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Effectiveness of Electroacupuncture or Auricular Acupuncture vs Usual Care for Chronic Musculoskeletal Pain Among Cancer SurvivorsThe PEACE Randomized Clinical Trial

Educational Objective
To learn the effectiveness of electroacupuncture and auricular acupuncture for the management of chronic musculoskeletal pain in patients with cancer.
1 Credit CME
Key Points

Question  Does electroacupuncture or auricular acupuncture reduce chronic musculoskeletal pain among cancer survivors?

Findings  In this randomized clinical trial of 360 diverse cancer survivors, patients receiving electroacupuncture and auricular acupuncture had significantly greater reductions in pain scores from baseline to week 12 compared with patients receiving usual care. However, auricular acupuncture was not noninferior to electroacupuncture, and patients receiving it had more adverse events.

Meaning  Electroacupuncture and auricular acupuncture are more effective than usual care at reducing chronic musculoskeletal pain in cancer survivors.


Importance  The opioid crisis creates challenges for cancer pain management. Acupuncture confers clinical benefits for chronic nonmalignant pain, but its effectiveness in cancer survivors remains uncertain.

Objective  To determine the effectiveness of electroacupuncture or auricular acupuncture for chronic musculoskeletal pain in cancer survivors.

Design, Setting, and Participants  The Personalized Electroacupuncture vs Auricular Acupuncture Comparative Effectiveness (PEACE) trial is a randomized clinical trial that was conducted from March 2017 to October 2019 (follow-up completed April 2020) across an urban academic cancer center and 5 suburban sites in New York and New Jersey. Study statisticians were blinded to treatment assignments. The 360 adults included in the study had a prior cancer diagnosis but no current evidence of disease, reported musculoskeletal pain for at least 3 months, and self-reported pain intensity on the Brief Pain Inventory (BPI) ranging from 0 (no pain) to 10 (worst pain imaginable).

Interventions  Patients were randomized 2:2:1 to electroacupuncture (n = 145), auricular acupuncture (n = 143), or usual care (n = 72). Intervention groups received 10 weekly sessions of electroacupuncture or auricular acupuncture. Ten acupuncture sessions were offered to the usual care group from weeks 12 through 24.

Main Outcomes and Measures  The primary outcome was change in average pain severity score on the BPI from baseline to week 12. Using a gatekeeping multiple-comparison procedure, electroacupuncture and auricular acupuncture were compared with usual care using a linear mixed model. Noninferiority of auricular acupuncture to electroacupuncture was tested if both interventions were superior to usual care.

Results  Among 360 cancer survivors (mean [SD] age, 62.1 [12.7] years; mean [SD] baseline BPI score, 5.2 [1.7] points; 251 [69.7%] women; and 88 [24.4%] non-White), 340 (94.4%) completed the primary end point. Compared with usual care, electroacupuncture reduced pain severity by 1.9 points (97.5% CI, 1.4-2.4 points; P < .001) and auricular acupuncture reduced by 1.6 points (97.5% CI, 1.0-2.1 points; P < .001) from baseline to week 12. Noninferiority of auricular acupuncture to electroacupuncture was not demonstrated. Adverse events were mild; 15 of 143 (10.5%) patients receiving auricular acupuncture and 1 of 145 (0.7%) patients receiving electroacupuncture discontinued treatments due to adverse events (P < .001).

Conclusions and Relevance  In this randomized clinical trial among cancer survivors with chronic musculoskeletal pain, electroacupuncture and auricular acupuncture produced greater pain reduction than usual care. However, auricular acupuncture did not demonstrate noninferiority to electroacupuncture, and patients receiving it had more adverse events.

Trial Registration  ClinicalTrials.gov Identifier: NCT02979574

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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Accepted for Publication: February 4, 2021.

Published Online: March 18, 2021. doi:10.1001/jamaoncol.2021.0310

Corresponding Author: Jun J. Mao, MD, MSCE, Integrative Medicine Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1429 First Ave, New York, NY 10021 (maoj@mskcc.org).

Author Contributions: Dr Mao had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Mao, Romero, Gallagher.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Mao, Liou, Baser, Panageas, Romero, Li.

Critical revision of the manuscript for important intellectual content: Mao, Liou, Baser, Bao, Panageas, Gallagher, Kantoff.

Statistical analysis: Baser, Panageas, Li.

Obtained funding: Mao.

Administrative, technical, or material support: Mao, Liou, Romero, Gallagher.

Supervision: Mao, Panageas, Kantoff.

Conflict of Interest Disclosures: Dr Mao reports grants from Tibet Cheezheng Tibetan Medicine Co Ltd and Zhongke Health International LLC outside the submitted work. Dr Panageas reports stock ownership in Johnson & Johnson, Pfizer, Viking Therapeutics, and Catalyst Biotech outside the submitted work. Dr Kantoff reports personal fees from Bavarian Nordic Immunotherapeutics, GE Healthcare, Genentech/Roche, Janssen, Merck, OncoCell MDx, Progenity, SynDevRx, and Tarveda Therapeutics; other support from Cogent Biosciences and Placon; and personal fees and other support from Context Therapeutics LLC, Druggability Technologies Holdings, Mirati, Seer Biosciences, and XLink outside the submitted work. No other disclosures were reported.

Funding/Support: This work was supported by the Department of Defense office of the Congressionally Directed Medical Research Programs through the Peer Reviewed Medical Research Program Clinical Trial Award (W81XWH-15-1-0245). This work was also supported in part by a National Institutes of Health/National Cancer Institute Cancer Center grant (P30 CA008748).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: Opinions, interpretations, conclusions, and recommendations in this article are those of the authors and are not necessarily endorsed by the Department of Defense.

Data Sharing Statement: See Supplement 3.

Additional Contributions: We thank the patients who participated in this study, as well as the acupuncturists and research staff for their dedication to the research process. Compensation was not provided for any contributions.

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AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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