Cancer is the second leading cause of mortality in the United States,1 and the majority of cancer patients experience cancer-related fatigue and pain as common symptoms due to the cancer itself, cancer treatment or both.2 Fatigue in cancer is well-described as feeling tired, worn out, and having no energy or "get up and go"; distinctly different from fatigue experienced by a healthy person due to daily activities, in that such fatigue can be relieved by sleep or rest.3 Fatigue with cancer can decrease the quality of life of the cancer patient. Pain is also a common symptom in metastatic cancer patients.2
Acupuncture has been used in America to treat the various symptoms and conditions of cancer patients and the side effects of the cancer treatment.4 Acupuncture has analgesic effects and reduces the amount of volatile anesthetics required.5,7
Case Presentation
A 64-year-old female was diagnosed with cancer that metastasized to other distant parts of the body and developed to the terminal stage. The patient was told by her doctor that she would live for fewer than three months. The patient was released from a hospital to her home after refusing her doctor's recommendation to stay in a hospice hospital.
The patient's chief complaint was pain and cancer-related fatigue. Pain level was 10 on a 0-10 pain scale. The quality of pain was sharp. Most of the time, her eyes were closed. The patient was in bed all the time, using a tube for urination. A caregiver was standing by the bed 24 hours a day. A nurse was regularly visiting the patient to administer morphine; she was not allowed to increase the dose or frequency. It was not possible for the patient to move to the restroom on her own.
Clinical Findings
On examination, the patient's BP was 102/66, pulse rate of 63 and body temperature of 98.5 F. Her pulse was weak and deep at all positions on both sides. Her tongue was pale, swollen with thick and dusky coating. Edema was observed on her legs and feet. She complained of fatigue, pain and dizziness. Her facial color was dark green and swollen. Other symptoms were diarrhea, poor appetite, feeling cold with no thirst, and poor sleep.
TCM Diagnosis / Interventions
Based on the signs and symptoms, the patient was diagnosed with pain and fatigue due to qi and blood stagnation, with underlying spleen qi and kidney yang deficiency and liver qi stagnation impacting the spleen. Treatment focus was on moving qi and blood, combined with transforming dampness and tonifying spleen qi and kidney yang.
According to the diagnosis, the primary acupuncture points used included LI 4, LV 3, ST 36, Ren 4, Ren 6, KD 3, HT 7, DU 20, SP 6, SP 9, PC 6, and Yin Tang; with a few additions and subtractions of acupuncture points based on the patient's evolving condition.
Treatment Plan / Details
The patient was treated basically once per week (due to her availability) with acupuncture for nine months with no herbal medicine. For the initial treatment period, the strategy was focused on relieving pain by using acupuncture points including LI 4, PC 6, ST 36 and GB 34. After that, additional acupuncture points including Ren 4, Ren 6, ST 36 and Du 20 were applied to tonify spleen qi and kidney yang; in combination with acupuncture points including KD 3, SP 9 and Ba Feng to dispel dampness.
During the treatment period, the patient reported that the pain level went down to four out of 10 for some time, even though it did not last long enough. Edema in the legs and feet also started to improve and the patient could move her legs. Her dark-green facial color was turning to brighter. The patient reported that she could move to the kitchen using a wheelchair on her own and could go to the restroom using a wheelchair again.
While the patient's condition was up and down, she reported extreme fatigue and remained in bed with her eyes closed all day long; and could not talk due to fatigue and exhaustion. Acupuncture points including ST 36, Ren 4, Ren 6, Du 20 with electric stimulation were used; plus the recommendation to take brown-sugar water after treatment. Later that day after treatment, the patient was able to open her eyes and could talk with friends visiting her.
When the patient complained that she could not drink water due to chest congestion and stuffiness with the throat discomfort, acupuncture points including Ren 22, Ren 23, Ren 17 and GB 21 were used for relieving throat congestion, chest congestion and stuffiness. A few hours after the treatment, it was reported that the patient could start to drink water again.
When the patient reported that she had vomited soon after eating food and feeling dizzy, acupuncture points including Two Gates, Ren 22, Ren 21, ST 36, SP 6, PC 6, and LU 7 were used to help stop vomiting; as well as Du 20 for dizziness. The patient reported she felt better after the treatment.
Other Components of Care
Rice porridge6 and brown-sugar water were recommended when no other foods could be tolerated. No greasy, fried or raw foods were recommended as dietary guidance. Massage on the legs and arms was recommended as well.
Treatment Outcome
Acupuncture treatment showed improvement in pain and fatigue in this final-stage cancer patient per self-reported outcomes via the Edmonton Symptom Assessment Scale (ESAS). The patient's pain level reduced to level four from level 10; and the level of tiredness also went down to a three from an eight. As described above, the patient was able go to the restroom, and she could talk and open her eyes.
Analysis and Discussion
The patient's symptoms of fatigue and poor appetite with diarrhea indicated spleen qi deficiency. The fatigue was due to the combination of both spleen qi and kidney yang deficiency derived from cancer itself and/or long-term cancer treatment. The acupuncture points including SP 6, ST 36 and Ren 6 worked to improve the symptoms by tonifying spleen qi; and KD 3 and Ren 4 by tonifying kidney yang.
Pain all over the body including the hip and legs, and feeling cold, indicated qi and blood stagnation in combination with kidney yang deficiency. Acupuncture points including PC 6, LI 4 and ST 36 were used for the purpose of pain relief and analgesic effect.5 In addition, acupuncture points including KD 3, Ren 4 and SP 6 were used to tonify kidney yang.
Conclusion
The acupuncture treatment used in this case as palliative care was effective in the terminal stage of this cancer patient's life by reducing pain and fatigue levels, thereby improving quality of life. A future study could be performed with shortened intervals of acupuncture treatment, together with moxibustion and herbal medicine depending on patient symptoms.
References
Over my almost 30 years in clinical practice, I have used Chai Hu Long Gu Mu Li Tang extensively for a wide array of clinical presentations ranging from chronic headaches to anxiety, insomnia, and prescription drug withdrawal symptoms if these situations fit the appropriate patterns – all with extremely positive clinical outcomes.
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