Nonhormonal Hot Flash Management for Breast Cancer Survivors: A Systematic Review and Network Meta‐Analysis

Abstract

Aim of the Study. Hot flashes impair the quality of life of breast cancer survivors. Nonhormonal management is an important consideration. The objective of this network meta-analysis (NMA) is to compare the therapeutic efficacy and safety of nonhormonal hot flash treatments for breast cancer survivors. Materials and Methods. We conducted a systematic literature search in PubMed, Cochrane Central Register of Controlled Trials, Embase, Chinese Biomedicine Database (CBM), China National Knowledge Infrastructure (CNKI), Wan Fang, and VIP up to May 2018. Randomized controlled trials (RCTs) reporting nonhormonal hot flash treatments for breast cancer survivors were included. Primary outcome measurements were hot flash frequency and hot flash score of posttreatment. The methodological quality of each study was assessed with Cochrane’s risk of bias tool. Results. 16 RCTs involving 2,349 participants were included. The nonhormonal therapies used in the included studies were classified as follows: lifestyle changes, mind-body techniques, dietary/supplements, SSRIs/SNRIs, other medications, and other therapies. Pairwise meta-analysis showed that the general effect of nonhormonal management was statistically more effective than no treatment/placebo/sham in reducing hot flash frequency (SMD = −0.60, 95% CI [−1.13, −0.06]; P=0.03)) and hot flash score (SMD = −0.38, 95% CI [−0.68, −0.08]). For hot flash frequency, results from the NMA showed that there was no statistically significant difference between any two of the nonhormonal treatments. Another NMA result indicated that acupuncture (other therapies) was 16.05 points more effective in reducing hot flash scores than no treatment/waitlist (SMD = −16.05, 95% CI [−30.2, −1.99]). These results were statistically significant. Acupuncture was also ranked the optimal nonhormonal therapy for both hot flash frequency and hot flash score. The safety analysis showed that there were few related adverse events during acupuncture and that drug related adverse reactions could have also occurred in studies using drug interventions Conclusions. This network meta-analysis comparing nonhormonal treatments suggested that acupuncture might be more effective in improving hot flashes for breast cancer survivors. A pronounced placebo response was found during hot flash treatments. The evidence of safety for nonhormonal therapies was also insufficient. Therefore, at present, we cannot make confirmative recommendations of nonhormonal hot flash management for breast cancer survivors. This study is registered with PROSPERO (CRD42018082008).

Implementation of Acupuncture in Routine Oncology Care: A Comparison of Physicians’, Nurses’, Physiotherapists’ and Acupuncturists’ Practice and Beliefs

“…Sham electro-acupuncture was accordingly more effective than genuine gabapentin. 34 A literature review 4 noted this pronounced placebo response. The conflicting results from studies using different kinds of control groups may have induced the conflicting attitudes to acupuncture effects across the oncology team.…”

“…19,43 If there are no better alternatives, acupuncture may be valuable to many patients despite the rather weak scientific evidence regarding genuine acupuncture effects. 3,9,20,21 Although different studies of acupuncture for cancer-related symptoms present conflicting results [3][4][5] and indicate great expectancy-driven effects, [3][4][5]12,13,23 patients often present self-perceived benefits from acupuncture treatments for cancer related symptoms. 13,23,43 Reasonably, effects from positive tations, communication, touch, and relaxation during acupuncture therapy, may be valuable for the patients.…”

“…Plausibly their valuing is based on research on acupuncture for cancer-related symptoms. [3][4][5]13,[19][20][21] The conclusions to be drawn vary highly depending on whether the studies compare the effect of acupuncture to the effect of no acupuncture (often demonstrating great effects 22,23 ), or if the comparison alternative is a sham device (often demonstrating minor or no effects 4,13 ). Accordingly, it seems reasonable that differences in interpretation of scientific studies produce differences in beliefs within different professionals of the oncology team.…”

“…All individual oncology professionals thus estimate their own competence and make their individual acupuncture treatment decisions, commonly based on papers reviewing the scientific evidence for effects of acupuncture in cancer related symptoms. [3][4][5]13,[19][20][21] Acupuncturists (ie, not licensed health care professionals) practicing acupuncture within private alternatives have no scientific evidence-based restrictions; they work outside the publicly financed "approved health care." However, they are prevented from using acupuncture to cure cancer per se, and to treat children (<12 years).…”

“…Integrative symptom management in oncology care is of broad interest since patients with cancer experience a variety of symptoms 2 that acupuncture may relieve. Examples are pain, 3 vasomotor symptoms due to iatrogenic menopause, 4 and nausea and vomiting. 5 Many patients ask for more than medical treatments to reduce burdensome symptoms.…”