Introduction

The COVID-19 pandemic has had a dramatic impact on health care delivery, by disrupting access to in-person health care services and prompting a rapid adoption of telemedicine, including within the field of supportive cancer care [1,2,3]. Following the outbreak, various integrative oncology therapies, such as yoga, meditation, and music therapy, transitioned from in-person sessions to remotely delivered, virtual programs throughout many academic cancer centers in the US [3,4,5]. Access to in-person oncology acupuncture services was also affected by the pandemic [4]. Because acupuncture is a “hands-on” therapy requiring physical contact for providers to administer treatment (i.e., acupuncture needling), transition to virtual care posed additional challenges, namely the need to deliver acupuncture-like treatment remotely.

Acupressure, like acupuncture, involves stimulation of specific locations on the body, but instead of needling, pressure or localized massage is applied. Thus, unlike acupuncture, acupressure can be self-administered by the patients themselves. When in-person acupuncture service was disrupted by COVID-19, a virtual acupuncturist-guided, patient self-acupressure service was implemented to ensure continuity of care by the oncology acupuncture team at the Leonard P. Zakim Center for Integrative Therapies and Healthy Living at Dana-Farber Cancer Institute (DFCI), an NCI-designated cancer center.

Previous studies have demonstrated that acupressure is effective in relieving chemotherapy-induced nausea and vomiting [6] as well as cancer-related fatigue [7] and sleep disturbances [8]. Self-administered acupressure has also been shown to be feasible, safe, and beneficial for alleviating various cancer-related symptoms [9, 10]. However, little is known about the feasibility and effectiveness of remotely delivered self-acupressure intervention for symptom management among cancer populations. To this end, we conducted a retrospective chart review to examine the characteristics and symptoms of patients receiving virtual acupressure service within our institution and to explore the potential impact of such service on patient-reported symptom burden.

Methods

Study design and study population

This study is a retrospective chart review of cancer patients who received virtual acupressure service from DFCI, a single academic cancer center from May 11 to December 31, 2020. At the start of each virtual appointment, symptom burden was evaluated with the Edmonton Symptom Assessment System (ESAS) as a part of the standard of care and documented on patients’ electronic health records by the treating acupuncturists. The collected symptom burden data along with patient characteristics (e.g., age, sex, cancer type) and details regarding the acupressure session (e.g., patient’s concerns and symptoms, points used, and any adverse effects) were abstracted from electronic health records and analyzed. This study was approved by the Institutional Review Board of the Dana-Farber/Harvard Cancer Center.

Acupressure service

Following the disruption of in-person acupuncture service on March 16, 2020, the oncology acupuncture team, consisting of six DFCI-credentialed acupuncturists, held weekly meetings to discuss development and implementation of virtual acupressure service. The lead acupuncturist (WL) drafted an initial acupressure protocol based on available literature and clinical experience. After a series of weekly discussions and planning as well as pilot testing among acupuncturists and staff, virtual acupressure service was implemented on May 11, 2020.

The virtual acupressure consisted of a one-on-one appointment, approximately 50 min in duration, between the patient and acupuncturist. The acupressure protocol consisted of three basic steps, with step 1 involving acupuncturist-guided relaxation and breathing for about 5 min. Then in step 2, the acupuncturist guided the patients through self-acupressure, which involved applying gentle pressure in a circular motion at acupoints for about 2 min at each point. While there was a standardized set of acupoints, acupuncturists could modify according to patients’ individual needs. The standardized set of acupoints consisted of Yintang on the forehead, Relaxation Point on the ear, ST6 and GB20 on the face and neck, and PC6 and HT7 on the forearm. The approximate locations of these acupoints are shown in Fig. 1. The session then ended with another acupuncturist-guided relaxation and breathing for about 5 min (step 3).

Fig. 1
figure 1

Semi-standardized set of points used during virtual acupressure session

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Measure of symptom burden

At the start of each session, the acupuncturist assessed the patient’s symptom burden using the Edmonton Symptom Assessment System (ESAS). At DFCI, ESAS is routinely collected as part of the standard of care by the oncology acupuncture team. The data used in this retrospective analysis was collected for clinical purposes and mirrors the data collected in our standard acupuncture practice.

ESAS is a widely used instrument for evaluating the severity of symptom burden in oncology settings for both clinical and research purposes [11, 12]. It has been validated for assessing symptom burden in cancer populations with good internal consistency and high correlation with other similar instruments, such as the Memorial Symptom Assessment Scale (MSAS) and the Functional Assessment Cancer Therapy (FACT) [12].

ESAS is composed of 9 items or symptoms, including pain, fatigue, drowsiness, nausea, loss of appetite, shortness of breath, depression, anxiety, and lack of well-being. Sleep disturbance was added as an additional symptom measure. Each symptom is scored on a 0–10 scale, and higher scores indicate greater symptom severity. Generally, scores of 1–3, 4–6, and 7–10 are considered mild, moderate, and severe, respectively [11]. The optimal cutoff for detecting clinically meaningful improvement is a reduction of symptom score by 1 or greater [13].

ESAS is subcategorized into Total (score 0–90), Physical (score 0–60) and Emotional distress subscales (score 0–20). The Total score includes all symptoms except for sleep. The Physical subscale consists of symptoms of pain, tiredness, drowsiness, nausea, lack of appetite, and shortness of breath, and the Emotional subscale consists of symptoms of anxiety and depression. The optimal cutoffs for detecting clinically meaningful improvement are 5.7 for Total score, 3 for Physical score, and 2.4 for Emotional score, respectively [14].

Data abstraction

Abstracted data included the ESAS symptom scores and the following information: 1) patient demographics (e.g., age, sex, race); 2) cancer-related information (e.g., cancer type, cancer treatment); and 3) acupressure-related information (e.g., reports of any adverse events, date(s) of all virtual acupressure appointment(s) from May 11 to December 31, 2020).

Statistical analysis

All data were analyzed with SAS software (version 9.4; SAS Institute, Cary, NC). Descriptive statistics were used to present the ESAS scores at baseline and first follow-up as mean (standard deviation, SD). For patients with at least one additional acupressure session within 14 days of the baseline visit, paired t-test was used to analyze changes in ESAS scores from baseline to first follow-up.

Results

Patient characteristics

Patient characteristics are shown in Table 1. There were 32 patients who received virtual acupressure session(s) during the study period. The mean age was 55.7 (SD 15.7, range: 26–82), and most patients were female (90.6%) and White/Caucasian (84.4%). The most common cancer type was breast (53.1%), followed by pancreatic (12.5%) and lung (9.4%). Many patients (59.4%) had at least one acupuncture appointment in-person at our center before the outbreak of COVID-19; for the other 40.6% of patients, virtual acupressure represented their first clinical encounter with a DFCI acupuncturist.

Table 1 Baseline Patient Characteristics
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Of 32 patients, 13 patients (41%) had a second acupressure session within 14 days of their baseline session. Change in ESAS scores following the first acupressure session was analyzed by examining the data collected from these 13 patients. Among these 13 patients, the mean age was 60.2 (SD 16.1, range: 37–82), all were female, most were White/Caucasian (92.3%), breast cancer (61.5%) was the most common cancer diagnosis, 69.2% had prior in-person acupuncture appointment at our center, and the mean number of days to first follow-up was 7.3 (SD 0.8, range: 6–9). Among the other 19 patients, 15 had only one session and 4 had a second session more than 14 days after the baseline session, with an average of 52 days between baseline and the first follow-up session (SD 25.8, range: 24–85).

Change in ESAS scores

There was a statistically significant improvement in ESAS Total score and in Physical and Emotional subscales from baseline to follow-up (Table 2). The mean change was -4.8 (SD 7.6, p = 0.04) for Total score, -3.5 (SD 5.4 p = 0.04) for Physical subscale, and -1.2 (SD 1.8, p = 0.03) for Emotional subscale. Of these changes, only Physical scores met the threshold for clinically meaningful improvements.

Table 2 Change in ESAS symptom score from baseline to follow-up
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For individual symptom scores, there was a statistically significant reduction in the severity of pain (mean change: -1.2, SD 1.4, p = 0.007), tiredness (mean change: -1.2, SD 1.2, p = 0.003), and anxiety (mean change: -1.1, SD 1.6, p = 0.03), as shown in Table 3. These changes, along with symptom change for sleep disturbances, met the threshold for clinically meaningful improvements.

Table 3 Change in ESAS individual symptom scores from baseline to follow-up
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Discussion

The rates of stress and symptom burden are high among cancer patients [15]. The COVID-19 outbreak not only imposed additional stress in this patient population, but also disrupted access to various supportive care services needed for symptom management [3, 4]. In this retrospective chart review, we sought to examine the utilization and potential impact of virtual acupressure service implemented following the COVID-19 outbreak at an NCI-designated cancer center. Our findings suggest that remote delivery of acupuncturist-guided, patient self-acupressure is feasible and potentially effective in improving symptom burden among cancer patients.

Acupuncture is a widely used integrative oncology therapy, with a growing body of research supporting its effectiveness for management of various cancer- and treatment-related symptoms. It has been increasingly integrated into conventional cancer care, and as of 2016, it was offered in approximately 73% of all NCI-designated cancer centers [16]. Because acupuncture is a “hands-on” therapy involving close contact between patients and providers for diagnosis and treatment (e.g., palpation and acupuncture needling), the outbreak of COVID-19 disrupted access to in-person oncology acupuncture services [3, 4]. This challenge, however, presented a unique opportunity to develop and implement virtual acupressure service at our institution to ensure continuity of care. To our knowledge, this is the first study to report on the potential feasibility and impact of such clinical service on patient-reported symptom burden.

Our preliminary findings suggest that virtual acupressure may be a promising adjunctive therapy for symptom management in cancer patients. We found statistically significant reductions in the overall symptom burden and in individual symptoms of pain, tiredness, and anxiety from baseline to follow-up in the subset of patients with pre-treatment assessments and follow-up within 14 days. These finding are consistent with reports from existing literature on the effects of acupressure. Previous studies have shown that acupressure is effective in improving various cancer- and treatment-related symptoms, including pain, fatigue, anxiety, and sleep disturbances [17,18,19,20,21,22,23].

Despite promising results, however, our study has several limitations. First, this was a retrospective analysis without a control or comparison group. Without a proper control, it is difficult to ascertain whether acupressure was responsible for the reduction in symptom burden, as there are other possible reasons for improvements, including regression to the mean. It is also possible that acupuncturist-guided relaxation and breathing before and after acupressure contributed to improvement in patient-reported symptoms. Additionally, the sample size in our analysis was very small, with only 13 patients receiving a second acupressure within 14 days of the initial session and thus meeting our a priori criteria to be included in the analysis. The small sample size also precluded us from evaluating whether changes in symptom burden before and after acupressure differed in individuals with prior acupuncture exposure vs those without. Finally, multiple comparisons were not controlled for in our statistical analysis, and the results from this study are from a single institution and may not be generalizable to a wider cancer population.

Nevertheless, this study fills an important knowledge gap in the literature regarding implementation of virtual acupressure service for symptom management in cancer populations. Telehealth services have been increasingly used following the COVID-19 pandemic and have been shown to improve patient access and engagement to symptom management while mitigating the cost of care and improving accessibility [24,25,26]. Although virtual acupressure service was initially implemented in response to the disruption of in-person acupuncture service, it may continue to be a promising and cost-effective intervention during the post-COVID era, especially for patients living in regions where in-person oncology acupuncture service is not readily available. It would also be of interest for future studies to evaluate the impact of virtual acupressure service in patient population with high symptom burden, for whom commuting is burdensome and presents a barrier to seeking an in-person supportive cancer care service.

In conclusion, our preliminary findings suggest that implementation of virtual acupressure may be feasible and beneficial for symptom management in cancer populations. However, given the limitations of this study, more rigorous research (e.g., prospective, large-scale, randomized, multicenter) are needed to confirm these findings and to further explore and better understand the impact of virtual acupressure on the many symptoms experienced by patients during and after cancer treatment.