JTCM Journal of

Traditional Chinese Medicine

Online Submissions: http://www.journaltcm.com
ISSN 0255-2922
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Meta Analysis

Acupuncture and moxibustion for malignant tumor patients with

psychological symptoms of insomnia, anxiety and depression: a
systematic review and Meta-analysis
MA Fangfang, ZHANG Hewei, LI Bingxue, CHENG Peiyu, YU Mingwei, WANG Xiaomin
MA Fangfang, Department of Acupuncture-Moxibustion, Tuina and the treatment group was significantly better than the
Rehabilitation, Kunshan Hospital of Traditional Chinese Medicine, control group in improving the depression effective rate
Kunshan 215300, China
ZHANG Hewei, Traditional Chinese Medicine Department, the First
[RR = 1.29, 95% CI (1.12, 1.49), P = 0.0004], the quality
Affiliated Hospital of Soochow University, Suzhou 215006, China of life (QOL) [MD = 1.11, 95% CI (0.80, 1.42), P < 0.000 01],
LI Bingxue, Department of General Surgery, Pancreatic Disease and reducing Self-rating Anxiety Scale (SAS) [MD =﹣7.75,
Center, Research Institute of Pancreatic Diseases, Ruijin Hospital, 95% CI (﹣10.44, ﹣5.05), P < 0.000 01]. But there was
Shanghai Jiaotong University School of Medicine, Shanghai 200025, no statistically significant difference between two groups
China
in improving the insomnia effective rate [RR = 1.18, 95%
CHENG Peiyu, YU Mingwei, WANG Xiaomin, Oncology
Department, Beijing Hospital of Traditional Chinese Medicine, Capital CI (0.93, 1.51), P = 0.18]. The subgroup analysis showed
Medical University, Beijing 100010, China the effectiveness of different intervention on CRPS.
Supported by Beijing Municipal Science and Technology Compared with routine care, AMT helps relieve CRPS
Commission: Demonstration and Popularization of Traditional Chinese better evaluated by Pittsburgh Sleep Quality Index (PSQI),
Medicine Standardized Diagnosis and Treatment of Common
Hamilton Depression Scale (HAMD), and Self-rating
Complications of Malignant Tumors (No. Z191100008319006);
Beijing Postdoctoral Science Foundation: Clinical Study of Five Depression Scale (SDS), and depression effective rate.
Elements Acupuncture and Moxibustion in Treatment of Tumor- Compared with conventional drug, AMT performs better
Related Insomnia (No. EE2019-22) and Key Medical Discipline of evaluated by SDS, depression effective rate and QOL.
Suzhou: Rehabilitation of Traditional Chinese Medicine (No. Moreover, the conventional drug showed higher
Szxk201822)
treatment efficacy on improving insomnia effective rate
Correspondence to: Prof. WANG Xiaomin, Oncology Department,
Beijing Hospital of Traditional Chinese Medicine, Capital Medical compared with AMT. Compared to conventional drug,
University, Beijing 100010, China. [email protected]; AMT plus conventional drug resulted in a significant
M.D. ZHANG Hewei, Traditional Chinese Medicine Department, the reduction on CRPS such as PSQI, HAMD, SDS, and SAS,
First Affiliated Hospital of Soochow University, Suzhou 215006, and also had a meaningful improvement on insomnia
China. [email protected]
effective rate, depression effective rate and QOL. Fewer
Telephone: +86-18310863610
DOI: 10.19852/j.cnki.jtcm.20230313.001 published reports were found on the adverse events of
Received: December 12, 2021 AMT than the conventional drug.
Accepted: April 27, 2022
Available online: March 13, 2023 CONCLUSION: The results suggested that AMT might be
Abstract effective in improving CPRI; however, a definite
conclusion could not be drawn because the quality of
OBJECTIVE: To evaluate the efficacy and safety of trials are low. Further large-scale and high-quality RCTs
acupuncture and moxibustion therapy (AMT) for cancer- to verify the efficacy and safety of AMT on CRPS are still
related psychological symptoms (CRPS) of insomnia, warranted.
depression and anxiety.
© 2023 JTCM. All rights reserved.
METHODS: Seven databases were searched for
randomized controlled trials (RCT) comparing AMT to Keywords: acupuncture; moxibustion; neoplasms; sleep
initiation and maintenance disorders; depression; anxiety;
routine care or conventional drug for alleviating CRPS of review
insomnia, depression, and anxiety before April 2020. Two
independent reviewers performed the data extraction and 1. INTRODUCTION
assessed the risk of bias.
As one of the leading causes of morbidity and mortality
RESULTS: A total of 30 RCTs involving 2483 cancer worldwide, cancer is steadily increasing in rate, resulting
patients were enrolled. The pooled analysis indicated that in a huge global burden over the past 30 years. The global
442 Ma FF et al / Journal of Traditional Chinese Medicine 2023 43(3): 441-456

cancer burden is expected to be 28.4 million cases in as pain, sleep disturbance, fatigue, chemotherapy side
2040, a 47% rise from 2020.1 Meanwhile cancer effects, psychological distress, and impairment in quality
survivors grow rapidly with ongoing therapy. More than of life.22-29 As effective interventions, acupuncture and
3% of the adult in Western countries have survived for moxibustion have been confirmed to improve financial
5 years as cancer cases. By 2022, 64% of 18 million distress and relieve the effect of CRPS on the quality of
cancer cases in the United States are estimated to survive life of advanced cancer patients.22
5 years or more; 40% survive 10 years or more and 15% Although three published reviews have reported the effects
survive 20 years or more after diagnosis.2 4.3 million new of acupuncture and moxibustion on CRPS,30-32 there is no
cancer cases and 2.9 million new cancer deaths estimated Meta-analysis of AMT on CRPS. Meanwhile the included
occurred in China in 2018,3 with 36.9% of cancer patients studies in the three published reviews are in low quality
surviving at least 5 years after diagnosis.4 Surviving without enough recent studies. With the rapid development
cancer patients generally suffer from various symptoms in recent years, more related studies with high quality have
and expect long-term survival as a chronic disease.5 On been published. Therefore, this study aims to screen recent
account of cancer invasion or its treatment, cancer studies on that issue for a systematic review and Meta-
treatments increase the risk for numerous late effects, analysis, thus examining the clinical efficacy and safety of
thus making cancer survivors psychologically and AMT on CRPS of insomnia, anxiety and depression
medically vulnerable.6 systematically.
Cancer-related psychological symptoms (CRPS)
includes highly prevalent symptoms like depression, 2. METHODS
anxiety and insomnia with the overall prevalence at 30%-
40%.7-11 Untreated depression and ongoing insomnia are Protocol register
associated with decreased immune responses and lower The protocol for this systematic review was registered in
survival rates.12 CRPS links to cancer incidence and the Prospective Register of Systematic Reviews
mortality risk, which presented a negative correlation (PROSPERO): CRD42020197084.
with the quality of life (QOL) and positive correlation
with physical symptoms.13-15 Failing to identify and treat Search strategy
CRPS promptly may lead to serious consequences on The following databases were searched from their
QOL in cancer patients,16 which can be alleviated with inception until April 15, 2020: PubMed, EMBASE,
appropriate interventions. Cochrane Library, China National Knowledge
There are at risk for antidepressant, anxiolytic and Infrastructure Database (CNKI), China Science and
hypnotic use up in five years after the diagnosis of cancer Technology Journal Database (VIP), Chinese
patients.17 However, pharmacological treatments of Biomedical Literature Database (CBM) and Wanfang
CRPS are not curative and in the meanwhile they often Database. The complete manuscripts of all relevant
result in additional side effects (dizziness, residual studies published in English and Chinese were retrieved.
daytime sedation, fatigue, daytime sleepiness, and The search terms included (acupuncture OR single
headache).18, 19 With the study of drug-drug interaction needle OR electric acupuncture OR blood-letting
between antidepressants and cancer treatment, direct puncture OR head acupuncture OR scalp acupuncture
consequences have shown that patients on tamoxifen and OR ear needle OR auricular acupuncture OR dermal
antidepressant have doubled the risk of relapse to cancer needle OR acupoint catgut embedding OR fire needle
in two years.12 Financial distress is also an important and OR meridian OR acupotomy OR moxibustion method
common factor contributing to the suffering of advanced OR moxibustion OR direct moxibustion OR indirect
cancer patients and their caregivers.20 Therefore cancer moxibustion OR heat-sensitive moxibustion OR needle
patients and providers alike are interested in evidence- warming moxibustion OR ginger-separated moxibustion
based nonpharmacologic alternatives like acupuncture OR salt-separated moxibustion) AND (cancer OR
and moxibustion to relieve these symptoms. tumour OR neoplasms OR malignancy OR carcinoma)
Acupuncture is performed by taking fine needles to insert AND (sleep disorder OR sleep disturbance OR insomnia
in the acupoints and stimulate needling response, either OR depression OR depressive disorder OR anxiety).
manually or electrically, to treat side effects of
conventional cancer treatment. Moxibustion involves Inclusion and exclusion criteria
burning the moxa on or above the skin at acupoints with
2.3.1 Types of studies
stick-on moxa, sandwiched moxibustion or indirect
moxibustion.21 Acupuncture and moxibustion therapy To collect evidence of high quality, only randomized
(AMT), originated from the system of Traditional controlled trials (RCTs) were included in this systematic
Chinese Medicine, has been in use at least 2500 years in review. Only full articles were included.
China and other Asian countries.21 AMT has a good
2.3.2 Types of participants
effect on CRPS and is easy to operate, safe, and
economical. National Cancer Institute (NCI) have The participants who were diagnosed with the
recommended “Acupuncture for Cancer Symptom psychological symptoms like insomnia, anxiety and/or
Management” to target common symptom clusters such depression due to interior-stirring by cancer would be
 Ma FF et al / Journal of Traditional Chinese Medicine 2023 43(3): 441-456 443

included. Additionally, patients with mental disorders × 100%, cure rate (reduced rate > 75%), effective rate
would be excluded. Serious organic disease and (reduced rate 50%-75%), improved rate (reduced rate
complications or pregnancy would not be considered. 25%-49%), invalid rate (reduced rate < 25%). The
effective rate of depression = recovery rate + marked
2.3.3 Types of intervention
effective rate.
All of the cancer patients with psychological symptoms (b) Scales or indices for the quality evaluation of the
were required to undergo basic cancer treatment in both psychological symptoms like insomnia, anxiety or
the treatment and control groups. depression, the Pittsburgh Sleep Quality Index (PSQI),
Treatment interventions. In the treatment group, the Hamilton Depression Scale (HAMD), Self-rating
intervention would be AMT combined with/without Depression Scale (SDS), Self-rating Anxiety Scale
conventional drug or routine care. These included studies (SAS).
could perform the forms of acupuncture (e.g., manual
2.3.4.2 Secondary outcomes
acupuncture, electro-acupuncture, intradermal needling
and scalp-acupuncture) and/or moxibustion (e.g., direct The secondary outcomes of this review mainly included
or indirect moxibustion, heat-sensitive moxibustion, the quality of life (QOL) and adverse events.
warm needling, ginger-separated moxibustion or salt-
Selection of studies and data extraction
separated moxibustion). The other forms of AMT, such
as acupressure, transcutaneous electrical nerve Two authors (MA Fangfang and LI Bingxue) screened
stimulation, point injection, laser irradiation, far infrared all the records independently and abstracted all related
moxibustion, auricular acupressure, auricular data from the enrolled papers, including first author’s
acupuncture and cupping would be excluded. name, country, year of publication, age, gender, sample
The conventional drug would be the regular and frequent size, diagnosis standard, details of interventions for
use on the treatment of insomnia, depression, and anxiety treatment groups and control groups, cointerventions,
of CRPS such as paroxetine, sertraline, diosmin tablets, outcome measures, treatment duration, and adverse
estazolam or diazepam. The routine care included events. Disagreements were resolved by discussion or
nursing intervention, explanation of disease knowledge, consulting a senior researcher (WANG Xiaomin).
life guidance and psychological health education.
Quality assessment
Control interventions. In the control group, the patients
would receive conventional drug or routine care that The methodological quality was assessed according to
prevent the psychological symptoms like insomnia, the Cochrane Handbook version 5.3. Two authors (MA
anxiety and/or depression. Placebo controls or sham Fangfang and LI Bingxue) independently extracted the
acupuncture for the purpose of blinding are encouraged. data from the included studies. The risk of bias quality
The following treatment comparisons would be studied: was assessed based on 7 domains: random sequence
Acupuncture and/or moxibustion compared with routine generation, allocation concealment, blinding of
care; participants and personnel, blinding of outcome
Acupuncture and/or moxibustion compared with assessment, incomplete outcome data, selective
conventional drug; reporting and other bias. There were three potential bias
Acupuncture and/or moxibustion plus conventional drug judgments according to the Cochrane criteria after
compared with conventional drug. assessing all the domains: (a) low risk; (b) high risk; and
(c) unclear risk. Disagreements were resolved by
2.3.4 Types of outcomes discussion between all of the authors.
2.3.4.1 Primary outcomes Statistical analysis
(a) the effective rate of the psychological symptoms like For dichotomous data, we present the treatment effect as
insomnia, anxiety or depression.30-32 relative risk with 95% confidence intervals (CIs). For
The effective rate of insomnia was used to assess the continuous data, we used the mean difference (MD) with
sleep effectiveness. Recovery: sleep time returned 95% CIs to measure the treatment effect. In the case of
normal or more than 6 h a night, with deep sleep and outcome variables with different scales, we used the
wake up energetically; Remarkable effect: sleep quality standardized mean difference (SMD) with 95% CIs. The
was obviously improved with sleep time and depth sleep χ2 test for heterogeneity and the I2 test were used to
increased; Effective: sleep quality was improved but evaluate the heterogeneity of the included studies. When
some symptoms still existed; Invalid effect: no P ≥ 0.10, I2 ≤ 50%, there was no statistical
significant improvement or reverse aggravation of heterogeneity between the results included in the study
insomnia after treatment. The effective rate of insomnia and the fixed effect model was used for analysis. If P <
= recovery rate + marked effective rate. 0.10, I2 > 50%, it was considered as statistically different.
The HAMD reduced rate was used to assess the Then we made an analysis on the heterogeneity sources
therapeutic effectiveness as the effective rate of to determine whether the sensitivity analysis and
depression. HAMD reduced rate (%) = (score before subgroup analysis were needed, whether random effects
treatment-score after treatment) /score before treatment models can be used for analysis or not. Descriptive
444 Ma FF et al / Journal of Traditional Chinese Medicine 2023 43(3): 441-456

analysis was used if the clinical heterogeneity was too publication period was from 2008 to 2020. One study
large or the literature was too few to perform Meta- was published in English and the other 29 studies were
analysis. Methodological quality evaluation was published in Chinese. Six studies were for female breast
performed by the bias risk map drawn by Revman 5.3 cancer patients. All of the included patients were
software (Cochrane Library, London, UK). When there concentrated in China with a wide variation in the age of
were more than 10 articles on a certain outcome indicator, subjects (18-80 years). All studies included at least one
an inverted funnel plot was used to assess the published of the main outcome indicators, which corresponding to
bias of the included study. All the analyses were done the diagnosis standards of the psychological symptoms
using Revman 5.3. like insomnia, anxiety and/or depression due to interior-
stirring by cancer.
We divided the studies into three subgroups according to
3. RESULTS
their different treatment comparisons. The first subgroup
Literature Search Results was AMT versus routine care in 8 studies;33,40,41,44,50-52,55
the second subgroup was AMT versus conventional drug
A total of 2474 studies were retrieved at the initial search.
(CD) in 11 studies;35,42,45,46,48,49,54,56,59,61,62 the third
After removing 799 duplicates, 1675 studies were
subgroup was AMT plus CD versus CD in 11 studies.34,
identified for further analysis. Through screening the 36-39,43,47,53,57,58,60
Total treatment sessions ranged from 7
titles and abstracts, 1615 studies were excluded because
d to 12 weeks, and intervention time ranged from 30 to
they were literature reviews, expert opinions,
60 min.
commentaries, case reports, case series, nonclinical
studies, animal research or irrelevant intervention. Of the
Risk of bias
remaining 60 studies, by reading the full text, 30 studies
met our inclusion criteria, as shown in Figure 1. According to the Cochrane Handbook for Systematic
Reviews of Interventions, we assessed the risk of bias of
Characteristics of included studies
the included literature. The details of the risk of bias
The basic characteristics of the included studies are listed (ROB) assessment in 30 studies are provided in Figure 2.
in Table 1.33-62 By integrating the 30 included studies, a 19 RCTs described the appropriate random sequence
total of 2483 cases were reported with 1235 cases in the generation method in detail while the other 11 studies did
treatment group and 1248 cases in the control group. The not. 19 studies using allocation concealment with sealed

Figure 1 Flow diagram of studies included in the review

CNKI: China National Knowledge Infrastructure Database; VIP: China Science and Technology Journal Database; CBMdisc: China Biology
Medicine disc; EMbase: Excerpt Medica Database; RCT: randomized controlled trial.
Table 1 Basic characteristics of the included studies
Study Sample Age year Gender Disease diagnosis Control Intervention Main treated acupoints and treatment frequency Course Outcome
size (T/C) (Male measure
(T/C) /Female)
Chen YH 30/30 T: 38-83 T: 18/12 Gastric cancer Routine care Moxibustion+C MT: Zusanli (ST36), Xuehai (SP10), Sanyinjiao (SP6) and Zhongwan (CV12). 2 w SDS, SAS
et al C: 24-82 C: 20/10 +anxiety and 1 time per day for 30 min
201333 depression
Chen J 18/18 T: 66.43±5.43 T: 10/8 Tumor+depression Paroxetine 20-60 Acupuncture AT: Neiguan (PC6), Shenmen (TF4), Yifeng (SJ17), Baihui (GV20), 6w HAMD,
201834 C: 65.13±5.98 C: 9/9 mg/d+anti-tumor +moxibustion+c Sishencong (EX-HN1), Hegu (LI4) and Taichong (LR3). depression
therapy 1 time per day for 30 min efficiency
MT: Guanyun (CV4) and Zusanli (ST36).
1 time per day for 30 min
Dan ZJ 27/28 T: T: 14/13 Tumor+insomnia Estazolam 1mg/d Acupuncture AT: Baihui (GV 20), Shenting (GV24), Yintang (EX-HN3), Shenmen (TF4), 7d Sleep
201335 52.222±7.153 C: 16/12 +boxed Zusanli (ST36) and Sanyinjiao (SP6). efficiency,
C: moxibustion PSQI
51.296±6.866 MT: Shenque (CV8) and Guanyun (CV4).

Deng XY 30/30 T: 48.93±4.03 T: 12/18 Tumor+depression Sertraline 10 mg/d+ Acupuncture+Elec AT: Yinlingquan (SP9), Fenglong (ST40), Hegu (LI4), Neiguan (PC6), 4w HAMD,
et al C: 50.13±4.09 C: 16/14 anti-tumor therapy tric acupuncture Taichong (LR3), Sanyinjiao (SP6), Yintang (EX-HN3) and Baihui (GV 20). QLQ-C30
201836
EA: Yinlingquan (SP9) and Fenglong (ST40).

Deng XY 30/30 T: 53±9 T: 11/19 Tumor+depression Sertraline 50 mg/d Acupuncture+C AT: Hegu (LI4), Taichong (LR3), Neiguan (PC6), Shenmen (TF4), Zusanli 4w HAMD,
et al C: 49±11 C: 10/20 (ST36), Sanyinjiao (SP6), Yintang (EX-HN3) and Baihui (GV 20). QLQ-C30
201937 for 30 min
Feng Y et 40/40 T: 63.80±5.47 T: 26/14 Malignant Fluoxetine 20 mg/d Acupuncture+C AT: Fenglong (ST40), Yinlingquan (SP9), Xuehai (SP10), Sanyinjiao (SP6), 30 d SDS,
al 201138 C: 63.60±4.26 C: 27/13 neoplasms+insomni Yintang (EX-HN3), Baihui (GV 20), Sishencong (EX-HN1), Neiguan (PC6) HAMD,
a and depression and Shenmen (TF4). depression
efficiency,
PSQI
Feng XT 70/70 35-78 61/79 Liver Paroxetine 20 mg/d Acupuncture AT: the acupoints of liver meridian and heart meridian, Shenmen (TF4), 8w SDS, SAS
et al (61.51±6.24) cancer+anxiety and +chinese herb+c Danzhong (CV 17), Taichong (LR3), Qimen (LR14) and Xingjian (LR2).
201939 depression
Ma FF et al / Journal of Traditional Chinese Medicine 2023 43(3): 441-456

Liao LL 35/34 T: T: 14/21 Tumor+insomnia Routine care Intradermal IN: Yintang (EX-HN3) and Shenmen (TF4). 2w PSQI
201940 63.63±16.30 C: 13/21 needling
C: +moxibustion MT: Zusanli (ST36) and Sanyinjiao (SP6).
63.18±15.04
Liu YL 30/30 T: 51.63±9.14 T: 10/20 Tumor+depression Routine care Thermal MT: Baihui (GV 20), Shenmen (TF4), Neiguan (PC6), Taichong (LR3) and 21 d HAMD,
201741 C: 54.63±9.89 C: 12/18 moxibustion Ganshu (BL18). depression
efficiency
445
 446

Table 1 Basic characteristics of the included studies (Continued)

Study Sample Age year Gender Disease diagnosis Control Intervention Main treated acupoints and treatment frequency Course Outcome
size (T/C) (Male measure
(T/C) /Female)
Liu XF et 40/40 T: Female Breast Diosmin tablets Needle warming Jianyu (LI15), Waiguan (SJ5), Yinlingquan (SP9), Quchi (LI11), Shuifen 28 d SDS,
al 201942 46.37±14.53 cancer+anxiety and 2.7 g/d moxibustion (IN9) and Zusanli (ST36). SAS,
C: depression QLQ-C30
49.32±13.22
Liu YP et 40/40 T: 63±13 T: 24/16 Tumor+depression Escitalopram 10 Acupuncture+C AT: Taichong (LR3), Hegu (LI4), Baihui (GV 20) and Yintang (EX-HN3). 12 w HAMD
al 201943 C: 63±12 C: 20/20 -20 mg/d 5
Mo ZY et 58/60 T: Female Breast Routine care Ginger moxi- MT: Hegu (LI4), Zusanli (ST36), Taichong (LR3) and Yongquan (KI1). 7d SDS, SAS
al 201744 48.22±10.28 cancer+anxiety and bustionwithbox
C: depression
48.60±11.02
Pei Y et 31/36 T: Female Breast Citalopram 20 mg/d Acupuncture AT: Feishu (BL13), Xinshu (BL15), Geshu (BL17), Ganshu (BL18), Pishu 6w SDS,
al 201045 51.76±10.21 cancer+anxiety and (BL20) and Shenshu (BL23). SAS,
C: 48.34±8.79 depression HAMD
Peng XH 93/97 T: T: 68/36 Tumor+insomnia Estazolam 1 mg/d Acupuncture AT: Baihui (GV 20), Shenting (GV24), Yintang (EX-HN3), Shenmen (TF4), 7 d Sleep
et al 59.36±12.54 C: 68/36 +moxibustion Zusanli (ST36) and Sanyinjiao (SP6). efficiency
201746 C:
60.95±11.11 MT: Shenque (CV8) and Guanyun (CV4).

Shen LP 50/50 T: 54. T: 28/22 Lung Zolpidem 10 mg/d+ Acupuncture+Elec AT: Zhaohai (KI6), Shenmai (BL62), Shenmen (TF4), Yintang (EX-HN3), 4w SDS,
et al 93±14.45 C: 31/19 cancer+insomnia Paroxetine 20 mg/d tric Sishencong (EX-HN1), Anmian(Extra 8), Hegu (LI4), Taichong (LR3), SAS,
201647 C: 58. (if needed) acupuncture+C Zusanli (ST36), Qihai (CV6) and Quchi (LI11). PSQI
09±12.11
EA: Shenmen (TF4), Anmian(Extra 8), Sishencong (EX-HN1), Hegu (LI4),
Taichong (LR3), Zusanli (ST36), Qihai (CV6) and Quchi (LI11).

Shi Y et 40/40 NR NR Tumor+insomnia Diazepam 5 mg/d Scalp-acupuncture AT: Baihui (GV 20), Sishencong (EX-HN1). 7d PSQI
al 201448
SA: Ezhongxian (MS2~3).

Song JR 60/60 NR NR Tumor+insomnia Estazolam 1 mg/d Acupuncture AT: Baihui (GV20), Shenting (GV24), Yintang (EX-HN3), Shenmen (TF4), 7d Sleep
et al boxed Zusanli (ST36) and Sanyinjiao (SP6). efficiency,
Ma FF et al / Journal of Traditional Chinese Medicine 2023 43(3): 441-456

201549 moxibustion PSQI

MT: Shenque (CV8) and Guanyun (CV4).

Liu XF et 40/40 T: Female Breast Diosmin tablets Needle warming Jianyu (LI15), Waiguan (SJ5), Yinlingquan (SP9), Quchi (LI11), Shuifen 28 d SDS, SAS,
al 201942 46.37±14.53 cancer+anxiety and 2.7 g/d moxibustion (IN9) and Zusanli (ST36). QLQ-C30
C: depression
49.32±13.22
Liu YP et 40/40 T: 63±13 T: 24/16 Tumor+depression Escitalopram 10- Acupuncture+C AT: Taichong (LR3), Hegu (LI4), Baihui (GV 20) and Yintang (EX-HN3). 12 w HAMD
al 201943 C: 63±12 C: 20/20 20 mg/d 5
Table 1 Basic characteristics of the included studies (Continued)
Study Sample Age year Gender Disease diagnosis Control Intervention Main treated acupoints and treatment frequency Course Outcome
size (T/C) (Male measure
(T/C) /Female)
Mo ZY et 58/60 T: Female Breast cancer+ Routine care Ginger moxi- MT: Hegu (LI4), Zusanli (ST36), Taichong (LR3) and Yongquan (KI1). 7d SDS, SAS
al 201744 48.22±10.28 anxiety and bustionwithbox
C: depression
48.60±11.02
Pei Y et 31/36 T: Female Breast Citalopram 20 mg/d Acupuncture AT: Feishu (BL13), Xinshu (BL15), Geshu (BL17), Ganshu (BL18), Pishu 6 w SDS, SAS,
al 201045 51.76±10.21 cancer+anxiety and (BL20) and Shenshu (BL23). HAMD
C: 48.34±8.79 depression
Peng XH 93/97 T: T: 68/36 tumor+insomnia Estazolam 1 mg/d Acupuncture AT: Baihui (GV 20), Shenting (GV24), Yintang (EX-HN3), Shenmen 7d Sleep
et al 59.36±12.54 C: 68/36 +moxibustion (TF4), Zusanli (ST36) and Sanyinjiao (SP6). efficiency
201746 C:
60.95±11.11 MT: Shenque (CV8) and Guanyun (CV4).

Shen LP 50/50 T: 54. T: 28/22 Lung Zolpidem 10 mg/d+ Acupuncture+Ele AT: Zhaohai (KI6), Shenmai (BL62), Shenmen (TF4), Yintang (EX-HN3), 4 w SDS, SAS,
et al 93±14.45 C: 31/19 cancer+insomnia Paroxetine 20 mg/d ctric Sishencong (EX-HN1), Anmian(Extra 8), Hegu (LI4), Taichong (LR3), PSQI
201647 C: 58. (if needed) acupuncture+C Zusanli (ST36), Qihai (CV6) and Quchi (LI11).
09±12.11
EA: Shenmen (TF4), Anmian(Extra 8), Sishencong (EX-HN1), Hegu
(LI4), Taichong (LR3), Zusanli (ST36), Qihai (CV6) and Quchi (LI11).

Shi Y et 40/40 NR NR Tumor+insomnia Diazepam 5 mg/d Scalp- AT: Baihui (GV 20), Sishencong (EX-HN1). 7d PSQI
al 201448 acupuncture
SA: Ezhongxian (MS2-3).

Song JR 60/60 NR NR Tumor+insomnia Estazolam 1 mg/d Acupuncture AT: Baihui (GV20), Shenting (GV24), Yintang (EX-HN3), Shenmen 7d Sleep
et al boxed (TF4), Zusanli (ST36) and Sanyinjiao (SP6). efficiency,
201549 moxibustion PSQI
MT: Shenque (CV8) and Guanyun (CV4).

Wang Y 40/40 NR Female Breast Routine care Five-element The acupoints according to five-element acupuncture therapy. 6w SDS, SAS
201550 cancer+anxiety and acupuncture+
depression wheat grain
Ma FF et al / Journal of Traditional Chinese Medicine 2023 43(3): 441-456

moxibustion
Wang 40/40 T: 52.47±9.62 Female Breast Routine care Intradermal IN: Shenmen (TF4), Sanyinjiao (SP6), Anmian (Extra 8), Zusanli (ST36) 4w PSQI
BN et al C: 50.16±7.34 cancer+insomnia needling and Taibai (SP3).
201951 5 times per week; 3 times per day (acupressing 1 min per point)

Wang 40/40 T: 39.52±8.35 T: 24/16 Brain tumor+ Routine care Acupuncture AT: Neiguan (PC6), Renzhong (GV26), Sanyinjiao (SP6), Chize (LU5), 4w SDS, SAS
WG et al C: 39.36±9.27 C: 22/18 Depression Jiquan (HT1), Fengchi (GB20), Weizhong (BL40), Tianzhu (BL10) and
202052 Wangu (BL12).
447
 448

Table 1 Basic characteristics of the included studies (Continued)

Study Sample Age year Gender Disease diagnosis Control Intervention Main treated acupoints and treatment frequency Course Outcome
size (T/C) (Male measure
(T/C) /Female)
Wei S 33/33 49.21±6.32 Female Gynecological Alprazolam Thunder-fire MT: Shenmen (TF4), Neiguan (PC6), Sanyinjiao (SP6)，Xinshu (BL15), 2 w PSQI, Sleep
201953 malignant 0.4 mg/d moxibustion+C Pishu (BL20), Zusanli (ST36), Danshu (BL19) and Qiuxu (GB40). efficiency,
tumor+insomnia QLQ-C30
Xia Q et 23/23 NR 18/28 Tumor+depression fluoxetine 20 mg/d Scalp-acupuncture SA: Dingzhongxian (MS5), Ezhongxian (MS1), Epangxian(MS2~ MS4), 4 w HAMD,
al 201754 Nieqianxian (MS10), Niehouxian (MS11). SDS,
depression
efficiency
Xia WM 37/37 T: 47.6±8.2 T: 10/27 Thyroid cancer+ Routine care Moxibustion MT: Baihui (GV 20). 7d SDS, SAS,
et al C: 46.2±7.5 C: 13/24 insomnia, anxiety PSQI
201955 and depression
Zeng XL 29/28 T: 60.28±10.22 T: 12/17 Tumor+depression Sertraline 50 mg/d Acupuncture AT: Neiguan (PC6), Shenmen (TF4), Laogong (PC8), The Stabilizing 4w HAMD,
201556 C: 61.71±11.58 C: 13/15 +moxibustion Four-Shen points and the Four-Shen pointsof Jin's Three-needle Therapy. SDS, QLQ-
C30
MT:
Zhang YT 35/34 T: 64.06±9.155 T: 18/17 Tumor+insomnia Routine Thermal MT: Shenque (CV8), Xinshu (BL15), Pishu (BL20), Shenmen (TF4) and 7d PSQI
201757 C: 64.46±10.947 C: 14/20 care+Estazolam moxibustion+C Sanyinjiao (SP6).
1 mg/d (if needed)
Zhang CH 32/32 T: 56.9±5.7 T: 13/19 Tumor+depression Amitriptyline 50- Acupuncture AT: Zusanli (ST36), Sanyinjiao (SP6), Feishu (BL13) and Yinlingquan 6w HAMD,
et al C: 56.8±6.1 C: 14/18 150 mg/d +chinese herb+c (SP9). depression
201758 efficiency
Zhang YL 31/31 18-65 38/24 Colorectal Loperamide 4 mg/d Needle warming Guanyun (CV4), Shenque (CV8), Tianshu (ST25) and Zusanli (ST36). 7d SDS, SAS
et al (53.55±11.60) cancer+anxiety and moxibustion
201759 depression
Zhang B 30/30 T: 59.8±4.3 T: 13/17 Tumor+depression Chinese herb Five-element The acupoints according to five-element acupuncture therapy. 6w HAMD
201760 C: 58.4±5.2 C: 15/15 acupuncture+C
Zhao YL 93/97 T: 59.36±12.541 T: 60/33 Tumor+insomnia Estazolam 1 mg/d Acupuncture+mox AT: Baihui (GV 20), Shenting (GV24), Yintang (EX-HN3), Shenmen 7d Sleep
201561 C: 60.95±11.112 C: 66/31 ibustion (TF4), Zusanli (ST36) and Sanyinjiao (SP6). efficiency,
PSQI
MT: Shenque (CV8) and Guanyun (CV4).
Ma FF et al / Journal of Traditional Chinese Medicine 2023 43(3): 441-456


Zhu JJ et 50/50 T: 63.38±8.34 T: 37/13 Liver Escitalopram Cake-separated MT: Fengfu (GV16), Geshu (BL17) and Danshu (BL19). 6w HAMD,
al 201762 C: 62.78±7.85 C: 38/12 cancer+depression 10 mg/d moxibustion depression
+Chinese herb efficiency
Notes: T: the treatment group; C: the control group; NR: not reported; AT: acupuncture; MT: moxibustion; EA: Electric acupuncture; IN: intradermal needling; SA: scalp-acupuncture; PSQI: the Pittsburgh Sleep
Quality Index; HAMD: the Hamilton Depression Scale; SDS: the Self-rating Depression Scale; SAS: the Self-rating Anxiety Scale; QLQ-C30: Quality of Life measurement Scale.
 Ma FF et al / Journal of Traditional Chinese Medicine 2023 43(3): 441-456 449

Figure 2 Risk of bias graph

A: risk of bias item among included studies; B: risk of bias item in each included study.

envelopes, nine studies did not report, while 2 studies rate, 391 cases in the treatment group and 399 cases in
broke randomization and thus were assigned with high the control group, with high heterogeneity between the
risk. Because it is impossible to blind participants and studies (P < 0.000 01, I2 = 83%). The Meta-analysis was
personnel from acupuncture and moxibustion to detailed in Figure 3A. The Meta-analysis showed no
conventional treatment, 13 studies were assessed to be a significant difference between the 2 groups [n = 790, RR
high ROB. Only 1 study was at low ROB for reporting = 1.18, 95% CI (0.93, 1.51), P = 0.18].
the blinding of participants and personnel, while the The subgroup analysis was explained the high
other 16 studies were at unclear ROB. All of the included heterogeneity by different intervention of treatment. The
studies reported the complete outcome data, and we Meta-analysis showed that 4 studies38,49,52,64 showed
considered them to be at low ROB. 24 studies had significant difference on the effective rate of insomnia
reported the details of adverse reactions or published between AMT and conventional drugs [n = 555, RR =
protocols with a low ROB, while the other 6 studies did 0.89, 95% CI (0.81, 0.98), P = 0.02] with low
not report. 20 studies reported the patients’ baseline heterogeneity (P = 0.32, I2 = 14%), 3 studies50,56,60
characteristics, while the other 10 studies were assessed showed significant difference on the effective rate of
to be at unclear ROB for lack of reporting details. The insomnia between AMT + CD and conventional drugs [n
overall quality of the trials was assessed as having = 235, RR = 2.18, 95% CI (1.34, 3.56), P = 0.002] with
moderate to high risk of bias. middle heterogeneity (P = 0.09, I2 = 59%).
3.4.1.2. Primary outcome measure: the Pittsburgh Sleep
Effectiveness assessment
Quality Index (PSQI)
3.4.1 Evaluation of efficacy in insomnia Eleven studies38,41,43,50-52,54,56,58,60,64 reported changes in
PSQI, 490 cases in the treatment group and 493 in the
3.4.1.1. Primary outcome measure: the effective rate of
control group, with high heterogeneity between the
insomnia
studies (P < 0.000 01, I2 = 95%), so random effects
Seven studies38,49,50,52,56,60,64 showed the equivalent model was used. The Meta-analysis was detailed in
effects of AMT on the cancer related insomnia effective Figure 3B. The results of Meta-analysis showed that the
450 Ma FF et al / Journal of Traditional Chinese Medicine 2023 43(3): 441-456

Figure 3 Results of the Meta-analysis of the efficacy of insomnia

A: Meta-analysis forest map of the effective rate of insomnia; B: Meta-analysis forest map of PSQI. AMT: acupuncture and moxibustion therapy;
CD: conventional drugs; PSQI: Sleep Quality Index.

difference in the reductions of the PSQI between the 3.4.2 Evaluation of efficacy in depression
treatment group and the control group was statistically
3.4.2.1 Primary outcome measure: the effective rate of
significant [n = 984, MD = −1.95, 95% CI (−3.01, −0.90),
depression
P = 0.0003].
A subgroup analysis was conducted to explore whether Seven studies41,44,46,57,59,61,65 showed the equivalent
heterogeneity could be partially explained by different effects of AMT on the cancer related depression effective
intervention of treatment. The Meta-analysis showed that rate, 244 cases in the treatment group and 243 cases in
3 studies43,54,58 showed significant difference on PSQI the control group, with moderate heterogeneity between
between AMT and routine care [n = 223, MD = −3.77, the studies (P = 0.02, I2 = 59%). The Meta-analysis was
95% CI (−5.43, −2.12), P < 0.000 01] with high detailed in Figure 4A. The Meta-analysis showed
heterogeneity (P = 0.002, I2 = 84%), 4 studies38,51,52,64 significant difference between the 2 groups [n = 487, RR
showed no significant difference on PSQI between AMT = 1.29, 95% CI (1.12, 1.49), P = 0.0004].
and conventional drugs [n = 445, MD = 0.10, 95%CI The subgroup Meta-analysis showed that 1 studies44
(−0.75, 0.94), P = 0.82] with high heterogeneity (P = showed significant difference on the effective rate of
0.005, I2 = 77%), 4 studies41,50,56,60 showed significant depression between AMT and routine care [n = 60, RR =
difference on PSQI between AMT + CD and 3.00, 95% CI (1.71, 5.25), P = 0.0001], 3 studies57,59,65
conventional drugs [n = 315, MD = −2.77, 95% CI showed significant difference on the effective rate of
(−3.67, −1.87), P < 0.000 01] with high heterogeneity (P depression between AMT and conventional drugs [n =
= 0.001, I2 = 81%). 203, RR = 1.18, 95% CI (1.05, 1.32), P = 0.005] with low
 Ma FF et al / Journal of Traditional Chinese Medicine 2023 43(3): 441-456 451

heterogeneity (P = 0.50, I2 = 0%), 3 studies41,46,61 showed groups was statistically significant [n = 770, SMD =
significant difference on the effective rate of depression −1.10, 95% CI (−1.77, −0.43), P = 0.001].
between AMT + CD and conventional drugs [n = 224, The Meta-analysis of the subgroups showed that 1
RR = 1.28, 95% CI (1.09, 1.50), P = 0.003] with low studies44 showed significant difference on HAMD
heterogeneity (P = 0.27, I2 = 24%). between AMT and routine care [n = 60, SMD = −0.54,
95% CI (−1.06, −0.03), P = 0.04], 5 studies39,48,57,59,65
3.4.2.2 Primary outcome measure: HAMD
showed no significant difference on HAMD between
Twelve studies37,39-41,44,46,48,57,59,61,63,65 reported changes AMT and conventional drugs [n = 330, SMD = −0.62,
in HAMD, 383 cases in the treatment group and 387 in 95% CI (−1.87, 0.62), P = 0.33] with high heterogeneity
the control group, with high heterogeneity between the (P < 0.000 01, I2 = 96%), 6 studies37,40,41,46,61,63 showed
studies (P < 0.000 01, I2 = 94%), so standard random significant difference on HAMD between AMT+CD and
effects model was used. The Meta-analysis was detailed conventional drugs [n = 380, SMD = −1.59, 95% CI
in Figure 4B. The results of Meta-analysis showed that (−2.47, −071), P = 0.0004] with high heterogeneity (P <
the difference in the reductions of the HAMD between 2 0.000 01, I2 = 93%).

Figure 4 Results of the Meta-analysis of the efficacy of depression

A: Meta-analysis forest map of the effective rate of depression; B: Meta-analysis forest map of HAMD. AMT: acupuncture and moxibustion
therapy; CD: conventional drugs; HAMD: Hamilton Depression Scale.
452 Ma FF et al / Journal of Traditional Chinese Medicine 2023 43(3): 441-456

3.4.2.3 Primary outcome measure: SDS showed no difference on SAS between AMT and
conventional drugs [n = 209, MD = −7.12, 95%CI
13 studies reported changes in
36,41,42,45,47,48,50,53,55,57-59,62
(−14.61, −0.37), P = 0.06] with high heterogeneity (P <
SDS, 519 cases in the treatment group and 525 in the
0.000 01, I2 = 95%), 2 studies42,50 showed significant
control group, with high heterogeneity between the
difference on SAS between AMT+CD and conventional
studies (P < 0.000 01, I2 = 92%), so random effects
drugs [n = 240, MD = −6.60, 95% CI (−11.32, −1.88), P
model was used. The Meta-analysis was detailed in Table
= 0.006] with high heterogeneity (P = 0.07, I2 = 71%).
2 and supplementary Figure 1A. The results of Meta-
analysis showed that the difference in the reductions of
3.4.4 Quality of life (QOL) and adverse events
the SDS between 2 groups was statistically significant
[n = 1044, MD = −9.40, 95% CI (−12.21, −6.59), P < 3.4.4.1 Secondary outcomes: QOL
0.000 01].
Five studies36,37,42,53,56 reported changes in quality of life,
The Meta-analysis of the subgroups showed that 5
162 cases in the treatment group and 161 cases in the
studies36,47,53,55,58 showed significant difference on SDS
control group, with moderate heterogeneity between the
between AMT and routine care [n = 412, MD = −13.28,
studies (P = 0.15, I2 = 40%), so random effects model
95%CI (−17.92, −8.64), P < 0.000 01] with high
was used. The Meta-analysis was detailed in Table 2 and
heterogeneity (P < 0.000 01, I2 = 93%), 5
supplementary Figure 2. The results of Meta-analysis
studies45,48,57,59,62 showed difference on SDS between
showed that the difference in the growth of the QOL
AMT and conventional drugs [n = 312, MD = −6.66,
between 2 groups was statistically significant [n = 323,
95%CI (−12.66, −0.65), P = 0.03] with high
MD = 1.11, 95% CI (0.80, 1.42), P < 0.000 01].
heterogeneity (P < 0.000 01, I2 = 95%), 3 studies41,42,50
The Meta-analysis of the subgroups showed that 2
showed significant difference on SDS between AMT +
studies42,56 showed significant difference on QOL
CD and conventional drugs [n = 320, MD = −7.44, 95%
between AMT and conventional drugs [n = 137, MD =
CI (−9.26, −5.63), P < 0.000 01] with low heterogeneity
1.36, 95%CI (0.99, 1.74), P < 0.000 01] with high
(P = 0.91, I2 = 0%).
heterogeneity (P = 0.31, I2 = 1%), 3 studies36,37,53 showed
3.4.3 Evaluation of efficacy in anxiety significant difference on QOL between AMT+CD and
conventional drugs [n = 186, MD = 0.93, 95% CI (0.59,
3.4.3.1 Primary outcome measure: SAS
1.28), P < 0.000 01] with high heterogeneity (P = 0.28,
Ten studies36,42,45,47,48,50,53,55,58,62 reported changes in SAS, I2 = 22%).
427 cases in the treatment group and 434 cases in the
3.4.4.2 Secondary outcomes: adverse reactions
control group, with high heterogeneity between the
studies (P < 0.000 01, I2 = 88%), so random effects Ten studies38,44,46,48,51,53,54,57,59,62 investigated adverse
model was used. The Meta-analysis was detailed in Table events, whereas other 20 studies did not report. One
2 and supplementary Figure 1B. The results of Meta- studie46 reported a total of 16 mild adverse events in 80
analysis showed that the difference in the reductions of cases including mild skin bruising (n = 8), dizziness (n
the SAS between 2 groups was statistically significant [n = 5), and headache (n = 3) which were improved after
= 861, MD = −7.75, 95% CI (−10.44, −5.05), P < symptomatic treatment. One studie51 investigated that
0.000 01]. adverse events of acupuncture included vertigo, reduced
The Meta-analysis of the subgroups showed that 5 ability of behave while adverse events of taking sleeping
studies36,47,53,55,58 showed significant difference on SAS pills “Estazolam” included hangover, nausea or dizziness,
between AMT and routine care [n = 412, MD = −8.61, and insomnia rebound. Two studies38,48 reported a total of
95% CI (−12.38, −4.84), P < 0.000 01] with high 5 adverse events including pain (n = 1), hematoma (n =
heterogeneity (P < 0.000 01, I2 = 88%), 3 studies45,48,62 2), palpitation (n = 1) and dizziness (n = 1) in the
Table 2 Summary of the Meta-analysis
Trials Participants Mean difference
Risk factor Heterogeneity P value
(n) (n) (95% CI)
SDS 13 1044 −9.40 (−12.21,−6.59) < 0.000 01 < 0.000 01
AMT and routine care 5 412 −13.28 (−17.92,−8.64) < 0.000 01 < 0.000 01
AMT and conventional drugs 5 312 −6.66 (−12.66,−0.65) < 0.000 01 0.03
AMT+CD and conventional 3 320 −7.44 (−9.26, −5.63) 0.91 < 0.000 01
SAS 10 861 −7.75 (−10.44, −5.05) < 0.000 01 < 0.000 01
AMT and routine care 5 412 −8.61 (−12.38, −4.84) < 0.000 01 < 0.000 01
AMT and conventional drugs 3 209 −7.12 (−14.61, −0.37) < 0.000 01 0.06
AMT+CD and conventional 2 240 −6.60 (−11.32, −1.88) 0.07 0.006
QOL 5 323 1.11 (0.80, 1.42) 0.15 < 0.000 01
AMT and conventional drugs 2 137 1.36 (0.99, 1.74) 0.31 < 0.000 01
AMT+CD and conventional 3 186 0.93 (0.59, 1.28) 0.28 < 0.000 01
Notes: CI: confidence interval; SDS: self-rating depression scale; SAS: self-rating anxiety scale; QOL: quality of life; AMT: acupuncture and
moxibustion therapy; CD: conventional drugs.
 Ma FF et al / Journal of Traditional Chinese Medicine 2023 43(3): 441-456 453

treatment group; 16 patients’ adverse reactions including associated with hypothalamic-pituitary-adrenal (HPA),
fatigue (n = 1), dizziness (n = 3), nausea (n = 4), sympathetic nervous system (SNS) dysregulation,67 the
sweating (n = 2), and dry mouth (n = 5) in the control kynurenine metabolic pathway activation,68 the
group. Two studies48,51 reported the incidence of adverse adenosinergic system,69 and neuroendocrine-immune
reactions in the treatment group was lower than that in mechanisms.70,71 Laboratory studies have provided
the control group with significant difference. Five evidence for acupuncture’s effect on sleep, depression,
studies44,53,57,59,62 reported that no significant adverse anxiety and psychological distress in cancer survivals by
reactions were found in either group. stimulating the HPA axis,72 SNS system,73 circadian
rhythms, cytokines and neurotransmitters(such as IL-1,
Publication bias IL-6, neuropeptide Y, serotonin, melatonin, dopamine,
norepinephrine, gamma-aminobutyric acid, β-
Based on the primary outcome measure including PQSI,
endorphins),74-76 which plays a significant role in all
HAMD, SDS and SAS in RevMan 5.3 software, we used
important targets in the psychiatric treatment of
a funnel plot to have a qualitative analysis of publication
depression and anxiety.77,78 At present, more studies are
bias. The distribution of graphical cues was not
needed on the definite mechanism of acupuncture and
symmetric, and a few points were distributed beyond the
moxibustion in patients with CRPS.
funnel, indicating that there might be publication bias in
our study that influenced the results of our analysis, as
Summary of main results
shown in supplementary Figure 3.
The aim of this study is to evaluate the effectiveness and
Sensitivity analyses safety of AMT in cancer patients with CRPS. After
literature screening, we pooled the data from 30 studies
We found that the results of heterogeneity comparing the
involving 2483 patients for further analysis. Our pooled
PSQI, the effective rate of insomnia, HAMD, SDS, SAS
analysis indicates that compared with routine care or
scale on AMT VS conventional drugs or routine care
combined with conventional drugs, AMT seems to
were not significantly reduced by omitting the study
improve cancer-related psychological symptoms to a
sequentially.
certain extent, especially in insomnia, depression and
However, the results of heterogeneity comparing the
anxiety; besides, it is likely to significantly reduce PSQI,
effective rate of depression significantly reduced from
HAMD, SDS, SAS and increase insomnia effective rate,
[RR = 1.29, 95% CI (1.12, 1.49), P = 0.0004, I2 = 59%]
depression effective rate and QOL with mild adverse
to [RR = 1.21, 95% CI (1.11, 1.32), P < 0.0001, I2 = 0%]
reactions. In addition, there is no statistically difference
after excluding the Liu’s study.41 Therefore, the Liu’s
in the therapeutic effects between the AMT and
study41 was regarded as the source of heterogeneity, it
conventional drug groups. Therefore, compared with
offered inferior evidence for the effect of AMT on
conventional drugs, AMT has the same effects as
cancer-related depression.
antidepressants and anti-anxiety medication to some
extent in improving cancer-related depression and
4. DISCUSSION anxiety.
Another systematic review also suggested that
Acupuncture and moxibustion Intervention acupuncture was slightly more effective than
Mechanism benzodiazepines of anti-insomnia drug, with effective
rate for acupuncture and benzodiazepines being 91% and
As a new and promising field of research, acupuncture
75% respectively, and equally as effective as zolpidem
and moxibustion therapy is strongly needed by more
for improving sleep.79, 80 Adverse reactions of AMT have
and more cancer patients and survivors for various
been observed as being relatively mild, mainly including
cancer-associated symptoms.63-65 The most common
bruises, soreness, nausea, and dizziness which can be
integrative medicine therapies mentioned on the 45
effectively avoided by strengthening the aseptic
National Cancer Institute (NCI)-designated
operation specification, and improving the professional
comprehensive cancer center were exercise (97.8%) and
ability of doctors. Therefore, acupuncture and
acupuncture and meditation (88.9%).66 A number of
moxibustion treatment for CRPS is considered as being
cancer centers in the U.S., including Dana-Farber Cancer
safe and effective, which is worthy of clinical application.
Institute (DFCI) in Boston, Memorial Sloan Kettering
Cancer Center in New York, and M.D. Anderson Cancer
Quality of evidence
Center in Houston are integrating acupuncture into
cancer care. Based on the selected criteria, 30 studies involving a total
The mechanism of AMT on cancer-related psychological of 2483 cancer survivors have been included in this study
problems has been studied as a new and promising field to illustrate the effect of acupuncture and moxibustion on
of research. The co-occurrence of multiple psycho- the improvement of CRPS. The quality of evidence
neurological symptoms, including pain, sleep differs from low to high based on the Cochrane Bias
disturbance, fatigue, depression, anxiety, and cognitive Evaluation Tools and Jadad scale. Among the 30 studies
disturbance among adult cancer survivors, may be included, 14 studies are of high quality, 3 studies are of
454 Ma FF et al / Journal of Traditional Chinese Medicine 2023 43(3): 441-456

moderate quality, and 13 studies are of low quality. which to some extent, weakens the credibility and
Therefore, the quality of the included studies is generally reliability of the evidence of AMT for cancer-related
moderate. The inappropriate random method, allocation psychological symptoms in this systematic review and
concealment, and a lack of blinding in most studies have Meta-analysis. For example, with few control groups being
exaggerated the results of the outcome measures. In this placebo controls or false AMT, it is difficult to eliminate
study, 76.67% of the literature and 10% of the literature the placebo effect. Although the word “random” appeared
have correctly reported randomized grouping and in all the included literature, only 19 studies described the
allocation of hidden information, respectively. This random method correctly. In most of the included studies,
could lead to overestimate. allocation concealment and blind method are not clear,
which may lead to potential implementation bias and
Discussion of heterogeneity selectivity bias. Besides, most of the included RCTs were
conducted in China, and only one article was published in
There was heterogeneity in the effectiveness of AMT on
English. And the results of the funnel plot indicates
the total effective rate of psychological symptoms. To
potential publication bias.
explore its source, we adopted subgroup analysis and
Compared with published systematic review and Meta-
found that clinical heterogeneity could not be explained
analysis, literature retrieval in this study is more
for sorts of western medicine and many factors, its
comprehensive with systematic literature retrieval strategy
methodological heterogeneity has been mainly affected
and a larger number of literature is included, ensuring more
by the quality of the included literature and the subjective
reliable and scientific evidence in this study. Regardless of
bias of literature quality evaluation. Similarly, by
the potential bias and limitations of this review, all of the
changing the research effect model and adopting the
included studies show that AMT intervention seems to
sensitivity analysis method, we’ve found that the
have significant effects in improving cancer-related
heterogeneity is significantly reduced after omitting the
psychological symptoms. As an effective adjunct
study of Liu.41 To explore its reasons, it has been found
treatment, AMT intervention has turned to a superior
that they all have problems such as low quality, the flaw
complementary and alternative medicine with a
in test design, or small sample sizes. This indicates that
treatment modality of potential efficacy and few adverse
the results of this Meta-analysis, to a certain extent, have
effects, reducing the economical burden on health care
been affected by the risk of bias.
resources and the community.
It seems that AMT is an effective and relatively safe
In conclusion, in this systematic review and Meta-analysis
complementary approach for the treatment of cancer-
of RCTs, the efficacy and safety of acupuncture and
related psychological symptoms. However, substantial
moxibustion in the treatment of cancer-related
heterogeneity was a limitation of the analysis of AMT for
psychological symptoms are confirmed. Acupuncture and
cancer-related insomnia, depression and anxiety. The
moxibustion have the potential to become an effective
variety of intervention and control groups may have
therapy than routine care, and superior to conventional
contributed to heterogeneity. But subgroup analysis
drugs for it was of the same efficacy on cancer-related
(according to the type of intervention, type of the
insomnia, anxiety and depression but caused less adverse
acupuncture and moxibustion) could not totally explain
reactions.
the heterogeneity.
Nevertheless, limited by the quality of existing published
studies, extreme heterogeneity in the analyses remains
Limitations and advantages
unexplained with few high-quality studies included.
There were several limitations of this systematic review Therefore, further properly designed RCTs with well-
and Meta-analysis: designed, rigorous, large sample, and multicenter
Firstly, the evaluation criteria are inconsistent for cancer- prospective are needed before the AMT therapy could be
related insomnia, depression and anxiety. There are 11 widely recommended in the treatment of cancer-related
studies using PSQI, and 7 studies using the effective rate of symptoms, so as to reduce the influence of publication bias,
insomnia with cancer-related insomnia. There are 12 improve the credibility of research and guide clinical
studies using the HAMD, 13 studies using the SDS, 7 practice better. The long-term efficacy of AMT
studies using the effective rate of depression with cancer- intervention on cancer-related psychological symptoms
related depression. Therefore, it might be one of the should also be evaluated.
sources of heterogeneity. However, due to the limitation of
the number of included literature and the lack of integrated
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