[Skip to Content]
[Skip to Content Landing]

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.

Abstract

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

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 Credit(s)™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

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.

References
1.
Steglitz  J , Buscemi  J , Ferguson  MJ .  The future of pain research, education, and treatment: a summary of the IOM report “Relieving pain in America: a blueprint for transforming prevention, care, education, and research”.   Transl Behav Med. 2012;2(1):6-8. doi:10.1007/s13142-012-0110-2PubMedGoogle ScholarCrossref
2.
Mao  JJ , Armstrong  K , Bowman  MA , Xie  SX , Kadakia  R , Farrar  JT .  Symptom burden among cancer survivors: impact of age and comorbidity.   J Am Board Fam Med. 2007;20(5):434-443. doi:10.3122/jabfm.2007.05.060225PubMedGoogle ScholarCrossref
3.
Deandrea  S , Montanari  M , Moja  L , Apolone  G .  Prevalence of undertreatment in cancer pain. A review of published literature.   Ann Oncol. 2008;19(12):1985-1991. doi:10.1093/annonc/mdn419PubMedGoogle ScholarCrossref
4.
van den Beuken-van Everdingen  MH , Hochstenbach  LM , Joosten  EA , Tjan-Heijnen  VC , Janssen  DJ .  Update on prevalence of pain in patients with cancer: systematic review and meta-analysis.   J Pain Symptom Manage. 2016;51(6):1070-1090.e9. doi:10.1016/j.jpainsymman.2015.12.340 PubMedGoogle ScholarCrossref
5.
Zylla  D , Steele  G , Gupta  P .  A systematic review of the impact of pain on overall survival in patients with cancer.   Support Care Cancer. 2017;25(5):1687-1698. doi:10.1007/s00520-017-3614-yPubMedGoogle ScholarCrossref
6.
Paice  JA .  Managing pain in patients and survivors: challenges within the united states opioid crisis.   J Natl Compr Canc Netw. 2019;17(5.5):595-598. doi:10.6004/jnccn.2019.5010PubMedGoogle Scholar
7.
Vitzthum  LK , Riviere  P , Murphy  JD .  Managing cancer pain during the opioid epidemic-balancing caution and compassion.   JAMA Oncol. 2020;6(7):1103-1104. doi:10.1001/jamaoncol.2020.0779PubMedGoogle ScholarCrossref
8.
Kaptchuk  TJ .  Acupuncture: theory, efficacy, and practice.   Ann Intern Med. 2002;136(5):374-383. doi:10.7326/0003-4819-136-5-200203050-00010PubMedGoogle ScholarCrossref
9.
Vickers  AJ , Cronin  AM , Maschino  AC ,  et al; Acupuncture Trialists’ Collaboration.  Acupuncture for chronic pain: individual patient data meta-analysis.   Arch Intern Med. 2012;172(19):1444-1453. doi:10.1001/archinternmed.2012.3654PubMedGoogle ScholarCrossref
10.
Vickers  AJ , Vertosick  EA , Lewith  G ,  et al; Acupuncture Trialists’ Collaboration.  Acupuncture for chronic pain: update of an individual patient data meta-analysis.   J Pain. 2018;19(5):455-474. doi:10.1016/j.jpain.2017.11.005PubMedGoogle ScholarCrossref
11.
CMS finalizes decision to cover acupuncture for chronic low back pain for Medicare beneficiaries. News release. Centers for Medicare & Medicaid Services. January 21, 2020. Accessed February 10, 2021. https://www.cms.gov/newsroom/press-releases/cms-finalizes-decision-cover-acupuncture-chronic-low-back-pain-medicare-beneficiaries
12.
He  Y , Guo  X , May  BH ,  et al.  Clinical evidence for association of acupuncture and acupressure with improved cancer pain: a systematic review and meta-analysis.   JAMA Oncol. 2020;6(2):271-278. doi:10.1001/jamaoncol.2019.5233PubMedGoogle ScholarCrossref
13.
Ulett  GA , Han  S , Han  JS .  Electroacupuncture: mechanisms and clinical application.   Biol Psychiatry. 1998;44(2):129-138. doi:10.1016/S0006-3223(97)00394-6PubMedGoogle ScholarCrossref
14.
Zhang  R , Lao  L , Ren  K , Berman  BM .  Mechanisms of acupuncture-electroacupuncture on persistent pain.   Anesthesiology. 2014;120(2):482-503. doi:10.1097/ALN.0000000000000101PubMedGoogle ScholarCrossref
15.
Fan  AY , Stumpf  SH , Faggert Alemi  S , Matecki  A .  Distribution of licensed acupuncturists and educational institutions in the United States at the start of 2018.   Complement Ther Med. 2018;41:295-301. doi:10.1016/j.ctim.2018.10.015PubMedGoogle ScholarCrossref
16.
Niemtzow  R , Baxter  J , Gallagher  RM ,  et al.  Building capacity for complementary and integrative medicine through a large, cross-agency, acupuncture training program: lessons learned from a military health system and veterans health administration joint initiative project.   Mil Med. 2018;183(11-12):e486-e493. doi:10.1093/milmed/usy028PubMedGoogle ScholarCrossref
17.
Zeliadt  SB , Thomas  ER , Olson  J ,  et al.  Patient feedback on the effectiveness of auricular acupuncture on pain in routine clinical care: the experience of 11,406 veterans.   Med Care. 2020;58(suppl 2 9S):S101-S107. doi:10.1097/MLR.0000000000001368 PubMedGoogle ScholarCrossref
18.
Liou  KT , Baser  R , Romero  SAD ,  et al.  Personalized electro-acupuncture versus auricular-acupuncture comparative effectiveness (PEACE): a protocol of a randomized controlled trial for chronic musculoskeletal pain in cancer survivors.   Medicine (Baltimore). 2020;99(21):e20085. doi:10.1097/MD.0000000000020085PubMedGoogle Scholar
19.
Mao  JJ , Farrar  JT , Armstrong  K , Donahue  A , Ngo  J , Bowman  MA .  De qi: Chinese acupuncture patients’ experiences and beliefs regarding acupuncture needling sensation—an exploratory survey.   Acupunct Med. 2007;25(4):158-165. doi:10.1136/aim.25.4.158PubMedGoogle ScholarCrossref
20.
Niemtzow  RC .  Battlefield acupuncture: my story.   Med Acupunct. 2018;30(2):57-58. doi:10.1089/acu.2018.29077.rcnPubMedGoogle ScholarCrossref
21.
Cleeland  CS , Ryan  KM .  Pain assessment: global use of the Brief Pain Inventory.   Ann Acad Med Singap. 1994;23(2):129-138.PubMedGoogle Scholar
22.
Hays  RD , Bjorner  JB , Revicki  DA , Spritzer  KL , Cella  D .  Development of physical and mental health summary scores from the patient-reported outcomes measurement information system (PROMIS) global items.   Qual Life Res. 2009;18(7):873-880. doi:10.1007/s11136-009-9496-9PubMedGoogle ScholarCrossref
23.
Revicki  DA , Kawata  AK , Harnam  N , Chen  WH , Hays  RD , Cella  D .  Predicting EuroQol (EQ-5D) scores from the patient-reported outcomes measurement information system (PROMIS) global items and domain item banks in a United States sample.   Qual Life Res. 2009;18(6):783-791. doi:10.1007/s11136-009-9489-8PubMedGoogle ScholarCrossref
24.
Harris  PA , Taylor  R , Thielke  R , Payne  J , Gonzalez  N , Conde  JG .  Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support.   J Biomed Inform. 2009;42(2):377-381. doi:10.1016/j.jbi.2008.08.010PubMedGoogle ScholarCrossref
25.
Robinson-Papp  J , George  MC , Wongmek  A ,  et al.  The Quantitative Analgesic Questionnaire: a tool to capture patient-reported chronic pain medication use.   J Pain Symptom Manage. 2015;50(3):381-386. doi:10.1016/j.jpainsymman.2015.03.013PubMedGoogle ScholarCrossref
26.
Dmitrienko  A , Millen  BA , Brechenmacher  T , Paux  G .  Development of gatekeeping strategies in confirmatory clinical trials.   Biom J. 2011;53(6):875-893. doi:10.1002/bimj.201100036PubMedGoogle ScholarCrossref
27.
Lu  K , Luo  X , Chen  P-Y .  Sample size estimation for repeated measures analysis in randomized clinical trials with missing data.   Int J Biostat. 2008;4(1):9. doi:10.2202/1557-4679.1098PubMedGoogle ScholarCrossref
28.
Dworkin  RH , Turk  DC , Wyrwich  KW ,  et al.  Interpreting the clinical importance of treatment outcomes in chronic pain clinical trials: IMMPACT recommendations.   J Pain. 2008;9(2):105-121. doi:10.1016/j.jpain.2007.09.005PubMedGoogle ScholarCrossref
29.
Liu  GF , Lu  K , Mogg  R , Mallick  M , Mehrotra  DV .  Should baseline be a covariate or dependent variable in analyses of change from baseline in clinical trials?   Stat Med. 2009;28(20):2509-2530. doi:10.1002/sim.3639PubMedGoogle ScholarCrossref
30.
Hershman  DL , Unger  JM , Greenlee  H ,  et al.  Effect of acupuncture vs sham acupuncture or waitlist control on joint pain related to aromatase inhibitors among women with early-stage breast cancer: a randomized clinical trial.   JAMA. 2018;320(2):167-176. doi:10.1001/jama.2018.8907PubMedGoogle ScholarCrossref
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.

Close
Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
Close
Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close

Name Your Search

Save Search
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Close
Close

Lookup An Activity

or

My Saved Searches

You currently have no searches saved.

Close

My Saved Courses

You currently have no courses saved.

Close