Nada-danmark.dkUsing the NADA Protocol to
Improve Wellbeing for Prostate
Cancer Survivors: Five Case Studies
Beverley de Valois
and Tarsem Degun
cardiovascular disease, and cardiac events. Distress, anxiety, This paper presents case studies of five men diagnosed and irritability, depression, and loss of confidence are emotional and treated for prostate cancer, who participated in a project to assess psychological consequences, and there may also be associated the potential for using the NADA ear acupuncture protocol to relationship problems (Roth et al., 2008).
improve wellbeing. Selected for their diversity, they illustrate the range of diagnoses, treatments, and associated bothersome Patients rarely present with a single symptom; cancer survivors symptoms experienced by prostate cancer survivors. They also have been reported to experience an average of 11-13 concurrent illustrate the variety of ways that NADA acupuncture in a group symptoms (Miaskowski et al., 2004; Fan et al., 2007). Cancer setting can contribute to overall wellbeing. Examining the survivorship programmes focus on the complex health issues progress of these individuals through treatment provides valuable experienced by survivors, including short- and long-term insights into the effects of NADA treatment. These cases may consequences of cancer and its treatments, as well as late effects influence perceptions of clinicians, patients, acupuncturists and of treatment (those arising many months or years after the end of funders about NADA's potential role in the ongoing support of treatment). These may occur alongside pre-existing health issues, men with cancer of the prostate. They also suggest that future as well as those that arise naturally as part of the aging process research is warranted.
(Macmillan Cancer Support, 2013).
Keywords: Acupuncture, ear acupuncture, auriculotherapy,
Acupuncture and prostate cancer
National Acupuncture Detoxification Association (NADA), prostate Increasing evidence supports using acupuncture in the cancer, survivorship, wellbeing, group treatment management of a range of symptoms, physical and psychosocial, experienced by cancer survivors (Cho, 2012). Its use for prostate Introduction to prostate cancer
cancer has focused primarily on hormone treatment-related hot The most common cancer affecting men in the UK and Europe, flushes (Lee et al., 2009; Cho, 2012). Some of these studies have prostate cancer is the second most common cancer affecting investigated additional hot flush-related symptoms including males worldwide, with over 1.1 million diagnoses in 2012 distress, sleep problems, vitality, and quality of life (Harding et al., (Globocan, 2012). In the UK, there are roughly 110 new diagnoses 2009; Beer et al., 2010; Capodice et al., 2011).
per day, with more than a third of cases diagnosed in men aged over 75 years of age (Cancer Research UK, 2014a). Early diagnosis Harding et al evaluated the effects of NADA ear acupuncture on and improved treatment mean that survival is improving; currently hot flushes experienced by men undergoing androgen-deprivation 84% of men with prostate cancer survive their disease by 10 or therapy for advanced prostate cancer (Harding et al., 2009). more years (Cancer Research UK, 2014b).
Providing ten sessions over ten weeks, they reported decreased severity of vasomotor symptoms in 95% of participants (n = 60, Treatment options include watchful waiting, active surveillance, p < 0.01), as well as significant improvements on the Measure hormonal therapies, external beam or internal (brachytherapy) Yourself Cancer and Wellbeing (MYCAW) questionnaire. The radiotherapy, surgery, and chemotherapy (Cancer Research UK, primary concerns recorded on MYCAW all related to hot flushes 2014c). In spite of earlier diagnosis and improved treatments and night sweats; secondary concerns included sleep disturbance, and survival rates, there is a considerable symptom burden fatigue, depression/anxiety, insomnia, panic attacks, headache, associated with prostate cancer. Consequences of treatment and poor mobility.
include erectile dysfunction, loss of libido, hot flushes, fatigue, bladder incontinence, bowel problems, anaemia, The aim in our project was to provide a service that was open osteoporosis, weight gain, and breast swelling (gynaecomastia). to any health concerns experienced by men with a diagnosis of Long-term consequences include increased risk of diabetes, prostate cancer, rather than restrict it to a single symptom. 8 The European Journal of Oriental Medicine
Using the NADA Protocol to Improve Wellbeing for Prostate Cancer Survivors Beverley de Valois and Tarsem Degun To our knowledge, there is no acupuncture research that focuses Charitable donations provided the opportunity to expand on the wider health issues related to prostate cancer. Our service provision to men, and we wanted to measure the previous acupuncture studies measured health issues beyond effects of treatment to support further service development a single symptom, including assessing physical and emotional and to assess the potential for research. We chose to conduct a wellbeing in breast cancer survivors experiencing hormone clinical outcomes study, which adopts a systematic approach to treatment-related hot flushes and night sweats (de Valois et assessing safety and benefit to patients, whilst permitting usual al., 2010; 2012b) and addressing wellbeing and quality of life treatment, and is a key starting point for most clinical research of people with lymphoedema (de Valois et al., 2012a). In the (Thomas and Fitter, 2002).
current project, we wished to develop further the focus on overall wellbeing of cancer survivors.
Consistent with our previous NADA research, we aimed to measure systematically the effects in the short and long term, The NADA protocol
to obtain a first measure of the approach, and to assess the The NADA ear acupuncture protocol was developed in the suitability of delivery. Our main questions were: 1970s for use in substance misuse detoxification. Since then, its application has expanded to a range of settings, from disaster 1 What symptoms do prostate cancer survivors find troublesome?
relief and humanitarian aid to mental health to specific conditions including HIV/Aids and cancer care (Bemis, 2013). Although used 2 Can the NADA protocol address these symptoms and improve
internationally in many cancer centres, research has focused on its effects on cancer treatment-related hot flushes, as mentioned above (Harding et al., 2009; de Valois et al., 2012b). 3 Is NADA treatment in a group setting acceptable to prostate
Our aim at the Lynda Jackson Macmillan Centre (LJMC) is to integrate acupuncture into the National Health Service (NHS) as This paper reports individual case studies from this group. a treatment option to address complex health issues experienced Qualitative and quantitative (de Valois et al., In press) data will be by cancer survivors. To achieve this, it is necessary to explore acupuncture approaches that fit within the current constraints of the NHS. We are interested in approaches that are simple to deliver, require minimal training, and can accommodate The service was open to men diagnosed with prostate cancer, who potentially large numbers of patients for potentially long periods were under the care of an oncology consultant at MVCC. Patients of time. In the UK, the lifetime risk of developing prostate cancer needed to be six or more months post active treatment (surgery, is one in eight, and survivors may experience consequences for chemotherapy, radiotherapy); if applicable, taking adjuvant many years after diagnosis (Cancer Research UK, 2014b).
hormonal treatment for six or more months; and experiencing symptoms and/or side effects of cancer or cancer treatments. We have chosen this standardised treatment because there is no They also needed to commit to completing a course of eight diagnostic element and in the UK, treatment can be administered NADA treatments in a maximum of ten weeks.
by healthcare professionals who are non-acupuncturists after a brief training. Delivery in a group setting facilitates treatment Available funding enabled us to treat 20 men over a period from of up to 20 patients by one therapist in an hour and a half May 2013 to July 2014. As is standard practice at the LJMC for (Peckham, 2005). These characteristics enable low-cost treatment all patients attending for complementary therapies, men gave for potentially high volumes of patients, desirable features with their written consent to receive treatment and to complete the current strictures on NHS funding. The Project
Aims and objectives
Men received weekly acupuncture treatment for eight sessions This project was carried out at the LJMC, an information and using the NADA protocol. This comprises bilateral auricular points drop-in centre associated with Mount Vernon Cancer Centre Auricular Sympathetic, Shen Men, Kidney, Liver, with Upper Lung (MVCC) in Northwood, Middlesex, United Kingdom. The LJMC in the right ear and Lower Lung on the left (see Figures 1 and 2). has a special interest in supportive care of cancer patients, Acupuncture needles were single-use, sterile, stainless steel needles and in researching innovative applications of acupuncture for 0.20mm diameter and 7mm long with plastic handles, manufactured cancer survivors. by D&D, and packaged for detox protocols (10 needles per pack). Needles were inserted perpendicular to the ear surface, using a swift, The LJMC also has over ten years experience of using the NADA single-handed motion with 180° rotation, to a depth at which the protocol in the management of breast cancer treatment-related needle tip was supported in the cartilage. No further stimulation was hot flushes and night sweats (de Valois, 2006; Boon et al., 2015). applied; needles were retained for 40 minutes.
The European Journal of Oriental Medicine 9
Figure 1 Figure 2
Initial plans were to treat groups of five men in the Thursday morning clinics. This is the number of patients the LJMC clinic rooms reasonably accommodate. However, this crowded the men and group size was reduced to four per session. Case studies
The following five cases were selected to illustrate a range of
diagnoses, treatments, and consequences experienced by prostate
cancer survivors, as shown in Table 1. They also demonstrate
diverse and highly individual responses to NADA treatment.
In this paper, we refer to treatment outcomes monitored using
the Measure Yourself Medical Outcomes Profile (MYMOP), which
was administered before the first and eighth (final) treatments.
MYMOP is a patient-generated, individualised questionnaire that
aims to measure outcomes the patient considers most important
(Paterson, 1996). Patients specify one or two symptoms that
Photos courtesy of NADA UK bother them most, and one activity that their problem makes difficult or prevents them doing. Our patients also completed Treatments were delivered by a NADA specialist (TD), a holistic written questionnaires at four and eighteen weeks after the therapist who completed NADA UK detoxification training in end of treatment. The narratives below are developed from the the year prior to this project. She screened referrals and invited treatment notes made by the NADA specialist. Quotations are prospective participants to an intake interview. After obtaining taken from the questionnaires returned by the men.
written consent, she took a case history, based on the ‘Ten Questions' used in Chinese medicine practice (Maciocia, 1994) to The men represented in these case studies gave permission for gain insight into the patient's symptoms and overall wellbeing. their anonymised data to be published; Stan, Alfred, Petroc and She also administered the outcome measures, including the Robert chose to be involved in the writing process of their cases. MYMOP questionnaires (see opposite), and gave the patient a Petroc chose his own name; other names were chosen by TD, who sample treatment so he could experience the needling.
also provided the NADA specialist's summary at the beginning of each case.
At the subsequent treatments, the NADA specialist spent a few minutes in private with each patient to discuss any issues, and Case study 1: Stan: "It calmed my nerves and general
then escorted them to the treatment room where she inserted the needles. Needling was prefaced with a brief relaxation session, NADA specialist's summary
wherein the NADA specialist directed the patients' focus to their Stan was a retired business man, who was very anxious and breathing and to becoming comfortable. This was instituted in stressed, as hot flushes and bladder urgency prevented him from response to patient feedback; due to the cancer site, the men having a "normal life".
experienced discomfort when sitting for long periods of time. Prostate cancer history
The brief private time (usually about five minutes) allowed Stan, 74, was diagnosed with early stage prostate cancer in 2003. patients to discuss any concerns about their symptoms or Treatments included external beam radiotherapyi and low-dose acupuncture. It also enabled the NADA specialist to recommend rate brachytherapyii during 2004, and hormonal therapy with lifestyle changes, where appropriate. These were tailored to the a three-year course of the pituitary down-regulatoriii goserelin individual, and could include advice on dietary habits, exercise, (Zoladex®). Rising PSA levelsiv in 2009 led to reassessment and rest, managing stress, management of hot flushes, or referral to restaging of his cancer in 2010. Pituitary down regulation with other supportive services.
Zoladex® recommenced. Tumour flare, the sudden worsening i External beam radiotherapy is the use of radiotherapy directed at the tumour using an external machine. Patients attend a hospital radiotherapy department for treatment, which is given daily (Monday to Friday) for four to eight weeks for early prostate cancer.
ii Low-dose rate (LDR) brachytherapy is the insertion of radioactive metal ‘seeds' into the tumour, to slowly release radiation. The seeds are left in situ, and the radiation gradually fades away over six months. There is no risk to other people.
iii Prostate cancers depend on the hormone testosterone to grow. Pituitary down-regulators, also known as gonadotrophin-releasing hormone (GnRH) reduce the levels of luteinising hormone (which stimulates the testicles to make testosterone), which in turns lowers the level of testosterone. Examples of this type of therapy include goserelin (Zoladex®), leuprorelin (Prostap®) and triptorelin (Decapeptyl®).
iv PSA refers to Prostate Specific Antigen, a type of protein in the blood. Normal PSA levels rise with age; men with prostate cancer tend to have very high levels of PSA in their blood.
10 The European Journal of Oriental Medicine
Using the NADA Protocol to Improve Wellbeing for Prostate Cancer Survivors Beverley de Valois and Tarsem Degun Table 1: Summary of diagnoses, cancer treatments, MYMOP and other symptoms
Time since diagnosis Hormone refractory Lack of sex drive Physical activity Muscle aches, pains Hot flushes (mild) Poor sleep Bladder: urgency, Hot flushes (minor) Bladder irregularities Digestive problems Benign prostatic of symptoms associated with the first injection, was managed and ibuprofen. Nausea, a side effect of this medication, was with Casodex®, an anti-androgenv tablet. In 2011, his hormonal controlled with prochlorperazine maleate.
therapy was changed to three-monthly injections of triptorelin (Decapeptyl IM®). This successfully controlled the prostate cancer, Bladder frequency and urgency meant Stan urinated six to seven and he was troubled mainly by side effects of cancer therapy. times during the day, and that many times again during the night. Oxybutynin was helpful in managing this. General health history
Having found acupuncture very effective for back pain in 2002,
Constipation was a long-term issue, although he was managing Stan was delighted when the urology research nurse referred him some movement once a day. He did not experience headaches, or to the NADA prostate service. On MYMOP he specified 1) hot any problems with memory and concentration. flushes and 2) hip pain as bothersome symptoms; walking and dancing were activities made difficult by these symptoms.
Stan was married and lived with his wife. He was a retired professional; however, he described his life as stressful due to He experienced six to seven hot flushes during the day, and his sleep was disturbed by three incidents a night. These were accompanied by anxiety, a tingling sensation, and cold shivering. Stan had lived with the consequences of treatment that "take Constant pain in his hips, diagnosed as osteoarthritis, was away the function of a man" for more than eight years. Initially, managed with strong painkillers, including tramadol hydrochloride these had been a concern, but he was trying to be positive, v Anti-androgens are hormonal therapy drugs that block testosterone receptors on the cancer cell surface. They may be used alone as hormonal treatment for prostate cancer, and are also used to prevent tumour flare, the flaring of symptoms that occurs with the first dose of a pituitary down-regulator. In this case, they are administered for the two weeks preceding, and one week following, the first dose. Bicalutamide (Casodex®) and flutamide (Chimax®, Drogenil®) are examples of anti-androgens.
The European Journal of Oriental Medicine 11
and had come to terms with the "no action", especially as the been good; he was relaxed, energetic, and his agitation had treatment for cancer appeared to be working. His aim was to disappeared due to the changes in the flushes. His bladder was "carry on as normal a life as possible".
Self-reported concurrent health problems included asthma and At his eighth and final treatment, Stan summarised the allergies to penicillin, paracetamol, and certain foods. Prescribed improvements he had experienced. Hot flushes were moderate medications included tramadol hydrochloride and ibuprofen now, and he no longer experienced the anxiety that had for hip pain, oxybutynin hydrochloride for urinary disorders, previously accompanied them. Bladder urgency was gone, and prochlorperazine maleate for nausea, cetirizine and piriton for his bowel function had improved so that he no longer needed to allergies, and prednisolone for asthma, for which he also used use Senekot. He was sleeping better and able to get back to sleep a symbicort turbohaler.
easily when wakened by a flush. His hip pain was "reduced by 80%"; he was no longer taking tramadol and ibuprofen.
Progress through treatment
Stan found his first NADA treatment relaxing. However, he
developed a chest infection during the following week, for Eighteen weeks following the end of the NADA treatments, which he was prescribed antibiotics. At his second treatment, he reported that his hot flushes had increased.
"I feel much more relaxed and not much anxiety and stress pre and post hot-flash (sic). Still have hot flashes but without At Treatment (Tx) 3, he said that the hot flushes were very intense, attending embarrassment. Acupuncture was [a] great experience - although frequency had reduced to five during the day, and five emotionally & psychologically." at night. His energy was good, although he was tired from lack of sleep. The bladder control was "not bad", with urgency being most intense in the morning.
Stan provides a study of a long-term survivor who has survived his diagnosis by over ten years. NADA treatment appears to have At his fourth treatment, Stan described significant changes. been beneficial to address the consequences of cancer treatment Hot flushes had reduced in frequency to three to four at night. (hormone therapy related hot flushes), as well as symptoms of aging Accompanying sensations were also changing; "tingles" had (osteoarthritis). It may be that bowel performance improved because disappeared, and the flushes were a "slow hotness", which Stan was able to reduce the pain medication, with which constipation was not as bad as before. Constipation had required the use of is a side effect. Above all, this study illustrates the potential beneficial Senokot, while bladder control was "not as brilliant" although he effects of NADA on emotional, as well as physical, wellbeing.
had more control over the urgency. Mood and energy levels were "very good"; he was feeling more relaxed and clear-minded. His Case study 2: Petroc: "an overall improvement in feeling
wife had noticed that Stan had a more focused, positive outlook. a state of wellbeing"
NADA specialist's summary
A poor night's sleep affected Stan's energy levels and mood Petroc was a retired professional, who was very methodical in when he presented for Tx 5. However, he reported that over the his approach to his cancer diagnosis. He had been implementing preceding week the flushes had improved further, and his energy dietary changes to help manage and improve his symptoms.
levels had also been good. Bladder function was "very much improved", with only one or two incidents at night.
Prostate cancer history
Petroc, 73, was diagnosed with prostate cancer five years
At Tx 6, Stan described the hot flushes as "quite good". They previously in 2008, and had been managed with long-term were very mild, unaccompanied by "tingling", and reduced goserelin (Zoladex®) since then. In 2012, rising PSA levels indicated in frequency to three during the day, and two to three during that the cancer had ceased to respond to hormonal therapy.vi the night. Energy and mood were good. More significantly, hip There was no evidence of metastatic spread, and in spring 2013 pain was now improving. Stan was not only able to walk more he received a course of radical external beam therapy and comfortably, he had also reduced his painkillers.
high-dose rate brachytherapy.vii At his penultimate treatment, Stan reported further progress. General health history
Flushes came on slowly and were "very mild". The week had Petroc became interested in having acupuncture after attending vi At some point, prostate cancer will stop responding to hormonal therapy. This is known as hormone-refractory prostate cancer, or castration-refractory prostate cancer.
vii High-dose rate (HDR) brachytherapy involves placing tiny plastic catheters into the prostate gland, through which radioactive seeds are inserted for a set period of time and then withdrawn. At the end of treatment, the catheters are removed. No radioactive material is left in the prostate gland.
12 The European Journal of Oriental Medicine
Using the NADA Protocol to Improve Wellbeing for Prostate Cancer Survivors Beverley de Valois and Tarsem Degun a talk given at the monthly Prostate Support Group. Although he His treatment notes describe a gradual improvement of symptoms. was sceptical about acupuncture, he was persuaded that it was Tx 5 is the first detailed account of specific changes. Petroc's energy worth trying. His oncologist also said that sometimes it could be was improving, and he was not sleeping as much in the afternoon.
His appetite was returning, and he was now able to "eat a plateful". Sleep had also improved, and he could now usually On MYMOP he specified 1) fatigue and 2) poor appetite as manage to sleep for four hours at a stretch before needing to bothersome symptoms; keeping busy was the activity made urinate. There were continuous small improvements in the flushes.
difficult by these symptoms.
At Tx 6, Petroc was disappointed as he had been waking up in the Petroc noticed fatigue particularly in the afternoon. If he sat night more frequently during the previous week. Consequently, down after lunch, he would fall asleep and find it difficult to get he reduced his fluid intake at night. He reported having one flush going. "I have been known to fall asleep at the table", typically during the week. Energy levels continued to improve, and he no at lunchtime. This had pre-existed his recent treatment, but had longer had the same desire to sit and rest in the afternoon. He become much more noticeable of late. was eating bigger meals.
His appetite had diminished after radiotherapy treatment. In At his penultimate treatment, Petroc reported that he was general, he ate smaller portions, and was beginning to lose managing to sleep through the night. His mood had brightened, interest in food. When his wife was away, he could not be and he no longer felt the need for a sleep in the afternoon. He bothered to cook for himself. He lost weight during radiotherapy also noticed improvements in his ability to walk.
treatment, and had not returned to his pre-treatment weight. Foods he had previously enjoyed (like curry) were no longer At his final session, Petroc said that he was "overall very satisfied" appealing. In 2008 he had put himself on a dairy-free diet; he with the results. Energy, appetite, and mood had improved, and his also reported a "minor allergy" to chocolate and soy milk.
hot flushes were virtually unnoticeable. The "leaky" bladder, which he said should have been one of the symptoms on the MYMOP, Nocturia interrupted his sleep. Previously as frequent as six times a had improved and was now "more or less under control".
night, this was now down to once nightly. Bladder control was still problematic, as he experienced "leaking" before being able to reach While Petroc had enjoyed the treatments and noticed benefits, he the bathroom. He was considering doing pelvic exercises for this.
could not be sure that they were due solely to the acupuncture, as his symptoms had been "generally improving anyway".
Hot flushes were a minor problem. Although he experienced a few on waking and before getting up in the morning, mostly they went unnoticed.
Nevertheless, at four weeks after the end of treatment he wrote that "over treatment there was a continuing improvement", Petroc was concerned about his memory, and reported severe providing the following details: short-term memory loss. He was unconcerned about the sexual changes that prostate cancer and his treatment had made, "The nocturia is now down to one per night on an increasingly as he and his wife had ceased to be sexually active prior to regular basis.
"There was a sudden and noticeable improvement in appetite (previously I ate at regular times, but insisted on small portions). Self-reported concurrent health problems included minor allergies Now my appetite is back to normal and the need for small and minor genitourinary conditions. Prescribed medications portions has disappeared.
included felodipine for high blood pressure and daily aspirin. As hormonal therapies are associated with an increased risk of "Fatigue. Previously I usually felt a desire to sit down and relax early in osteoporosis, and in view of Petroc's dairy-free diet, Petroc also the afternoon (when I usually fell asleep). Now I am increasingly able to took a calcium supplement as recommended by his GP. ‘keep going' until supper time (though I do still fall asleep if I do relax).
Progress through treatment
My urge incontinence (noticeable mostly at night) began to Petroc found acupuncture relaxing, and tended to fall asleep diminish during the treatment and is now almost on the point during the sessions.
of disappearing." viii Some studies have reported a relationship between cancer supplements and fatal prostate cancer. However, in a recent review, the World Cancer Research Fund International concluded that the evidence for any links between high calcium intake and increased risk of prostate cancer is limited. (See World Cancer Research Fund International/American Institute for Cancer Research Continuous Update Project Report: Diet, Nutrition, Physical Activity, and Prostate Cancer. 2014. Available at www.wcrf.org/sites/default/files/Prostate-Cancer-2014-Report.pdf ).
The European Journal of Oriental Medicine 13
Petroc's feedback at 18 weeks records that these improvements Sweats interrupted his sleep and he did not nap during the day. remained. The lack of appetite had "largely gone away", He experienced aches and pains "like a viral achiness". Urination flushes were "now fairly rare", and urinary incontinence was had improved after a procedure to widen the urethra in June that "increasingly under control", although he was not "home and year, although he still experienced some urgency. Nocturia was dry" yet. It was also rare for Petroc to need to get up more than variable, occurring two to three times some nights, while other once a night. The fatigue remained a problem in the afternoons nights he did not go at all.
unless Petroc was "fully occupied doing something engaging".
Bowel function was "okay". He experienced headaches, for Petroc also commented on the specifics of the NADA treatment, which he tried to avoid taking medication, and controlled them noting that he didn't like the "twinges of pain on insertion of by drinking more water and taking some natural remedies. some (sic) needles". Of the group sessions he said, "I enjoyed the He had a history of migraines, but these were now infrequent. company of other participants", and found it useful to have "a A low back injury contracted at the age of 16 sometimes played relaxing morning away from my usual activities" even though he up (he had acupuncture treatment for it in 1999). He had no "invariably fell asleep for most of the session".
problems with memory and concentration, and he reported no sexual concerns.
Petroc supplied his own summary. For him, NADA treatment
Emotionally, he was inclined to keep his feelings to himself. He "assisted the steady slow improvement of various side effects". sometimes felt inadequate because of lack of work, and not being Nevertheless, he acknowledged that a particular benefit "was an able to do things as before.
overall improvement in feeling a state of wellbeing." Self-reported concurrent health problems included hypothyroidism Case study 3: Alfred: "I am back to feeling my ‘old' self"
(levothyroxine sodium was prescribed for this), and depression, NADA specialist's summary
genitourinary conditions, musculoskeletal problems, sleep, Alfred was very friendly and open about his symptoms. He was dizziness and hot flushes. He also experienced claustrophobia.
willing to give ear acupuncture a go as he was desperate to have some control over his symptoms of pain and hot flushes.
Progress through treatment
Alfred experienced few benefits until Tx 4, when night flushes
Prostate cancer history
reduced by half. There was no change in the day flushes. Sleep Alfred, 65, was diagnosed with low risk localised prostate cancer was improving, he was getting "fairly good nights", and was able in 2012, a year prior to starting NADA treatment. Although he to get back to sleep more easily if he woke. He was very short- was a candidate for active surveillanceix, he opted for definitive tempered, and did not have the patience he felt he should have.
therapy. However, an enlarged prostate gland ruled out brachytherapy as a treatment option. He had had a single implant At Tx 5 he reported a "bad week"; flushes had worsened, of goserelin early in 2013, and was transferred to a ‘watch and especially in the evening when he was experiencing five to six wait'x policy.
incidents. He was still easily irritated, and used counting to ten to calm down. However, some of his joint and neck problems were General health history
improving, and he didn't "feel 90 any more".
Alfred suffered greatly from treatment-related hot flushes, and was referred for acupuncture by his oncologist. On MYMOP he Tx 6 saw significant improvement in hot flushes. Alfred was specified 1) hot flushes and 2) dizziness as bothersome symptoms; having "fewer and fewer", with frequency reduced from eight physical activity was made difficult by these symptoms.
to two to three per night. Itching was returning, although at this stage he was not scratching, and did not need to apply any He experienced up to four to five hot flushes during the day soothing creams. His energy, too, was coming back, sleep was and at least eight to ten during the night. He often had to "step improving, and he described his bladder function as "normal". outside to cool down". "Itchiness" accompanied these incidents, and could occur anywhere on the body. The flushes were At his penultimate treatment, the hot flushes had remained "very upsetting" when they were severe.
stable. He was sleeping through the night, his energy had increased, and his aches and pains had reduced to a small patch Dizziness occurred on standing and when bending down.
on the right side of the neck.
ix Most low-grade, early-state prostate cancers are likely to remain asymptomatic. Active surveillance means periodic monitoring (by digital rectal examinations and PSA blood tests every one to three months) to monitor whether the tumour is growing. x Watch and wait, or watchful waiting, is used for slow-growing prostate cancers. The doctor monitors the patient for any new symptoms. Regular blood tests monitor PSA levels, and there may be digital rectal examinations.
14 The European Journal of Oriental Medicine
Using the NADA Protocol to Improve Wellbeing for Prostate Cancer Survivors Beverley de Valois and Tarsem Degun At his final treatment, Alfred reported that his "hot flushes were Shortly after commencing the NADA treatment in spring 2014, 90% better, energy 60% better, aches and pains 70% better". metastatic spread to the spine was confirmed. Sleep continued to improve, and his mood was getting back to where he was pre-diagnosis. He had a "feeling of wanting to do General health history
things"; he was "feeling good".
Robert had found acupuncture effective for back pain ten years previously. He had heard that ear acupuncture could be beneficial, At the end of treatment he wrote that the sessions had been very and his oncologist had referred him for the NADA sessions. On beneficial: "they have helped me with my hot flushes and my MYMOP he specified 1) shoulder pain and 2) constipation as sleeping" and he was "able to move without pain".
bothersome symptoms; playing snooker was the activity made difficult by his symptoms.
At four weeks after the end of treatment, Alfred wrote:
Robert experienced extreme pain in his right shoulder. The "Hot flushes have practically gone allowing me to sleep virtually possibility of metastatic cancer was being investigated. He also through the night. My appetite has returned and the body aches experienced mid and lower back pain, which was eased by lying and pains have decreased." down. Constipation was also being investigated; a colonoscopy revealed a possible small bowel obstruction that was resolving. At 18 weeks after the end of treatment, Alfred confirmed that It also confirmed an existing diagnosis of radiation proctitis, the itching, dizziness, and hot flushes had ceased. Without the a long-term consequence of radiotherapy that causes symptoms acupuncture he was "sure my symptoms would have lasted such as feelings of wanting to strain, rectal bleeding, and much longer". When commenting on what the experience of mucous discharge.
acupuncture affected most in his life, he wrote:"Quality of life, was feeling very ‘down' and tired before the Robert managed at least seven hours sleep a night, waking once treatment … As I have said my quality of life has improved or twice to urinate. Previously able to get back to sleep easily, dramatically and I am back to feeling my ‘old' self." the recent onset of shoulder pain made it more difficult. Hotflushes were mild and infrequent. He described his digestion as "okay", although his appetite had recently diminished slightly While many of Alfred's bothersome symptoms might be expected as medications upset his stomach. His energy levels were "not to improve normally, NADA treatment provided an important too bad"; Robert was physically active and walked most days. boost, speeding his recovery, and helping him to regain his former He wanted to lose some weight. Memory was fine, although sense of self. As well as improving physical health, it appears his attention levels reduced when stressed. to have alleviated the distress triggered by his diagnosis and treatment.
Emotionally he was "okay at the moment", although a few days previously he had been feeling low. St John's Wort was helpful, Case study 4: Robert: "It helped me relax and come out
now and in the past. Robert was separated from his wife and lived on a high"
alone. He had no sexual concerns at the moment.
NADA specialist's summary
Robert was seeking relief for severe back and shoulder pain. It was
He reported no concurrent health problems. He had sustained necessary to find a comfortable chair for him to sit in when having fractures to his right shoulder a few years previously, and to his acupuncture, as he was very uncomfortable in the clinic chairs.
right patella 25 years ago in a motorcycle accident. He had been having physiotherapy for many months during the previous year. Prostate cancer history
Prescribed medications at the time of starting NADA treatment Robert, 61, was diagnosed with locally advanced prostate cancer were ibuprofen (3/day) and paracetamol (4/day) for pain control.
nearly four years previously in 2010. Treatments had included a laparascopic radical prostatectomyxi later that year, followed Progress through treatment
by external beam radiotherapy. Hormonal therapies included a Robert enjoyed his first NADA treatment, and valued "being previous course of leuprorelin (Prostap®), and Robert was currently peaceful, relaxed. Comfortable." treated with goserelin (Zoladex®). Progressive disease was confirmed in autumn 2013, and treated with the anti-androgen At Tx 2, he had been struggling with lower back pain. Shoulder pain bicalutamide (Casodex®) until spring of 2014.
was "not too bad now" after five palliative radiotherapyxii sessions. xi Keyhole surgery to remove the prostate gland.
xii When prostate cancer spreads to the bones, radiotherapy may be give to the affected bone or area to control the pain. This may be given as a single treatment, or as a short series of treatments.
The European Journal of Oriental Medicine 15
His sleep was still "okay" in spite of getting up once or twice a "It has helped me with mobility, pain control, and improved my night to urinate. At the end of the session, his lower back pain mood. Hot flushes were not a problem as they were very few. The was relieved, and he was "calm, relaxed, peaceful".
biggest benefit is that it has helped with relaxation. I am relaxed and on a ‘high' after the sessions." At Tx 3, he reported that the back pain had been relieved for a day and half after the previous session. Although his sleep was good, his moods had been variable as he was still At four weeks after the end of treatment, Robert again experiencing pain.
noted that:"After the treatment I was always feeling very relaxed and on a At Tx 4, Robert's feedback from the previous week was that he high which helped me to do things for a day or two … I notice was able to "walk normally", much "faster and freer". This had that I didn't feel tired so much." lasted for a day. He had felt calmer and brighter. Emotionally, he was a bit better, and had arranged to stay with a friend during At 18 weeks after the end of treatment, he wrote that the his next series of five radiotherapy treatments to the lower back. benefits had been long lasting: He confirmed that the cancer had spread to his spine, and that "The ear acupuncture treatment continued to help me with he wished to continue with acupuncture. Robert arrived at the side effects and still does … it was an eye opener and [I] this session with considerable shoulder pain, and had to take thoroughly enjoyed the course." painkillers before he could settle down to receive treatment. He did manage to relax and be comfortable.
Robert commenced NADA treatment just as cancer progression was
Robert completed radiotherapy prior to his fifth NADA session. diagnosed. His comments confirm that having acupuncture helped He was still in a great deal of discomfort; however, at the end of him at a challenging time in his life. While it might be difficult to the session he was "very warm, calm, peaceful, relaxed".
attribute how much the radiotherapy or NADA was responsible for relieving his pain, it is clear that acupuncture helped with relaxation At the sixth session, Robert said the benefits of the previous and improved his mental and emotional wellbeing.
treatment had been long lasting. He had felt fine and had been able to walk more comfortably and faster. However, his mood at Case study 5: Paul: "Hearing other people's stories makes
the moment was not good. He had tripped and jolted his back, me feel more anxious"
causing more pain that had not settled, and he was unable to NADA specialist's summary
relax. During treatment, he drifted off to sleep, and awakened Paul was very anxious, and looking for an improvement in his feeling "peaceful" and pain-free.
sex drive and weight.
The following day, he was feeling more relaxed and the pain Prostate cancer history
was manageable. Unfortunately, the lower back pain worsened Paul, 60, was diagnosed with high-risk locally advanced prostate during the week, and he was taking Oramorph® (morphine in cancer one year previously in 2012. This was managed with syrup form) for pain control. He slept very badly the night before injections of the pituitary down regulator goserelin (Zoladex®). his penultimate NADA treatment, and arrived an hour late. At the Bicalcutamide (Casodex®) tablets were taken prior to and following end of the session he was "relaxed. Peaceful, calm and relaxed".
the first injection to manage tumour flare. A course of external beam radiotherapy followed a few months later. Tamsulosin was Robert presented for his last NADA session "feeling okay". His prescribed for benign prostatic hyperplasia (BPH).xiii lower back pain was manageable after a change in medication, and now his back just felt a "bit stiff". The previous NADA session General health history
had given him a lot of relief; he had been able to do more and Paul was an urgent referral to the NADA service from his went out for walks. He had noticed that twitches and spasms were oncologist and the Urology Research Team. On MYMOP he developing in his arm and body. Sleep was "okay", and the NADA specified 1) lack of sexual desire and 2) fatigue as bothersome specialist noted that his mood was not as bright as it had been.
symptoms; playing tennis was the activity he stated was affected by his symptoms.
Robert found that the acupuncture sessions had "exceeded my expectation", helping him to manage pain and relax. Prior to diagnosis, Paul had enjoyed an active sex life. Since then, He summarised the benefits: he had made love twice in six months, but now had no desire for xii BPH is a non-cancerous condition common in men over the age of 50. A benign enlargement of the prostate gland, its symptoms are similar to those of prostate cancer and include difficulty passing urine, frequent urination, nocturia, pain when passing urine, and (unusually) blood in the urine.
16 The European Journal of Oriental Medicine
Using the NADA Protocol to Improve Wellbeing for Prostate Cancer Survivors Beverley de Valois and Tarsem Degun sex. He had used tadalafil (Cialis®) to address erectile dysfunction had stopped taking this before commencing acupuncture as the about three times in the previous five months, but disliked using medication had caused breathlessness, palpitations and cramps in this approach. Lack of desire caused him extreme distress.
his hands. Now taken at a low dose, these side effects were less bothersome, but Paul felt he was a bit "out of puff". The sweats Hot flushes were less debilitating than they had been, and were were still disturbing his sleep, waking him four to five times at occurring four to six times during the day. These were sweats night. His libido remained the same.
about the waist, lasting from one to five minutes. Night incidents were difficult to assess; however, he woke up with a sweat and This last treatment occurred the day before his final day at work. the need to urinate.
He thought that his mental attitude might have improved during the NADA sessions; however it had been a difficult time with a lot Sleep was always disrupted, which he attributed to tiredness. happening with regard to redundancy, retirement, and planning He tossed and turned all night, and had "weird" dreams. He also for the future.
suffered chronic digestive problems: there was a family history of IBS, and Paul noticed that certain foods and stress caused Paul also disliked the group sessions. He was "not a lover of group bloating. Cancer medication had caused weight gain, and he therapies", and "hearing other people's problems makes me had started to diet. He experienced nightly headaches, which he feel anxious". He often avoided the group by arriving late for his associated with his sleep problems. Memory and concentration appointments; when possible, the NADA specialist treated him in "wavered a bit", but was not considered to be a problem. a separate room. Nevertheless, Paul valued the service, and at the end of treatment, he wrote that it was: Paul had initially felt "suicidal" when diagnosed. His wife had "Comforting to come into a service regularly. A positive focus to helped to put things in perspective, and he had been able to start have regular contact with the therapist." to cope with it. Nevertheless, he felt upset for his wife and family. Physically, he felt "like an old man", with aching joints and being unsteady on his feet. He did not have sufficient energy to exercise.
At 18 weeks after the end of treatment, Paul wrote:"I found that having the treatment with a group was not a nice Self-reported concurrent health problems included fatigue, experience due to distractions from other patients (snoring, breathlessness, hot sweats/night sweats, swollen fingers, and talking, etc). I did find that on my second treatment, I felt very aching Achilles tendons first thing in the morning. Prescribed good afterwards, but this did not continue sadly." medications included tamsulosin hydrochloride (Pinexil PR®) for BPH, and metoclopramide hydrochloride to relieve stomach upset.
Nevertheless, Paul was positive about acupuncture, and said he would recommend it to others, saying: Progress through treatment
"Just because this has not worked for me I can see no reason for Paul commenced NADA treatment at a very difficult time in his it not working for others." life, as he had just been made redundant and was working his notice. This happened to coincide with a period of very hot weather.
Paul was at a difficult transition point in his life when he commenced NADA treatment. Redundancy and sexual difficulties, Paul's NADA treatment notes are sparse, as much of the issues that deeply affect self-esteem and self-image, were not discussion about sexual matters remains confidential between helped by the intractable bothersome consequences of cancer himself and the NADA specialist.
treatment. Disliking the group therapy approach, Paul was not able to benefit from aspects of NADA treatment that many After his second NADA session, Paul had more energy and patients find supportive. "felt the best I've felt for at least a year – felt pretty good in myself." This lasted all day and into the beginning of the following day. Sleep remained disrupted, and the sweats were These cases are valuable illustrations of the complexity of prostate now "the worst thing".
cancer and its treatments. They encompass a range of cancer diagnoses, from recently diagnosed early stage disease (both low A holiday break after Tx 3 left a two-week gap in treatment. Paul and high risk), to long-term survivorship, to advanced metastatic presented for Tx 4 feeling "worse than before". Hot weather over disease. These five studies also demonstrate a wide range of the ensuing four weeks found his flushes continuing to worsen, cancer therapies, and the associated consequences of prostate with no apparent improvement in any other symptoms.
cancer and its treatments.
At his final treatment, Paul reported no changes. He had resumed Although a standardised treatment, NADA ear acupuncture taking cyproterone acetate (Cyprostat®) to manage flushes. He appears to be beneficial in many ways. Responses remain highly The European Journal of Oriental Medicine 17
individualised, with most patients reporting positive outcomes. NADA treatment was not effective for everyone, nor was group A legacy donation to the Lynda Jackson Macmillan Centre treatment to everyone's liking. Even so, the men expressed (LJMC), and a donation from the Hale Lodge of Middlesex appreciation for the level of care, as well as continuity of care by (No.5141) made this project possible. Thank you to the men the same practitioner. These aspects have been identified as being who participated in this project; and to the following staff of important for the supportive care of men diagnosed and treated the LJMC: Pam Thorpe and Jill Preston, complementary therapy for prostate cancer. (King et al., 2015) service co-ordinators; Teresa Young, research co-ordinator; Diane Back, data administrator. Also to Rachel Peckham MSc LicAc In conclusion, this small exploratory study provides sufficient MBAcC, formerly of NADA UK, for her continuous support of indication of potential benefit to warrant further research. our NADA projects.
Beer, T.M., Benavides, M., Emmons, S.L., et al. (2010). Acupuncture for
Fan, G., Filipczak, L., Chow, E. (2007). Symptom clusters in cancer
hot flashes in patients with prostate cancer. Urology, 76(5): 1182-8.
patients: a review of the literature. Current Oncology, 14(5): 173-9.
Bemis, R. (2013). Evidence for the NADA ear acupuncture protocol:
Globocan. (2012). Prostate cancer: estimated incidence, mortality and
summary of research [online]. Available at: http://www.acudetox.com/ prevalence worldwide in 2012 [online]. Available at: http://globocan.iarc.fr/ index.php/evidence-for-the-nada-protocol [Accessed 4 December 2014].
Pages/fact_sheets_cancer.aspx [Accessed 9 April 2015].
Boon, H., Kania-Richmond, A., Verhoef, M., Tsui. T., Danelesko,
Harding, C., Harris, A., Chadwick, D. (2009). Auricular acupuncture:
E. (2015). 2014 IN-CAM Research Symposium: The Next Wave of
a novel treatment for vasomotor symptoms associated with luteinizing- Complementary and Integrative Medicine and Health Care Research. hormone releasing hormone agonist treatment for prostate cancer. British Journal of Complementary and Integrative Medicine, 12(1): eA1–eA71.
Journal of Urology International, 103(2): 186-90.
Cancer Research UK. (2014a). Prostate cancer incidence statistics [online].
King, A., Evans, M., Moore, T., et al. (2015). Prostate cancer and
supportive care: a systematic review and qualitative synthesis of men's types/prostate/incidence/#geog [Accessed 11 December 2014].
experiences and unmet needs. European Journal of Cancer Care, doi: 10.1111/ecc.12286.
Cancer Research UK. (2014b). Prostate cancer: cancer statistics key stats
[online]. Available at: http://publications.cancerresearchuk.org/cancerstats/
Lee, M., Kim, K-H., Shin, B-C., Choi, S.M., Ernst, E. (2009). Acupuncture
statsprostate/keyfactsprostate.html [Accessed 11 December 2014].
for treating hot flushes in men with prostate cancer: a systematic review. Supportive Care in Cancer, 17763-70.
Cancer Research UK. (2014c). Treatment options for prostate cancer
[online]. Available at: http://www.cancerresearchuk.org/about-cancer/type/
Maciocia, G. (1994). The practice of Chinese medicine. Edinburgh: Churchill Livingstone, [Accessed 11 December 2014].
Macmillan Cancer Support. (2013). Cured - but at what cost: long-term
Capodice, J.L., Cheetham, P., Benson, M.C., McKiernan, J.M., Katz, A.
consequences of cancer and its treatment [online]. Available at: www.
(2011). Acupuncture in the treatment of hot flushes in men with advanced prostate cancer. International Journal of Clinical Medicine, 251-5.
11 December 2014].
Cho, W. (Ed). (2012). Acupuncture and moxibustion as an evidence-based
Miaskowski, C., Dodd, M., Lee, K. (2004). Symptom clusters: the new
therapy for cancer. Dordrecht: Springer. frontier in symptom management research. Journal of the National Cancer Institute, 3217-21.
de Valois, B. (2006). In Centre for Complementary Health and Integrated
Medicine, Vol. PhD Thames Valley University, London.
Paterson, C. (No date). MYMOP: General information [online]. Available
de Valois, B., Young, T., Melsome, E. (2012a). Assessing the feasibility
information/ [Accessed 9 April 2015].
of using acupuncture and moxibustion to improve quality of life for cancer survivors with upper body lymphoedema. European Journal of Oncology Peckham, R. (2005). The role and the impact of the NADA protocol (daily
Nursing, 16(3): 301-9.
group acupuncture treatment used in addiction): explanatory case studies [MSc Thesis]. University of Westminster, London.
de Valois, B., Young, T., Robinson, N., McCourt, C., Maher, E. (2010).
Using traditional acupuncture for breast cancer-related hot flashes and
Roth, A.J., Weinberger, M.I., Nelson, C.J. (2008). Prostate cancer: quality
night sweats. Journal of Alternative and Complementary Medicine, 16(10): of life, psychosocial implications and treatment choices. Future Oncology, 4(4): 561-8.
de Valois, B., Young, T., Robinson, N., McCourt, C., Maher, E. (2012b).
Thomas, K., Fitter, M. (2002). Possible research strategies for evaluating
NADA ear acupuncture for breast cancer treatment-related hot flashes and CAM interventions. In: Lewith G, Jonas WB, Walach H, eds. Clinical night sweats: an observational study. Medical Acupuncture, 24(4): 256-68.
research in complementary therapies (pp. 59-91). Edinburgh: Churchill Livingstone.
de Valois, B., Young, T., Thorpe, P., Preston, J., Degun, T. (In press).
Improving wellbeing of prostate cancer survivors using the NADA
acupuncture protocol: a clinical outcome study. Medical Acupuncture.
18 The European Journal of Oriental Medicine
Theralogix newsletter v1_iss6
thoughtful, intelligent and safe information for your health Vol 1, Issue 6 Saw Palmetto for Symptoms of BPH What is BPH? BPH (Benign Prostatic Hyperplasia) is What can you do? defined as noncancerous enlargement of the If you feel like you've developed a problemwith BPH, there is good news! There are prostate. As men age, it is common for
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