women with BC, which
accelerated the difficulty to treat HFs. HFs in women with
BC may occur as natural climacteric phenomena.[12] They may
also result from recommended discontinuation of hormone
replacement therapy or as a result of adjuvant treatments
for BC such as cytotoxic chemotherapy and selective
estrogen‑receptor modulator.[16] Even so, as a traditional
Chinese method, acupuncture possesses its unique therapeutic
principles and makes it possible to overcome HFs. From the
perspective of traditional Chinese medicine, HFs may be
induced by deficiency of yin and qi in postmenopausal or
menopausal women, especially kidney yin deficiency.[50,51]
However, in the theoretical system of acupuncture and
moxibustion, acupuncture can regulate and replenish yin,
540
yang, qi, and blood of the body, which may be the reason that
acupuncture can alleviate and treat HFs in women with BC.
However, acupuncture can evoke complex somatic‑sensory
sensations and may modulate the function of the body through
the brain and extending central nervous system networks.[52]
Huang et al.[53] present that the mechanism of acupuncture
regulates visceral sensation from the relationship between
meridians and viscera. Spetz Holm et al.[54] explained that
acupuncture can increase estrogen or release calcitonin
gene‑related peptide, which was effective to reduce HFs.
Walker et al. [38] and Hervik and Mjåland [34] proved that
acupuncture may reduce HFs in women with BC with fewer
side effects than conventional pharmacologic therapies. In this
review, two[38,40] trials definitely pointed out that acupuncture
had no side effect and one[38] even had additional beneficial.
Hence, though lack of evidence, acupuncture is bounded to
be chosen by BC patients to administrate HFs, and it will win
more attention.
The risk of bias in the studies was assessed based on the
descriptions of adequate sequence generation, blinding,
incomplete outcome data, selective outcome reporting,
allocation concealment, and other sources of bias. Most of the
studies suffered a relatively high‑risk of bias. Seven[34,35,39‑41,44,45]
RCTs reported the allocation concealment and the others did
not describe that, which led to exclusion or high risk of bias.
Six[34,35,40,43‑45] RCTs employed the double‑blinded methods of
patient‑investigator, one[39] trial made an attempt to blind
patients, and the blind methods were unclear in the other
RCTs. Though the acupuncturist could not be blinded, it was
necessary to blind patients and as well as the investigator
who was responsible for the data collection and evaluation
was possible to achieve. Thus, the reliability of the evidence
presented is clearly limited. In addition, though the model of
SA is tested and has been widely applied, there is still some
debate about it from the perspective of meridian theory.
However, another debated question is the homogeneity
of the participant in the included RCTs. (1) Reasons of HFs
did not clearly describe in this review. First, patients in
nine[34,35,36,37,39‑41,43] trials had finished treatment (primary
surgery and/or undergoing corresponding auxiliary therapy)
and the detailed information in other three[38,42,45] trials were
unknown. Second, tamoxifen played an important role in
anti‑estrogen therapy and was associated with the side
effect of HFs caused by estrogen deficiency.[55‑57] Although
participants in four[34,38,39,44] trials used tamoxifen, just one[34]
trial got a positive result and the other three did not get the
similar positive conclusion. It was difficult to analyze the
connection between the anti‑estrogen therapy and the effect of
acupuncture for HFs. (2) In this review, the women BC patients
in postmenopause condition in three[34,38,40] trials, two[34,40] of
them got significant difference compared with the control
groups, though the link between the effect of acupuncture for
HFs and the menopause status of the BC patients could not
definitely acquire. (3) Due to the incomplete information and
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Chen, et al.: Acupuncture for breast cancer
different standard of the limits of the number/severity of HFs
of the participants, the relationship between the improvement
and the baseline of HFs in the patients could not be obtained.
Further resolution is needed to minimize the risk and acquire
a convincing result.
CONCLUSION
Acupuncture seems to be an effective therapy to reduce HFs
in women with BC and improve BC women’s quality‑of‑life;
however, there was insufficient evidence to support the
efficacy of acupuncture. However, the results should be
interpreted cautiously, because of the poor quality and small
number of included studies.
Acknowledgments
The authors would like to thank all the people involved in
this process.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
1. Dalal S, Zhukovsky DS. Pathophysiology and management of hot
flashes. J Support Oncol 2006;4:315‑2025.
2. Pachman DR, Jones JM, Loprinzi CL. Management of menopause
‑associated vasomotor symptoms: Current treatment options,
challenges and future directions. Int J Womens Health 2010;2:123.
3. Freedman RR. Menopausal hot flashes: Mechanisms, endocrinology,
treatment. J Steroid Biochem Mol Biol 2014;142:115‑20.
4. Kronenberg F. Hot flashes: Epidemiology and physiology. Ann N Y
Acad Sci 1990;592:52‑86.
5. Freeman EW, Sammel MD, Sanders RJ. Risk of long‑term hot flashes
after natural menopause: Evidence from the Penn Ovarian Aging
Study cohort. Menopause 2014;21:924‑32.
6. Couzi RJ, Helzlsouer KJ, Fetting JH. Prevalence of menopausal
symptoms among women with a history of breast cancer and
attitudes toward estrogen replacement therapy. J Clin Oncol
1995;13:2737‑44.
7. Avis NE, Brockwell S, Colvin A. A universal menopausal syndrome?
Am J Med 2005;118 Suppl 12B: 37‑46.
8. Bień A, Rzońca E, Iwanowicz‑Palus G, Pańczyk‑Szeptuch M. The
influence of climacteric symptoms on women’s lives and activities.
Int J Environ Res Public Health 2015;12:3835‑46.
9. Ganz PA. Menopause and breast cancer: Symptoms, late effects, and
their management. Semin Oncol 2001;28:274‑83.
10. Carpenter JS, Johnson D, Wagner L, Andrykowski M. Hot flashes and
related outcomes in breast cancer survivors and matched comparison
women. Oncol Nurs Forum 2002;29:E16‑25.
11. Tchen N, Juffs HG, Downie FP, Yi QL, Hu H, Chemerynsky I, et al.
Cognitive function, fatigue, and menopausal symptoms in
women receiving chemotherapy for breast cancer. J Clin Oncol
2003;21:4175‑83.
12. Savard J, Davidson JR, Ivers H, Quesnel C, Rioux D, Dupéré V, et al.
The association between nocturnal hot flashes and sleep in breast
cancer survivors. J Pain Symptom Manage 2004;27:513‑22.
13. Goodwin PJ, Ennis M, Pritchard KI, McCready D, Koo J, Sidlofsky S,
Journal of Cancer Research and Therapeutics - April-June 2016 - Volume 12 - Issue 2
et al. Adjuvant treatment and onset of menopause predict weight
gain after breast cancer diagnosis. J Clin Oncol 1999;17:120‑9.
14. Guimond AJ, Massicotte E, Savard MH, Charron‑Drolet J, Ruel S,
Ivers H, et al. Is anxiety associated with hot flashes in women with
breast cancer? Menopause 2015;22:864‑71.
15. Bordeleau L, Pritchard K, Goodwin P, Loprinzi C. Therapeutic options
for the management of hot flashes in breast cancer survivors: An
evidence‑based review. Clin Ther 2007;29:230‑41.
16. David SM, Salzillo S, Bowe P, Scuncio S, Malit B, Raker C, et al.
Randomised controlled trial comparing hypnotherapy versus
gabapentin for the treatment of hot flashes in breast cancer survivors:
A pilot study. BMJ Open 2013;3:e003138.
17. Mao JJ, Leed R, Bowman MA, Desai K, Bramble M, Armstrong K,
et al. Acupuncture for hot flashes: Decision making by breast cancer
survivors. J Am Board Fam Med 2012;25:323‑32.
18. Albertazzi P, Steel SA, Bottazzi M. Effect of pure genistein on bone
markers and hot flushes. Climacteric 2005;8:371‑9.
19. Lewis JE, Nickell LA, Thompson LU, Szalai JP, Kiss A, Hilditch JR.
A randomized controlled trial of the effect of dietary soy and
flaxseed muffins on quality of life and hot flashes during menopause.
Menopause 2006;13:631‑42.
20. Verhoeven MO, van der Mooren MJ, van de Weijer PH, Verdegem PJ,
van der Burgt LM, Kenemans P; CuraTrial Research Group. Effect
of a combination of isoflavones and Actaea racemosa Linnaeus on
climacteric symptoms in healthy symptomatic perimenopausal
women: A 12‑week randomized, placebo‑controlled, double‑blind
study. Menopause 2005;12:412‑20.
21. Tice JA, Ettinger B, Ensrud K, Wallace R, Blackwell T, Cummings SR.
Phytoestrogen supplements for the treatment of hot flashes: The
Isoflavone Clover Extract (ICE) Study: A randomized controlled trial.
JAMA 2003;290:207‑14.
22. Fisher WI, Johnson AK, Elkins GR, Otte JL, Burns DS, Yu M, et al. Risk
factors, pathophysiology, and treatment of hot flashes in cancer. CA
Cancer J Clin 2013;63:167‑92.
23. Pockaj BA, Gallagher JG, Loprinzi CL, Stella PJ, Barton DL, Sloan JA,
et al. Phase III double‑blind, randomized, placebo‑controlled crossover
trial of black cohosh in the management of hot flashes: NCCTG Trial
N01CC1. J Clin Oncol 2006;24:2836‑41.
24. Jacobson JS, Troxel AB, Evans J, Klaus L, Vahdat L, Kinne D, et al.
Randomized trial of black cohosh for the treatment of hot flashes among
women with a history of breast cancer. J Clin Oncol 2001;19:2739‑45.
25. Newton KM, Reed SD, LaCroix AZ, Grothaus LC, Ehrlich K, Guiltinan J.
Treatment of vasomotor symptoms of menopause with black cohosh,
multibotanicals, soy, hormone therapy, or placebo: A randomized
trial. Ann Intern Med 2006;145:869‑79.
26. Barton DL, Loprinzi CL, Quella SK, Sloan JA, Veeder MH, Egner JR,
et al. Prospective evaluation of Vitamin E for hot flashes in breast
cancer survivors. J Clin Oncol 1998;16:495‑500.
27. Biglia N, Sgandurra P, Peano E, Marenco D, Moggio G, Bounous V, et al.
Non‑hormonal treatment of hot flushes in breast cancer survivors:
Gabapentin vs. Vitamin E. Climacteric 2009;12:310‑8.
28. Beer TM, Benavides M, Emmons SL, Hayes M, Liu G, Garzotto M,
et al. Acupuncture for hot flashes in patients with prostate cancer.
Urology 2010;76:1182‑8.
29. Frisk J, Spetz AC, Hjertberg H, Petersson B, Hammar M. Two modes
of acupuncture as a treatment for hot flushes in men with prostate
cancer – a prospective multicenter study with long‑term follow‑up.
Eur Urol 2009;55:156‑63.
30. Hammar M, Frisk J, Grimås O, Höök M, Spetz AC, Wyon Y. Acupuncture
treatment of vasomotor symptoms in men with prostatic carcinoma:
A pilot study. J Urol 1999;161:853‑6.
31. Lee MS, Kim KH, Choi SM, Ernst E. Acupuncture for treating hot
flashes in breast cancer patients: A systematic review. Breast Cancer
Res Treat 2009;115:497‑503.
32. Jeong YJ, Park YS, Kwon HJ, Shin IH, Bong JG, Park SH. Acupuncture
for the treatment of hot flashes in patients with breast cancer
541
[Downloaded free from http://www.cancerjournal.net on Sunday, May 10, 2020, IP: 190.238.16.154]
Chen, et al.: Acupuncture for breast cancer
receiving antiestrogen therapy: A pilot study in Korean women.
J Altern Complement Med 2013;19:690‑6.
33. Higgins J P T. Green S. Cochrane handbook for systematic reviews of
interventions version 5.1.0[J]. The Cochrane Collaboration 2011;5.
34. Hervik J, Mjåland O. Acupuncture for the treatment of hot flashes in
breast cancer patients, a randomized, controlled trial. Breast Cancer
Res Treat 2009;116:311‑6.
35. Deng G, Vickers A, Yeung S, D’Andrea GM, Xiao H, Heerdt AS, et al.
Randomized, controlled trial of acupuncture for the treatment of hot
flashes in breast cancer patients. J Clin Oncol 2007;25:5584‑90.
36. Frisk J, Carlhäll S, Källström AC, Lindh‑Astrand L, Malmström
A, Hammar M. Long‑term follow‑up of acupuncture and
hormone therapy on hot flushes in women with breast cancer: A
prospective, randomized, controlled multicenter trial. Climacteric
2008;11:166‑74.
37. Frisk J, Källström AC, Wall N, Fredrikson M, Hammar M. Acupuncture
improves health‑related quality‑of‑life (HRQoL) and sleep in women with
breast cancer and hot flushes. Support Care Cancer 2012;20:715‑24.
38. Walker EM, Rodriguez AI, Kohn B, Ball RM, Pegg J, Pocock JR, et al.
Acupuncture versus venlafaxine for the management of vasomotor
symptoms in patients with hormone receptor‑positive breast cancer:
A randomized controlled trial. J Clin Oncol 2010;28:634‑40.
39. Liljegren A, Gunnarsson P, Landgren BM, Robéus N, Johansson H,
Rotstein S. Reducing vasomotor symptoms with acupuncture
in breast cancer patients treated with adjuvant tamoxifen: A
randomized controlled trial. Breast Cancer Res Treat 2012;135:791‑8.
40. Bokmand S, Flyger H. Acupuncture relieves menopausal discomfort
in breast cancer patients: A prospective, double blinded, randomized
study. Breast 2013;22:320‑3.
41. Nedstrand E, Wijma K, Wyon Y, Hammar M. Vasomotor symptoms
decrease in women with breast cancer randomized to treatment
with applied relaxation or electro‑acupuncture: A preliminary study.
Climacteric 2005;8:243‑50.
42. Davies F. The effect of acupuncture treatment on the incidence and
severity of hot flushes experienced by women following treatment for
breast cancer: A comparison of traditional and minimal acupuncture.
Eur J Cancer 2001;37:S438.
43. Bao T, Cai L, Snyder C, Betts K, Tarpinian K, Gould J, et al.
Patient‑reported outcomes in women with breast cancer enrolled
in a dual‑center, double‑blind, randomized controlled trial assessing
the effect of acupuncture in reducing aromatase inhibitor‑induced
musculoskeletal symptoms. Cancer 2014;120:381‑9.
542
44. Hervik J, Mjåland O. Long term follow up of breast cancer patients
treated with acupuncture for hot flashes. Springerplus 2014;3:141.
45. Nedstrand E, Wyon Y, Hammar M, Wijma K. Psychological well‑being
improves in women with breast cancer after treatment with
applied relaxation or electro‑acupuncturefor vasomotor symptom.
J Psychosom Obstet Gynecol 2006;27:193‑9.
46. Frisk JW, Hammar ML, Ingvar M, Spetz Holm AC. How long do the
effects of acupuncture on hot flashes persist in cancer patients?
Support Care Cancer 2014;22:1409‑15.
47. Dodin S, Blanchet C, Marc I, Ernst E, Wu T, Vaillancourt C, et al.
Acupuncture for menopausal hot flushes. Cochrane Libr 2013,7:
CD007410.
48. Dos Santos S, Hill N, Morgan A, Smith J, Thai C, Cheifetz O.
Acupuncture for treating common side effects associated with breast
cancer treatment: A systematic review. Med Acupunct 2010;22:81‑97.
49. Tao M, Shao H, Li C, Teng Y. Correlation between the modified
Kupperman index and the menopause rating scale in Chinese women.
Patient Prefer Adherence 2013;7:223‑9.
50. Borud EK, Alræk T, White A, Grimsgaard S. The acupuncture treatment
for postmenopausal hot flushes (Acuflash) study: Traditional Chinese
medicine diagnoses and acupuncture points used, and their relation
to the treatment response. Acupunct Med 2009;27:101‑8.
51. Scheid V. Traditional Chinese medicine – what are we investigating?
The case of menopause. Complement Ther Med 2007;15:54‑68.
52. Stener‑Victorin E, Waldenström U, Andersson SA, Wikland M.
Reduction of blood flow impedance in the uterine arteries of infertile
women with electro‑acupuncture. Hum Reprod 1996;11:1314‑7.
53. Huang R, Zhao J, Wu L, Dou C, Liu H, Weng Z, et al. Mechanisms
underlying the analgesic effect of moxibustion on visceral pain in
irritable bowel syndrome: A review. Evid Based Complement Alternat
Med 2014;2014:895914.
54. Spetz Holm AC, Frisk J, Hammar ML. Acupuncture as treatment of
hot flashes and the possible role of calcitonin gene‑related peptide.
Evid Based Complement Alternat Med 2012;2012:579321.
55. Pérez AL. Antagonism of tamoxifen and antidepressants among
women with breast cancer 2011;139:89-99.
56. Klein DJ, Thorn CF, Desta Z, Flockhart DA, Altman RB, Klein TE.
PharmGKB summary: Tamoxifen pathway, pharmacokinetics.
Pharmacogenet Genomics 2013;23:643‑7.
57. Cronin‑Fenton DP, Damkier P, Lash TL. Metabolism and transport of
tamoxifen in relation to its effectiveness: New perspectives on an
ongoing controversy. Future Oncol 2014;10:107‑22.
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