Introduction
Hot flashes (HFs) are depicted as the occasional aesthesis of heat, flashing, and periods of profound sweating affecting the face and the chest, and in most instances, are accompanied by anxiety and palpitations (Deng et al., 2007; Jeong et al., 2013). These symptoms commonly last for 3 minutes to 10 minutes, and their occurrences frequently vary. Some patients, as Frisk et al., (2012) reports, experiences these flushed hourly or daily, and almost certainly, most patients report that these hot flushes have an adverse effect on the quality of their lives.
HFs are both a common phenomenon and have detrimental effects in females who have survived breast carcinomas. Factors that influence the rapid withdrawal of estrogen from the body have the capacity to influence the onset and worsening of hot flashes in women with breast cancer. These include cancer therapies (chemotherapy, oophorectomy, and endocrine therapies) and the menopausal status of the affected women (Salehi, Marzban, and Zadeh, 2016; Mao et al., 2015).
From the literature reviewed, hot flashes are apprehended as a subjective sensation of profound body heating whose duration, magnitude and associated symptomatology have a great variance in accordance to the affected woman (Mao et al., 2015). As an underlining characteristic of naturalistic menopause, the technical aspects underlying night sweats and hot flushes have not been fully delaminated. The reduction or total withdrawal of estrogen, adverse changes in the levels of the female gonadotropin hormone, and the role of catecholamine are all but implicated – however, no clear mechanisms of these propositions have been put forward (Frisk et al., 2008; Pirotta et al., 2014).
On the other hand, both the biological and psychological factors, best exemplified by cultural factors, the environment and the level of stress have also been proposed to trigger hot flushes and the accompanying night sweats – adding a layer of complexity to the overall pathophysiology of this phenomenon (Deng et al., 2007). The wide range of variation of how hot flushes and night sweats manifest associated with menopause, for example, makes it difficult to identify the general patterns of the phenomenon in the general population. Prevalence of as high as 93% and as low as 24% have all been reported in Northern European, and the United States respectively (Jeong et al., 2013). The severity and frequency of hot flushes have a wide variance from one woman to the other and have been proved to fluctuate within an individual as they progress through the menopausal period. The hurdles associated with measuring and managing these subjective and variable symptomatology is well established (Hill, Crider, & Hill, 2016).
History of the Problem
According to Pirotta et al. (2014), survivors of the breast cancer experience hot flashes at a greater frequency in comparison to women naturally undergoing their menopause, and that these flashes related to cancer may be more distressing, of greater severity and last longer. The occurrence of hot flushes may then be consorted by a variance of other physical sensations, including redness or flushing, dizziness, palpitations, nausea, feelings of suffocation, chills before and after the flash and tingling sensation on the hands (Chen et al., 2016).
The concomitant emotional symptomatology associated with hot flashes include feelings of panic, frustration, anxiety, irritation, annoyance and even contemplation of suicide (Hill, Crider, & Hill, 2016). Hot flushes disrupt normal sleep patterns in these women, leading to irritability and constant fatigue during the day (Hill et al., 2016). Hot flushes are both socially embarrassing and disabling, and their adverse effects on the ability of the affected women to lead a quality life are severely affected; the phenomenon is usually underrated (Frisk et al., 2012; de Valois et al., 2010).
In breast cancer patients, hot flashes may occur regardless of the natural menopause patterns of the woman. Bordeleau et al., (2010) note that young women have been recorded to experience the symptoms of menopause prematurely. Women who have a breast cancer diagnosis that happenstances with the natural menopause may have the symptomatology exacerbated. Women in their postmenopausal phase, on the other hand, may suffer from an unwanted return of the symptomatology. Users of Tamoxifen – for example – are frequently counselled that their symptomatology may subsidize over time (Hervik & Mjaland, 2009). However, studies conducted into the efficacy of Tamoxifen on hot flushes and night sweats reveal that on average, women suffer symptomatology after three years into the distinctive five-year tamoxifen therapy period and that these symptoms may continue to recur even after consummation of the drug therapy (Chen et al., 2016). While these symptoms are never life threatening, hot flushes and night sweats that occur during the therapy tend to encourage non-adherence to adjuvant hormonal therapies, potential compromising the improvement of the quality of life and the long-term survival of the affected patient (Deng et al., 2007).
Although hormonal replacement therapies are considered as one of the most effective treatments for the management of hot flushes (and other associated menopausal symptomatology), its long-term use has always been a red area for controversies and raging discussions (Frisk et al., 2012; Bordeleau et al., 2010). Such disagreements arise from the fears of increasing the risks of thromboembolism, breast cancer, and endometrial cancer and increases the chances of recurrences in breast cancer patients (Hervik, & Mjaland, 2009). Women who are definitively diagnosed with breast cancer on most instance get advised to avoid taking any hormonal replacement therapies, and in following these instructions, many women stop taking medicine when they are diagnosed with breast cancer. Accordingly, therefore, these women and in conjunction to their physicians become more eager in seeking alternative means to address hot flashes. In light of this, a range of pharmacological regimes, combinations and other therapies have been thoroughly investigated. These drug therapies include antidepressants (exemplifying the selective serotonin reuptake inhibitors (SSRIs) paroxetine and venlafaxine), anticonvulsants such as gabapentin, and anti-hypertensive such as clonidine (Pirotta et al., 2014; Walker et al., 2009).
Many women never desire to live through further adverse effects associated with conventional pharmacological options, or merely never want to take any additional medicinal to their adjuvant hormonal replacement regimen (Johns et al., 2016). For this group of women, alternative and complementary therapeutic approaches are seen as a likely choice. These include plant-derived remedies such as alfalfa, clover isoflavones and soy, vitamin E, exercise, cognitive behavioral treatments and lifestyle changes (Nedstrand, Wijma, Wyon, & Hammar, 2005).
According to Lesi et al. (2016), the management of menopausal symptoms is extensively discussed within Chinese medicine literature, and that the results from their controlled studies are a suggestion that acupuncture may be a beneficial therapy for the remediation of hot flushes in natural menopause. In light of this, acupuncture may offer alternative possibilities for the management of hot flashes related to additive hormonal treatments, and relevantly so, the intent of this research is to conduct an investigation into the topic (Lesi et al., 2016). In this research, the role of traditional acupuncture (TA) protocol in the treatments and management of menopausal symptoms in relation to is the application in the management of hot flushes is investigated. The main research questions were then that:
- Can Traditional acupuncture used in the management of the symptomology associated with natural menopause be used in the management of hot flushes that may be a result of hormonal replacement therapies instituted in a patient who has breast cancer?
- Does traditional acupuncture affect the overall emotional and physical well-being of the breast cancer patient?
Salehi et al. (2016) note that recent research on patients experiencing breast cancer plunged into garnering insights on the effectiveness of acupuncture in reducing hot flushes. Nevertheless, neither has managed to efficiently produce a clearly defined result or non-ambiguous statistical evidence, although they are a concrete demonstration of a pharmaceutical methodology that ought to be investigated to a greater extent. Lee and his associate researchers in Chen et al. (2016) conducted a systematic analysis of the effects of acupuncture on hot flushes in patients with a definitive diagnosis of breast carcinomas, which was related to six studies, and never gave a good estimation of the extent of this efficacy, nor definite conclusions. Additionally, they did not take into consideration the duration of treatment as one of the significant variables, a rationale for which this study is also founded in contributing to the current information (Chen et al., 2016).
In light of the research question hypothesized above, this study aims at systematically measuring the outcomes in both the short term and the long term, to garner a first measure of acupuncture in the management of hot flashes and test the suitability of the outcome measures. The study will be a rapid review, summarizing and critically assessing the effectiveness of traditional acupuncture in the management of hot flashes in cancer patients. In this article, a summary of the study methodology and results on the efficacy of acupuncture will be presented.
The research hypothesized that the use of acupuncture has the potential of lowering the frequencies of hot flashes by up to 50% at the end of the treatment in study participant and that the participants are likely to show an overall improvement in their physical and emotional well-being.
Methods/Materials
Data Sources
The study entailed searching databases for articles published to February 2017. The databases searched included PubMed, CINAHL, MEDLINE, Science Direct and Springer Link. My internship at the Highland Hospital enabled me to access their medical library to access any related materials. The research terms used included traditional acupuncture, electro-acupuncture, sham acupuncture, breast cancers, breast carcinomas, breast carcinogens, hot flash and hot flushes. Additionally, the hand searched reference lists of reviews constituted articles and conference proceedings. Available hard and soft copies of the materials were also adequately consulted.
Study Selection
First, only studies that titled the intervention as “acupuncture,” including electro-puncture, traditional acupuncture, self-acupuncture, ear-acupuncture and injection acupuncture were incorporated into this paper. The methodology of these studies included randomized clinical trials (main), case-control studies, observational studies, cohort studies, qualitative studies and case series were included.
Secondly, studies with patients who accepted acupuncture as the main treatment or an adjunct therapy to other therapies for the management of hot flushes (if the control participants were randomized to the same concomitant treatments as the group receiving acupuncture) were also included in the research. Thirdly, that the control groups would either be sham acupuncture (SA), non-acupoint acupuncture, relaxation or some other medicine (Conventional medicine). That in Randomized control trials, the study was only to be included when the resultant measurement was relevant to the hot flushes in breast cancer survivors.
The primary outcome of note was the frequencies or number of hot flushes after the institution of the treatments and during follow-ups. The secondary outcome measure was the effect on improvement in the quality of life that were measured on the validated indexes such as the Kupperman index (KI). Finally, it was ineligible if only immunological or biological parameters were estimated.
Within the study, articles were to be included if they entailed studies only carried out on females with who had survived breast cancer undergoing traditional needle acupuncture for the management of their hot flushes, adjuvant to or short of electrical stimulation. Other research publications reviewed presented needle acupuncture as the main single management therapy or as an add-on therapy to other instituted therapies, their efficacy of which will be evaluated in the study. Importantly, the preceding research materials included no intervention or active interventions less traditional acupuncture or sham acupuncture. This study also included articles in English. No language restrictions were imposed.
The Extraction of Data, Validity, and Quality Assessment
Two independent reviewers extracted the collected data in relevance to a predefined criterion. A modification of the Jadad score was then calculated by conducting an evaluation of the described randomization, criteria for withdrawal and blinding; with a score that ranged from 0 points to a 5-point score. Considering that it is an insurmountable hurdle to blind the therapist and their patients on the institution of acupuncture, a point was assigned for the blinding if the assessors who conducted outcome assessment were blinded. It was anticipated that no disagreements between the reviewers over assessing the issues tabled were to arise. Nevertheless, if the assessments conducted by the two reviewers proved incompatible, the variances in opinion, a consensus had to be reached through discussions or alternatively through the opinion of an external reviewer.
Performing a Data Analysis
The efficacy of acupuncture on the outcomes in this study was denoted as a mean change of hot flushes and the frequency during and at post-treatment, compared to the baseline. The confidence intervals were determined. (Example: by employing the meta-analysis software (CMA (V 2.2064 for Windows) a 95% CI of the individual studies would be determined). A follow-up time was then chosen as a baseline and considered as one of the important variables. The follow-up time, in this study, was then divided into five categories; as treatments instituted for less than one month (the 1st categorization). Between one and two months (the 2nd categorization). Between three to six months (the third categorization). Between seven to twelve months (the 4th categorization). And 13-25 months (the 5th categorization). Exemplifying this, a research publication is placed in the 3rd and the 2nd categorization if the follow-up times were denoted as three and six months respectively. The Q tests, τ2, and the I2 tests were used in assessing the heterogeneity of the studies.
Article Selection
The data search conducted managed to identify 111 items from which 65 articles were eliminated because of either inclusion in the various databases or inclusion. Additionally, 20 more research publications were excluded, of which 11 were in relation to the delamination of hot flashes, or were causally connected with non-relevant menopausal situations and not related patients suffering from breast cancer, 5 were related to the delamination of prostatic carcinoma and other unrelated malignant states, linked to the magnetic study. The final 10 publications were further subjected to a qualitative analysis. Some research publications posited the size of the effect as the median. The latter was added to the study and employed in the estimation of the mean and variance, range, and the sample size by the Hozo formula, the measures therefore minimizing the loss of informative data.
Problems and Limitations
- The outcomes of the studies were not presented in similar formats, therefore, analysis of the research findings had to be conducted based on the individual study
- Some studies did not include a validated measure of hot flashes. It might prove very valuable if objective measures of changes in the frequencies of hot flashes were made available (the measurement of facial temperature using an infrared thermography has on occasions presented unreliable measurements)
- Some studies lacked a control/placebo group – especially the observational studies. Without a control group, the benefits of acupuncture for the management of hot flashes may be potentially overestimated. Large, randomized and double-blinded groups are required to produce reliable results.
- The follow-up period after the completion of the therapies in some publications (for example 4 weeks and 12 weeks) may not have been sufficient. The results of a long-term follow-ups are necessary for the clarification of the efficacy of acupuncture.
Results
Salehi, Marzban, and Zadeh (2016), “Acupuncture for treating hot flashes in breast cancer patients: an updated meta-analysis.”
The authors purposed to appraise the efficacy of acupuncture as a therapeutic method that can be used in managing hot flashes in females who have been diagnosed with breast cancer. Methodologically, the aspects that the authors investigated included conducting a search until the April of 2015 and consultation of reference lists of the reviews and other relevant publications. Their inclusion criteria encompassed all publication on women survivors of breast cancer who received treatments with needle acupuncture in conjuction to or less of electrical stimulation to treat hot flushes. The researchers used the Jadad score to conducted a methodological quality assessment of the included articles.
With their inclusion criteria, the researches managed to identify 10 relevant articles. According to the researchers, conduction of a meta-analysis short of any subgroup or moderator had a shortcoming of failing to present any favorable outcomes of acupuncture on lowering the frequencies of hot flashes after the end of the intervention (n = 680, SMD = − 0.478, 95 % Confidence Interval −0.397 to 0.241, P = 0.632) but nevertheless managed to exhibit a marked heterogeneity of the search outcomes (Q value = 83.200, P = 0.000, I^2 = 83.17, τ^2 = 0.310).
That the conducted meta-analysis presented unconvincing and confounding evidence in suggesting that acupuncture may prove helpful in the management of hot flashes in female patients who have survived breast carcinomas. Relevantly, multi-central research that encompasses relatively large sample sizes is required for the conduction of investigations on the efficacy of therapeutically using acupuncture to treat hot flushes in female survivors of breast cancer.
This study came short of presenting any imperative evidence for the subservient outcomes of the various kinds of acupuncture (electro-acupuncture, sham acupuncture, traditional acupuncture) on hot flashes in female patients who have been definitively diagnosed with breast carcinomas. A reason underlying this is that the studies conducted in are heterogeneous in their nature, and include a handful of patients, short of taking into consideration the issues of methodology to minimize biases and dismiss poor quality primary data.
Whereas researchers have outlined the importance of conducting further research on the efficacy of acupuncture for both the management and alleviation of the hot flashes symptomatology in breast carcinoma patients, the situation has relatively remained unchanged despite the ever-increasing number of studies. Therefore, the authors strongly underline the need for comprehensive guidelines be provided in the conduction of multicenter clinical trials. In doing so, the propitious effects of acupuncture will be underlined.
Lesi et al., (2016), “Acupuncture as an Integrative Approach for the Treatment of Hot Flashes in Women with Breast Cancer: A Prospective Multicenter Randomized Controlled Trial (AcCliMaT).”
In this research, the researchers purposed to delaminate the effects of using acupuncture as a therapy in improving the frequency of the hot flashes symptomatology amongst the female survivors of breast carcinomas. Participants and research methodology: the researchers carried out a pragmatic, RCT study making a comparison of acupuncture in conjunction to enhanced self-care to the institution of only enhanced care. 169 participants (n=169) women survivors of breast cancer were randomized to either the control or the trial therapy. The randomization was conducted with a stratification for hormone therapy; a 1:1 allocation ratio was presented. The researchers furnished the participants (the control and the intervention groups) with information (in a booklet) on the menopausal symptomatology (climacteric syndrome), and the treatment was carried out for at least twelve weeks. The participants receiving acupuncture received ten additional treatment sessions of traditional acupuncture which involved needling of predetermined acupoints.
Then, the researchers recorded the hot flashes score as the primary outcome at completion of the treatment (the twelfth week), worked out as the frequency of the hot flashes as a multiplication of the mean severity of the hot flashes. The other effects recorded were the climacteric symptomatology and the quality of life, which were appropriately gauged based on the Greene Climacteric and Menopause Quality of Life scales respectively. The outcomes in the quality of health in these participants were continuously gauged for up to 6 months after completion of the therapy. Within the study, another secondary outcome measured was the evaluation of the expectations of acupuncture and the satisfaction accrued from the effects of the therapy in addition to its safety. The intention-to-treat analysis was used.
Enhanced self-care was randomly assigned to 105 of the study participants whereas 85 others were assigned to enhanced self-care in conjunction to acupuncture. At the end of the treatment, it was revealed that acupuncture plus enhanced self-care had a high association with a significant diminution of the frequency of hot flushes than when enhanced self-care was instituted as a stand-alone therapy, (P < 0.001) and at three and six-month after completion of the treatment follow-ups (P = .0028 and .001, respectively), lesser climacteric symptomatology and an enhanced life quality in the psychological, physical and vasomotor domains (P < 0.05).
Relevantly, the researchers present that the institution of any form of acupuncture in conjunction with enhanced self-care serves as one of the efficacious and integrative approaches for the management of the climacteric symptomatology and the improvement of the quality of life for female patients diagnosed with breast cancers.
Hervik and Mjaland (2009). “Acupuncture for the treatment of hot flashes in breast cancer patients, a randomized, controlled trial.”
The researchers posit that acupuncture has been employed numerously in managing of hot flushes in healthy postmenopausal women. In light of this, their research purposed to conduct an investigation of the efficacy of acupuncture as an alternative/complementary treatment for the management of hot flushes in women related to anti-estrogen medication. The study was a prospective, controlled clinical trial.
59 study participants (n=59) with a definitive diagnosis of breast cancer and then experiencing hot flashes pursuant to surgical interventions for breast cancer and subsequent adjuvant tamoxifen (estrogen-antagonist treatment) were randomly assigned to either ten weeks of sham acupuncture or traditional Chinese’ acupuncture. The man frequency of hot flashes that experienced both at night and during the day before the treatment, over the duration of the treatment as well as during the 12 weeks that followed the treatment were all recorded. The researchers used the Kupperman Index as a validated health score at the baseline, after completion of the therapy and after twelve weeks after treatment completion.
Over the course of the treatment, the average frequency of hot flashes during the day and at night was notably lowered by 50 to almost 60%, respectively from the record of the acupuncture group, and that it was additionally reduced by 39% both at daytime and at night over the next 12 weeks of follow-up. In the group receiving sham acupuncture, the frequency of hot flushes during the day were significantly reduced up to 25% over the course of the treatment but then were reversed to the initial status during the next 12 weeks of follow-up. Also, no major reduction on the frequency of hot flashes was recorded at night. The Kupperman index drastically diminuend by 44% from the figures recorded on the commencement of the treatment (baseline) to completion of the treatment period in the group receiving acupuncture, and then to a greater extent maintained for the 12 weeks after completion of the treatment. No accompanying changes were recorded in the group that received the sham acupuncture.
Seemingly then, the authors conclude that acupuncture provides an efficient way of managing and relieving hot flushes both during the day and at night in females patients who have been operated for breast cancer and receiving Tamoxifen therapy. The researchers, in conclusion, then posit that the treatment seemingly coincides with the general health improvements measured by the validated Kupperman index.
Johns et al., (2016), “Informing hot flash treatment decisions for breast cancer survivors: a systematic review of randomized trials comparing active interventions.”
The authors posit that the making of patient-centered decisions on the institution of hot flashes in most instances will incorporate a balance between the efficacy and the adverse outcomes of the therapy in conjunction to the specified preferences of the patient. The study, in light of this then, was a systematic review conducted to examine a number of randomized control trials (RCTs) that at least made a comparison of two non-hormonal hot flash management therapies in the survivors of breast carcinoma. Appropriately then, the conducted a search in 5 major databases (CINAHL, SCOPUS, PubMed, Cochrane and Web Science Databases) on the July of 2015, with the inclusion criterion being that only research materials that had RCTs comparing active, non-hormonal hot flash treatments in the survivors of breast carcinomas.
From their results, then, 13 RCTs studies were included in the systematic review from a potential of 906 studies. Four of the RCTs Research presented findings on dose comparison studies of the pharmacologic therapies of venlafaxine, paroxetine, citalopram, and gabapentin. The frequency of hot flashes experienced by the survivors of breast cancer did not have any notable differences when aromatase inhibitors or tamoxifen was used. Citalopram in the dosages of 10mg, 20mg, and 30mg instituted daily also were proved to have comparable outcomes. The administration of 75mg of venlafaxine on a daily basis improved the prevalence of hot flushes with an advantage of not having associated side effects from higher dosages. 900mg of gabapentin on a daily basis effectively improved the frequency of hot flushes than daily dosages of 300mg. 10 mg of paroxetine administered daily was proved to confer fewer side effects than 20 mg of the drug on a daily basis.
The researchers also present that amongst the four trials that made a comparison of the different pharmacologic treatments, it was found that venlafaxine alleviated the symptomatology of hot flashes faster than clonidine; that also the research participants had a preference for venlafaxine over gabapentin. Of the five RCTs that compared pharmacologic treatments to non-pharmacologic therapies, it was found out that acupuncture conferred the survivors of breast cancer the same efficacy as gabapentin and venlafaxine; but that the therapy would last longer after completion of the treatments and analysis as the outcomes of the studies were not presented in comparable formats.
Relevantly then, data from the examined RCTs on non-hormonal therapies for the management of hot flashes provides an efficient way of making a comparison of the efficacy of the treatments and presents and valuable guide for the clinical management of the symptomatology. Medical practitioners can use the information presented within the literature then to appropriately select the best hot flush intervention based on efficacy, expected outcomes and patient preferences.
De Valois et al. (2010), “Using Traditional Acupuncture for Breast Cancer-Related Hot Flashes and Night Sweats.”
In this study, the authors posit that women on the Tamoxifen regimen often experience hot flushes and night sweats; that acupuncture has the potential of offering non-pharmaceutical methods of management. Their study, appropriately then, made an exploration on the effectiveness of traditional acupuncture in reducing the frequency of night sweats, improve the emotional and physical well-being of the patient and free the perceptions on this phenomenon.
The researchers employed the single arm observational methodology to conduct the research before and after measurements carried out at the National Health Service cancer treatment facility located at the southerly parts of England. 50 (n=50) participants who had an early-onset breast cancer accomplished eight traditional acupuncture therapies. The participant inclusion criteria were women aged >35 years, had undergone >6 months of post active cancer therapy, having taken tamoxifen for >6months, and self-reporting >4 incidences of night sweats and hot flashes per 24 hours for >3 months.
The intervention: that the study participants were to receive a weekly individualized traditional acupuncture therapy based on a core standardized protocol for the treatment of night sweats and hot flushes in natural menopause. The measured outcomes include: Hot flush diaries were used to record the frequency of night sweats and hot flushes over a fourteen-day time frame. The Women’s Health Questionnaire was used to assess the emotional and physical well-being of the participants. The hot flashes and night sweat questionnaire was used to evaluate the hot flushes and night sweats as a state of difficulty that needed to be solved. The authors measure five-point measurement over 30 weeks: baseline, mid-therapy, end of therapy, and at 4 and 18 weeks after completion of the regimen.
Results: The research indicates that for the primary outcome, the mean frequency of night sweats and hot flushes was lowered by 49.8% (95% CI 40.5–56.5, p < 0.0001, n ¼ 48) at the end of the therapy over the recorded figures at the baseline. The trends also indicated long-term effects at the 4 and 18 weeks after the therapy was completed. That, at the completion of the therapy, seven Women’s Health Questionnaire domain demonstrated significant clinical and statically positives, including memory/concentration, anxiety/fears, sexual behavior, menstrual problems. Somatic symptomatology, sleep problems, and vasomotor symptomatology. The authors also indicate that the perception of the hot flashes and the night sweats as 2.2 points lowered a perpetual problem (an SD ¼ 2.15, n ¼ 48, t ¼ 7.16, p < 0.0001).
Relevantly, the outcomes realized can be favorably be compared with other research conducted that employ acupuncture in the movement of night sweats and hot flashes, as well as research on non-hormonal pharmaceutical management strategies. Additional to the reduced frequency of hot flushes and night sweats, women enjoyed a heightened emotional and physical well-being, and that few adverse effects from the study were reported. The study, call upon for more research plunging into understanding the effectiveness of this, which presents the survivors of breast cancer with a choice in managing their chronic condition.
Frisk et al. (2012), “Acupuncture improves health-related-quality-of-life (HRQoL) and sleep in women with breast cancer and hot flashes.”
The researchers conducted this study to evaluate the effectiveness of instituting electro-acupuncture and hormonal therapies on health-related quality of life and patterns of sleep in survivors of breast carcinomas suffering from concomitant vasomotor symptomatology. 45 women (n=45), randomized to electro-acupuncture (n=27) for twelve weeks or hormone therapy (n=18) for a period of twenty-four months were enlisted in the study and followed for up to 12 years. The mean frequency of, and distress caused by hot flushes, the number of sleeping hours and the and the times woken up during the day/night, The Psychological and General Well-being Index and the Women’s Health Questionnaire were all recorded prior to and over the curse of the therapy at six months, nine months, twelve months, eighteen months and twenty-four months after commencing the therapy.
After twelve weeks of the electro-acupuncture therapy (n=19 (8 dropped)), the WHQ improved from a 0.32 (Interquartile range 0.23–0.53) at the beginning of the study to 0.24 (Interquartile range of 0.12–0.39; p<0.001) and the Psychological and General Well-being index from 78 (IQR 53–89) to 79 (IQR 68–93; p=0.002). That all the measure parameters of sleep were noted to have significantly ameliorated and the Hot Flush Score decreased by a whopping 80%. On the 12th month after the initiation of the therapy, the WHQ, the Psychological and General well-being index and all the parameters of sleep measured were noted to have remained significantly improved (n=14). The Hot Flush Score was significantly reduced by 65%.
On the other hand, after twelve weeks of hormonal therapy, (n=18), the Women’s Health Questionnaire improved from 0.29 (IQR 0.15–0.44) at the beginning of the study to 0.15 (IQR 0.05–0.22; p=0.001). The Psychological and General Well-Being index also improved from 75 (IQR 59–88) to 90 (62–97; p=0.102). The therapy was also associated with the improvement of there of the five parameters of sleep measured.
Relevantly, the authors posit that both Hormonal Therapy and Electro-acupuncture increases the patient’s Health-Related Quality of Life and sleep, most apparently by lowering the frequency and distress associated with hot flushes and night sweats. Although the frequency of hot flushes amongst the participants receiving electro-acupuncture reduced less than the group receiving hormonal therapy, the Health-Related quality of life improved leastwise to a similar extent probably as a result of other effects of the acupuncture, not brought about by the hormone treatment. Exemplifying this is sleep, vitality, and anxiety, supported by other subscale analyses conducted. Relevantly, the authors echo the need for evaluating the efficacy of Electro-acupuncture further in managing hot flashes in survivors of breast cancer and those with climacteric complaints, who can longer be recommended to take Hormonal Therapy.
Nedstrand, Wijma, Wyon, and Hammar, (2005), “Vasomotor symptoms decrease in women with breast cancer randomized to treatment with applied relaxation or electro-acupuncture: a preliminary study.”
The authors conducted this research to evaluate the outcomes of electro-acupuncture and applied relaxation on vasomotor symptomatology in survivors of breast cancer. In their study, 38 (n=38) women in their post-menopausal age experiencing vasomotor symptomatology related to breast carcinomas were randomized to either receive therapy with applied relaxation (n=19) or electro-acupuncture (n=19) over the course of the 12 weeks of the study. The frequencies of hot flushes experienced was logged daily prior to and after the commencement of the treatment and after three and six months of follow-up.
From their study, 31 women managed to completed the 12 weeks’ therapy and the following six months of intensive follow-ups. After twelve weeks of applied relaxation, the frequency of flushes per 24 hours had lowered from a baseline of 9.2 (95% Confidence Interval 6.6–11.9) to 4.5 (95% Confidence Interval 3.2–5.8) at the end of the treatment and to 3.9 (95% CI 1.8–6.0) at the 6th month of continued follow-up (n = 14). The frequency of flushes per 24 hours was reduced from 8.4 (95% Confidence Interval 6.6–10.2) at the baseline to 4.1 (95% CI 3.0–5.2) after a 12-week treatment regimen with electro-acupuncture and to 3.5 (95% Confidence Interval 1.7–5.3) after 6 months’ follow-up (n = 17). From both groups, then, it was revealed, the mean score on the Kupperman Index was notably decreased after the institution of the treatment regimen and remained static for six months after the completion of the therapy.
Relevantly then, electro-acupuncture and applied relaxation are techniques that should be further evaluated as possible treatment regimens for vasomotor symptomology in post-menopausal survivors of breast cancer.
Frisk et al., (2008), “Long-term follow-up of acupuncture and hormone therapy on hot flushes in women with breast cancer: a prospective, randomized, controlled multicenter trial.”
This study was objectively conducted as a study evaluating the effects of hormone therapy and electro-acupuncture on the vasomotor symptomatology in survivors of breast cancer. 45 (n=45) participant women were randomly assigned to receive electro-acupuncture (n ¼ 27) for twelve weeks or hormonal therapy (n ¼ 18) for twenty-four months. The frequency of hot flush distresses was logged in at the baseline, during and up to 24 months after commencement of the therapy.
It was revealed that of the 19 (n=19) women who had managed to complete the 12 weeks of the electro-acupuncture, the median frequency of hot flushes per 24 hours had been lowered from the baseline 9.6 (with an interquartile range (IQR) 6.6–9.9) number to 4.3 (IQR 1.0–7.1) on the 12th week of the therapy (p 5 0.001). At the 12th month after commencing the therapy, 14 women with only the initial 12 weeks of electro-acupuncture has a median frequency of flushes per 24 hours of 4.9 (IQR 1.8–7.3), and on the 24th month after the treatment seven women with no other treatment other than the electro-acupuncture had a frequency of 2.1 (IQR 1.6–2.8) flushes per a 24hour period. Another, five other women has lowered the frequency of flashes after having an additional electro-acupuncture. The 18 women receiving the hormonal therapy had their baseline median on the number of flushes experienced within 24 hours to be 6.6 (IQR 4.0–8.9), and 0.0 (IQR 0.0–1.6; p ¼ 0.001) on the 12th week after the commencement of the treatment.
In light of this, the authors post that electro-acupuncture presents new possibilities for the treatment of the vasomotor symptomatology for the survivors of breast cancer and should be further studied.
Garland et al., (2017), “Comparative effectiveness of electro-acupuncture versus gabapentin for sleep disturbances in breast cancer survivors with hot flashes: a randomized trial.”
In the study, the researchers evaluated the effects of electro-acupuncture versus gabapentin in the treatment of sleep disturbances among the survivors of breast cancer experiencing daily hot flushes.
The researchers analyzed data from an RCT involving 58 survivors of breast cancer experiencing bothersome hot flashes at least twice in a day. The participants of the study were then randomized to receive eight weeks of electro-acupuncture or a daily dosage of gabapentin (a total dose of 900mg per day). Primarily, the authors were to measure the total change in the Pittsburgh Sleep Quality Index (PSQI) score between the two groups of participants at the 8th week. The secondary outcome measured included the specific PSQI parameters.
At the end of the instituted regimen on the 8th week, the mean reduction in the PSQI total score proved to be significantly greater in the group receiving the electro-acupuncture than the group on the Gabapentin regimen (2.6 versus 0.8, P ¼ 0.044). The group receiving electro-acupuncture also experienced improved sleep latency (0.5 versus 0.1, P ¼ 0.041) and slept efficiently (0.6 versus 0.0, P ¼ 0.05) as compared to the group that only received the gabapentin. By the 8th week, the group receiving the electro-acupuncture had an improved sleep duration, had shorter sleep latency, experienced less sleep disturbance, had a decrease in daytime dysfunction, had an improvement in sleeping efficiency, and their sleeping quality was significantly improved (P < 0.05 for all) as in comparison to the baseline. On the other hand, the group receiving gabapentin only had an improvement in the duration and quality of sleep only (P < 0.05).
That among the women who experience hot flashes, the effects of electro-acupuncture can be compared to the drug gabapentin in the improvement of the quality of sleep, specifically in the areas of sleep efficacy and latency. The need for larger randomized controlled trials which incorporate longer follow-up periods in confirming these preliminary findings is underlined.
Deng et al., (2007), “Randomized, Controlled Trial of Acupuncture for the Treatment of Hot Flashes in Breast Cancer Patients.”
This study purposed at determining the effects of instituting both short term and long term traditional acupuncture against sham acupuncture in the management of the frequencies of hot flashes in women with a definitive diagnosis of breast cancer.
72 women who had survived breast cancer and experiencing >3 hot flushes per day were randomized to get either traditional acupuncture or sham acupuncture. In the study, the interventions were instituted twice weekly for four consecutive weeks. The frequency of hot flushes was evaluated at the baseline, on the 6th week, and on the 6th month after initiation of the treatment. According to the researchers, the patients randomized to sham acupuncture were then crossed over to traditional acupuncture on the 7th week.
In examining the posited results, the average number of hot flashes experienced on a daily basis was significantly lowered from 8.7 (Standard Deviation, 3.9) to a frequency of 6.2 (SD, 4.2) among the group receiving traditional acupuncture and from 10.0 (SD, 6.1) to 7.6 (SD, 5.7) in the participants that were randomized to receive sham acupuncture. The authors posited that the frequency of hot flashes among the participants randomized to traditional acupuncture led to a prevalence of 0.8 fewer hot flashes on a daily basis as compared to the group that received the sham acupuncture at the 6th week, but the difference never attained the statistical significance (95% CI, 0.7 to 2.4; P = .3). When the group receiving sham acupuncture were crossed over joining the group receiving traditional acupuncture, an additional decrease in the daily frequency of hot flashes was also realized. That such a frequency in the study persisted for up to 6 months after completion of the treatment.
Relevantly then, the authors posit that the frequency of hot flushes in cancer patients was significantly lowered following treatment with acupuncture. However, in comparison to sham acupuncture, the diminution noted in the frequency of hot flashes noted by the instituted acupuncture regimen as provided within the fabric of the study never managed to attain the set statistical significance. The possibility that more intense and longer acupuncture has the potential of significantly reducing the symptomatology cannot be precluded.
Discussion
The physiology and treatment of hot flushes
According to de Valois, (2010), hot flushes, also referred to as hot flashes, are a group of symptomatology marked by periods of intense feeling of warmth that have a sudden onset, and usually begin at the chest and radiate to the face and neck. The episodic hot flushes are commonly accompanied by heart palpitations, sweating, and flushing. The duration of hot flashes has a great variance, from second to minutes. Whereas hot flashes have been recorded to occur at any time over a period of 24 hours, hot flushes that occur at night tend to be bothersome, as they disruptive normal sleep patterns (Nedstrand, Wijma, Wyon, & Hammar, 2005).
In a study conducted to determine the patterns of cognitive behavior in breast cancer survivors, hot flashes and night flushes were proved to significantly lead to greater wake time, lowered stage II of sleep and longer rapid eye movements latencies in comparison to nights comfortably slept without night sweats (Deng et al., 2007). According to Hill, Crider, and Hill, (2016), the deprivation of sleep in this group of women has a negative impact on the daytime activities, alters normal functioning, elevates fatigues, pain, depression and heightens the level of anxiety. All this when working in tandem, significantly alter the normal quality of life.
Within the literature reviewed, the etiology of hot flashes is an area that has not garnered insights into its fabric (Mao et al., 2015). The contributing factors in this category (the survivors of breast cancer) include the age of the woman at which the disease was diagnosed, the occurrence of premature menopause related to the surgeries undergone and the subsequent chemotherapy and deficiencies in endogenous estrogen that result from the use aromatase inhibitors and tamoxifen (Chen et al., 2016; Hervik & Mjaland, 2009).
Hormone replacement therapies, once regarded as one of the most effective treatment options, has admittedly (and consistently) been found to heighten risk of the recurrence of cancer in trial women who had a history of cancer; with studies getting terminated prematurely because of this finding. Hormonal replacement therapies have since been contraindicated. Non-hormonal pharmacologic elements currently in use, such as gabapentin, venlafaxine, clonidine, and citalopram confer benefits, but then also are associated with numerous adverse effects, including drowsiness, headaches, and dizziness (Walker et al., 2009).
Acupuncture in Literature
According to Hill et al. (2016), the first Women’s Health Initiative (WHI) clinical trial was published, leading to clinicians and patients to interrogate the safety profiles of menopausal hormonal therapies. Prior to the publication of the research, patients used to take hormonal therapies to improve their overall health, treat menopausal symptomatology and prevent cardiac diseases. The extensive study (n=16,000 women) made a comparison of an amalgamated oral hormonal regimen constituting of a conjugated equine estrogen and medroxyprogesterone with a placebo (Hill et al., 2016). The researchers realized that the combined regimen of these drugs heightened the risk of breast cancer, stroke, coronary artery diseases and venous thromboembolism incidences. The study also presented findings that the hormonal therapy conjured the benefits of decreasing the risk of hip fractures, colorectal cancer and the total fractures experienced by the patients (Hill et al., 2016). The critiques of this study hold the position that it is never appropriate to make a generalization of the results to all women undergoing menopause, partly as the average age of the study’s participants was 63 years (Hill et al., 2016, pg. 885).
Subsequent research then conducted helped refine this rudimental information. The WHI 2004 publication of a conjugated estrogen (carried out in women without a uterus) led to the revelations of no major change in the risk of breast cancer or coronary heart diseases, and that a similar trial that followed combining progesterone and estrogen heightened the risk of VTE and strokes (Hill et al., 2016). A 2013 review of the findings of both trials after a median follow-up period of thirteen years posited that women on a combined hormonal therapy had a heightened risk of VTE and breast carcinomas, and significantly had a lower risk of hip fractures (Jeong et al., 2013). Contrasting this, women on estrogen therapy alone had a marked reduction in the risks of developing breast carcinomas.
According to Frisk et al. (2008), a handful of studies have managed to plunge into exploring acupuncture as an alternative therapy for treating the symptomatology of hot flashes and managed to yield promising results, but then only come short in outlining the efficacy of this methodology. In the systematic review conducted by Chen et al (2016) constituting of only studies that employed the randomized controlled trial test on breast cancer participants also indicated that acupuncture led to a realization of a positive improvement in hot flashes in comparison with the baseline records. Twelve of the publications identified agreed on the potential of therapeutically using acupuncture for the treatment of hot flushes in women diagnosed with breast carcinomas. The evidence presented within the studies, however, was deemed as insufficient by the researcher citing that the methodologies of study conduction were flawed.
In more recent randomized control trials (Lesi et al.,2016; Mao et al., 2015; Bordeleau et al., 2010; Deng et al., 2007; Frisk et al., 2012), many patients with breast cancer were randomized to traditional manual acupuncture, sham acupuncture and/or self-care. The participants to whom acupuncture was assigned to reported positive effects. Not only was the score of hot flushes at the end of the studies significantly improved, but also after 12 weeks, three months, six months and twelve months into the follow-up visits. Acupuncture also was proved to significantly enhance the quality of life in the control groups (Hill et al., 2016).
Noteworthy findings also included are in another meta-analysis conducted by Salehi, Marzban, and Zadeh, (2016) titled. In the study, breast cancer survivors suffering from bothersome hot flashes and night sweats from twelve studies were included. The researchers randomized the participants to receive sham acupuncture, electro-acupuncture, gabapentin or placebo for a specified period (eight weeks, twelve weeks, four months, twelve months and eighteen months). The data analyzed was indicative that the effects of acupuncture can be compared to those of gabapentin, and that they had fewer side effects and were durable on follow-ups. Although the effect size of the participants receiving electro-acupuncture was small in comparison to the control groups at the end of the treatments, the effects were considerably heightened in the weeks of follow-up, clearing suggesting that acupuncture may produce long-lasting physiologic effects (Jeong et al., 2013).
Additionally, electro-acupuncture has been reported to be comparable to gabapentin (and other drugs thereof) in improving the patterns of sleep in the survivors of breast cancer (Deng et al., 2007; Bordeleau et al., 2010). Although the mechanisms of this complementary treatment has not been completely understood, the studies reviewed have illustrated that electro-acupuncture can effectively mediate its effects via the action of endorphins and other centrally acting (and produced) neuropeptides (Wyon et al., 2004; Deng et al., 2007; Bordeleau et al., 2010). Such thereof presents a new basis for the alleviation of hot flashes.
Patient Concern and Patterns on the Use of Acupuncture
Mao et al. (2012) present that patients may never want to use acupuncture because they fear needles. Other patients wondered on how acupuncture may affect their co-morbidities (such as lymphedema – will the acupuncture worsen the lymphedema or better it?). Other respondents stated that taking pills may be an easier option when compared to the more desired choice of acupuncture. Potential hurdles to the use of acupuncture, from the perspectives of the patient, also include the location of the practitioner proximal to their areas of residence, difficulties in finding a credible specialist, and commitment of time to the therapy (Mao et al., 2012).
Breast cancer survivors indicate that the decisions on the use of acupuncture – or thereof choose another treatment modality for hot flashes – is entirely theirs. Two groups of individuals who are consulted on decisions to treat hot flashes were revealed: the immediate family members (adult children, partners, or spouses) and qualified medical practitioners (Mao et al., 2012). Whereas some breast cancer survivors may turn to their doctors for matters related to the treatment of symptoms (especially the Caucasians), other survivors of breast cancer turn to their primary care practitioner for a major decision (the African Americans) (Mao et al., 2012).
Acupuncture, on its position as a therapy for the management of hot flashes, is majorly perceived on what it is not rather than what it is. Specifically, acupuncture is not a medicine. Medication is described as toxic, foreign, and have side effects related to their use and that these side effects may worsen the hot flashes (Mao et al., 2012). Concurrently then, the treatment is endorsed based on the notion that it is natural even when its efficacy is in question. Relevantly then, a major determinant of the utilization of acupuncture by the survivors of breast carcinomas is in its appeal as a natural alternative (Mao et al., 2012). Citing the minimalist comprehension of acupuncture and the relative lack of knowledge of how acupuncture can be specifically used to treat hot flashes, a patient will often rely on their families and consult their physicians on the use of any of the various forms of acupuncture in managing the symptomatology of hot flashes (Mao et al., 2012).
Conclusion
Research predicts that the number of breast cancer survivors in the US would nearly be 6million by the year 2020. Such an estimate then underlines the need for identifying effective interventions aimed at controlling the symptomatology. Compounding this is the fact that patients are growing a heightened desire for natural alternatives to curtail the unwanted side effects of the prescription medicine currently in use. Acupuncture, as one of the alternative therapies that have garnered extensive study, acupuncture within the literature reviewed has been documented to be one of the most valuable complementary therapies that can be employed in the settings of oncology to control symptoms.
The evidence presented on the ability of acupuncture to alleviate hot flashes and positively ameliorate the overall quality of life are but encouraging, but also point out the need for larger rigorous clinical trials to attain conclusive data. Until then, for the patients that experience the bothersome symptoms who are never amenable to medications, nurses and oncologists then recommend that a course of six to ten acupuncture treatments would suffice in treating the symptomatology. Finally, it is of paramount importance that patients suffering from cancer and considering acupuncture seek credentialed practitioners who have both the experience and training in working with such a population.
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