Acupuncture may be a new tool for treating lymphedema but data is lacking

Always on the look-out for new approaches to treating lymphedema, we took a close look at a new study that examines the use of acupuncture for treating the condition.

The study in question (Cassileth B.R., Van Zee K.J., et al. Acupuncture in the treatment of upper-limb lymphedema: Results of a pilot study. Cancer. 2013 Apr 10 Epub) was designed as a pilot trial to investigate the safety of acupuncture in treating lymphedema.  A total of 33 patients with breast cancer related lymphedema were included.  The patients were treated in 30 minute sessions twice weekly for four weeks, for a total of 255 treatment sessions (across all patients).  The researchers used a combination of 14 acupuncture points, four of which were located in the affected arm/hand.  This study appears to be the most rigorously designed prospective study to date to examine the use of acupuncture for treating lymphedema.

Figure from Cassileth B.R. et al. showing locations of the 14 acupuncture points used in the study.

Using acupuncture on limbs with lymphedema is contentious.  Lymphedematous tissue has a higher risk of developing infection, and so use of needles is contraindicated.  In fact, therapists trained in acupuncture are specifically taught to avoid these high risk areas entirely.  Based on the personal experience of the authors of this latest study, as well as anecdotal evidence from others, the authors hypothesize that acupuncture can be a safe and efficacious treatment for lymphedema.  So what did the results of their study actually say?

The results suggest that acupuncture performed by qualified practitioners under sterile conditions can indeed be safe.  Of the 255 acupuncture treatments given, the researchers observed no infections or adverse outcomes.  This result is supported by a handful of earlier (but more poorly designed) studies.  However, the authors go further with their conclusions, stating that they “saw evidence that acupuncture decreases lymphedema”.  While we agree that their data suggests that acupuncture may be safe, the usefulness of acupuncture for treating lymphedema is neither supported nor refuted by their data. 

This study was not designed to be able to answer the question of acupuncture efficacy for treating lymphedema.  At the most basic level the study did not include a group of patients who had lymphedema but were NOT given acupuncture.  Treatment efficacy conclusions cannot be drawn from any study that does not use a randomized controlled trial design (and better yet, a double-blind placebo controlled randomized design).

A variety of other possibilities exist that could explain why some patients in this study demonstrated reductions in lymphedema symptoms.  In particular, the majority of participants were also undergoing “standard treatments for lymphedema” both before and during this study, and presumably also undertaking at-home lymphedema management and flare-avoidance practices.  This could be a very simple and logical explanation for the reduction in lymphedema symptoms observed.  There is also the possibility that the reduction in lymphedema symptoms reported in this study is sheer coincidence, or even a placebo effect.  Clearly the data in this paper does not and cannot provide evidence for or against the use of acupuncture in lymphedema, regardless of the explicit personal biases of the researchers, or the enthusiasm of headline writers at Reuters Health: “Acupuncture eases lymphedema in breast cancer patients: pilot study”.

Thankfully, further insight into this question is forthcoming.  The authors have plans to publish results from a randomized controlled trial that is currently underway.  Hopefully the design of this new trial will be sufficient to provide quality evidence to evaluate the potential utility of acupuncture for this condition.  Past studies suggest that acupuncture can influence a range of biological phenomena such as inducing the production of endogenous opioids (pain killers), anti-inflammatory mediators and neuropeptides, as well as the placebo effect.  It is therefore reasonable to explore the use of acupuncture for this condition.  Being trained in acupuncture ourselves, we look forward to seeing additional data!