The development of an acupuncture service to treat hot flushes as a consequence of cancer treatment

Summary

A physiotherapy specialist services provides acupuncture treatment to help manage side effects of cancer treatment.

6 weekly interventions of acupuncture have resulted in an average 88% improvement in their self-reported Measure Yourself Medical Outcome Profile (MYMOP) score and 77% reduction of impact on the Hot Flash Related Daily Interference Scale (HFRDIS) over two years.

Description

Acupuncture is a therapeutic technique involving the insertion of fine needles into certain points in the body. It is a commonly used modality in physiotherapy and is now widely accepted as a recognised treatment along with conventional physiotherapy.

Cancer has long been considered a contra-indication for physiotherapists practicing acupuncture. The skills of the team working with cancer patients are utilised to identify when it is safe to use this modality for the benefit of this group.

Many individuals who have been treated for cancer, either with chemotherapy or adjuvant hormonal treatment can experience debilitating hot flushes, which can be successfully treated with a course of acupuncture. Oestrogen is one of the factors that can stimulate some breast cancers to grow by triggering particular proteins (receptors) in the cancer cells. If a patient has the oestrogen receptors, the breast cancer is termed oestrogen-receptor positive (ER positive). Tamoxifen is a hormonal drug that blocks the oestrogen from reaching the cancer cells and thereby either slows or completely stops the cancer from growing.

The oestrogen deprivation brought about by the anti-oestrogen therapy, such as Tamoxifen, in addition to the chemotherapy can abruptly disrupt or permanently cease ovarian function, which can lead to the onset of hot flushes also known as vasomotor symptoms. (Leining et al, 2006).

In line with the Welsh Government’s National Standards for Rehabilitation of Adult Cancer Patients (2010) and Together for Health - Cancer Delivery Plan (2012), the aim of the Therapies team is to provide a consistent approach for the treatment of patients within rehabilitation services.

The NICE guidance ‘Improving Supportive and Palliative Care for Adults with Cancer’ (2004) states that “rehabilitation attempts to maximise patients’ ability to function, to promote their independence and to help them adapt to their condition.  It offers a major route to improving their quality of life, no matter how long or short the timescale.  It aims to maximise dignity and reduce the extent to which cancer interferes with an individual’s physical, psychological and economic functioning”. 

Recent advances in acupuncture clinical research and the resulting growing evidence base suggest that, due to its systemic effects, acupuncture provides clinical benefit for cancer patients with treatment-related side effects such as: -

  • Hormone treatment related side effects e.g.: hot flushes
  • Nausea and vomiting
  • Cancer related fatigue
  • Anxiety
  • Sleep disorders
  • Xerostomia (dryness in the mouth)
  • Connective tissue (?) and muscle tension
  • Pain
  • Loss of wellbeing.

A recent paper published by Johns et al (2016)4, showed acupuncture to have similar efficacy to venlafaxine and gabapentin (pharmacological intervention) but to have possible longer durability after completing treatment and fewer side effects. 

Velindre Cancer Centre (VCC) is a specialist centre in Cardiff providing services to a population of more than 1.5 million people across south east Wales and beyond.

The physiotherapy team at Velindre identified a common theme with the post-op breast surgery patients as they were constantly being asked about treatment options for hot flushes. Following a literature review, acupuncture was identified as an evidence based treatment option. Further funding was then granted from charitable funds at Velindre Cancer Centre to allow a two-year project of the use of acupuncture to cancer patients at Velindre.

The service currently treats hot flushes for all tumour sites with the majority of referrals being breast and prostate cancers.

Over the past four years we have had four members of the physiotherapy team complete their foundation in acupuncture course, band 6 and above (3x band 6 and 1x band 7). 

The acupuncture service officially started in July 2015.

Initiation and implementation

Training:

One member of the physiotherapy team obtained funding through Macmillan to carry out her acupuncture training to start up the service. Further funding to train up and deliver the service by the physiotherapy department was provided for an initial two-year period from charitable funds at Velindre Cancer Centre.

A typical referral for acupuncture will follow these steps:

  • Patient’s needs are identified by a health care professional i.e. hot flushes, anxiety, insomnia and if appropriate referred to the physiotherapy acupuncture service 
  • The referral is entered into an excel database and a letter along with an information leaflet is sent out inviting patients to a 45-minute group introductory session which runs monthly. A presentation outlining what acupuncture is, what to expect and to allay any fears about the intervention and are provided with an information leaflet explaining everything discussed in the consenting session.
  • 6 weekly group or 1:1 appointments are allocated to each patient and a letter is sent in the post confirming this
  • 1st session: validated outcome measures are completed including Hot Flash related Daily Interference Scale (HFRDIS) and MYMOP. Needling regime is started 
  • 2nd – 5th sessions: review of MYMOP and needling regime is reviewed / continued
  • 6th session: review of MYMOP, review of HFRDIS and needling regime is continued. Top is offered in 6 weeks if deemed appropriate.

Self-management techniques are taught and encouraged and patients are told to contact the service if they encounter any further problems with hot flushes. The uptake rate of this has been minimal over the last two years, indicating maintained improvement in the management of hot flushes and cancer related symptoms.

An acupuncture policy was reviewed with the palliative care team and a patient information leaflet was produced to ensure patients are fully informed of the treatment intervention.

Quality

Number of patients treated in the acupuncture service
2014: 101(124 referred, 23 didn’t complete six-week course)
2015: 85 (104 referred, 19 didn’t complete six-week course)

2016: 143 (157 referred, 14 didn’t complete the six-week course)  

% of patients demonstrating improvement in MYMOP hot flush score from week 1 to week six of treatment (weekly)
2014: 92% 93 patients
2015: 87% - 74 patients                                                                                                                                                                                             2016: 89% - 128 patients

Over half (51%) of the patients improved MYMOP by dropping 3 or more points this is combining the 2-year period, 2014/15.

% of patients showing a reduction in the HFRDIS score from week 1 to week 6 (wk1 & 6)
2014: 81% - 82 patients
2015: 73% - 62 patients                                                                                                                                                                                               2016: 88% - 125 patients

Cost and savings

More than half of patients seen to date in 2016 had unsuccessfully tried medication to help reduce hot flushes. This costs £2.56 per 56 tabs of Venlafaxine, repeated for many months, compared to a six-week acupuncture course, which costs approximately £5 in total. This represents a large cost saving compared to pharmacological intervention.

The group consenting sessions on average have 8 people attending with either a band 6 or band 7 leading a half hour induction session (pre changes we used to consent everyone individually).

Regarding the 6 treatment sessions, this may be a band 6 or 7 and appointments lasting for 30mins.

We use on average 8 needles per session x6 sessions = 48 needles on average. A box of 100 needles costs approx. £5.

Lack of evidence regarding the length of time the symptoms last for – anecdotal evidence suggests 12-18 months. We offer an evidence based top-up session within 8 weeks of completing the 6 sessions. We’ve had 3 people referred back into the system over the last 2 years.

What did you learn?

One change to the service: the introduction of group consenting sessions for acupuncture. This includes education about acupuncture and puts the treatment into context for the patient and allows them to complete the consenting paperwork at the same time. This has reduced the number of one to one consenting sessions required and has reduced the waiting time for patients to be seen for their initial contact

The service has been shown to be cost-effective at a time when resources are a major factor in service planning, with a six-week acupuncture course proving cheaper than the pharmaceutical alternative. In addition, the group consenting sessions have cut waiting times and freed up valuable clinic time. Following face-face appointments in the first 5 months of 2014 for 43 patients, the service introduced the group consenting sessions, accommodating 58 patients within 7 group sessions; effectively saving 51 appointment slots. We currently run consenting sessions twice a month ensuring patients don’t breech our waiting target of 4 weeks.  

The service is sustainable and is now embedded at VCC. In less than six years it has brought about real change in the treatment options available to a large percentage of the cancer patients in Wales. The south west Wales physiotherapy teams are developing a business case to present to Macmillan to extend the service, as the results of this innovative approach have demonstrated it can improve the quality of life for many patients.

The service was short-listed for an Excellence award.

Relevant contacts and resources

1. Centre for Academic Care. Measure Yourself Medical Outcome Profile (MyMOP) score. University of Bristol.  http://www.bris.ac.uk/primaryhealthcare/resources/mymop/

2. Carpenter JS. (2001). The hot flash related daily interference scale: a tool for assessing the impact of hot flashes on quality of life following breast cancer. Journal of Pain Symptom Management 2001;22:979–89.  https://dash.harvard.edu/bitstream/handle/1/11877078/3773636.pdf?sequence=1

http://demoshealth.com/media/DH-downloads/Elkins_PDFfiles/Hot_Flash_Related_Daily_Interference_Scale_(HFRDIS).pdf

3. Leining MG, Gelber S, Rosenberg R, Przypyszny M, Winer EP, Partridge AH. (2006) Menopausal-type symptoms in young breast cancer survivors. Annals of Oncology 17: 1777–1782, 2006. https://annonc.oxfordjournals.org/content/17/12/1777.full.pdf

4. Welsh Assembly Government (2010) National Standards for Rehabilitation of Adult Cancer Patients  http://www.wales.nhs.uk/sites3/Documents/322/National_Standards_for_Rehabilitation_of_Adult_Cancer_Patients_2010.pdf

5.  Welsh Assembly Government (2012) Together for Health: Cancer Delivery Plan for the NHS to 2016.  http://gov.wales/topics/health/nhswales/plans/cancer/?lang=en

6. The National Institute of Innovation and Clinical Effectiveness (2004) Improving Supportive and Palliative Care for Adults with Cancer. Cancer service guideline (CSG4). https://www.nice.org.uk/guidance/csg4

7. Johns C, Seav SM, Dominick SA, Gorman JR, Li H, Natarajan L, Mao JJ, Su HI. (2016). Informing hot flash treatment decisions for breast cancer survivors: a systematic review of randomized trials comparing active interventions. Breast Cancer Research and Treatment (2016) doi:10.1007/s10549-016-3765-4. http://www.hello-doll-face.com/download/uploads/27015968.pdf