Stimulated by Epstein et al 2023.[1] IMPACT Integrative Medicine for Pain in Patients with Advanced Cancer TrialMSKCC Memorial Sloan Kettering Cancer CenterPEACE Personalised EA vs AA Comparative EffectivenessMSK musculoskeletalRCT randomised controlled trialBPI short...
Stimulated by Epstein et al 2023.[1]
Visual abstract
IMPACT Integrative Medicine for Pain in Patients with Advanced Cancer Trial
MSKCC Memorial Sloan Kettering Cancer Center
PEACE Personalised EA vs AA Comparative Effectiveness
MSK musculoskeletal
RCT randomised controlled trial
BPI short form brief pain inventory
This trial was based at MSKCC and I wrote about the protocol in February: Acupuncture vs massage in cancer pain.[2] It is a trial with an acronym (IMPACT) and has some similarities to a previous trial from MSKCC, which also had an acronym (PEACE) and I wrote about in March 2021: EA or AA vs UC the PEACE trial.[3]
Unlike the PEACE trial (n=360), which had 2 acupuncture arms and a usual care arm, IMPACT (n=300) had 2 parallel arms a straight comparison of acupuncture and massage. Whilst PEACE examined effectiveness of 2 different acupuncture approaches to MSK pain in cancer survivors, IMPACT focussed on MSK pain in patients with advanced cancer.
Ten weekly sessions were provided of either intervention, followed by monthly top-ups for a further 4 months. As I said on the previous blog, I like this approach in RCTs because it is a better reflection of usual clinical care using acupuncture.
The primary outcome was the worst pain severity on the BPI that is the worst pain severity in the prior week measured on a 0 to 10 scale. The two time points of interest were 10 weeks and 26 weeks, the latter being the primary outcome.
I guessed that the acupuncture would be better in terms of pain relief, but that it might be associated with a higher dropout rate.
I was quite surprised to see that the massage group had a mean reduction in pain that was larger than the acupuncture group. This was not a significant result according to the usual standards of comparing distributions, but it was very close, with a p value of 0.07 at 24 weeks and 0.06 at 10 weeks.
The numerical difference between group means was -0.48 at both time points in favour of massage. We usually consider a 1-point change on a 0 to 10 pain score to be clinically significant, although some authors use a 2 point difference. The difference from baseline at 26 weeks was -2.53 in the acupuncture arm and -3.01 in the massage arm, so both interventions were associated with clinically relevant reductions in pain.
As I predicted the attrition was greater in the acupuncture group, with 116 completing the 26 weeks from a start figure of 151, compared with 126 in the massage group, which started with 149. So, that is a 23% attrition (or dropout) rate in the acupuncture group and 15% in the massage group.
This is a well conducted and reported study, and probably the first of this size and quality measuring massage effects in this population. I was impressed that the massage edged ahead and considering the fact that it is a non-invasive therapy with limited or no serious AEs it would have to be my first choice in setting up a service.
Of course, we should be careful about making such decisions based on group means, since the individuals that make up the whole distribution are the real people, rather than a theoretical average patient. So, there will be a proportion who do very well with acupuncture, and they may be different from the ones who do well with massage.
A service would ideally provide both and give patients the choice. This leaves plenty of room for further research questions to tease out the nuances of how to provide the ideal supportive service to this patient population.
References
1 Epstein AS, Liou KT, Romero SAD, et al. Acupuncture vs Massage for Pain in Patients Living With Advanced Cancer: The IMPACT Randomized Clinical Trial. JAMA Netw Open. 2023;6:e2342482.
2 Romero SAD, Emard N, Baser RE, et al. Acupuncture versus massage for pain in patients living with advanced cancer: a protocol for the IMPACT randomised clinical trial. BMJ Open. 2022;12:e058281.
3 Mao JJ, Liou KT, Baser RE, et al. Effectiveness of Electroacupuncture or Auricular Acupuncture vs Usual Care for Chronic Musculoskeletal Pain Among Cancer Survivors: The PEACE Randomized Clinical Trial. JAMA Oncol. 2021;7:7207.