Full title: “Acupuncture for Treatment of Post-Radiation Skin Lesions in a State 4 Triple Positive Breast Cancer Patient: A Case Study”
Abstract:
This case study of a 33-year-old patient with stage 4 triple positive breast cancer illustrates how acupuncture can be used as an adjunct therapy for late-stage breast cancer, helping to improve quality of life by relieving pain and other symptoms of the cancer and treatment side effects.
Introduction
Mary (name has been changed for privacy purposes) is a 33-year-old-female who was diagnosed with stage 4 triple positive breast cancer in February 2016, shortly after the birth of her first child. By the time she presented for acupuncture in June 2018 she had already been treated with 4 types of chemotherapy, and was about to undergo radiation for progression of the tumors in her breasts and for metastatic disease in her brain. At this time, she was experiencing increasing discomfort in her right breast. The tumors in the breast were progressing, and they were pressing through the skin and causing inflammation.
This case study illustrates how acupuncture can be used as an adjunct therapy for late-stage breast cancer, helping to improve quality of life by relieving pain and other symptoms of the cancer and treatment side effects.
Case Presentation
Mary is a 33-year-old-female who was diagnosed with stage 4 triple positive breast cancer in February 2016, shortly after the birth of her first child. By the time she presented for acupuncture in June 2018 she had already been treated with 4 types of chemotherapy, and was about to undergo radiation for progression of the tumors in her breasts and for metastatic disease in her brain. At this time, she was experiencing increasing discomfort in her right breast. The tumors in the breast were progressing, and they were pressing through the skin and causing inflammation. She was about to begin a 5-week course of radiation to attempt to reduce the size of the tumors in the breast. Chemotherapy had been paused for brain surgery to remove a metastasis and allow for her recovery, and she was scheduled to begin weekly infusions of gemcitabine and Herceptin with a 3 week on/1 week off schedule.
The primary complaint Mary was seeking help for was pain. She was using Hydrocodone as prescribed and was beginning to develop tolerance to the medication and had thus been prescribed oxycontin which she was trying to minimize use of. She was actively caring for her 2-year-old son, and did not want to be under the influence of narcotics during the day to the extent that she could function without them. She described a constant ache in the right breast which was always uncomfortable, with occasional sharp pains which were enough to “stop her cold”. She described sleeping only a few hours each night due to inability to get comfortable.
Secondary complaints included sleep disturbance, anxiety, and generalized inflammation. She also reported a history of lymphedema in the right arm and hand which was generally well controlled with use of a compression sleeve as needed.
Medications:
Gemcitabine is infused intravenously over approximately 30 minutes. The most common side effects include nausea, vomiting, diarrhea, loss of appetite, hair loss, fatigue, mouth sores, neuropathy in the hands and feet, headache, and muscle pain.1 Herceptin is a monoclonal antibody which is used for treatment of HER2+ breast cancers which have progressed despite other chemotherapy. It is also administered intravenously, and common side effects include nausea, vomiting, loss of appetite, headache, insomnia, altered sense of taste, weight loss, bone and muscle pain, mouth sores, and fatigue.2
Evaluation:
Traditional Chinese medicine evaluation revealed moderate to poor appetite, minimal nausea even when on chemotherapy, and occasional loose stools with digestion varying depending on the medications she was taking. Urination was unremarkable. She noted no particular changes in body temperature regulation, and no hot flashes or night sweats. Sleep was disturbed due to pain, and she would wake when her dose of medication started to wear off, remaining awake until she was able to take the next dose. Pain was specific to the affected right breast. She was continuing to menstruate and menstruation was unremarkable. On examination, Mary’s tongue was slightly red throughout the body with a redder tip. There was a center crack, and thin white coat. Pulse on the right was slippery without force in all positions. The left cun was superficial and the left guan and chi positions were deep and thin. The skin of the right breast was red, ulcerated, and blistered, with appearance similar to a second-degree burn.
Diagnosis was heat in the Stomach channel, stagnation of fluids, and Spleen/Kidney yang deficiency with yang unrestrained and rising upwards to affect the heart.
Heat in the stomach channel was diagnosed purely on the location of the pain and inflammation on the right breast which was mostly along the stomach channel.
The red tongue with redder tip was an indication that the heat was beginning to appear internally as well as on the channel, particularly affecting the Heart as evidenced by the redder tip and the superficial left cun pulse, yet the underlying pattern appeared to be more of a qi and yang deficiency. The white tongue coat was suggestive that the heat was still in the channels and had not yet permeated the interior. The patient had some loose stools, lack of appetite, and fatigue along with deep, thin pulses in the guan and chi positions, consistent with Spleen qi deficiency. In my over 20 years of clinical experience, a pulse which has a slippery feeling but without the force to be truly a slippery pulse is an indication of fluid stagnation where there is not enough qi to transform fluids and the dampness is weighing down the pulse at the same time it is causing fatigue. The most common underlying mechanism for dampness stagnating is deficiency of Spleen qi or yang. If my assertion that the heat in the Heart was due to unrestrained yang floating upward is correct, it implies that the yang of the Kidney was sufficiently deficient to allow the yang to float unrestrained to harass the Heart. Often in long standing, chronic cases, there is a point where an underlying cold condition begins to cause sufficient stagnation to begin to generate heat. At that point, tongue and pulse may show a transitional state which is difficult to interpret, which is how I interpreted the pattern in this patient who had already undergone 2 years of cancer treatment immediately following giving birth.
The initial treatment consisted of acupuncture only, administered with #36 needles which were inserted 2-7mm, and retained for 30 minutes without additional stimulation. Points used included LI 16 (right side), LI 11 (right side), LI 4 (bilateral), and St 44 (bilateral), to clear heat and stagnation in the Yang Ming channels. SI 1 (right side) was chosen to benefit the ipsilateral breast. Ren 17 was used as a local point which was outside the area of inflammation. St 36 (right side), K 3 (left side) were used to support the Spleen and Kidneys. H 6 (left side), extra points Yintang, Anmien (bilateral), ear point zero (bilateral), and ear shenmen (bilateral) were used to calm the spirit, relieve anxiety, and aid sleep through their actions on the sympathetic nervous system and vagus nerve.3 All insertions on the right side were superficial, just tapped in with a guide tube due to her history of lymphedema in that extremity. Home recommendations included increasing her water intake to a minimum of 3 liters daily, 10-15 minutes of gentle walking daily as tolerated, and 25-50 deep relaxation breaths before bed each night. Calendula cream was recommended to use between radiation appointments, and we discussed use of medical cannabis in a 25:1 CBD:THC ratio for anxiety if her medical oncologist agreed. This ratio was chosen because the patient was strongly motivated to minimize intoxication, and where CBD is helpful for anxiety, some THC is necessary for pain relief.4,5
Mary returned on July 5, two weeks after the initial visit and reported that her pain level had dropped significantly. She was able to sleep through the night and was using less hydrocodone, no longer considering oxycontin. She reported that she had attempted less costly treatment at a local school clinic between visits and found this visit to be less effective.
At this point, her skin was raw and wet where the radiation had been applied. Her physician had provided silvadene and she was also using calendula and aloe vera to relieve the skin burns, waiting for an appointment with the wound care clinic at her cancer center which was scheduled for three weeks out. She was taking 5mg Hydrocodone before bed, and no pain medication during the day. Pulse was slippery and full on the right and slightly thin on the left with cun position superficial. Her tongue was no longer red and was more swollen with teeth marks, suggesting that the heat from radiation was clearing and the underlying qi and yang deficiency with fluid stagnation was now predominating.
Treatment this visit was a similar point prescription with LI 16 (right side), LI 11 (right side), SI 1 (right side), LI 4 (left side), H 6 (left side), K 3 (right side), Ren 17, anmien (bilateral), St 36 (right side), St 40 (left side), Sp 9 (left side), St 44 (bilateral), yintang, and ear shenmen plus point zero (bilateral). She reported that her medical oncologist was uncomfortable with sublingual medical cannabis, but was open to use of topical hemp for symptom relief. She was given a topical hemp formula to use for anxiety and pain as needed. There are no known adverse interactions between hemp and gemcitabine, and in fact, studies have shown that CBD may augment the effects of gemcitabine in treatment of pancreatic cancers.6 There are no known adverse interactions between hemp and Herceptin, and CBD has been shown to have no significant effect on HER2+ breast cancer cell lines when combined with Herceptin.7 However, a topical formula was chosen over an internal formula to minimize risk of interaction between the hemp and the patient’s chemotherapy as the patient’s medical oncologist agreed to use of topicals.
Mary returned one week later on July 12 and reported that her breast and chest were feeling overall better, with much less pain. Her skin was now itchy, flaking, and peeling, and there were no longer open/weepy wounds. She reported experiencing several temporal/occipital migraines which were relieved by vomiting, and noted that her white blood cell count (WBC) and platelets had dropped to the point of necessitating a delay in chemotherapy. Her pulse was slippery on the left with the guan position thinner than the rest of the pulse, and slightly slippery especially on the right guan. Her tongue was pale pink with a slightly red tip, swollen sides, and a thin, wet, white coat. The increasingly slippery pulse is an indication that the damp stagnation was worsening, and the healing skin was an indication that the heat in the stomach channel was improving. A drop in white blood cell count and platelets is an indication of blood deficiency, in this case, caused directly by the gemcitabine which is known to cause neutropenia.8 Points used included St 36 (bilateral), Liv 8 (bilateral), Liv 3 (right side), K 6 (left side), GB 41 (left side), SI 1 (right side), LI 11 (right side), Ren 17, H 6 (left side), SJ 5 (left side), yintang, anmien (bilateral), and ear shenmen/point zero (bilateral). Liv 8 was added to the point prescription due to its action to build blood. Since the wounds were now closed, she was given Sweet Bee Magic® to use as a healing balm for the skin. This product contains honey, propolis, olive oil, avocado oil, and sea buckthorn oil. With closed wounds and completion of her course of radiation, the patient’s physician was open to any topical which may help with healing the skin. This product was chosen because of the known action of honey and propolis as antimicrobials, as well as their ability to stimulate healing of the skin.9
On July 19, Mary reported some pain had returned to the right breast. She reported the pain was minimal, not constant, and not bad enough to require medication. She noted that her skin was healing, and she was scheduled for a skin check with her radiation oncologist on August 2. Her platelets had increased, but were still too low to proceed with chemotherapy so she was given Herceptin without gemcitabine. She reported that her latest CT scan showed mild progression in the left breast and some small spots on her liver. She noted that her digestion was doing ok, sleep was much better, and her mood was good. At this visit, her pules was overall slightly wiry, left cun was floating, and the guan position was thinner bilaterally. Points applied included St 36 (bilateral), Liv 8 (left side), Liv 3 (bilateral), GB 40 (right side), LI 11 (right side), SI 1 (right side), H 6 (left side), SJ 5 (left side), LI 4 (left side), Ren 17, Ki 6 (right side), SP 6 (left side), yintang, shenmen (bilateral), and point zero (bilateral). She was scheduled to return in one week.
Mary was seen again on July 26. She indicated that her platelets had increased enough that she would be able to have her full chemotherapy on her next scheduled date. Her pain was minimal, digestion doing well. She was using CBD at night to aid with sleep and was no longer using the hydrocodone. She had a consultation with a wound care nurse who cleaned up a small spot of ulceration, and indicated that ongoing wound care was unnecessary due to her mostly dry, healing skin. Acupuncture treatment was continued with emphasis on clearing heat from the Stomach channel, calming the spirit, supporting the Stomach and Spleen, and supporting blood. At her next visit on August 9, Mary reported that she was now able to sleep on her stomach again. Breast and chest pain were mostly gone and the skin on her breast was mostly healed. She noted that her radiation oncologist was surprised by how completely she had healed and how quickly. At that point, her tumor markers were starting to come down, and her medical oncologist reported that her lymph nodes felt smaller on examination. Platelets had dropped, but were still in a range where treatment could continue. Updated brain MRI showed a small spot behind her left eye which would be treated with a single radiation treatment.
Mary continued to receive acupuncture treatment until she eventually succumbed to her cancer in June of 2019. Acupuncture was used consistently to help her manage symptoms of pain, sleep disturbances, anxiety, and stomach upset due to treatment.
Discussion
This case serves to demonstrate how acupuncture can be used effectively alongside conventional cancer treatment to relieve symptoms caused by the cancer and cancer treatment and improve quality of life for the patient. Mary was diagnosed at stage 4 and lived for 3 years beyond her initial diagnosis. Triple positive breast cancers tend to be aggressive and resistant to treatment, with poor prognosis.10,11 Because of her acupuncture treatment, Mary was able to spend more quality time with her son and participate more fully in her life outside of treatment until she eventually became too sick to do so. Even as the cancer progressed, she continued to use acupuncture to manage her pain and treatment side-effects. She refused home treatment when she became too weak to travel. In Mary’s case, minimal herbs/supplements were offered due to concern for potential interactions with the ongoing chemotherapy. Topical formulations were helpful for clearing heat from her wounds, relieving pain, relieving anxiety, and helping with sleep.
References
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9 Tashkandi H. Honey in wound healing: an updated review. Open Life Sci. 2021 Oct 6;16(1):1091-1100. doi: 10.1515/biol-2021-0084. PMID: 34708153; PMCID: PMC8496555.
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