Effectiveness of acupuncture in mediating chemotherapy-related fatigue

by Donna Dupre LAc., DAOM


A.   Specific Aims

Fatigue and nausea are the most common and distressing symptoms experienced by cancer patients receiving chemotherapy treatment.1  The effective treatment of nausea resulting from chemotherapy through medications has been demonstrated in several recent studies2,3,4 even though “many patients still experience these symptoms”.2  Anemia is one known cause of fatigue that can be treated effectively with erythropoietin.  Fatigue, however, is not well understood and can be related to psychological, physical and cognitive factors.  Fatigue, therefore, is not always associated with anemia, nor is fatigue completely dissipated by erythropoietin treatment.  The fact is that established effective usual-care protocols for fatigue resulting from chemotherapy do not exist.

Acupuncture has been shown to be effective in reducing symptoms of nausea and vomiting resulting from cancer treatment.  Acupuncture has been used to treat chronic fatigue syndrome although research studies investigating effectiveness are absent.  Interest in acupuncture as a complementary treatment for chemotherapy-related fatigue is growing because acupuncture has proven successful in treating nausea.

We have several broad aims for this study.

One is to investigate the combination of best methods in conventional treatment for breast cancer, i.e., chemotherapy, with acupuncture as a complementary treatment for a symptom – fatigue - that has proven especially difficult to treat using conventional approaches.

Another is to employ the best in scientific methods – randomization to treatment and control groups, and use of standard protocols (in the case of acupuncture) – in our study design.

We propose to follow on the only published research on effectiveness of acupuncture in mitigating fatigue related to chemotherapy by employing several of the key study features in our own.  These include use of the Brief Fatigue Inventory as a principle outcome measure as used in the only other study.  This instrument has very good reliability (Cronbach's {alpha}= .96) and concurrent validity, correlating strongly with other measures of fatigue.5

Finally, our most important aim is to demonstrate a treatment approach that can be utilized immediately by integrative practices across the USA.  Relief can be brought to current and future patients diagnosed with cancer who experience the symptoms of fatigue.

The specific research aim of our study is to:

1.       Observe a difference between control and experimental groups in percentage difference for scores from baseline to post treatment on the Brief Fatigue Inventory (BFI) measure.


B.   Background and Significance

Background of acupuncture in the USA: Acupuncture is one of the newest medical modalities in the USA, having been licensed in this country beginning in the early 1980s.  There are approximately 18,000 licensed acupuncturists including 3,000 medical acupuncturists (physician members of the American Academy of Medical Acupuncture).  An ancient medicine of the Far East acupuncture dates back 2,500 years.

As a medical discipline acupuncture falls under the umbrella of complementary and alternative medicines (CAM).  The attempt to categorize non-conventional therapies and treatment modalities such as vitamins/nutrition, prayer, massage, chiropractic and more can be traced to the seminal 1993 publication by Eisenberg that documented a substantial and previously unrecognized (at least by conventional medicine) preference for non-conventional approaches to illness by the American public.6

The term CAM may have already outgrown its usefulness.  Integrative medicine is preferred, commonly and frequently used by providers of both conventional western and non-conventional eastern disciplines.  The reason may be that there are a growing number of clinics, hospitals and individual practitioners that readily employ disciplines such as acupuncture in combination with conventional medical practice.  This is a choice clearly driven not only by philosophical harmony on the part of the providers but by Eisenberg’s revelation that consumers have already chosen integrative approaches without the benefit of conventional medical wisdom or research.7,8,9

Acupuncture as a complement to conventional treatment holds appeal because it is believed to be a treatment with relatively few side effects or negative treatment interactions.  Additionally, there are a substantial number of highly experienced acupuncturists, such as those at the center, who have administered acupuncture as a complementary treatment for longer than ten years.10

Our Principle Investigator Peter Kennedy, MD, is a conventional oncologist who was instrumental in establishing the non-conventional treatment center – the Center for Health and Healing.  The center, which began as a complementary treatment service under Dr. Kennedy’s direction in 1997, features the exclusive use of traditional Chinese medicine including acupuncture.  Dr. Kennedy and the center are based at St. Vincent Medical Center in Los Angeles and located in the same professional office building.  Center director Ms. Victoria Blake, LAc, has treated patients from Dr. Kennedy’s practice since joining the Center as Director in 2000.

Research issues with acupuncture: Even though there are more than 10,000 reviews of CAM in the western medical literature the preponderance of studies fails to document significant treatment effects.  There is well documented resistance within conventional medicine to accept CAM modalities as legitimate and effective treatments.11,12,13  Reasons advanced to explain this phenomenon include the absence of well-trained researchers in CAM, and the failure of CAM researchers to employ standard scientific research methods.14  Standard methods include randomization (selection of subjects, assignment to study arms), standardization of treatment protocols, use of standard and established outcome measures, sufficient sample sizes and the lack of confirmatory studies.

From the acupuncturists’ point of view challenges posed by conventional scientific methods to the effective practice of Chinese medicine include constriction of acupuncture treatment protocols, and existing variation within acupuncture as a discipline.  There are multiple schools of practice with substantial differences in approach to diagnosis and treatment.  As Cohen pointed out in his comprehensive review of acupuncture as a complementary treatment for patients with cancer, selection of points is dependent on several factors.  There are several styles of acupuncture (Chinese, Japanese, Korean, electrostimulation, etc).  Additionally, in Traditional Chinese Medicine certain value is placed on varying acupuncture point selection according to variation in other diagnostic information which the acupuncturist may discern.

Acupuncture research must find a compromise between western research methodology which requires standardization of procedures and Chinese medical practice which calls for variation based upon individual differences.  The success of this blending is an inevitable outcome of our approach to the proposed study.  If success can be demonstrated with one acupuncture protocol in research this would suggest the basic treatment method is effective.  In acupuncture research, where methodological issues are frequently invoked to explain poor or insignificant outcomes, it is very important to employ as many accepted research methods as possible, e.g., random assignment and standard point selection, which can be tolerated within the practice of Chinese medicine.

The use of complementary and alternative therapies by women diagnosed with breast cancer is significant, ranging from approximately one in five patients to as many as four in five.10  The most widely studied complementary acupuncture treatment for cancer is mitigation of nausea which the National Institutes of Health (NIH) has concluded can be highly effective as a complementary treatment.15  The NIH has also recognized complementary acupuncture is effective in the treatment of numerous other conditions associated with cancer as well as other than cancer.  Only one published study (Vickers, 2004) has looked at how acupuncture can mitigate symptoms of fatigue related to chemotherapy.16  The authors concluded that “acupuncture is worthy of further study in the treatment of post-chemotherapy fatigue”.

How our study follows and improves on Vickers The Vickers study found a 31.3% improvement in the outcome measure, the Brief Fatigue Inventory administered pre and post treatment.  The Vickers study focused on patients who undertook acupuncture following completion of a three week or longer chemotherapy protocol.

Our study is exceptional in three important ways.  First, we are following on the Vickers study by investigating the effects of concurrent complementary acupuncture as a treatment for relieving symptoms of fatigue.  However, we are focusing on women diagnosed with breast cancer.  Patients in Vickers were diagnosed with different cancers.

Second, as recommended by Vickers in their conclusions we are applying more methodological controls.  The Vickers study was an uncontrolled, prospective single arm design.  Our study has two arms with subjects assigned randomly to a treatment or control group.

Third, we will administer acupuncture as a concurrent complement to chemotherapy.  The chemotherapy protocol and length of treatment is standardized in our study.  Patients in the Vickers study completed chemotherapy before undertaking acupuncture treatment.

Our study replicates several features of Vickers with a couple of important variations.  For example, we will use two surveys as outcomes measures including the BFI used by Vickers.  Our second outcome measure differs from the one used by Vickers  We will use the SF12v2TM, a quality of life measure we believe is a more frequently used standard appropriate for a study that aims to measure improved quality of life.  Like Vickers we will conduct debriefing interviews with each study participant.

Vickers followed a standard acupuncture protocol for treating fatigue, inserting needles at six points; ST36, SP8, SP9, CV6, and CV4.

Our protocol is different using sixteen points in total.  Sixteen points will be used for fatigue; DU 20, REN 17, REN 6, REN 4, LI 10 (bilateral), ST 36 (bilateral), LIV 3 (bilateral), LI 4 (bilateral), GB34(bilateral),

SP 6 (bilateral).  In addition, we will use two supplemental points for constipation, ST 25 (bilateral); three for nausea, PC 6 (bilateral) and Ren 12; four for night sweats, Lu 7 (bilateral) and Kid 6 (bilateral); and one for insomnia, Yintang.  Our protocol has been selected under the supervision of Xiuling Ma, LAc, PhD, who is expert in Chinese and Western medicine.

The Center for Health and Healing evolved an alternative cancer treatment from a project initiated by Dr. Kennedy in 1997 with support from the Daughters of Charity.  Dr. Kennedy was one of the earliest conventional physicians to include acupuncture services in treatment of cancer.  Patient demand and satisfaction with the service motivated the Daughters of Charity to fund the Center for Health and Healing in its current location on the fifth floor of the same building in which Dr. Kennedy is located.  The Center provides acupuncture and herbal therapies to the underserved from a continuing annual grant from the Daughters of Charity.  The Center has treated 300 unique patients since inception in 1997.  Of these 300 patients approximately one fourth are diagnosed with breast cancer.  The vast majority receive adjunat therapy including chemotherapy .  Dr. Kennedy has seen approximately 200 unique patients per year over the past three years.  Dr. Kennedy refers approximately 20% of his patients to the Center for Health and Healing for treatment using principles and methods or traditional Chinese medicine.


Every patient at the Center for Health and Healing is presently receiving acupuncture treatment for symptoms of fatigue and nausea related to chemotherapy.  Some also receive herbal remedies under the direction of Ms. Victoria Blake, LAc.  The relationship between Dr. Kennedy and the Center is past the exploratory stage.  In collaboration with Dr. Stumpf the team of Dr. Kennedy and Ms. Blake seeks to scientifically demonstrate the effectiveness of acupuncture in improving treatment for breast cancer and improving the lives of cancer patients using scientific-based methods.  We seek to extend the work that has already shown how acupuncture can mitigate nausea by applying the treatment modality to fatigue using accepted research methodology.

C.   Research Design and Methods

Study phases: The overall project period spans 24 months.  The first phase will be a three month ramp up period.  During this period the Study Coordinator, Dr. Stumpf, will be brought on board.  He will schedule and lead meetings with Dr. Kennedy and his clinical team and with acupuncturists and clinic staff at the Center for Health and Healing.  He will preview data collection tools and data collection procedures, review HIPAA concerns, preview the informed consent and human subject forms, and review the research design.  He will identify the survey administrators and preview the BFI and SF12v2TM instruments with them.

Dr. Stumpf will establish patient recruitment procedures, inclusion and exclusion criteria, collection of informed consent procedures, and the random assignment process to treatment or control groups with Dr. Kennedy’s clinical team.  Dr. Stumpf will create the data matrix for tracking study data, methods for recording study data, and methods for subject tracking during the 3-month long ramp-up phase.

The second phase will be marked by enrollment of the first subjects in the study.  This will begin in the fourth month leaving 20 months to meet the study enrollment goal.  The last patient cohort will be enrolled in the 17th month.  Therefore, the 20 patients will be enrolled in the study over the course of 18 months.

The third phase will overlap the second phase, likely beginning in the 18th study month.  Data analysis will initiate and be completed during this phase.  The last patient cohort will complete treatment during the third phase therefore the second and third phases will end at the same time.

Patients assigned to the control group will be offered the same acupuncture protocol upon completing their chemotherapy regimen.  The opportunity to receive cost-free acupuncture for fatigue is a benefit of participating in the study.


Description of Study Design and Methods: This is a single blind, randomized control study.  Survey administrators will be blinded as to subject assignment when administering the two outcome measures (BFI and SF12v2TM).

Candidate participants will be identified by staff in Dr. Kennedy’s outpatient practice throughout the project period.  Candidate participants will be told during the selection process that they will be randomly assigned to either receive acupuncture during their chemotherapy or after they have completed their chemotherapy.  Patients meeting inclusion criteria will be enrolled in the study as they become available.

An identified Kennedy staff member (trained by the Study Coordinator) will administer the Informed Consent form.  Patients electing to participate in the study will be randomly assigned to either the control (chemotherapy only) or the treatment (chemotherapy and acupuncture) group.  At the end of their first three-week cycle of chemotherapy each subject will complete the BFI (with the assistance of a trained survey administrator).  BFI scores will be calculated and only subjects diagnosed with moderate to severe chemotherapy-related fatigue as indicated by a score of 4 or greater will continue in the study.  These subjects will then complete the SF12v2TM to establish a baseline score on quality of life.

All continuing subjects will complete four rounds (12 weeks total) of chemotherapy with Cytoxan and Adriamycin.  Subjects assigned to the treatment group will begin acupuncture immediately upon completing the first round of chemotherapy.  They will receive acupuncture twice weekly at the Center for Health and Healing for 12 weeks, totaling 24 acupuncture treatments.  No subject in the treatment group will be enrolled longer than 14 weeks.  Missing more than 2 consecutive acupuncture appointments or more than four total will be deemed non-compliant and released from study.  Non-compliance in the study has no bearing upon treatment.  The center is located in the same office building as Dr. Kennedy’s office optimizing logistical convenience.

Subjects assigned to the control group will receive standard usual-care fatigue protocols for 12 weeks. Control group subjects who miss a cycle must complete the four cycles within 15 weeks.

Finally, a structured interview will be completed at key treatment intervals to collect and record data on daily routine of study participants, e.g., exercise, diet, meditation, vitamins, supplements, prayer, medication, etc.  These interviews will be completed by the Study Coordinator Dr. Stumpf who is a trained and experienced interviewer with 20 years experience as a psychotherapist.

Kenmar Research Institute, L.L.C. (KRI) is a research management organization established to bring clinical trials to community-based medical practices.  KRI contracts with pharmaceutical companies to manage research studies conducted under the direction of qualified physicians. The company’s primary area of interest is oncology.  Our primary goals are to facilitate access to clinical trials and provide the support services necessary to make it easy to conduct these studies in a private practice setting.


KRI provides all direct interactions with sponsoring pharmaceutical companies including:

·         Protocol review and contracting.

·         IRB approval.

·         Informed consent development.

·         Protocol supervision and implementation of quality control measures.

·         Data collection and management.

·         Submission of case report forms and other reports.

·         Site monitoring visits.

·         Budget management and financial administration.

Sara Margiotta and Anne D. Kennedy, M.S., M.B.A. are the Principals of KRI.  Ms. Margiotta, Vice President, oversees Research Operations and Ms. Kennedy, President, manages Business Operations and Marketing.  Both have lengthy and wide-ranging experience in clinical research, bringing expertise in the coordination, management, quality control and statistical analysis of clinical trials


Subjects: The subject pool will be drawn from a busy urban private outpatient clinic for treating cancer patients.  Twenty women, ages 18 to 65 years, with stage I or II breast cancer who are receiving chemotherapy will be recruited from Dr. Kennedy’s private practice.  Staff will observe the following inclusion and exclusion criteria when identifying potential study participants.

Inclusion criteria

Exclusion criteria

stage I and II Breast cancer patients with symptoms of fatigue from chemotherapy

Severe chronic illness including heart disease, diabetes, HIV, Hepatitis B, Hepatitis C, Emphysema, drug addiction, kidney disease, TB, dialysis

completed one cycle of chemotherapy (Cytoxan and Adriamycin), currently receiving chemotherapy

diagnosis of chronic fatigue and/or fibromyalgia

between 18 and 65 years of age

bleeding disorders

Each subject will be deemed to have “completed” the study once she has either completed four chemotherapy cycles only (control group between 12 and 15 weeks), or has completed four chemotherapy cycles and 24 acupuncture treatments within the specified time frame (treatment group between 15 and 17 weeks).

Subject pool will be drawn from a busy urban private outpatient clinic treating cancer patients.  Signed consents for study participation will be obtained by referring physicians.  Potential subjects who meet inclusion criteria will complete the BFI with the assistance of trained project staff. 

Statistical Analysis: Mean BFI scores within and between groups will be compared pre and post treatment using t test procedures for two independent samples randomly assigned to groups.  SF12v2TM findings will be used to stratify study subjects for post-secondary analysis if significant differences are found between mean scores.  Interview data will be organized into thematic groups and analyzed to enrich and contextualize survey outcomes.

D.   Budget Justification: The project budget is $251,615 for two years.  Approximately 75% of the budget covers salaries for project staff.  All staff will receive 1099 forms therefore fringe benefits do not apply.  Indirect costs are not applied because the applicant is a private medical practice.  A brief justification for each project staff person follows.

Principle Investigator, Peter Kennedy, MD, 0.50 FTE: The PI will be responsible for all project activities and fiscal management.  Study participants will be recruited from Dr. Kennedy’s private practice.  Dr. Kennedy is affiliated with St. Vincent Medical Center.  His office is located on the first floor of the Professional Office Building (POB) directly adjacent to the hospital.  Dr. Kennedy has been Chairperson of the SVMC Tumor Board since 1990.  He has directed the SVMC Oncology Unit since 1981.  He is currently the PI on a study investigating the use of MRI to predict clinical response to 5FU Infusion in patients with metastatic colon cancer.  He was the Principal Investigator on a study that investigated screening of adult Koreans with seroconversion to Hepatitis B for hepatocellular.  Dr. Kennedy has a clinical appointment with the USC Keck School of Medicine since 1978.  Dr. Kennedy will dedicate one half-day per week to this project.

Study Coordinator, Steven H. Stumpf, EdD, 0.40 FTE: Dr. Stumpf will be responsible for continuing coordination of study activities.  He will oversee participant enrollment, data collection, data aggregation, survey administration, and all reporting functions.  He will be the primary contact person and manage most interactions with CTRF.  He is the primary author of this proposal.  Dr. Stumpf has been the coordinator and/or director on more than a dozen grant-funded research projects in his career.  He has written more than 20 successful grant proposals that have been funded by agencies in both public and private sectors including the National Library of Medicine, State of California Office of Statewide Health Planning and Development, Los Angeles County Department of Health Services, the QueensCare Foundation, Wyeth-Ayerst Corporation, and The California Endowment.  Dr. Stumpf was with the USC Keck School of Medicine for 18 years.  He is the former Provost and Doctorate Program Director with a Los Angeles acupuncture college.  He received his doctorate in research methods and evaluation from the UCLA Graduate School of Education.  He has published more than 25 articles, half in peer-reviewed journals.  Dr. Stumpf will dedicate two days per week to this project.

Co-PI Victoria Blake, RN, LAc, 0.40 FTE: Ms. Blake directs the Center for Health and Healing.  She will oversee and directly supervise and schedule acupuncture treatment services for study participants at the center.  She will also supervise the treating acupuncturists.  The center is located on the fifth floor of the Professional Office Building (POB) directly adjacent to the hospital.  Ms. Blake will dedicate two days per week to this project.  Her time is contributed in-kind by the Center for Health and Healing.

Co-PI Donna Dupre, LAc, 0.20 FTE: Ms. Dupre is a licensed acupuncturist in private practice in Los Angeles.  She has been the driving force behind creating this research proposal.  She has acted as project coordinator during this preliminary phase.  She will continue to contribute to the project by recruiting the treating acupuncturists from her professional contacts.  She will also support Dr. Stumpf in his coordinator role.  Ms. Dupre trained at the Center for Health and Healing while completing her master degree program.  She is presently enrolled in the doctorate program at Emperor’s College in Santa Monica.  She expects to graduate in December, 2006.  She will dedicate one day per week to this project.

Co-PI Stacey Green, RN: Ms. Green is the clinic coordinator with Dr. Kennedy’s private practice.  She will be responsible for identifying candidate participants for the study.  She will work closely with Dr. Stumpf in completing the enrollment process (completing informed consent).  She will work closely with Ms. Blake in coordinating care for study participants in the treatment group.  Ms. Green and Ms. Blake have worked together and have established competent lines of communication that will ensure smooth continuity of care for study participants.

Treating acupuncturists, 0.40 FTE total: Two licensed acupuncturists will be recruited by Ms. Dupre to provide acupuncture treatments to study participants.  Each acupuncturist will dedicate one day per week at the Center for Health and Healing.  Ms. Dupre will recruit the acupuncturists from a doctorate program (which only enrolls licensed acupuncturists).  These acupuncturists will have flexibility of schedule to work in the clinic according to a schedule determined by Ms. Blake in consultation with Ms. Dupre.


Survey administrators: Stacey Green will identify one or two staff to administer the BFI and SF12v2TM on an as-needed basis, i.e., as each participant is enrolled in the study.  Dr. Stumpf will train the designated staff persons to administer both instruments.  Value will be placed on selecting bilingual staff.  The survey administrators will be compensated for each survey administered.  Survey administrators will be blinded as to group assignment of study participants.

Research consultant, KenMar: KenMar will provide (and has already provided in preparation of this proposal) consultation regarding project methodology.  KenMar will conduct data analysis under the direction of Dr. Stumpf.  KenMar will prepare a report on final outcomes data.  KenMar is a research consultation group that works with physician-led medical research.  St. Vincent Medical Center is a primary site for KenMar activities.

Survey outcome measures: The Brief Fatigue Inventory (BFI) is the primary outcome measure.  The instrument consists of a one-page fatigue assessment tool that contains nine items, each measuring the severity of fatigue on a 0-through-10 scale.  The first three items assess current level of fatigue, and worst and usual fatigue in the preceding 24 hours.  Six items assess the extent to which fatigue has interfered with different aspects of life, such as work or social relations, during the preceding 24 hours.  The BFI score is calculated from the mean of completed items.

The SF12v2TM is a quality of life measure specifically designed for use in clinical trials.  The SF12v2TM consists of 12 items that can be used to stratify (categorize) cohort members into sub-groups for secondary analysis.  The SF12v2TM is a reliable and valid instrument that has been developed by QualityMetric Incorporated.  The mission of QualityMetric is to present patient-reported outcomes measurement science in a way that makes sense in the real world of health care decision making.  We are not certain, however, we suspect our project must be among the first to use the SF12v2TM with an acupuncture study.

Acupuncture treatments: The ten study participants in the treatment group will receive 24 acupuncture treatments.  The ten participants in the control arm will be offered the same number of treatments after they have completed their arm of the study.  We have included 15% additional acupuncture treatments for subjects that initiate but do not complete the treatment course (i.e., drop-outs).  A total of 552 treatments are reimbursed to the Center for Health and Healing at $70 each.

Conference travel: We have budgeted for two persons, the PI and another project staff member, to travel to a national conference on cancer and CAM in the second project year.  We have estimated $6,000 for airfare, food and lodging, any ground transportation and conference fees.  We plan to select the conference in consultation with CTRF to ensure the foundation and our project receives the widest exposure possible.

E.   Timetable and milestones for the project: The timetable below presents projected milestones by quarter over the 24-month project period.  The Project begins with Q1 in January 2007. 









New project staff hired


Coordinator coordination meetings







Train survey administrators, clinic staff on procedures for informed consent, subject recruitment, random assignment



Enroll first and subsequent subject cohorts





CTRF site visit


Y1 Progress Report


Enroll final subject cohort


Attend annual cancer conference


Aggregate data



CTRF site visit


Prepare and Submit Final Report


Submit manuscript to peer-reviewed journal(s)



F.   Literature Cited

1.             Curt GA, Breitbart W, Cella D, et al: Impact of cancer-related fatigue on the lives of patients: New findings from the fatigue coalition. Oncologist 5:353–360, 2000

2.             Ezzo J, Vickers A, Richardson MA, Allen C, Acupuncture-point stimulation for chemotherapy-induced nausea and vomiting. Journal of Clinical Oncology. 2005; 23(28):7188-7198.

3.             Lu W., Leonard P. Acupuncture for side effects of chemoradiation therapy in cancer patients. Semin Oncol Nurs. 2005 Aug;21(3):190-5.

4.             Shen J, Wenger N, Glaspy J, Hays RD, Albert PS, Choi C, Shekelle PG. Electroacupuncture for control of myeloablative chemotherapy-induced emesis: A randomized controlled trial. JAMA. 2000 Dec 6;284(21):2755-61.

5.             Mendoza TR, Wang XS, Cleeland CS, et al: The rapid assessment of fatigue severity in cancer patients: Use of the Brief Fatigue Inventory. Cancer 85:1186–1196, 1999.

6.             Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL. Unconventional medicine in the United States. Prevalence, costs, and patterns of use. N Engl J Med. 1993;328:246-252.

7.             Kessler RC, Davis RB, Foster DF, Van Rompay ML, Walters EE, Wilkey SA, et al. Long-term trends in the use of complementary and alternative medical therapies in the United States. Ann Intern Med 2001; 135: 262–8.

8.             Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S, Van Rompay M, Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. JAMA. 1998;280:1569-75.

9.             Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL. Unconventional medicine in the United States. Prevalence, costs, and patterns of use. N Engl J Med. 1993;328:246-52.

10.         Balneaves LG, Bottorff JL, Hislop TG and Herbert C. Levels of commitment: Exploring complementary therapy use by women with breast cancer. The Journal of Alternative and Complementary Medicine. 2006; 12(5):459-466.

11.         Marusic M. "Complementary and alternative" medicine-a measure of crisis in academic medicine. Croat Med J. 2004 Dec;45(6):684-8.

12.         Neff S. Letter to the editor: Complementary and alternative medical education. Annals of Internal Medicine. 2004; 140(1): 67.

13.         Wetzel MS, Kaptchuck TJ, Haramati A, Eisenberg DM. Complementary and alternative therapies: Implications for medical education. Annals of Internal Medicine. 2003; 138:191-196.

14.         Cohen AJ, Menter A, and Hale. Acupuncture: Role in comprehensive cancer care – a primer for the oncologist and review of the literature. Integrative Cancer Therapies. 2005; 4(2):131-143.

15.         Acupuncture. NIH Consensus Statement. 1997; 15(5):1-34.

16.         Vickers AJ, Straus DJ, Fearon B, Cassileth BR, Acupuncture for post-chemotherapy fatigue: a phase II study. Journal of Clinical Oncology. 2004; 22:1731-1735.

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