Running head: CHRONIC PAIN IN BREAST CANCER PATIENTS
Chronic Pain in Breast Cancer Patients
Ashlee Feyes, Student Nurse
University of South Florida
1
CHRONIC PAIN IN BREAST CANCER PATIENTS
2
Abstract
Pain is a chronic occurrence in patients with breast cancer, and the effects can range anywhere
from feeling uncomfortable to depression from severe pain. The goal of this project is to
decrease the levels of pain in patients with breast cancer through the use of pharmacological
methods as well as acupuncture for a three-month trial period. This paper explores four articles
found through search engines CINAHL, PubMed, and FindIt at USF. Key terms included: breast
cancer, acupuncture, pain management, complementary medicine, alternative medicine,
Aromatase Inhibitors, joint pain and stiffness. Results of the studies showed that acupuncture as
an adjunctive therapy for pain decreased pain rates significantly, and therefore should be used to
decrease the rates of chronic pain in breast cancer patients. After researching and synthesizing
the evidence, a pilot study will be performed on the oncology unit using the Iowa Evidence
Based Practice model. Results will be evaluated through the Visual Analogue Scale (VAS) for
pain after three-months of acupuncture co-treatment.
CHRONIC PAIN IN BREAST CANCER PATIENTS
3
Chronic Pain in Breast Cancer Patients
According to Smith & Wu, one debilitating issue that breast cancer treatment survivors
suffer is persistent pain after breast cancer treatment (PPBCT) (2012). This side effect of chronic
pain is so common, it is shown in 50% of breast cancer survivors (Smith, 2012). Breast cancer
patients are treated with pharmacological methods to relieve pain, but there would be better pain
control if they were treated with both pharmaceuticals and alternative therapies, such as
acupuncture. Decreasing the rate and severity of pain will lead to an increase in patient
satisfaction, better patient outcomes, compliance with medications and shorter hospitalizations.
The initial clinical question for this project is: In breast cancer patients with pain symptoms, how
does the use of a combination of acupuncture and pharmacological methods compared to the use
of pharmacological methods alone affect rates of pain in three months?
Infrastructure necessary for this project is to recruit women with breast cancer who are
using aromatase inhibitors and are having chronic back pain due to these medications to combat
the breast cancer. There will also need to be oncology nurses, who will be responsible for
measuring and recording pain before and after acupuncture treatments, as well as administering
any pharmacological interventions for pain in the control group. Another member of the team
will be an acupuncturist, who is responsible for administering acupuncture to patients in need.
This project may be implemented in oncology clinics, pain management clinics, hospitals, and
outpatient facilities. The culture at St. Joseph’s hospital is very open to EBP, and is willing to run
a pilot study and adopt the method of practice if positive results are seen. This topic is a priority
for the organization because the main goal is patient satisfaction, and decreased pain rates will
increase patient satisfaction scores.
Research, Review, and Synthesize
CHRONIC PAIN IN BREAST CANCER PATIENTS
4
Literature Search
During the research phase, there were multiple search engines used. Research began with
CINAHL and PubMed, and finished by using FindIt on the USF library website EBSCO host.
Key terms used included “chronic pain,” “breast cancer,” “acupuncture,” “cancer,” and “back
pain.” Multiple searches were performed, and those with relevant beneficial results were
extracted. After retrieving the most relevant sources for chronic breast cancer pain and
acupuncture therapy, we shifted our research focus to articles with chronic lower back pain and
acupuncture therapy.
Literature Review
In Crew et al. (2010), the study was performed to determine if true acupuncture, when
compared to sham acupuncture, resulted in decreased rates of pain in patients with
musculoskeletal pain symptoms due to AI use. This study consisted of 51 women with breast
cancer, who were on aromatase inhibitors (AI) that were causing joint pain and stiffness. These
women were enrolled in true acupuncture (TA) over their full body or sham acupuncture (SA),
which was in non-acupoint locations. Patients were allowed to use NSAIDS and nonnarcotic
medications during the sessions. Pain was scored on a Brief Pain Inventory-Short Form (BPISF), which compared pain severity (0-10) and the effects on the patient’s daily life. Using this
scale from baseline, pain was lower in TA versus SA after six weeks (p<0.001). Refer to Table 1
for additional source information. The greatest strength of this study was that it was a double
blind study. Another strength is having most women in early stages of breast cancer (12 in stage
1 for each in TA and SA group). Weaknesses include a small sample size, and different uses of
AI therapy (anastrozole, letrozole, and examestane). This study was also done over six weeks,
CHRONIC PAIN IN BREAST CANCER PATIENTS
5
which fits into our three-month time frame. This study shows that patients who receive true
acupuncture have a greater reduction in pain versus the control group.
In Mao et al. (2014), the study was performed to determine if rates of pain in breast
cancer patients on AIs were decreased through the use of electro-acupuncture or sham
acupuncture. This study consisted of 67 breast cancer patients who were having joint pain and
stiffness due to AI use. These patients were randomly assigned to electro-acupuncture (EA) and
sham acupuncture (SA) treatments over eight weeks. Pain was rated on the Brief Pain Inventory
(BPI) scale. Over eight weeks, the EA group had a reduction in pain severity of 2.2 and SA had a
decrease of 2.3 (p=0.0004). The real surprise came from reassessing the patients at twelve weeks
to see if the acupuncture had lasting effects; the EA group had a reduction of pain by 2.4, and the
SA group had a reduction by 1.7 (p<0.0001). Compared to baseline, EA produced a 43.1%
reduction in pain severity and 52.6% reduction in pain-related life interferences (see Table 1).
Strengths of this study include that it is double blind, and showed there was an increase in pain
reduction through the use of acupuncture. One weakness of this study was that the sham
acupuncture group had more pain relief over the eight weeks. This study shows that electroacupuncture does relieve pain in breast cancer patients using AI therapy.
In Yun et al. (2012), the study was performed to determine if Hegu acupuncture or
standard acupuncture would decrease the rates of pain in patients with chronic back pain versus
the control group over eight weeks, and to see the lasting effects of acupuncture over 48 weeks.
This study was performed on 187 patients with chronic low back pain (CLBP). Patients were 2045 years old, and must have presented with back pain for at least three months prior to the study.
The study separated patients into Hegu acupuncture (acupuncture on the hand), standard
acupuncture, or the usual care (control) group. Measurements were performed through the
CHRONIC PAIN IN BREAST CANCER PATIENTS
6
Roland-Morris Disability Questionnaire (RMDQ), which shows the level of disability due to the
back pain, and the Visual Analogue Scale (VAS), which assesses pain intensity. Patients were
assessed using these tools at baseline, after eight weeks, and again 48 weeks later to see the
duration of pain relief. Over eight weeks, RMDQ mean scores in the Hegu group were 5.7,
standardized was 6.6, and usual care was 8.8 (p<0.001). Also over these eight weeks, the VAS
scale in Hegu was 4.6, in standardized was 5.0, and usual care was 5.6 (p<0.001). Refer to Table
1 for additional source information. The randomization of patients strengthens this study, since
this minimizes bias and helps to assure that groups are similar. The study also utilized a valid and
reliable measure of pain (e.g. VAS). Another strength is the ample amount of follow-up time (48
weeks), which provided enough time to measure the lasting effects of acupuncture. Another
strength of this study includes it being a double blind, sham controlled study. Enrolling those
who have had low back pain for at least three months prior, and excluding those with
complicated back issues (scoliosis/sciatica) and those who have had prior acupuncture treatments
for any condition were a few other strengths of this study (Yun et al., 2012). A weakness of this
study is that pain scores did not see a significant change over the course of the study during the
initial eight-week trial, however there was a difference after the 48-week reevaluation. This
study shows how acupuncture relieves chronic pain, which cancer patients deal with daily.
In Weib et al. (2013), the study was performed to determine if acupuncture would
decrease the rates of pain and increase the quality of life in patients with chronic back pain. This
study consisted of 160 patients with CLBP, who were recruited from an inpatient rehabilitation
program and randomized into two treatment groups. Each group consisted of 80 participants,
who either received acupuncture interventions, or acted as part of the control group.
Effectiveness was measured through patient surveys (Short-form 36) on their health related
CHRONIC PAIN IN BREAST CANCER PATIENTS
7
quality of life, which included pain quality, intensity, and duration. Upon a three-week posttreatment versus prior to treatment review of the Short-form 36, patients showed an increase in
physical functioning (p=0.02), vitality (p<0.01), social functioning (p=0.08), and emotional roles
(p=0.05). Bodily pain scores decreased three weeks post-treatment as well (p=0.28) (see Table
1). Strengths of this study include the randomization of patients, patient diversity, and a large
population size (160 patients). Another strength is the results show that acupuncture does benefit
the patients with minimal to no adverse effects on those without a prior clotting or platelet
disorder. Weaknesses include only being able to follow up on 143 patients out of the total
enrolled 160, use of a quality of life form instead of an actual pain rating scale, and inability to
distinguish patients reasoning for back pain or prior treatments tried. This study shows that
acupuncture has pain relieving capabilities in correlation with rehabilitation for patients living
with chronic lower back pain or musculoskeletal system, which is something most cancer
patients deal with daily.
Synthesis
All of the above mentioned studies are similar in their outcomes, which is that
acupuncture is an effective treatment option for pain. Another similarity is that Crew et al.
(2010) and Mao et al. (2014) include women with breast cancer who are receiving acupuncture
therapy to relieve joint pain and stiffness due to AI medication usage, and also use the same
measurement scale for pain (BPI and BPI-SF). Likewise, the other two studies from Weib et al.
(2013) and Yun et al. (2012) include both women and men who have chronic low back pain and
receive acupuncture therapy for the treatment of this musculoskeletal disorder. Differences
include sample sizes, types of acupuncture used, length of treatment, and number of treatments
during the specified length in weeks (Refer to Table 1).
CHRONIC PAIN IN BREAST CANCER PATIENTS
8
Key pieces from each study are necessary to develop this project. Crew et al. (2010)
shows that women receiving true acupuncture for six weeks alleviate more pain than use of
NSAIDs or non-narcotic pain medication alone (p<0.001). Mao et al. (2014) shows that women
receiving electro-acupuncture for eight weeks also show a decreased pain score after the eight
weeks (p=0.004), as well as having a lasting pain decrease when reassessed after twelve weeks
(p<0.0001). The next two studies involve chronic low back pain, which can be related to the
incidence of joint pain and stiffness in breast cancer patients. Weib et al. (2013) shows that
acupuncture in conjunction with rehabilitation over a three-week period alleviates more pain than
those without acupuncture treatments. Lastly, Yun et al. (2012) shows that Hegu (or hand)
acupuncture over eight weeks alleviates more pain versus sham acupuncture or no acupuncture
on both the RMDQ and the VAS for pain (p<0.001). Through this knowledge, it can be inferred
that acupuncture is a reliable treatment option to alleviate musculoskeletal pain in breast cancer
individuals. However, further studies must be conducted to determine the lasting effects of
acupuncture with reference to pain scores, which acupuncture works best for musculoskeletal
pain (TA/EA/Hegu acupuncture), as well as any possible side effects, and how patients who
cannot undergo acupuncture treatments will receive pain relief.
Practice Change Proposal
Clinical recommendations for our clinical setting and population are to decrease the rate
and severity of pain, which will lead to an increase in patient satisfaction, better patient
outcomes, greater compliance with medications and shorter hospitalizations. These
recommendations will be achieved by allowing breast cancer patients to receive a combination
therapy of pain medications, rehabilitation and true acupuncture. An acupuncturist will perform
ten, forty minute treatments, of true acupuncture over eight weeks time. The nurse will evaluate
CHRONIC PAIN IN BREAST CANCER PATIENTS
9
pain before and after each treatment for the eight weeks, then again through a phone survey four
weeks post-treatment. Oncology nurses will have core measures for patients with breast cancer to
receive acupuncture along with their scheduled pain medication.
Strategy Change
As a result of this new evidence, this topic has become a priority. Through synthesis of
the evidence, and adequate information, a pilot change will be conducted on the oncology unit.
Strategies to promote staff/team engagement include thorough education for staff and a resource
individual to answer any questions the staff may have about the newly placed core measures.
There will also be a Frequently Asked Questions (FAQ) sheet placed on the bulletin boards of
the oncology units. This sheet will state evidence reflecting the combination use of
pharmaceuticals and acupuncture to treat chronic musculoskeletal pain for breast cancer
individuals. Lastly, there will be a goal chart online, which will state the three-month timeline
and show the progression towards the goal through numbers of patients, numbers of acupuncture
treatments, and pain ratings among patients. Once the practice change reaches its’ three-month
trail, results should show that pain scores were decreased by at least 2/10 levels. We will be
using the IOWA EBP implementation model for the pilot study.
Roll Out Plan and EBP Process

Identifying Triggers: Pain management is the goal of every nurse, although it can
be difficult to manage chronic pain. Acupuncture as a co-treatment for pain
management is a new topic of priority. The issue was identified through thorough
research, and occurred in January 2015.

Gathering and Synthesizing evidence: A team was developed to gather evidence,
and new research showed that chronic back pain, as well as joint pain and
CHRONIC PAIN IN BREAST CANCER PATIENTS
10
stiffness, can be relieved at higher rates through acupuncture in conjunction with
pharmacological pain management methods. This research took place between
January and February of 2015.

Pilot change: A pilot change will be conducted beginning in April and continue
until the end of June 2015, which will follow core measures for acupuncture and
pharmacological methods to decrease pain in breast cancer patients.
Implementation and evaluation of results will occur during this three-month trial.

Dissemination of Evidence: If there is a result of decreased pain ratings in patients
who receive acupuncture as a combination therapy with usual care treatments, this
practice change will be implemented throughout the hospital for any breast cancer
patient, the evidence will be written into the Journal of Complementary and
Alternative Medicine, and it will be suggested in a board meeting with Moffitt
Cancer Center in August 2015.
Project Evaluation
Pain will be measured using a 0 – 10 VAS scale. Patients will be assessed at baseline, and
reevaluated at the end of the three-month acupuncture therapy. Mean scores will be compared to
evaluate the effectiveness of the practice change. The goal of the project is to decrease pain
levels by at least two points (mean values) on the VAS. For example, if the mean value at the
beginning is eight, and after three-months the mean value is seven, the goal was not met, and the
study will be deemed unsuccessful. If the beginning value is eight, and the ending mean value is
four, the study will be highly successful, and may proceed to a second phase in which the lasting
effects of acupuncture will be evaluated six-months post-treatment. Data collection will be
CHRONIC PAIN IN BREAST CANCER PATIENTS
11
performed through nurse evaluation or surveys sent to the patients’ homes (for those who opt for
outpatient treatments).
Dissemination of EBP
As mentioned above, the first step will be to implement the core measures throughout the
hospital for any breast cancer patient. Next, a meeting will be arranged with the clinical
specialists at Moffitt Cancer Center to discuss the evidence, the results of the pilot project, and to
suggest implementation throughout the facility. Also, the evidence will be submitted to the
Journal of Complementary and Alternative Medicine to distribute regionally in hopes of
improving patient outcomes throughout the US. Lastly, there will be a documentary on the
Discovery Channel of women who would like to participate while going through the acupuncture
treatments.
CHRONIC PAIN IN BREAST CANCER PATIENTS
12
References
Crew, K., Capodice, J., Greenlee, H., Brafman, L., Fuentes, D., Awad, D., ... Hershman, D.
(2010).Randomized, blinded, sham-controlled trial of acupuncture for the management of
aromatase Inhibitor-associated joint symptoms in women with early-stage breast cancer.
Journal of Clinical Oncology, 28(7), 1154-1160. doi:10.1200/JCO.2009.23.4708
Mao, J. J., Xie, S. X., Farrar, J. T., Stricker, C. T., Bowman, M. A., Bruner, D., & DeMichele, A.
(2014). A randomised trial of electro-acupuncture for arthralgia related to aromatase
inhibitor use. European Journal Of Cancer, 50(2), 267-276.
doi:10.1016/j.ejca.2013.09.022
Smith, H. & Wu, S. (2012). Persistent pain after breast cancer treatment. Annals of Palliative
Medicine. 1(3), 182-194. doi: 10.3978/j.issn.2224-5820.2012.10.13
Weib, J., Quante, S., Xue, F., Muche, R., & Reuss-Borst, M. (2013). Effectiveness and
acceptance of acupuncture in patients with chronic low back pain: Results of a
prospective, randomized, control trial. Journal of Alternative & Complementary
Medicine, 19(12), 935-941.
Yun, M., Shao, Y., Zhang, Y., He, S., Xiong, N., Zhang, J., ... Yan, J. (2012). Hegu
acupuncture for chronic low-back pain: A randomized controlled trial. Journal Of
Alternative & Complementary Medicine, 18(2), 130-136. doi:10.1089/acm.2010.0779
CHRONIC PAIN IN BREAST CANCER PATIENTS
13
Table 1
Review of the Literature
Reference
Aims
Design and Measures
Sample
Crew, K.,
Capodice, J.,
Greenlee, H.,
Brafman, L.,
Fuentes, D., Awad,
D., ... Hershman,
D. (2010).
Randomized,
blinded, shamcontrolled trial of
acupuncture for the
management of
aromatase
Inhibitorassociated joint
symptoms in
women with earlystage breast
cancer. Journal of
Clinical Oncology,
28(7), 1154-1160.
doi:10.1200/JCO.2
009.23.4708
Mao, J. J., Xie, S.
X., Farrar, J. T.,
Stricker, C. T.,
Bowman, M. A.,
Bruner, D., &
DeMichele, A.
(2014). A
randomised trial of
electroacupuncture for
arthralgia related
to aromatase
inhibitor use.
European Journal
Of Cancer, 50(2),
267-276.
doi:10.1016/j.ejca.
2013.09.022
Purpose:
compare
true
acupuncture
to sham
acupuncture
for results
of decreased
pain rates
Women were enrolled in
true acupuncture (TA)
over their full body or
sham acupuncture (SA).
Patients were allowed to
use NSAIDS and
nonnarcotic medications
during the sessions.
 Six weeks total,
30-minute
treatments twice
a week.
 Brief Pain
Inventory-Short
Form (BPI-SF).
51
women
with
breast
cancer,
which
were
currently
taking
Aromatas
e
Inhibitors
.
Purpose:
compare
eletroacupuncture
to sham
acupuncture
for results
of decreased
pain rates.
Patients were randomly
assigned to either
electro-acupuncture
(EA) or sham
acupuncture (SA)
treatments.
 Ten thirtyminute
treatments over
eight weeks
 Twice a week for
the first two
weeks, then once
a week for the
remaining six
weeks.
 2Hz
67
patients
with
breast
cancer,
which
were
having
joint pain
and
stiffness
due to AI
use.
Outcomes /
statistics
Of the 51 women,
only 38 were
evaluable in the end.
Pain was scored on a
Using this scale from
baseline; pain was
lower in TA versus
SA after six weeks
(p<0.001). At
baseline, TA patients
had a mean pain
score of 6.70, and
SA patients scored
5.61. After six
weeks, the mean
pain score for TA
patients was 3.00,
and SA patients
scored 5.50.
After four weeks,
EA patients had a
decrease in pain
severity by 1.7 and
SA had a decrease in
pain severity by 1.5.
Over eight weeks,
the EA group had a
reduction in pain
severity of 2.2 and
SA had a decrease of
2.3 (p=0.0004).
Patients were
reassessed at twelve
weeks to see if the
acupuncture had
lasting effects; the
EA group had a
CHRONIC PAIN IN BREAST CANCER PATIENTS
Weib, J., Quante,
S., Xue, F.,
Muche, R., &
Reuss-Borst, M.
(2013).
Effectiveness and
acceptance
of acupuncture in
patients with
chronic low back
pain: Results of a
prospective,
randomized,
control trial.
Journal of
Alternative &
Complementary
Medicine, 19(12),
935-941.
electrostimulatio
n by a
Transcutaneous
Electrical Nerve
Stimulation
(TENS) unit in
the EA sample
 No
electrostimulatio
n in SA sample.
 Brief Pain
Inventory (BPI)
scale
Purpose:
Patients were
determine if randomized into two
acupuncture treatment groups. Each
decreases
group consisted of 80
the rates of
participants, who either
pain and
received acupuncture
increases
interventions, or acted
the quality
as part of the control
of life in
group.
patients
 21-day inpatient
with chronic
rehabilitation
back pain.
program for back
pain.
 Those in the
intervention
group received
acupuncture
twice a week for
three weeks in
addition to the
rehabilitation.
 Effectiveness
was measured
through patient
surveys (Shortform 36) on their
health related
quality of life,
which included
pain quality,
intensity, and
duration.
 Inclusion criteria
14
160
patients
with
Chronic
Low
Back
Pain
(CLBP),
recruited
from an
inpatient
rehab
program.
reduction of pain by
2.4, and the SA
group had a
reduction by 1.7
(p<0.0001).
Compared to
baseline, EA
produced a 43.1%
reduction in pain
severity and 52.6%
reduction in painrelated life
interferences.
Upon a three-week
post-treatment
versus prior to
treatment review of
the Short-form 36,
patients showed an
increase in physical
functioning
(p=0.02), vitality
(p<0.01), social
functioning
(p=0.08), and
emotional roles
(p=0.05). Bodily
pain scores
decreased three
weeks post-treatment
as well (p=0.28).
CHRONIC PAIN IN BREAST CANCER PATIENTS
Yun, M., Shao, Y.,
Zhang, Y., He, S.,
Xiong, N., Zhang,
J., ... Yan, J.
(2012). Hegu
acupuncture for
chronic low-back
pain: A
randomized
controlled trial.
Journal Of
Alternative &
Complementary
Medicine, 18(2),
130-136.
doi:10.1089/acm.2
010.0779
included chronic
low back pain
for at least six
months prior,
and age range
between 25-75
years old.
Exclusion
criteria included
anticoagulation
therapy,
coagulation
disorders,
thrombocytopeni
a, poor
understanding of
the German
language, recent
surgeries, or any
herniation of
spinal disks.
Purpose:
The study separated
determine if patients into Hegu
Hegu
acupuncture
acupuncture (acupuncture on the
versus
hand), standard
standard
acupuncture, or the
acupuncture usual care (control)
will
group.
decrease the
 Patients per
rates of pain
group were: 64
in patients
in Hegu, 60 in
with chronic
standard, and 63
back pain
in control.
over eight
 Treatments were
weeks. Also
every other day
to see the
for three weeks,
lasting
then twice a
effects of
week for four
acupuncture
weeks
over 48
 Eighteen
weeks.
treatments total
in seven weeks.
 The RolandMorris Disability
Questionnaire
15
187
patients
with
chronic
low back
pain
(CLBP)
Patients
were 2045 years
old and
must
have
presented
with back
pain for
at least
three
months
prior to
the study.
Patients were
assessed at baseline,
after eight weeks,
and again 48 weeks
later to see the
duration of pain
relief. Over eight
weeks, RMDQ mean
scores in the Hegu
group was 5.7,
standardized was
6.6, and usual care
was 8.8 (p<0.001).
Also over these eight
weeks, the VAS
scale in Hegu was
4.6, in standardized
was 5.0, and usual
care was 5.6
(p<0.001).
CHRONIC PAIN IN BREAST CANCER PATIENTS

16
(RMDQ): shows
the level of
disability due to
the back pain.
The Visual
Analogue Scale
(VAS): assesses
pain intensity.
(0-10)