While novel advances in therapeutics have extended longevity for patients with urologic cancers, increasing intensity of multimodal therapies as well as additional lines of therapy are associated with increased risk of toxicity and treatment burden that can significantly impact the quality of life of patients. Evidence-based complementary and alternative treatments, when used in conjunction with conventional therapies, can help patients cope with treatment side effects and toxicities and improve overall well-being during treatment. In this article, we highlight the potential roles and rationale for considering incorporating acupuncture and acupressure in the care of patients with urologic cancers.

Acupuncture involves the placement of small needles at specific defined acupoints that have been identified as being associated with the alleviation of specific symptoms or the promotion of specific responses. Mechanistically, needle placement is thought to deform fascial networks, which results in neuromodulation via neurotransmitter release as well as the elaboration of anti-inflammatory cytokines, as demonstrated by emerging basic science and animal data.^1-4 In acupressure, sustained repeated manual pressure at these points is applied with the goal of eliciting similar responses⁵ with the added benefit that patients and caregivers can be trained to perform the interventions with limited added cost.⁶

Acupuncture and acupressure have specifically emerged as safe⁷ and effective adjunctive treatments to reduce perioperative pain,^8-10 resulting in reduced opioid requirements,⁸ mitigate surgical complications, and improve health-related quality of life in patients undergoing surgery. For example, acupuncture and acupressure have demonstrated utility in treating and preventing postoperative nausea and vomiting,¹¹ as well as in reducing postoperative ileus and promoting return of bowel function and postoperative oral intake with resultant reductions in length of stay.^11,12 To explain this finding, animal models have suggested that mechanistically, acupuncture at the ST36 acupoint is associated with accelerated bowel transit time via vagal nerve stimulation.¹³ Furthermore, acupuncture is included as a treatment option in the consensus guidelines statements by the Society for Ambulatory Anesthesiology as a nonpharmacologic intervention to reduce perioperative nausea and vomiting.¹⁴ Finally, acupuncture has demonstrated benefits in reducing anxiety and improving overall health and well-being, which may have implications for reducing distress associated with frequent surveillance procedures (especially invasive surveillance procedures such as in-office cystoscopy) and improving outcomes in cancer survivorship as part of multimodal well-being–directed interventions.¹⁵ A meta-analysis showed reduced admission times, decreased postoperative opioid use, and shorter time to both first defecation and flatus in patients receiving targeted perioperative interventions.¹⁶

Importantly for urologists, acupuncture is effective in reducing the symptoms of overactive bladder and pain with interstitial cystitis.^17-20

Recently, we evaluated whether we could extrapolate the experience with acupuncture in managing overactive bladder to the bladder symptoms experienced during intravesical therapy for nonmuscle-invasive bladder cancer. Over 90% of patients receiving bacillus Calmette-Guérin (BCG) report at least one treatment-related adverse event, including hematuria, chemical and bacterial cystitis, and increased urinary frequency.²¹ Therefore, we investigated the feasibility and potential efficacy of incorporating in-office acupuncture in the care of patients undergoing induction BCG-associated in a prospective phase 1/2 randomized controlled trial. Patients with nonmuscle invasive bladder cancer were randomized to the acupuncture arm and received in-office treatments before each of their weekly BCG instillations vs standard of care treatment. The primary finding of this trial was that acupuncture could be successfully and safely delivered without substantial additive treatment burden to patients and without delaying or otherwise negatively impacting receipt of BCG treatments. We observed 2 grade 1 adverse events associated with acupuncture that spontaneously resolved and no grade 3 or greater associated adverse events. Furthermore, in-office acupuncture was favorably perceived by participants. Finally, while not powered to assess efficacy, patients in the intervention arm reported a statistically significant improvement in urinary symptoms over the course of the trial compared to controls. This trial suggests that acupuncture before BCG treatments is not only feasible but also tolerable to patients, and it opens the door for further trials to investigate its efficacy. Key questions that remain following this initial pilot study in a modest sample of 45 patients include mechanistic evaluations of the efficacy signals observed, greater evaluation of the efficacy end points, as well as evaluations regarding whether adjuvant acupuncture/acupressure can be delivered outside of the clinic with similar effect to address concerns about scalability and adoption outside of clinics with in-house acupuncture resources. Further trials are needed to further demonstrate acupuncture’s efficacy and accessibility in the bladder cancer space across health care systems.

To conclude, integrative therapies are emerging as potentially beneficial adjuncts to the multidisciplinary approach of patients with genitourinary malignancies, both in the perioperative setting as well as with respect to impacting health-related quality of care for patients undergoing nonoperative management and throughout survivorship. Limitations of the available literature include a low level of evidence of many trials as well as a lack of data regarding the optimal implementation of therapies. Future carefully designed trial studies are needed to continue to provide evidence regarding the optimal utilization of these strategies to guide their integration into clinical care pathways.