Abstract
Objective
Approximately 24–68% of breast cancer survivors report co-occurring psychoneurological symptoms of pain, fatigue, sleep disturbance, depression, and anxiety during and after cancer treatment. This study aimed to assess the feasibility and acceptability of acupuncture for the treatment of multiple psychoneurological symptoms among breast cancer survivors and explore metabolomic changes before and after acupuncture.
Methods
We conducted a single-arm, prospective pilot study of breast cancer survivors with at least two moderate to severe psychoneurological symptoms (>3 on a 0–10 scale). Acupuncture was administered twice weekly for 5 weeks, for 30 minutes per session. Along with Patient-Reported Outcomes Measurement Information System (PROMIS) questionnaires, a fasting serum comprehensive hydrophilic metabolites panel was analyzed at baseline and after acupuncture.
Results
Eight participants (mean age 52.5 ± 10.9 years; 62.5% Black) were enrolled. Feasibility was supported, with 67% recruitment, 87.5% retention, and 98% acceptability. Post intervention, PROMIS T-scores were reduced for all psychoneurological symptoms. Significant differences in serum metabolites before and after acupuncture were F-1,6/2,6-DP, glutathione disulfide, phosphorylcholine, 6-methylnicotinamide, glutathione, and putrescine (variable importance of projection values larger than 1.5 and p values <0.05). Pathway analysis indicated that glutathione metabolism (p = 0.002, q = 0.071), and arginine and proline metabolisms (p = 0.009, q = 0.166) were potentially involved in mechanisms of acupuncture.
Conclusions
Acupuncture to reduce multiple psychoneurological symptoms among breast cancer survivors was feasible and acceptable. Study findings also shed light on the metabolic pathways involved in the acupuncture response and will be tested in future studies.
Introduction
Approximately 24–68% of breast cancer survivors report multiple co-occurring psychoneurological symptoms of pain, fatigue, sleep disturbance, depression, and anxiety during and after cancer treatment (Bjerkeset et al., 2020). Some psychoneurological symptoms can persist 5–10 years after completion of cancer treatment and have a detrimental impact on quality of life, functional status, and work functioning (Al-Bashaireh et al., 2021; Dorland et al., 2018). The typical symptom management approach is to provide intervention for each symptom; this approach does not address the burden and cost of managing multiple treatments or the risks of polypharmacy (Kwekkeboom et al., 2020). There is urgent need to efficiently coordinate symptom management strategies for co-occurring psychoneurological symptoms among breast cancer survivors.
Effective management of psychoneurological symptoms is challenging. Pharmacotherapy is the primary treatment modality for symptom management; however, opioids are often associated with significant adverse effects. Nonpharmacological interventions can be used to manage multiple psychoneurological symptoms, leading to decreased prescription opioids (Mannes et al., 2022). Clinical practice guidelines for the management of chronic pain in adult cancer survivors support nonpharmacological approaches (Paice et al., 2016).
Acupuncture has been used as a nonpharmacological, complementary and integrative health (CIH) treatment to manage cancer symptoms in more than 60% of National Cancer Institute–designated comprehensive cancer centers in the United States (Brauer et al., 2010). Emerging evidence shows that acupuncture is effective at reducing cancer-related pain (Hershman et al., 2018), fatigue (Smith et al., 2013), depression (Xiao & Liu, 2014), and sleep disturbance among cancer survivors (Garland et al., 2017). A major tenet of Traditional Chinese Medicine (TCM) is holism, which asserts that the body itself is a unified whole (Giovanni, 1989). The viscera and tissues of the body each comprise an entire coordinated system, which together communicate with and influence one another (Zhang & Chor, 2021). This interrelationship is fostered by the connecting and communicating actions of the meridians. Because of the holistic interrelationships of the viscera, tissue, and meridians, each acupuncture point can treat multiple symptoms. However, whether acupuncture can mitigate multiple psychoneurological symptoms simultaneously remains unclear.
According to TCM theory, qi is the vital energy that flows throughout the body along invisible pathways called meridians (Zhou & Benharash, 2014). Pain, fatigue, and sleep disturbance result from an excess or deficiency in qi and blood in the meridians (Lozano, 2014). The insertion of needles at specific acupoints is thought to improve the flow of qi and blood in the meridians, thereby producing therapeutic effects. Animal studies have provided evidence that the sympathetic and parasympathetic nervous systems are activated after acupuncture needle stimulation, resulting in a series of neural, endocrine, and immune responses (Wu et al., 2017). Significant gaps still remain in our understanding of the mechanisms underlying acupuncture for treating cancer-related symptoms in humans.
Metabolomic profiling can capture hundreds of key molecules simultaneously and may identify diverse metabolic pathways (Beger et al., 2016), reveal metabolic changes consequent to genetic variation, and illuminate the time-effect relationship between acupuncture treatment and symptoms. For example, glutathione metabolism may be one of the targeted therapeutic mechanisms underlying acupuncture. Glutathione is a tripeptide and plays an important role of antioxidant defense (Morris et al., 2014). Studies show evidence of the effects of acupuncture on the glutathione system and its antioxidant effect among obese individuals and people with depression (Ghaemi et al., 2021; Li et al., 2020). Acupuncture can significantly increase glutamine and glutathione concentrations (Li et al., 2020). Several human studies have used metabolomics profiling to understand the molecular mechanisms involved in acupuncture treatment for hypertension and depression (Li et al., 2020; Zhang et al., 2016). To date, no study has (1) utilized a standardized acupuncture protocol for treating multiple psychoneurological symptoms and (2) applied a metabolomics approach prior to and following acupuncture for psychoneurological symptoms among breast cancer survivors. The purposes of this study are to assess the feasibility and acceptability of acupuncture for the treatment of multiple co-occurring psychoneurological symptoms among breast cancer survivors and to explore metabolomic changes before and after acupuncture.
Methods
Study Design
This was a single-arm, prospective pilot study conducted with breast cancer survivors. A research team member met or spoke on the phone with eligible survivors who expressed an interest in the study, explained the study, screened for eligibility, and obtained written informed consent. The university’s institutional review board approved the study (IRB 2021–0840). This study was registered at ClinicalTrials.gov (ref. NCT05417451).
Setting and Sample
Breast cancer survivors attending the breast oncology clinic at the University of Illinois Chicago Hospital and Health Sciences System (UI Health) were recruited for this study. UI Health has a diverse patient population that is 8% Asian, 48% Black, 24% Hispanic, and 20% non-Hispanic White. This study’s participant inclusion criteria were: (1) women with histologically confirmed stage 0–III breast cancer; (2) ≥ 18 years old; (3) who had completed primary cancer treatment (e.g., surgery, radiotherapy, chemotherapy); (4) was able to read and speak English; and (5) had self-reported pain, fatigue, sleep disturbance, depression, and/or anxiety in the last month with an average severity rating of three or more (on a 0–10 numeric rating scale) for at least two of the five symptoms. Exclusion criteria were: (1) having a bleeding disorder; (2) being physically or cognitively unable to complete the study procedures; or (3) being pregnant.
Sample Collection and Procedures
Each consented participant then completed a self-reported demographic, clinical, and symptom questionnaire. A fasting blood sample (10 cc) for serum metabolites was collected between 8
Metabolomics Processing
Frozen serum samples were processed and analyzed for targeted metabolomics profiling at the Metabolomics Core Facility of the Robert H. Lurie Comprehensive Cancer Center of Northwestern University. A standard protocol was used to process the samples. Serum samples were thawed at room temperature for ∼30 minutes, then vortexed. Next, 25 μL of each sample was transferred to a 2 mL Eppendorf tube, combined with 150 μL high-performance liquid chromatography (HPLC) grade methanol, vortexed for 2 minutes, and stored at −20°C for 20 minutes. The extraction solution was dried using a SpeedVac. The dried samples were stored at −20°C and were reconstituted in 500 μL of 5 mM ammonium acetate in 40% water/60% acetonitrile, followed by overtaxing for 30 seconds. The samples solution was then centrifuged for 30 minutes at 20,000 g, 4°C, and the supernatant was transferred to a liquid chromatography vial for liquid chromatography-mass spectrometry (LC-MS) analysis.
Comprehensive metabolomics profiling was carried out by HPLC and high-resolution liquid chromatography mass spectrometry and tandem mass spectrometry (HPLC-MS/MS) in both positive and negative ion modes. Extracts were analyzed by LC-MS using an UltiMate 3000 series HPLC (Thermo Fisher Scientific, LesUlis, France) coupled with a Thermo Scientific Q Exactive mass spectrometer in line with an electrospray source. In positive/negative polarity switching mode, an m/z scan range from 60 to 900 was chosen and MS1 data was collected at a resolution of 70,000. The automatic gain control target was set at 1 × 106 and the maximum injection time was 200 ms. The top five precursor ions were subsequently fragmented, in a data-dependent manner, using the higher energy collisional dissociation cell set to 30% normalized collision energy in MS2 at a resolution power of 17,500. Besides matching m/z, metabolites were identified by matching retention time with analytical standards and/or with MS2 fragmentation pattern. Data acquisition and analysis were carried out by Xcalibur 4.1 software and Tracefinder 4.1 software, respectively (both from Thermo Fisher Scientific).
Acupuncture Intervention
Standardized Acupuncture Point Protocol for Breast Cancer Survivors With Psychoneurological Symptoms.
Acupuncture Intervention Fidelity
To ensure the scientific rigor of this study, we followed the established methods outlined in the NIH Behavior Change Consortium treatment fidelity guidelines (Bellg et al., 2004; Eaton et al., 2011) using the treatment fidelity checklist to assess research team training, treatment delivery, receipt of treatment, and enactment of the treatment skills (Borrelli et al., 2005). We trained acupuncturist in the acupuncture protocol with written instructions and diagrams, until fidelity of the intervention was achieved. The acupuncturists documented the points needled for the standardized acupuncture protocol as well as the extra points needled per individual participants’ pain symptoms. For the random unscheduled fidelity checks, we monitored the needle insertions for appropriate placement during training and fidelity checks.
Measures
Demographics and Clinical Characteristics
Self-reported sociodemographic characteristics (age, race, education, income, marital status) were collected via a questionnaire. Clinical status (disease stage, types of treatments) was extracted from the electronic health record.
PROMIS Measures
Self-reported symptom experience was collected through Patient-Reported Outcomes Measurement Information System (PROMIS) short-form questionnaires, which are reliable measures of symptom experience among cancer patients, with good internal consistency and convergent validity (Cronbach alphas: 0.86–0.96) (Cessna et al., 2016; Quach et al., 2016). PROMIS Pain Interference (8 items) specifically focuses on pain interference, defined as the interference of pain in daily activities involving physical, psychological, and social functioning (Amtmann et al., 2010). PROMIS Fatigue (8 items) is used to assess fatigue from mild subjective feelings of tiredness to an overwhelming and sustained sense of exhaustion (Cella et al., 2010). PROMIS Sleep Disturbance (8 items) is used to assess perceived sleep quality, sleep depth, and restoration associated with sleep; perceived difficulties and concerns with getting to sleep or staying asleep; and perceived adequacy of and satisfaction with sleep (Yu et al., 2011). PROMIS Depressive Symptoms (8 items) addresses sadness, loss of interest, worthlessness, low self-esteem, loneliness, and interpersonal alienation over the past 7 days (Pilkonis et al., 2011). PROMIS Anxiety (8 items) is used to assess fearfulness, worry, and nervousness (Pilkonis et al., 2011).
Feasibility and Acceptability Outcomes
Recruitment feasibility (set as >60%) is the process for determining the time frame and parameters necessary for successful recruitment. We measured this by number of participants enrolled divided by number of participants invited to participate. Retention (set as >80%) was measured at post-intervention by dividing the number of participants present at these time points by the number of individuals who were enrolled and began the acupuncture protocol.
The Protocol Acceptability Scale for Treating Psychoneurological Symptoms with Acupuncture (Wilkie et al., 2001, 2003), completed after the last acupuncture session, was used to assess the acceptability of all study measures. This acceptability scale is a 9-item self-report measure, with scores ranging from 0 to 18, to assess acceptability to the study participants. The scale is reliable and valid and has been used in other studies with stable test-retest reliability (Wilkie et al., 2001, 2003). This study’s protocol would be deemed acceptable if the total mean acceptability scale score is higher than 80% of the maximum score.
Statistical Analyses
Descriptive statistics such as mean and standard deviation (for continuous variables) and frequency and proportion (for categorical variables) were used to depict participants’ sociodemographic and clinical characteristics and to calculate feasibility and acceptability. Metabolomics datasets were loaded into MetaboAnalyst 5.0 (https://www.metaboanalyst.ca) for analysis. Missing values were replaced with the minimum values registered in the samples. All metabolites missing in more than 60% of samples overall were filtered and then were log2 transformed and normalized. Univariate analysis (paired t-test and fold change analysis), multivariate analysis (principal component analysis [PCA]), and orthogonal partial least squares discriminant analysis [OPLS-DA]) were used to compare metabolic changes before and after the acupuncture intervention as in Statistical Data Analysis of Microbiomes and Metabolomics (Xia & Sun, 2022). We used the Benjamini-Hochberg false discovery rate (FDR) method, with a threshold q value of 0.05, to control the number of false positives (false discoveries) for multiple comparisons (Benjamini & Hochberg, 1995). Fold change above two was considered statistically significant. We selected differential metabolites as significant if their VIP values were larger than 1.5 from the OPLS-DA and their p values were greater than 0.05 from the 2-tailed Student’s t-test (Weljie et al., 2011). Pathway analysis was conducted on the MetaboAnalyst website. The differential metabolites of serum samples were imported to match the Human Metabolome Database, PubChem database, and KEGG (Kyoto Encyclopedia of Genes and Genomes) database (the mass error tolerance was <15 ppm).
Results
Sociodemographic and Clinical Characteristics
Characteristics of the Sample (N = 8).
(a) Volcano plot showing metabolites that were upregulated (red dots) or downregulated (blue dots) before versus after the acupuncture intervention. (b) Principal component analysis for same samples; red dots represent before-acupuncture cases and green dots represent after-acupuncture cases. (c) Heat map showing the top 25 metabolite changes before (red) and after (green) the acupuncture intervention.
Feasibility and Acceptability
We screened 12 potential participants. Eight met eligibility requirements and agreed to participate in the study. All eight completed the pre-intervention procedures, and seven completed all 10 acupuncture sessions for an attrition rate of 12.5%, which is less than our target of 20%. Among those who completed the Protocol Acceptability Scale for Treating Psychoneurological Symptoms with Acupuncture, the mean acceptability score was 97.6%, well over the criterion of 80% or more.
Symptom Changes After Acupuncture
Reported PROMIS Outcomes Before and After the Acupuncture Intervention (N = 8).
Abbreviation: PROMIS, Patient-Reported Outcomes Information System.
Potential Biomarkers
Differential Metabolites Before and After the Acupuncture Intervention.
Abbreviation: VIP, Variable importance in projection.
As seen in the PCA plot (Figure 1(b)), each point represents a serum metabolite. The distribution in the PCA plot revealed that metabolite profiles were separated at baseline but became clustered after the 10-session acupuncture protocol, indicating that the serum metabolic pattern changed significantly after acupuncture.
Given the small sample and preliminary nature of the study, we considered a q-value (FDR) of 20% to be significant (Benjamini & Hochberg, 1995) and found that glutathione metabolism (raw p = 0.002, q = 0.071) and arginine and proline metabolisms (raw p = 0.009, q = 0.166) were potentially involved in mechanisms of acupuncture (Figure 2). Pathway analysis of differential serum metabolites false discovery rate.
Discussion
This study demonstrates that implementation of acupuncture to manage multiple psychoneurological symptoms among breast cancer survivors is indeed feasible and acceptable. It was achievable to enroll and retain most participants to complete all study measures, and the participant acceptability criterion was met.
Pain, fatigue, sleep disturbance, depression and anxiety usually co-occur and cluster together as a psychoneurological symptom cluster among breast cancer survivors (Doong et al., 2015; Langford et al., 2016). The etiology of the psychoneurological symptom cluster is unclear. But evidence showed that these symptoms usually share common biological mechanisms and can be managed together (Kim et al., 2012; Kwekkeboom et al., 2018; Starkweather et al., 2017). In this study, most of the breast cancer survivors were experiencing three or more co-occurring psychoneurological symptoms following their major cancer treatment. This result is consistent with the finding that nearly 50% of breast cancer survivors report three or more long-term symptoms after primary cancer treatment (Schumacher, 2021). As shown in both this study and our recent meta-analysis (Li et al., 2021), acupuncture offers a holistic treatment that has the ability to alleviate multiple psychoneurological symptoms at the same time; this effect is supported by the underlying theory of TCM holism.
The absence of a single treatment to effectively address the wide variety of physical and emotional problems experienced by breast cancer survivors, and to treat the whole person focusing on the mind-body connection, remains a significant gap in the oncology field. It was to fill this gap that we developed a standardized acupuncture protocol and provide preliminary evidence for acupuncture as a single therapy with minimal side effects that can have a synergistic effect on multiple symptoms and improve whole-person health. Future studies can implement this standardized protocol in a larger trial to test the effectiveness of acupuncture for reducing multiple co-occurring psychoneurological symptoms among breast cancer survivors.
Based on our metabolomic analysis and pathway analysis, glutathione metabolism stands out as a significant pathway underlying the mechanism of acupuncture. Glutathione is a tripeptide with multiple functions: it is the key antioxidant within cells and is responsible for the detoxification of reactive oxygen species and reactive nitrogen species; it also modifies the activity of numerous proteins, including intracellular signaling molecules, and plays an important role in the regulation of pro-inflammatory cytokines (Morris et al., 2014). Decreased glutathione is associated with many neuroimmune symptoms and diseases (e.g., fatigue, depression) (Chou et al., 2021; Savushkina et al., 2022). Evidence from animal studies suggests that acupuncture can inhibit oxidative stress by increasing glutathione levels, thus enhancing the activity of antioxidative enzymes and inhibiting the excessive generation of reactive oxygen species (Su et al., 2020).
Consistent with this study’s findings, Li et al. (2020) recently found that electroacupuncture was involved in glutathione metabolism among 60 people with moderate depression. Glutamine (p = 0.02) and glutathione (p < 0.011) concentrations were significantly increased after electroacupuncture. Based on this evidence, glutathione metabolism warrants further research as a targeted therapeutic mechanism underlying acupuncture for psychoneurological symptoms. In addition, research has also found that gut microbiota have systemic effects on the host’s amino acid metabolism and regulate glutathione metabolism (Mardinoglu et al., 2015). Given the important role of the gut microbiome in regulating host metabolism (Agus et al., 2018), future studies can use multi-omics and investigate the response of the gut microbiome to metabolite changes induced by acupuncture.
Limitations
The present study has several limitations. The human metabolome is sensitive to many external factors, including diet, lifestyle habits (i.e., sleep patterns, exercise), and medications. Given the sample size of this feasibility study, we did not control and adjust them in the analysis. Future studies can measure these external factors as well as control for them in the data analysis. This study explored the possible metabolic targets of acupuncture, and future findings may eventually predict the metabolic pathways involved in acupuncture for reducing psychoneurological symptoms among breast cancer survivors. However, the small sample size and single-arm design reduced our ability to rule out the role of the placebo effect. Findings of the mechanism of acupuncture in survivors of breast cancer should thus be viewed as preliminary and interpreted with caution. However, results from this study can inform a powered, rigorous future randomized controlled trial using metabolomics to understand the effect of acupuncture in reducing co-occurring psychoneurological symptoms among breast cancer survivors.
Conclusion
In conclusion, our study suggests it is feasible and acceptable to implement our acupuncture protocol to manage multiple psychoneurological symptoms among breast cancer survivors. This study provides preliminary data to support the potential involvement of glutathione metabolism and arginine and proline metabolisms in the mechanisms of acupuncture. Leveraging metabolomics and microbiome approaches, we will further explore biomarkers associated with treatment response to acupuncture and ultimately promote precision symptom care among breast cancer survivors.
Footnotes
Author Contributions
HL contributed to conception and design contributed to acquisition, analysis, and interpretation drafted manuscript critically revised manuscript gave final approval agrees to be accountable for all aspects of work ensuring integrity and accuracy JS contributed to conception and design contributed to interpretation drafted manuscript critically revised manuscript gave final approval agrees to be accountable for all aspects of work ensuring integrity and accuracy CP contributed to conception contributed to interpretation drafted manuscript critically revised manuscript gave final approval agrees to be accountable for all aspects of work ensuring integrity and accuracy OD contributed to conception contributed to acquisition drafted manuscript critically revised manuscript gave final approval agrees to be accountable for all aspects of work ensuring integrity and accuracy YX contributed to design contributed to analysis drafted manuscript critically revised manuscript gave final approval agrees to be accountable for all aspects of work ensuring integrity and accuracy JS contributed to design contributed to interpretation drafted manuscript critically revised manuscript gave final approval agrees to be accountable for all aspects of work ensuring integrity and accuracy AD contributed to conception and design contributed to interpretation drafted manuscript critically revised manuscript gave final approval agrees to be accountable for all aspects of work ensuring integrity and accuracy.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article. Research reported in this study was supported by the National Center for Complementary and Integrative Health of the National Institutes of Health under Award Number K24AT011995-01.
