Evaluating the Outcomes and Patient Experience of Group and Individual Acupuncture in an NHS Cancer Care Setting: A Mixed Methods Study

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Previously, group acupuncture (GA) has been compared with individual acupuncture (IA) for specific cancer-related symptoms or patient experience, but has not correlated symptoms with patient experience between GA and IA. This service evaluation, using a mixed-methods design, aimed to compare GA with IA for symptom-related outcomes and patient experience and explore their inter-relationships, in order to inform future development of the service. Methods Cancer patients referred to the acupuncture service in a UK NHS hospital received six treatments of GA or IA. Outcomes were gathered using Measure Yourself Concerns and Wellbeing (MYCaW) questionnaires pre- and post-treatment. Experience of acupuncture was gathered post-treatment using a questionnaire and analysed using reflexive thematic analysis. Results 48 participants’ data were analysed. There were statistically significant improvements in outcomes overall, with no difference between GA and IA. Most participants had a positive experience; IA participants focused more on the relationship with their acupuncturist whilst GA participants focused more on environmental factors. For a few GA participants, the group experience was negative, but data synthesis revealed this did not impact symptom-related outcomes. Conclusion In both GA and IA arms, symptom-related outcomes mostly improved alongside a positive experience. For those participants for whom GA was not an ideal setting, there was no effect on symptom-related outcomes. These results may be of relevance when establishing acupuncture services in supportive cancer care settings. acupuncture group acupuncture integrative oncology patient experience cancer care mixed methods Figures Figure 1 Figure 2 Background As cancer incidence and survivorship increases worldwide ( 1 ), an estimated 39% of cancer patients use nonpharmacological integrative therapies, such as acupuncture, for symptom relief ( 2 ). Acupuncture for cancer care (defined as treatments for the alleviation of symptoms of cancer, the side-effects of cancer treatment and cancer survivorship)( 3 ) has a growing body of evidence showing it to be safe ( 4 ) and effective for multiple symptoms, including pain, chemotherapy-induced peripheral neuropathy, hot flushes and night sweats, nausea, xerostomia, insomnia and anxiety ( 5 ). The American Society of Clinical Oncology has recently recommended that acupuncture may be used for various cancer-related pain symptoms ( 6 ) and Cancer Research UK states that acupuncture is equal to, or better than, standard treatment for chemotherapy-induced nausea, tiredness, pain, anxiety, depression and mood changes, quality of life and hot flushes ( 7 ). Acupuncture can be provided individually in a one-to-one consultation, or in a group setting, where more than one person is treated in a shared space. Group acupuncture (GA), also known as community or multibed acupuncture, has been shown to be cost-effective when compared to individual acupuncture (IA)( 8 , 9 ) and acceptable to National Health Service (NHS) patients ( 10 ). Different styles of acupuncture are utilised in a group, such as traditional acupuncture, auricular acupuncture or a combination of both; research into each modality has reported improved outcomes ( 11 )( 12 )( 13 ). GA was shown to be noninferior to IA for cancer pain ( 14 ), although noninferiority was not shown in a similar non-cancer pain trial ( 15 ). In an NHS study, there was no statistical difference between GA and IA for improved hot flushes and night sweats at 18 weeks post-treatment ( 16 ). Qualitative research has shown the experience of GA to be positive ( 10 ) and valued similarly by patients when compared with IA ( 17 ). Cancer patients value the social support of GA compared with the privacy and one-to-one interaction provided in IA ( 18 ). In real-world clinical settings, acupuncture clinics see a broad range of cancer care symptoms, whereas current research comparing the symptom-related outcomes of GA and IA tend to focus on individual symptoms. The majority of these studies are based in North America ( 11 ), lacking representation of diverse healthcare settings such as the NHS in the UK. Furthermore, no studies were identified that synthesise the experience of acupuncture with symptom-related outcomes in cancer care. Real-world research aims to understand the value of interventions in routine settings ( 19 ). The aim of this study, using real-world data in an NHS cancer care setting, is to evaluate and compare group and individual acupuncture for symptom-related outcomes and patient experience overall, and to explore the relationships between outcomes and patient experience both within and between the two arms, in order to inform future development of the acupuncture service. Methods Approval and design Evaluation of an acupuncture service based in a supportive care service (DCC) within a cancer centre of a large NHS hospital trust between October 2022 and April 2023 was approved by the Trust’s Quality Improvement and Audit Committee. This study used a convergent mixed methods research design where quantitative and qualitative data were concurrently collected, independently analysed and then merged in order to integrate, compare and interpret the results. Service description and setting Patients referred to the DCC acupuncture service received six treatments, in either the GA or IA clinic, with appointments lasting 45–60 minutes. Allocation to GA or IA was based on DCC diary and/or patient availability, and booked via a telephone consultation. Eligibility criteria were: aged ≥ 18, in active cancer treatment or ≤ 12 months following the last day of treatment (surgery, radiotherapy, chemotherapy, immunotherapy or adjuvant hormone therapy), English-speaking, not an in-patient and not receiving concurrent acupuncture. GA was seated, in a room with up to three patients, with dimmed lighting and quiet music. Appointments were staggered at 20-minute intervals, and consultations took place chair-side. Patients removed footwear and placed their feet and hands on pillows. Point locations were predominantly below knees and elbows, or on head and neck. IA was in a clinic room with a single patient lying on a couch. All participants were seen by a single therapist (who was also the researcher) with 17 years’ clinical experience and a member of the British Acupuncture Council ( 20 ). Treatments were based on Traditional Chinese Medicine theory ( 21 ), where patients are individually diagnosed and treated accordingly with needles and relevant adjunctive components ( 22 ), such as scalp or auricular acupuncture ( 23 ), auricular ear pellets ( 24 ), indirect smokeless moxibustion, infrared light therapy ( 25 ) and lifestyle advice ( 26 ). Assorted gauge and size Aculine copper handle needles were used with manual stimulation and varied depth depending on de qi , a subjective sensation ( 27 ). The number of needles inserted varied from 6 to 25. Needles were retained between 20 to 30 minutes. Outcome measures and informed consent DCC complementary therapists routinely collect outcome data for all complementary therapy interventions using the validated outcome measure, Measure Yourself Concerns and Wellbeing (MYCaW). MYCaW scores patients’ self-designated one or two Concerns and Wellbeing using a 7-point Likert scale in a first and follow-up questionnaire ( 28 ). The first questionnaire is completed prior to treatment one and additionally collects some demographic data. A follow-up questionnaire is completed at the end of treatment (EOT), and includes two qualitative questions. These qualitative questions, and the Wellbeing scores, are completed routinely but not analysed in this study. Participants also completed an EOT open-ended questionnaire, designed by the researcher, asking about their experience of acupuncture (Online Resource 1). Potential study participants were given a Participant Information Sheet (PIS) and consent form (CF) in either the first appointment (when a new patient) or second to fifth follow-up appointments (when an existing patient). Consent could be given any time up to the start of the 6th appointment. Data analysis Quantitative analysis Data was analysed to compare baseline to post-treatment scores for Concern/s both within and between the study arms. Descriptive statistics were presented with clinical and demographic characteristics and Concerns were categorised into broad symptom groups; GA was compared with IA using Chi-square and Fisher-Freeman-Halton Exact tests. Tests were carried out with SPSS V29.0 ( 29 ) using a significance level of 5% (P < 0.05). Concern datasets were skewed according to a Shapiro-Wilk test (p < .05). Consequently, non-parametric tests were applied to test for statistically significant changes from baseline to post-treatment (within-subjects) and between-subjects. Qualitative analysis Qualitative data exploring the experience of acupuncture was gathered from open-ended questions in the EOT questionnaire and analysed using reflexive thematic analysis (RTA)( 30 ). As a researcher-practitioner, this method was selected for its emphasis on reflexivity, enabling knowledge to be co-produced by the researcher and the researched subjects, whilst valuing the subjectivity of the researcher and helping mitigate the possibility of researcher bias. Synthesis Data was merged after analysis using a side-by-side joint display (JD) table that combined statistical results and qualitative themes ( 31 ). A triangulation protocol was applied ( 32 ), whereby relationships were explored for consonance or dissonance between outcomes and patient experience both within and between the GA and IA study arms. Results Participant Flow During the data collection period, 52 patients were referred to the acupuncture service (33 to GA and 19 to IA). One non-English speaking patient was ineligible. Three patients attended one appointment only and therefore did not provide consent, 48 participants consented and five were lost to follow-up, leaving 43 participants for analysis using a complete-cases analysis model (Fig. 1 ). a appt = appointment b acu= acupuncture Participant Baseline Demographics The mean age for the overall sample was 57.8, 66.7% were female, 56.3% identified as white, 22.9% black, 14.6% Asian and 3% other. 47% of participants had breast cancer, with other cancer diagnoses at 10% or lower. There was no statistical difference in baseline demographics between the two arms (Table 1 ). Table 1 Participant Baseline Demographics Demographic GA IA Total p-value n = 30 % (mean/SD) n = 18 % (mean/SD) n = 48 % (mean/SD) Age 30 (57.1 / 9.6) 18 (59.0 / 9.2) 48 (57.8 / 9.4) .534 Gender Female 20 66.7 12 66.7 32 66.7 1.00 Male 10 33.3 6 33.3 16 33.3 Ethnicity White 14 46.7 13 72.2 27 56.3 .340 Black 8 26.7 3 16.7 11 22.9 Asian 6 20.0 1 5.6 7 14.6 Other 2 6.7 1 5.6 3 6.3 Tumour Breast 14 46.7 6 33.3 20 41.7 .549 Gynae 2 6.7 3 16.7 5 10.4 Head & Neck 2 6.7 3 16.7 5 10.4 Bowel 2 6.7 2 11.1 4 8.3 Pancreas 2 6.7 2 11.1 4 8.3 Prostate 3 10.0 0 0 3 6.3 Other 5 16.6 2 11.1 7 14.7 Participant symptoms Chemotherapy-induced peripheral neuropathy was the most common symptom category at 29%, with all other pain (including cancer-related pain and aromatase inhibitor-induced arthralgia) at 26% and the remaining 45% reporting other symptoms (Fig. 2 ). There was no difference between GA and IA (p > 0.05). Quantitative Data Across both arms, using a Wilcoxon signed-rank test, Concerns data showed statistically significant decreases in median scores (indicating improvement) (Table 2 ). Table 2 Descriptive statistics of decreases in Concerns scores overall Variable Baseline n = 43 Post-treatment n = 43 p-value Mean (median) SD (IQR) Mean (median) SD (IQR) Total Concern 1 5.4 ( 6 ) 0.9 ( 1 ) 2.9 ( 3 ) 1.5 ( 2 ) < .001 Concern 2 5.2 ( 6 ) 1.0 ( 1 ) 2.7 ( 3 ) 1.7 (2.3) < .001 When comparing between-arms, a Mann-Whitney U-test showed no statistically significant difference in decrease in median scores between GA and IA for Concern 1 or Concern 2 (Table 3 ). Table 3 Descriptive statistics of differences of MYCaW scores in GA and IA GA n = 28 IA n = 15 Total n = 43 p-value mean (median) decrease SD (IQR) mean (median) decrease SD (IQR) mean (median) decrease SD (IQR) Concern 1 2.5 ( 3 ) 1.7 ( 2 ) 2.4 ( 2 ) 1.7 ( 3 ) 2.5 (2.5) 1.7 ( 3 ) .786 Concern 2 2.3 ( 3 ) 1.7 ( 2 ) 2.6 ( 2 ) 1.8 ( 3 ) 2.4 ( 3 ) 1.7 ( 3 ) .621 Qualitative data Although 41 participants completed the EOT questionnaire, 22 questionnaires had at least one missing answer. Using reflexive thematic analysis, three themes were identified across the two study arms: ( 1 ) physical and emotional change versus expectations , ( 2 ) the gift of time and ( 3 ) the clinical environment . Each theme is described overall, highlighting the similarities and differences between each arm. All quotes are verbatim. Theme 1: Physical and emotional change versus expectations Theme one captured the value participants placed on improvements in their physical and emotional symptoms when reflecting on their expectations of acupuncture. Whether expectations were high or low, they tended to be met if symptoms improved. There were no differences between GA and IA. Many participants had no or low expectations: “I have not believed that this will work, but actually now I think that I would not be in the situation without it – more calm and better within myself.” (P131/IA) “The initial session I was not too sure but as the weeks and sessions went by I felt my joint pain, anxiety improve and felt a lot more calm.” (P360/GA) Those with higher expectations were mostly met: “I had acupuncture before and it always produce results. I was expecting to get better during the acupuncture period and it happened” (P858/GA) “I felt improvement in the issues being addressed. Wish it was widely available to cancer patients as I find it more effective than medications.” (P588/IA) However, there were some participants for whom expectations were not met: “I was hoping for a more positive outcome but unfortunately there was not a great improvement in my symptoms” (P770/IA) “The treatments are good and helpful but in my case, I don’t feel too much better at all.” (P157/GA) Overall, there were nineteen participants who commented on symptomatic improvement in the ‘treatment expectations’ question: “The joint pain reduced.” (P599/IA) “Had a positive impact on my flushes and pain relief.” (P709/GA) Often, when describing expectations, participants commented on needles. For most, needling was less painful than expected: “Did not hurt like I thought it would” (P161/IA) “I thought getting needles would be painful but it was the opposite.” (P416/GA) However, there were a few for whom the needling was a challenge: “I am still not a fan of needles.” (P873/IA) However, even when the needling was painful, this did not impact the overall experience: “Amazed by the results. Although, I thought it might hurt less!” (P318/GA) Theme 2: The gift of time Theme two captured the many ways in which time enhanced participants’ experience of acupuncture. This included reflective time for themselves, time to be listened to, and time given to them to understand their treatments and personal health. This theme was expressed equally between the arms with the exception of one participant in GA, who would have preferred more time with the acupuncturist. Participants in both arms felt they would have benefitted from more sessions. Some participants valued the personal ‘me-time’ afforded to them: “The sessions were very relaxing and provided ‘me time’.” (P998/IA) “I think they’ve helped me feel calmer – and to reflect/spend more time on my own well-being.” (P485/GA) Listening, and time to be listened to, was a subtheme: “She didn’t dismiss any concern and really listened – which is a substantial skill in this health environment.” (P179/IA) “Felt I was listened to, and given sound advice.” (P532/GA) Participants in IA valued the time given to them to discuss their treatment and health: “[The acupuncturist] spent all the time needed to help me understand the treatment, benefits and possible outcomes and effects.” (P829/IA) Participants in GA mostly thought that time was sufficient: “Although [the acupuncturist] was treating 2 other patients in the room, she made time to explain and listen to any concerns.” (P360/GA) However, one participant in GA would have preferred more time: “Some of the sessions I felt I could have needed more time to talk.” (P926/GA) Participants in both arms felt they needed more sessions: “It feels like as we are getting somewhere the 6 weeks was over. I feel this should be a 10-week course” (P161/IA) “…just wished I could have more sessions as it helps me. What happens next for me?” (P796/GA) Theme 3: The clinical environment Theme 3 captured the value placed on environmental factors such as conversation and sensory stimuli, highlighting the core difference between GA and IA. Whereas IA participants focused on their relationship with the acupuncturist, GA participants had a broader focus, including conversation, music and the presence of others. Although fewer in number, there were GA participants for whom some environmental factors, such as the presence or noise of others, or having to be mindful of their own behaviour, contributed to a more negative experience. Participants in both arms valued the relationship with their acupuncturist, describing the professionalism, knowledge and empathy shown to them. “It has been professional, supportive, sympathetic…” (P546/IA) “[The acupuncturist] fills you with confidence about her knowledge/field of expertise.” (P318/GA) Participants in IA frequently mentioned the conversations they had with their acupuncturist: “My conversations with my therapist were superb, great support, great conversation…” (P370/IA) Conversely, GA participants only mentioned conversation as a function of the group setting. For most, this was a positive experience: “Obviously I was able to hear other patients (and them me) talking of problems but I didn’t find it troubling. We were all in it together in a way.” (P455/GA) Although for a few, the presence of others was challenging: “…didn’t want other patients to feel I was listening to their consultations or feel uncomfortable.” (P363/GA) “Some patients were not particularly sensitive to others. They spoke about their pain, sickness which could bring anxiety to others” (P882/GA) Or the noise of others was distracting: “There were some distractions when people came in or left for treatment, but nothing major.” (P360/GA) Or respecting the quiet environment was difficult: “Had to remind myself to keep quiet…” (P104/GA) The sensory space was of greater value to GA participants. Despite identical music playing in both settings, only GA participants mentioned it: “I think everyone was in their own world, as the classic music makes you dive into your dream.” (P152/GA) Data synthesis Data synthesis aimed to explore the relationships between outcomes and patient experience both within, and between GA and IA. Through the use of a joint display (JD) table, data was juxtaposed from each theme with the corresponding Concern/s scores, triangulating for consonance or dissonance ( 32 ). Data was considered consonant when the quantitative outcomes and qualitative experience converged with either all positive or all negative results, and dissonant when it diverged, with a combination of positive and negative results. Most participants’ data was consonant, with improved Concern/s alongside a positive experience. There were no examples of negative Concern/s with a negative experience. The JD table illustrates a sample of consonance and dissonance from each theme (Table 4 ). Table 4 Joint Display Table Theme Quote Concern/s Score a Triangulation Physical and emotional change versus expectations 1. “The treatments are good and helpful but in my case, I don’t feel too much better at all.” (P157/GA) ↑ Dissonance 2. I was hoping for a more positive outcome...” (P770/IA) ↑ Dissonance 3. “I was expecting better results.” (P321/GA) ↑ Dissonance 4. “Great relief for my hands and feet” (P370/IA) ↑↑ Consonance 5. “The initial session I was not too sure but as the weeks and sessions went by, I felt my joint pain, anxiety improve and felt a lot more calm.” (P360/GA) ↑↑ Consonance The gift of time 6. “Some of the sessions I felt I could have needed more time to talk.” (P926/GA) ↑ Dissonance 7. “Felt I was listened to, and given sound advice.” (P532/GA) ↓ Dissonance 8. “I think they’ve helped me feel calmer – and to reflect/spend more time on my own well-being.” (P485/GA) ↑↑ Consonance 9. “It feels like as we are getting somewhere the 6 weeks was over. I feel this should be a 10-week course.” (P161/IA) ↑↑ Dissonance 10. “The sessions were very relaxing and provided ‘me time’.” (P998/IA) ↑↑ Consonance The clinical environment 11. “Some patients were not particularly sensitive to others. They spoke about their pain, sickness which could bring anxiety to others.” (P882/GA) ↑↑ Dissonance 12. “[The acupuncturist] is a lovely lady and I feel very secure and relaxed in her company.” (P802/GA) ↓↓ Dissonance 13. “I think everyone was in their own world, as the classic music makes you dive into your dream.” (P152/GA) ↓ Dissonance 14. “We were all in it together in a way” (P455/GA) ↑ Consonance 15. “I really liked the atmosphere and the friendly staff.” (P131/IA) ↑↑ Consonance a ↑ = Concern/s score improved ↑↑ =Concern/s score improved ≥ 3 points ↓= Concern/s score unchanged or worse ↓↓= Concern/s score worse ≥ 3 points In the first theme, three participants expressed a negative experience, stating that their expectations were not met in terms of symptomatic improvement. The JD table showed that for these participants, their Concern/s improved, showing dissonance (quotes 1, 2 & 3). In the final two themes, dissonance showed that where Concern/s worsened, there was no corresponding relationship with negative experiences (quotes 7, 12 & 13); and where there was a negative experience in GA, there was no corresponding relationship with worsening Concern/s (quotes 6, 9 & 11). Discussion This mixed methods study aimed to compare and synthesise symptom-related outcomes and patient experience of GA with IA in a cancer care setting in the NHS. Outcomes and experience Symptom-related outcomes improved equally between arms, corroborating previous studies ( 16 )( 9 ) and substantiating their results with a more diverse population (both gender and ethnicity) and diverse cancer diagnoses. When comparing patient experience of GA with IA, the results were mostly consistent with previous comparative studies; the majority of participants in both arms valued the treatment effects and relationship with their acupuncturist, with minor concerns around privacy in GA ( 15 )( 18 ). Where Oberoi et al ( 18 ) and Chuang et al ( 17 ) found that GA did not hinder a deeper therapeutic relationship, this study added context to both findings: the depth of relationship was valued equally, with an additional focus on depth of conversation in IA. This depth of conversation may be the relevant aspect of the therapeutic relationship that differs between GA and IA. Synthesis of outcomes and experience To the researcher’s knowledge, this is the first study to synthesise symptom-related outcomes with patient experience when comparing GA with IA. There were two interrelated findings: where symptom-related outcomes (Concern/s) were either unchanged or worsened in either GA or IA, there was not a corresponding negative experience; where there were negative experiences, there was not a corresponding worsening in symptom-related outcomes. Worsening symptom-related outcomes corresponding to positive experiences suggests there were other aspects of receiving acupuncture contributing towards the positive experience. Acupuncture uses a different theoretical model to biomedicine, where talking, listening and the diagnostic process are considered integral to the overall treatment effect ( 22 ). The gift of time highlights the importance participants placed on being listened to, and time to tell their story, unrelated to symptomatic change. Contrary to this finding, a recent study (not in cancer care) suggested that non-responders to acupuncture did experience negative non-specific effects (treatment effects other than from needle insertion and stimulation) ( 33 ). It is unclear from this whether these negative non-specific effects were due to different styles of acupuncture, the personality of participants or a perceived negative effect following a non-response. It is possible that vulnerable patients, such as those in cancer care, are more likely to respond positively to the non-specific aspects of acupuncture, which may explain the contradictory findings. Alternatively, research participation biases ( 34 ) may have impacted the reporting of negative experiences. More research is necessary to explore the relationship between non-responders and the non-specific experiences of acupuncture. Five participants said they would have preferred more sessions, although data synthesis showed these participants reported improved symptoms. Previous studies have shown that more sessions have led to further improvement in cancer-related symptoms in both GA ( 16 ) and IA ( 35 ), corroborating the participants’ request. However, with limited resources, six sessions improved symptoms whilst also enabling more patients to access the acupuncture service. Future service development may consider greater provision of GA over IA, potentially allowing more sessions per patient. In the four examples where there were negative experiences in GA, there was no corresponding worsening of symptom-related outcomes; in fact, the participant with the largest improvement in symptom-related outcomes reported negative comments regarding their experience. To the researcher’s knowledge, this is a new finding, suggesting potential implications for GA clinics. The negative experiences in GA were related to the group itself; for example, the presence of others being distracting, or being mindful of one’s behaviour. These experiences differ from the non-specific effects of acupuncture ( 22 ) such as the therapeutic relationship ( 36 ) or aspects of the acupuncture consultation ( 37 ) that enhance the patient-practitioner relationship and could potentially impact the symptomatic response (Ho et al., 2022). The negative experiences of GA appear not to impact the patient-practitioner relationship. Data synthesis, therefore, suggests that although the experience of GA may not suit all participants, the non-specific aspects of acupuncture remain positive, leading to negative group experiences not corresponding to similarly negative symptom-related outcomes. Although not generalisable, this finding may be relevant for future planning of acupuncture services in cancer care. GA in cancer care has been shown to be affordable and accessible ( 8 ) when compared with IA. This study suggests that for those few patients for whom GA is not an ideal setting, there is potentially no impact on treatment outcomes. More research is necessary to explore the relationship between GA experience and symptom-related outcomes. Limitations As a researcher-practitioner led study, research participation bias may have impacted the data because patients may be reluctant to report negative experiences to their practitioners ( 38 ). Missing data and a small sample size may have further impacted the results. Two participants chose to stop their treatments because they did not like acupuncture and a further six did not provide informed consent or were lost to follow-up. In the data synthesis, only a few examples from each triangulation formed the basis of the results and discussion. Conclusion When comparing GA with IA in an NHS cancer care setting, there were statistically and qualitatively significant improvements in symptom-related outcomes overall with no difference between the study arms. Most participants had a positive experience; IA participants focused more on the relationship with their acupuncturist, whilst GA participants had a broader focus on environmental factors. For a few GA participants, the presence of others was a negative experience. However, data synthesis revealed that for those participants, there was no effect on symptom-related outcomes. These results may be of relevance when establishing acupuncture services in supportive cancer care settings. Declarations Funding The authors declare that no funds, grants, or other support were received during the preparation of this manuscript . Competing interests Mandy Brass is employed by GSTT NHS Foundation Trust. This service evaluation was conducted by Mandy Brass in part completion of a self-funded MSc in Advanced Oriental Medicine: Research and Practice at the Northern College of Acupuncture. Dr Karen Charlesworth is research director of the Northern College of Acupuncture. Author contributions Mandy Brass and Dr Karen Charlesworth contributed to the study conception, design and material preparation. Data collection and analysis were performed by Mandy Brass. The first draft of the manuscript was written by Mandy Brass. Review and editing by Mandy Brass and Dr Karen Charlesworth. Ethics approval This was a service evaluation approved by the Trust Quality Improvement and Audit Committee in October 2022. As an academic project, it also received early ethics approval from the Northern College of Acupuncture Research Ethics Committee in October 2022 and full ethics approval in December 2022. The study was performed in accordance with the ethical standards of the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. The project was conducted in accordance with General Data Protection Regulations (GDPR) and the NCA Statement of Research Integrity (39). The legal basis for processing health information is Condition (j) in Article 9 (2) of the General Data Protection Regulations, alongside consent, as given by the patient in the Consent Form. Consent to participate Informed consent was obtained from all individual participants included in the study. Consent to publish Informed consent was obtained from all individual participants included in the study for their data to be published in pseudonymised form. References Miller KD, Nogueira L, Mariotto AB, Rowland JH, Yabroff KR, Alfano CM, et al. Cancer treatment and survivorship statistics, 2019. CA Cancer J Clin. 2019;69(5):363–85. https://doi.org/10.3322/caac.21565 John GM, Hershman DL, Falci L, Shi Z, Tsai W-Y, Greenlee H. Complementary and Alternative Medicine Use among US Cancer Survivors HHS Public Access. J Cancer Surviv. 2016;10(5):850–64. https://doi.org/10.1007%2Fs11764-016-0530-y Bashkin O, Asna N, Amoyal M, Dopelt K. The Role of Nurses in the Quality of Cancer Care Management: Perceptions of Cancer Survivors and Oncology Teams. Semin Oncol Nurs. 2023;39(4):151423. https://doi.org/10.1016/j.soncn.2023.151423 Höxtermann MD, Haller H, Aboudamaah S, Bachemir A, Dobos G, Cramer H, et al. Safety of acupuncture in oncology: A systematic review and meta-analysis of randomized controlled trials. Cancer. 2022;128(11):2159–73. https://doi.org/10.1002/cncr.34165 Birch S, Lee MS, Alraek T, Kim T-H. Evidence, safety and recommendations for when to use acupuncture for treating cancer related symptoms: a narrative review. Integr Med Res. 2019;8(3):160–6. https://doi.org/10.1016/j.imr.2019.05.002 Mao JJ, Bao T, Barton D, Ben-arye E, Garland EL. Integrative Medicine for Pain Management in Oncology: Society for Integrative Oncology – ASCO Guideline. J Clin Oncol. 2022;40(34):3998–4024. https://doi.org/10.1200/JCO.22.01357 Cancer Research UK. Acupuncture [Internet]. 2022 [cited 2022 Oct 29]. Available from: https://www.cancerresearchuk.org/about-cancer/cancer-in-general/treatment/complementary-alternative-therapies/individual-therapies/acupuncture Yaguda S, Gentile D. Group Acupuncture Model in a Cancer Institute: Improved Access and Affordability. J Altern Complement Med. 2019;25(7):675–7. https://doi.org/10.1089/acm.2019.0071 Oberoi D V, Longo MCJ, Reed EN, Piedalue JLK-AL, Linda E. Carlson. Cost–Utility of Group Versus Individual Acupuncture for Cancer-Related Pain Using Quality-Adjusted Life Years in a Noninferiority Trial. J Altern Complement Med. 2021;27(5):390–7. https://doi.org/10.1089/acm.2020.0386 Asprey A, Paterson C, White A. All in the same boat: A qualitative study of patients’ attitudes and experiences in group acupuncture clinics. Acupunct Med. 2012;30(3):163–9. https://doi.org/10.1136/acupmed-2012-010150 Tofthagen C, Boses S, Healy G, Jooma N. Evaluation of Group Acupuncture for Cancer-Related Symptoms: A Retrospective Analysis. J Palliat Med. 2015;18(10):878–80. https://doi.org/10.1089/jpm.2015.0143 de Valois B, Young T, Thorpe P, Degun T, Corbishley K. Acupuncture in the real world: evaluating a 15-year NADA auricular acupuncture service for breast cancer survivors experiencing hot flushes and night sweats as a consequence of adjuvant hormonal therapies. Support Care Cancer. 2022;30(6):5063–74. https://doi.org/10.1007%2Fs00520-022-06898-7 Simcock R, Fallowfield L, Jenkins VA. Group Acupuncture to Relieve Radiation Induced Xerostomia: A Feasibility Study. Acupunct Med. 2009;27:109–13. https://doi.org/10.1136/aim.2009.000935 Reed EN, Landmann J, Oberoi D, Piedalue K-AL, Faris P, Carlson LE. Group versus Individual Acupuncture (AP) for Cancer Pain: A Randomized Noninferiority Trial. Evidence-based Complement Altern Med. 2020. https://doi.org/10.1155/2020/7209548 McKee MD, Nielsen A, Anderson B, Chuang E, Connolly M, Gao Q, et al. Individual vs. Group Delivery of Acupuncture Therapy for Chronic Musculoskeletal Pain in Urban Primary Care—a Randomized Trial. J Gen Intern Med. 2020;35(4):1227–37. https://doi.org/10.1007/s11606-019-05583-6 De Valois B, Young TE, Robinson N, Mccourt C, Maher EJ. NADA ear acupuncture for breast cancer treatment-related hot flashes and night sweats: An observational study. Med Acupunct. 2012;24(4):256–68. https://doi.org/10.1089/acu.2012.0897 Chuang E, Hashai N, Buonora M, Gabison J, Kligler B, McKee MDi. ‘it’s Better in a Group Anyway’: Patient Experiences of Group and Individual Acupuncture. J Altern Complement Med. 2018;24(4):336–42. https://doi.org/10.1089/acm.2017.0262 Oberoi D, Reed EN, Piedalue K-A, Landmann J, Carlson LE. Exploring patient experiences and acceptability of group vs. individual acupuncture for Cancer-related pain: a qualitative study. BMC Complement Med Ther Med Ther. 2022;22(155). https://doi.org/10.1186/s12906-022-03600-6 National Institute for Health and Care Excellence. NICE real-world evidence framework [Internet]. 2022 [cited 2023 Feb 28]. Available from: British Acupuncture Council. Who we are [Internet]. [cited 2023 Nov 2]. Available from: https://acupuncture.org.uk/ British Acupuncture Council. About Acupuncture [Internet]. [cited 2023 May 6]. Available from: https://acupuncture.org.uk/about-acupuncture/ Paterson C, Dieppe P. Characteristic and incidental (placebo) effects in complex interventions such as acupuncture. BMJ. 2005;330(7501):1202–5. https://doi.org/10.1136/bmj.330.7501.1202 Aoyama N, Fujii O, Yamamoto T. Efficacy of Parietal Acupoint Therapy: Scalp Acupuncture for Neck/Shoulder Stiffness with Related Mood Disturbance. Med Acupunct. 2017;29(6):383–9. https://doi.org/10.1089/acu.2017.1250 Lan Y, Wu X, Tan HJ, Wu N, Xing JJ, Wu FS, et al. Auricular acupuncture with seed or pellet attachments for primary insomnia: A systematic review and meta-analysis. BMC Complement Altern Med. 2015;15(1):1–14. https://doi.org/10.1186/s12906-015-0606-7 Abbate S. An Overview of the Therapeutic Application of Moxibustion. J Chinese Med. 2002;(69):5–12. MacPherson H, Thomas K. Self-help advice as a process integral to traditional acupuncture care: implications for trial design. Complement Ther Med. 2008;16(2):101–6. https://doi.org/10.1016/j.ctim.2008.02.010 Hui KK, Nixon EE, Vangel MG, Liu J, Marina O, Napadow V, et al. Characterization of the ‘deqi’ response in acupuncture. BMC Complement Altern Med. 2007;7:1–16. https://doi.org/10.1186/1472-6882-7-33 Seers HE, Gale N, Paterson C, Cooke HJ, Tuffrey V, Polley MJ. Individualised and complex experiences of integrative cancer support care: Combining qualitative and quantitative data. Support Care Cancer. 2009;17(9):1159–67. https://doi.org/10.1007/s00520-008-0565-3 IBM. IBM SPSS software [Internet]. [cited 2023 Nov 2]. Available from: https://www.ibm.com/spss Braun V, Clarke V. Reflecting on reflexive thematic analysis. Qual Res Sport Exerc Heal. 2019;11(4):589–97. https://doi.org/10.1080/2159676X.2019.1628806 Creswell JW. A Concise Introduction to Mixed Methods Research. Los Angeles: SAGE Publications Inc.; 2015. 155 p. Tonkin-Crine S, Anthierens S, Hood K, Yardley L, Cals JWL, Francis NA, et al. Discrepancies between qualitative and quantitative evaluation of randomised controlled trial results: Achieving clarity through mixed methods triangulation. Implement Sci. 2016;11(1):1–8. https://doi.org/10.1186/s13012-016-0436-0 Ho RST, Ho FF, Adams J, Cramer H, Leung B, Ward L, et al. Patients’ perceptions on non-specific effects of acupuncture: Qualitative comparison between responders and non‐responders. Integr Med Res. 2022;11(1). https://doi.org/10.1016/j.imr.2021.100771 McCambridge J, Kypri K, Elbourne D. Research participation effects: A skeleton in the methodological cupboard. J Clin Epidemiol. 2014;67(8):845–9. https://doi.org/10.1016/j.jclinepi.2014.03.002 Stringer J, Ryder WD, Mackereth PA, Misra V, Wardley AM. A randomised, pragmatic clinical trial of ACUpuncture plus standard care versus standard care alone FOr Chemotherapy Induced peripheral Neuropathy (ACUFOCIN). Eur J Oncol Nurs. 2022;60. https://doi.org/10.1016/j.ejon.2022.102171 White P, Bishop FL, Prescott P, Scott C, Little P, Lewith G. Practice, practitioner, or placebo? A multifactorial, mixed-methods randomized controlled trial of acupuncture. Pain. 2012;153(2):455–62. https://doi.org/10.1016/j.pain.2011.11.007 Lewith G, Brien S, Barlow F, Eyles C, Flower A, Hall S, et al. The meaning of evidence: Can practitioners be researchers? Forsch Komplementarmed. 2009;16(5):343–7. https://doi.org/10.1016/j.ctim.2003.12.004 White P, Prescott P, Lewith G. Does needling sensation (de qi) affect treatment outcome in pain? Analysis of data from a larger single-blind, randomised controlled trial. Acupunct Med. 2010;28(3):120–5. https://doi.org/10.1136/aim.2009.001768 NCA. NCA: Research Integrity Statement [Internet]. [cited 2023 Nov 2]. Available from: https://nca.ac.uk/research/integrity-statement Additional Declarations Competing interest reported. Mandy Brass is employed by Guy's and St Thomas' NHS Foundation Trust. This service evaluation was conducted by Mandy Brass in part completion of a self-funded MSc in Advanced Oriental Medicine: Research and Practice at the Northern College of Acupuncture. Dr Karen Charlesworth is research director of the Northern College of Acupuncture. Supplementary Files EOTquestionnaires.pdf Cite Share Download PDF Status: Published Journal Publication published 10 Feb, 2025 Read the published version in Supportive Care in Cancer → Version 1 posted Editorial decision: Revision requested 08 Jan, 2025 Reviews received at journal 31 Jul, 2024 Reviewers agreed at journal 19 Jul, 2024 Reviewers invited by journal 01 Jul, 2024 Editor assigned by journal 01 Jul, 2024 Submission checks completed at journal 24 May, 2024 First submitted to journal 17 May, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4435751","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":306200615,"identity":"d1ba290f-6b51-48df-a9c0-0ded922b2acb","order_by":0,"name":"Mandy Brass","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9klEQVRIiWNgGAWjYJACCQaGAyCa8QGEzwMiEojSwmzAwGAgQZIWNgmitOi2nz14m4fhTj5///FnlV/+/KljkO49/IGxLQ2nFrMzecnWPAzPLGfcyDG7LdsGtEXmXJoEY1sObi0HcsykeRgOGzDc4GG7LdkA1CKRY8bA2FaBW8v5NxAt8uePPyuW+APWYvwBr5YbUFsMDiSYMX5gA2sxwO+wG2+MLecYPDMwvJFjLM3YZizZBnSYRMI5PN4/n2N4403FHQO588cffvzxR46fH+SwD2XJOLWAABOPAYTBDIoRNhArAa8GYEL5gc4YBaNgFIyCUYAMACczUBTgmV3cAAAAAElFTkSuQmCC","orcid":"","institution":"Northern College of Acupuncture","correspondingAuthor":true,"prefix":"","firstName":"Mandy","middleName":"","lastName":"Brass","suffix":""},{"id":306200616,"identity":"492a4cd8-e279-4861-80e8-66732d0711d7","order_by":1,"name":"Karen Charlesworth","email":"","orcid":"","institution":"Northern College of Acupuncture","correspondingAuthor":false,"prefix":"","firstName":"Karen","middleName":"","lastName":"Charlesworth","suffix":""}],"badges":[],"createdAt":"2024-05-17 09:38:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4435751/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4435751/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00520-025-09226-x","type":"published","date":"2025-02-10T15:58:09+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":57954695,"identity":"0a584aa0-ae9a-43a2-bc1f-9ea7e94bf10c","added_by":"auto","created_at":"2024-06-07 23:17:18","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":141900,"visible":true,"origin":"","legend":"\u003cp\u003eParticipant flow chart\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-4435751/v1/ffdac5f7de9aea9449a80ea7.png"},{"id":57954698,"identity":"0367c382-a3f7-43bd-a669-bc8478ec4816","added_by":"auto","created_at":"2024-06-07 23:17:18","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":9243,"visible":true,"origin":"","legend":"\u003cp\u003eSymptom categories in combined GA and IA\u003c/p\u003e","description":"","filename":"Onlinedrawingimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-4435751/v1/d8709e5e03b374478bbf487d.png"},{"id":76487635,"identity":"d1e4acc1-1a34-4f3d-81f6-bf10c6f659b6","added_by":"auto","created_at":"2025-02-17 16:10:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1068257,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4435751/v1/fb5a2008-f05f-4afc-bf56-d3fa87c237d8.pdf"},{"id":57955300,"identity":"0684ca57-6639-4012-8432-1f542d156e8a","added_by":"auto","created_at":"2024-06-07 23:25:18","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":385604,"visible":true,"origin":"","legend":"","description":"","filename":"EOTquestionnaires.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4435751/v1/603844b1ad30ca75a6cd257a.pdf"}],"financialInterests":"Competing interest reported. Mandy Brass is employed by Guy's and St Thomas' NHS Foundation Trust. This service evaluation was conducted by Mandy Brass in part completion of a self-funded MSc in Advanced Oriental Medicine: Research and Practice at the Northern College of Acupuncture.\nDr Karen Charlesworth is research director of the Northern College of Acupuncture.","formattedTitle":"Evaluating the Outcomes and Patient Experience of Group and Individual Acupuncture in an NHS Cancer Care Setting: A Mixed Methods Study","fulltext":[{"header":"Background","content":"\u003cp\u003eAs cancer incidence and survivorship increases worldwide (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e), an estimated 39% of cancer patients use nonpharmacological integrative therapies, such as acupuncture, for symptom relief (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAcupuncture for cancer care (defined as treatments for the alleviation of symptoms of cancer, the side-effects of cancer treatment and cancer survivorship)(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) has a growing body of evidence showing it to be safe (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) and effective for multiple symptoms, including pain, chemotherapy-induced peripheral neuropathy, hot flushes and night sweats, nausea, xerostomia, insomnia and anxiety (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). The American Society of Clinical Oncology has recently recommended that acupuncture may be used for various cancer-related pain symptoms (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) and Cancer Research UK states that acupuncture is equal to, or better than, standard treatment for chemotherapy-induced nausea, tiredness, pain, anxiety, depression and mood changes, quality of life and hot flushes (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAcupuncture can be provided individually in a one-to-one consultation, or in a group setting, where more than one person is treated in a shared space. Group acupuncture (GA), also known as community or multibed acupuncture, has been shown to be cost-effective when compared to individual acupuncture (IA)(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) and acceptable to National Health Service (NHS) patients (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDifferent styles of acupuncture are utilised in a group, such as traditional acupuncture, auricular acupuncture or a combination of both; research into each modality has reported improved outcomes (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eGA was shown to be noninferior to IA for cancer pain (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), although noninferiority was not shown in a similar non-cancer pain trial (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). In an NHS study, there was no statistical difference between GA and IA for improved hot flushes and night sweats at 18 weeks post-treatment (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eQualitative research has shown the experience of GA to be positive (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) and valued similarly by patients when compared with IA (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Cancer patients value the social support of GA compared with the privacy and one-to-one interaction provided in IA (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn real-world clinical settings, acupuncture clinics see a broad range of cancer care symptoms, whereas current research comparing the symptom-related outcomes of GA and IA tend to focus on individual symptoms. The majority of these studies are based in North America (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), lacking representation of diverse healthcare settings such as the NHS in the UK. Furthermore, no studies were identified that synthesise the experience of acupuncture with symptom-related outcomes in cancer care.\u003c/p\u003e \u003cp\u003eReal-world research aims to understand the value of interventions in routine settings (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). The aim of this study, using real-world data in an NHS cancer care setting, is to evaluate and compare group and individual acupuncture for symptom-related outcomes and patient experience overall, and to explore the relationships between outcomes and patient experience both within and between the two arms, in order to inform future development of the acupuncture service.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eApproval and design\u003c/h2\u003e \u003cp\u003eEvaluation of an acupuncture service based in a supportive care service (DCC) within a cancer centre of a large NHS hospital trust between October 2022 and April 2023 was approved by the Trust\u0026rsquo;s Quality Improvement and Audit Committee.\u003c/p\u003e \u003cp\u003eThis study used a convergent mixed methods research design where quantitative and qualitative data were concurrently collected, independently analysed and then merged in order to integrate, compare and interpret the results.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eService description and setting\u003c/h2\u003e \u003cp\u003ePatients referred to the DCC acupuncture service received six treatments, in either the GA or IA clinic, with appointments lasting 45\u0026ndash;60 minutes. Allocation to GA or IA was based on DCC diary and/or patient availability, and booked via a telephone consultation. Eligibility criteria were: aged\u0026thinsp;\u0026ge;\u0026thinsp;18, in active cancer treatment or \u0026le;\u0026thinsp;12 months following the last day of treatment (surgery, radiotherapy, chemotherapy, immunotherapy or adjuvant hormone therapy), English-speaking, not an in-patient and not receiving concurrent acupuncture.\u003c/p\u003e \u003cp\u003eGA was seated, in a room with up to three patients, with dimmed lighting and quiet music. Appointments were staggered at 20-minute intervals, and consultations took place chair-side. Patients removed footwear and placed their feet and hands on pillows. Point locations were predominantly below knees and elbows, or on head and neck. IA was in a clinic room with a single patient lying on a couch.\u003c/p\u003e \u003cp\u003eAll participants were seen by a single therapist (who was also the researcher) with 17 years\u0026rsquo; clinical experience and a member of the British Acupuncture Council (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Treatments were based on Traditional Chinese Medicine theory (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e), where patients are individually diagnosed and treated accordingly with needles and relevant adjunctive components (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), such as scalp or auricular acupuncture (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e), auricular ear pellets (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e), indirect smokeless moxibustion, infrared light therapy (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) and lifestyle advice (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Assorted gauge and size Aculine copper handle needles were used with manual stimulation and varied depth depending on \u003cem\u003ede qi\u003c/em\u003e, a subjective sensation (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). The number of needles inserted varied from 6 to 25. Needles were retained between 20 to 30 minutes.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eOutcome measures and informed consent\u003c/h2\u003e \u003cp\u003eDCC complementary therapists routinely collect outcome data for all complementary therapy interventions using the validated outcome measure, Measure Yourself Concerns and Wellbeing (MYCaW). MYCaW scores patients\u0026rsquo; self-designated one or two Concerns and Wellbeing using a 7-point Likert scale in a first and follow-up questionnaire (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). The first questionnaire is completed prior to treatment one and additionally collects some demographic data. A follow-up questionnaire is completed at the end of treatment (EOT), and includes two qualitative questions. These qualitative questions, and the Wellbeing scores, are completed routinely but not analysed in this study. Participants also completed an EOT open-ended questionnaire, designed by the researcher, asking about their experience of acupuncture (Online Resource 1).\u003c/p\u003e \u003cp\u003ePotential study participants were given a Participant Information Sheet (PIS) and consent form (CF) in either the first appointment (when a new patient) or second to fifth follow-up appointments (when an existing patient). Consent could be given any time up to the start of the 6th appointment.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003eQuantitative analysis\u003c/h2\u003e \u003cp\u003eData was analysed to compare baseline to post-treatment scores for Concern/s both within and between the study arms. Descriptive statistics were presented with clinical and demographic characteristics and Concerns were categorised into broad symptom groups; GA was compared with IA using Chi-square and Fisher-Freeman-Halton Exact tests. Tests were carried out with SPSS V29.0 (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e) using a significance level of 5% (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eConcern datasets were skewed according to a Shapiro-Wilk test (p\u0026thinsp;\u0026lt;\u0026thinsp;.05). Consequently, non-parametric tests were applied to test for statistically significant changes from baseline to post-treatment (within-subjects) and between-subjects.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eQualitative analysis\u003c/h2\u003e \u003cp\u003eQualitative data exploring the experience of acupuncture was gathered from open-ended questions in the EOT questionnaire and analysed using reflexive thematic analysis (RTA)(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). As a researcher-practitioner, this method was selected for its emphasis on reflexivity, enabling knowledge to be co-produced by the researcher and the researched subjects, whilst valuing the subjectivity of the researcher and helping mitigate the possibility of researcher bias.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eSynthesis\u003c/h2\u003e \u003cp\u003eData was merged after analysis using a side-by-side joint display (JD) table that combined statistical results and qualitative themes (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). A triangulation protocol was applied (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e), whereby relationships were explored for consonance or dissonance between outcomes and patient experience both within and between the GA and IA study arms.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eParticipant Flow\u003c/h2\u003e \u003cp\u003eDuring the data collection period, 52 patients were referred to the acupuncture service (33 to GA and 19 to IA). One non-English speaking patient was ineligible. Three patients attended one appointment only and therefore did not provide consent, 48 participants consented and five were lost to follow-up, leaving 43 participants for analysis using a complete-cases analysis model (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003csup\u003ea\u003c/sup\u003eappt = appointment \u003csup\u003eb\u003c/sup\u003eacu= acupuncture\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eParticipant Baseline Demographics\u003c/h2\u003e \u003cp\u003eThe mean age for the overall sample was 57.8, 66.7% were female, 56.3% identified as white, 22.9% black, 14.6% Asian and 3% other. 47% of participants had breast cancer, with other cancer diagnoses at 10% or lower. There was no statistical difference in baseline demographics between the two arms (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipant Baseline Demographics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eDemographic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eGA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eIA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;30\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e% \u003cem\u003e(mean/SD)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;18\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e% \u003cem\u003e(mean/SD)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;48\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e% (mean/SD)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e(57.1 / 9.6)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003e(59.0 / 9.2)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003e(57.8 / 9.4)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.534\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e66.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e66.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e33.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e33.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003eEthnicity\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e72.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e56.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e.340\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlack\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e22.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e14.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003eTumour\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBreast\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e33.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e41.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003e.549\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGynae\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e10.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHead \u0026amp; Neck\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e10.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBowel\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e8.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePancreas\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e8.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProstate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e14.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eParticipant symptoms\u003c/h2\u003e \u003cp\u003eChemotherapy-induced peripheral neuropathy was the most common symptom category at 29%, with all other pain (including cancer-related pain and aromatase inhibitor-induced arthralgia) at 26% and the remaining 45% reporting other symptoms (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). There was no difference between GA and IA (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eQuantitative Data\u003c/h2\u003e \u003cp\u003eAcross both arms, using a Wilcoxon signed-rank test, Concerns data showed statistically significant decreases in median scores (indicating improvement) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescriptive statistics of decreases in Concerns scores overall\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003ePost-treatment\u003c/p\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean \u003cem\u003e(median)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSD \u003cem\u003e(IQR)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMean \u003cem\u003e(median)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSD \u003cem\u003e(IQR)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConcern 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.4 (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.9 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.9 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.5 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConcern 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.2 (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.0 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.7 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.7 \u003cem\u003e(2.3)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWhen comparing between-arms, a Mann-Whitney U-test showed no statistically significant difference in decrease in median scores between GA and IA for Concern 1 or Concern 2 (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescriptive statistics of differences of MYCaW scores in GA and IA\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eGA\u003c/p\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;28\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eIA\u003c/p\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;15\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;43\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003emean \u003cem\u003e(median)\u003c/em\u003e\u003c/p\u003e \u003cp\u003edecrease\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSD \u003cem\u003e(IQR)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003emean \u003cem\u003e(median)\u003c/em\u003e decrease\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSD \u003cem\u003e(IQR)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003emean \u003cem\u003e(median)\u003c/em\u003e decrease\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSD \u003cem\u003e(IQR)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConcern 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.5 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.7 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.4 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.7 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.5 \u003cem\u003e(2.5)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.7 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.786\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConcern 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.3 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.7 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.6 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.8 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.4 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.7 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.621\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eQualitative data\u003c/h2\u003e \u003cp\u003eAlthough 41 participants completed the EOT questionnaire, 22 questionnaires had at least one missing answer. Using reflexive thematic analysis, three themes were identified across the two study arms: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) \u003cem\u003ephysical and emotional change versus expectations\u003c/em\u003e, (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) \u003cem\u003ethe gift of time\u003c/em\u003e and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) \u003cem\u003ethe clinical environment\u003c/em\u003e. Each theme is described overall, highlighting the similarities and differences between each arm. All quotes are verbatim.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eTheme 1: Physical and emotional change versus expectations\u003c/h2\u003e \u003cp\u003eTheme one captured the value participants placed on improvements in their physical and emotional symptoms when reflecting on their expectations of acupuncture. Whether expectations were high or low, they tended to be met if symptoms improved. There were no differences between GA and IA.\u003c/p\u003e \u003cp\u003eMany participants had no or low expectations:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I have not believed that this will work, but actually now I think that I would not be in the situation without it \u0026ndash; more calm and better within myself.\u0026rdquo; (P131/IA)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The initial session I was not too sure but as the weeks and sessions went by I felt my joint pain, anxiety improve and felt a lot more calm.\u0026rdquo; (P360/GA)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThose with higher expectations were mostly met:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I had acupuncture before and it always produce results. I was expecting to get better during the acupuncture period and it happened\u0026rdquo; (P858/GA)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I felt improvement in the issues being addressed. Wish it was widely available to cancer patients as I find it more effective than medications.\u0026rdquo; (P588/IA)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHowever, there were some participants for whom expectations were not met:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I was hoping for a more positive outcome but unfortunately there was not a great improvement in my symptoms\u0026rdquo; (P770/IA)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;The treatments are good and helpful but in my case, I don\u0026rsquo;t feel too much better at all.\u0026rdquo; (P157/GA)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOverall, there were nineteen participants who commented on symptomatic improvement in the \u0026lsquo;treatment expectations\u0026rsquo; question:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The joint pain reduced.\u0026rdquo; (P599/IA)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Had a positive impact on my flushes and pain relief.\u0026rdquo; (P709/GA)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e Often, when describing expectations, participants commented on needles. For most, needling was less painful than expected:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Did not hurt like I thought it would\u0026rdquo; (P161/IA)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I thought getting needles would be painful but it was the opposite.\u0026rdquo; (P416/GA)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eHowever, there were a few for whom the needling was a challenge:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I am still not a fan of needles.\u0026rdquo; (P873/IA)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eHowever, even when the needling was painful, this did not impact the overall experience:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Amazed by the results. Although, I thought it might hurt less!\u0026rdquo; (P318/GA)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eTheme 2: The gift of time\u003c/h2\u003e \u003cp\u003eTheme two captured the many ways in which time enhanced participants\u0026rsquo; experience of acupuncture. This included reflective time for themselves, time to be listened to, and time given to them to understand their treatments and personal health. This theme was expressed equally between the arms with the exception of one participant in GA, who would have preferred more time with the acupuncturist. Participants in both arms felt they would have benefitted from more sessions.\u003c/p\u003e \u003cp\u003eSome participants valued the personal \u0026lsquo;me-time\u0026rsquo; afforded to them:\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;The sessions were very relaxing and provided \u0026lsquo;me time\u0026rsquo;.\u0026rdquo; (P998/IA)\u003c/em\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I think they\u0026rsquo;ve helped me feel calmer \u0026ndash; and to reflect/spend more time on my own well-being.\u0026rdquo; (P485/GA)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eListening, and time to be listened to, was a subtheme:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;She didn\u0026rsquo;t dismiss any concern and really listened \u0026ndash; which is a substantial skill in this health environment.\u0026rdquo; (P179/IA)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Felt I was listened to, and given sound advice.\u0026rdquo; (P532/GA)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eParticipants in IA valued the time given to them to discuss their treatment and health:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;[The acupuncturist] spent all the time needed to help me understand the treatment, benefits and possible outcomes and effects.\u0026rdquo; (P829/IA)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipants in GA mostly thought that time was sufficient:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Although [the acupuncturist] was treating 2 other patients in the room, she made time to explain and listen to any concerns.\u0026rdquo; (P360/GA)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHowever, one participant in GA would have preferred more time:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Some of the sessions I felt I could have needed more time to talk.\u0026rdquo; (P926/GA)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eParticipants in both arms felt they needed more sessions:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;It feels like as we are getting somewhere the 6 weeks was over. I feel this should be a 10-week course\u0026rdquo; (P161/IA)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;just wished I could have more sessions as it helps me. What happens next for me?\u0026rdquo; (P796/GA)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eTheme 3: The clinical environment\u003c/h2\u003e \u003cp\u003eTheme 3 captured the value placed on environmental factors such as conversation and sensory stimuli, highlighting the core difference between GA and IA. Whereas IA participants focused on their relationship with the acupuncturist, GA participants had a broader focus, including conversation, music and the presence of others. Although fewer in number, there were GA participants for whom some environmental factors, such as the presence or noise of others, or having to be mindful of their own behaviour, contributed to a more negative experience.\u003c/p\u003e \u003cp\u003e Participants in both arms valued the relationship with their acupuncturist, describing the professionalism, knowledge and empathy shown to them.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;It has been professional, supportive, sympathetic\u0026hellip;\u0026rdquo; (P546/IA)\u003c/em\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;[The acupuncturist] fills you with confidence about her knowledge/field of expertise.\u0026rdquo; (P318/GA)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003eParticipants in IA frequently mentioned the conversations they had with their acupuncturist:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;My conversations with my therapist were superb, great support, great conversation\u0026hellip;\u0026rdquo; (P370/IA)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e Conversely, GA participants only mentioned conversation as a function of the group setting. For most, this was a positive experience:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Obviously I was able to hear other patients (and them me) talking of problems but I didn\u0026rsquo;t find it troubling. We were all in it together in a way.\u0026rdquo; (P455/GA)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAlthough for a few, the presence of others was challenging:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;didn\u0026rsquo;t want other patients to feel I was listening to their consultations or feel uncomfortable.\u0026rdquo; (P363/GA)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Some patients were not particularly sensitive to others. They spoke about their pain, sickness which could bring anxiety to others\u0026rdquo; (P882/GA)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOr the noise of others was distracting:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;There were some distractions when people came in or left for treatment, but nothing major.\u0026rdquo; (P360/GA)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOr respecting the quiet environment was difficult:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Had to remind myself to keep quiet\u0026hellip;\u0026rdquo; (P104/GA)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe sensory space was of greater value to GA participants. Despite identical music playing in both settings, only GA participants mentioned it:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I think everyone was in their own world, as the classic music makes you dive into your dream.\u0026rdquo; (P152/GA)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eData synthesis\u003c/h2\u003e \u003cp\u003eData synthesis aimed to explore the relationships between outcomes and patient experience both within, and between GA and IA. Through the use of a joint display (JD) table, data was juxtaposed from each theme with the corresponding Concern/s scores, triangulating for consonance or dissonance (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eData was considered consonant when the quantitative outcomes and qualitative experience converged with either all positive or all negative results, and dissonant when it diverged, with a combination of positive and negative results. Most participants\u0026rsquo; data was consonant, with improved Concern/s alongside a positive experience. There were no examples of negative Concern/s with a negative experience. The JD table illustrates a sample of consonance and dissonance from each theme (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eJoint Display Table\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eQuote\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eConcern/s\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eScore\u003c/b\u003e\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eTriangulation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003ePhysical and emotional change versus expectations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1. \u003cem\u003e\u0026ldquo;The treatments are good and helpful but in my case, I don\u0026rsquo;t feel too much better at all.\u0026rdquo; (P157/GA)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026uarr;\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDissonance\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2. \u003cem\u003eI was hoping for a more positive outcome...\u0026rdquo; (P770/IA)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026uarr;\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDissonance\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3. \u003cem\u003e\u0026ldquo;I was expecting better results.\u0026rdquo; (P321/GA)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026uarr;\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDissonance\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4. \u003cem\u003e\u0026ldquo;Great relief for my hands and feet\u0026rdquo; (P370/IA)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026uarr;\u0026uarr;\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eConsonance\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5. \u003cem\u003e\u0026ldquo;The initial session I was not too sure but as the weeks and sessions went by, I felt my joint pain, anxiety improve and felt a lot more calm.\u0026rdquo; (P360/GA)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026uarr;\u0026uarr;\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eConsonance\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eThe gift of time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6. \u003cem\u003e\u0026ldquo;Some of the sessions I felt I could have needed more time to talk.\u0026rdquo; (P926/GA)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026uarr;\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDissonance\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7. \u003cem\u003e\u0026ldquo;Felt I was listened to, and given sound advice.\u0026rdquo; (P532/GA)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026darr;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDissonance\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8. \u003cem\u003e\u0026ldquo;I think they\u0026rsquo;ve helped me feel calmer \u0026ndash; and to reflect/spend more time on my own well-being.\u0026rdquo; (P485/GA)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026uarr;\u0026uarr;\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eConsonance\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9. \u003cem\u003e\u0026ldquo;It feels like as we are getting somewhere the 6 weeks was over. I feel this should be a 10-week course.\u0026rdquo; (P161/IA)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026uarr;\u0026uarr;\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDissonance\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10. \u003cem\u003e\u0026ldquo;The sessions were very relaxing and provided \u0026lsquo;me time\u0026rsquo;.\u0026rdquo; (P998/IA)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026uarr;\u0026uarr;\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eConsonance\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eThe clinical environment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11. \u003cem\u003e\u0026ldquo;Some patients were not particularly sensitive to others. They spoke about their pain, sickness which could bring anxiety to others.\u0026rdquo; (P882/GA)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026uarr;\u0026uarr;\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDissonance\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12. \u003cem\u003e\u0026ldquo;[The acupuncturist] is a lovely lady and I feel very secure and relaxed in her company.\u0026rdquo; (P802/GA)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026darr;\u0026darr;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDissonance\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13. \u003cem\u003e\u0026ldquo;I think everyone was in their own world, as the classic music makes you dive into your dream.\u0026rdquo; (P152/GA)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026darr;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDissonance\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14. \u003cem\u003e\u0026ldquo;We were all in it together in a way\u0026rdquo; (P455/GA)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026uarr;\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eConsonance\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15. \u003cem\u003e\u0026ldquo;I really liked the atmosphere and the friendly staff.\u0026rdquo; (P131/IA)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026uarr;\u0026uarr;\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eConsonance\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003ea\u003c/sup\u003e\u003cb\u003e\u0026uarr;\u003c/b\u003e= Concern/s score improved \u003cb\u003e\u0026uarr;\u0026uarr;\u003c/b\u003e=Concern/s score improved\u0026thinsp;\u0026ge;\u0026thinsp;3 points\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e\u0026darr;= Concern/s score unchanged or worse \u0026darr;\u0026darr;= Concern/s score worse\u0026thinsp;\u0026ge;\u0026thinsp;3 points\u003c/p\u003e \u003cp\u003eIn the first theme, three participants expressed a negative experience, stating that their expectations were not met in terms of symptomatic improvement. The JD table showed that for these participants, their Concern/s improved, showing dissonance (quotes 1, 2 \u0026amp; 3).\u003c/p\u003e \u003cp\u003eIn the final two themes, dissonance showed that where Concern/s worsened, there was no corresponding relationship with negative experiences (quotes 7, 12 \u0026amp; 13); and where there was a negative experience in GA, there was no corresponding relationship with worsening Concern/s (quotes 6, 9 \u0026amp; 11).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis mixed methods study aimed to compare and synthesise symptom-related outcomes and patient experience of GA with IA in a cancer care setting in the NHS.\u003c/p\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eOutcomes and experience\u003c/h2\u003e \u003cp\u003eSymptom-related outcomes improved equally between arms, corroborating previous studies (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) and substantiating their results with a more diverse population (both gender and ethnicity) and diverse cancer diagnoses.\u003c/p\u003e \u003cp\u003eWhen comparing patient experience of GA with IA, the results were mostly consistent with previous comparative studies; the majority of participants in both arms valued the treatment effects and relationship with their acupuncturist, with minor concerns around privacy in GA (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Where Oberoi et al (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) and Chuang et al (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) found that GA did not hinder a deeper therapeutic relationship, this study added context to both findings: the depth of relationship was valued equally, with an additional focus on depth of conversation in IA. This depth of conversation may be the relevant aspect of the therapeutic relationship that differs between GA and IA.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eSynthesis of outcomes and experience\u003c/h2\u003e \u003cp\u003eTo the researcher\u0026rsquo;s knowledge, this is the first study to synthesise symptom-related outcomes with patient experience when comparing GA with IA. There were two interrelated findings:\u003c/p\u003e \u003cp\u003e \u003col\u003e\u003col style=\"list-style-type:lower-roman;\"\u003e\n \u003cspan\u003e \u003cli\u003e \u003cp\u003ewhere symptom-related outcomes (Concern/s) were either unchanged or worsened in either GA or IA, there was not a corresponding negative experience;\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ewhere there were negative experiences, there was not a corresponding worsening in symptom-related outcomes.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eWorsening symptom-related outcomes corresponding to positive experiences suggests there were other aspects of receiving acupuncture contributing towards the positive experience. Acupuncture uses a different theoretical model to biomedicine, where talking, listening and the diagnostic process are considered integral to the overall treatment effect (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). \u003cem\u003eThe gift of time\u003c/em\u003e highlights the importance participants placed on being listened to, and time to tell their story, unrelated to symptomatic change.\u003c/p\u003e \u003cp\u003eContrary to this finding, a recent study (not in cancer care) suggested that non-responders to acupuncture did experience negative non-specific effects (treatment effects other than from needle insertion and stimulation) (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). It is unclear from this whether these negative non-specific effects were due to different styles of acupuncture, the personality of participants or a perceived negative effect following a non-response. It is possible that vulnerable patients, such as those in cancer care, are more likely to respond positively to the non-specific aspects of acupuncture, which may explain the contradictory findings. Alternatively, research participation biases (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e) may have impacted the reporting of negative experiences. More research is necessary to explore the relationship between non-responders and the non-specific experiences of acupuncture.\u003c/p\u003e \u003cp\u003eFive participants said they would have preferred more sessions, although data synthesis showed these participants reported improved symptoms. Previous studies have shown that more sessions have led to further improvement in cancer-related symptoms in both GA (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) and IA (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e), corroborating the participants\u0026rsquo; request. However, with limited resources, six sessions improved symptoms whilst also enabling more patients to access the acupuncture service. Future service development may consider greater provision of GA over IA, potentially allowing more sessions per patient.\u003c/p\u003e \u003cp\u003eIn the four examples where there were negative experiences in GA, there was no corresponding worsening of symptom-related outcomes; in fact, the participant with the largest improvement in symptom-related outcomes reported negative comments regarding their experience. To the researcher\u0026rsquo;s knowledge, this is a new finding, suggesting potential implications for GA clinics. The negative experiences in GA were related to the group itself; for example, the presence of others being distracting, or being mindful of one\u0026rsquo;s behaviour. These experiences differ from the non-specific effects of acupuncture (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) such as the therapeutic relationship (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e) or aspects of the acupuncture consultation (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e) that enhance the patient-practitioner relationship and could potentially impact the symptomatic response (Ho et al., 2022). The negative experiences of GA appear not to impact the patient-practitioner relationship.\u003c/p\u003e \u003cp\u003eData synthesis, therefore, suggests that although the experience of GA may not suit all participants, the non-specific aspects of acupuncture remain positive, leading to negative group experiences not corresponding to similarly negative symptom-related outcomes. Although not generalisable, this finding may be relevant for future planning of acupuncture services in cancer care. GA in cancer care has been shown to be affordable and accessible (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) when compared with IA. This study suggests that for those few patients for whom GA is not an ideal setting, there is potentially no impact on treatment outcomes. More research is necessary to explore the relationship between GA experience and symptom-related outcomes.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eAs a researcher-practitioner led study, research participation bias may have impacted the data because patients may be reluctant to report negative experiences to their practitioners (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMissing data and a small sample size may have further impacted the results. Two participants chose to stop their treatments because they did not like acupuncture and a further six did not provide informed consent or were lost to follow-up. In the data synthesis, only a few examples from each triangulation formed the basis of the results and discussion.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWhen comparing GA with IA in an NHS cancer care setting, there were statistically and qualitatively significant improvements in symptom-related outcomes overall with no difference between the study arms. Most participants had a positive experience; IA participants focused more on the relationship with their acupuncturist, whilst GA participants had a broader focus on environmental factors. For a few GA participants, the presence of others was a negative experience. However, data synthesis revealed that for those participants, there was no effect on symptom-related outcomes. These results may be of relevance when establishing acupuncture services in supportive cancer care settings.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript\u003c/em\u003e\u003cem\u003e.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMandy Brass is employed by GSTT NHS Foundation Trust. This service evaluation was conducted by Mandy Brass in part completion of a self-funded MSc\u0026nbsp;in Advanced Oriental Medicine: Research and Practice at the Northern College of Acupuncture.\u003c/p\u003e\n\u003cp\u003eDr Karen Charlesworth is research director of the Northern College of Acupuncture.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMandy Brass and Dr Karen Charlesworth contributed to the study conception, design and material preparation. Data collection and analysis were performed by Mandy Brass. The first draft of the manuscript was written by Mandy Brass. Review and editing by Mandy Brass and Dr Karen Charlesworth.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis was a service evaluation approved by the Trust Quality Improvement and Audit Committee in October 2022. As an academic project, it also received early ethics approval from the Northern College of Acupuncture Research Ethics Committee in October 2022 and full ethics approval in December 2022. The study was performed in accordance with the ethical standards of the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. The project was conducted in accordance with General Data Protection Regulations (GDPR) and the NCA Statement of Research Integrity (39). The legal basis for processing health information is Condition (j) in Article 9 (2) of the General Data Protection Regulations, alongside consent, as given by the patient in the Consent Form.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all individual participants included in the study for their data to be published in pseudonymised form.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMiller KD, Nogueira L, Mariotto AB, Rowland JH, Yabroff KR, Alfano CM, et al. Cancer treatment and survivorship statistics, 2019. CA Cancer J Clin. 2019;69(5):363\u0026ndash;85. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3322/caac.21565\u003c/span\u003e\u003cspan address=\"10.3322/caac.21565\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJohn GM, Hershman DL, Falci L, Shi Z, Tsai W-Y, Greenlee H. Complementary and Alternative Medicine Use among US Cancer Survivors HHS Public Access. J Cancer Surviv. 2016;10(5):850\u0026ndash;64. https://doi.org/10.1007%2Fs11764-016-0530-y\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBashkin O, Asna N, Amoyal M, Dopelt K. The Role of Nurses in the Quality of Cancer Care Management: Perceptions of Cancer Survivors and Oncology Teams. Semin Oncol Nurs. 2023;39(4):151423. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.soncn.2023.151423\u003c/span\u003e\u003cspan address=\"10.1016/j.soncn.2023.151423\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eH\u0026ouml;xtermann MD, Haller H, Aboudamaah S, Bachemir A, Dobos G, Cramer H, et al. Safety of acupuncture in oncology: A systematic review and meta-analysis of randomized controlled trials. Cancer. 2022;128(11):2159\u0026ndash;73. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/cncr.34165\u003c/span\u003e\u003cspan address=\"10.1002/cncr.34165\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBirch S, Lee MS, Alraek T, Kim T-H. Evidence, safety and recommendations for when to use acupuncture for treating cancer related symptoms: a narrative review. Integr Med Res. 2019;8(3):160\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.imr.2019.05.002\u003c/span\u003e\u003cspan address=\"10.1016/j.imr.2019.05.002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMao JJ, Bao T, Barton D, Ben-arye E, Garland EL. Integrative Medicine for Pain Management in Oncology: Society for Integrative Oncology \u0026ndash; ASCO Guideline. J Clin Oncol. 2022;40(34):3998\u0026ndash;4024. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1200/JCO.22.01357\u003c/span\u003e\u003cspan address=\"10.1200/JCO.22.01357\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCancer Research UK. Acupuncture [Internet]. 2022 [cited 2022 Oct 29]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.cancerresearchuk.org/about-cancer/cancer-in-general/treatment/complementary-alternative-therapies/individual-therapies/acupuncture\u003c/span\u003e\u003cspan address=\"https://www.cancerresearchuk.org/about-cancer/cancer-in-general/treatment/complementary-alternative-therapies/individual-therapies/acupuncture\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYaguda S, Gentile D. Group Acupuncture Model in a Cancer Institute: Improved Access and Affordability. J Altern Complement Med. 2019;25(7):675\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1089/acm.2019.0071\u003c/span\u003e\u003cspan address=\"10.1089/acm.2019.0071\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOberoi D V, Longo MCJ, Reed EN, Piedalue JLK-AL, Linda E. Carlson. Cost\u0026ndash;Utility of Group Versus Individual Acupuncture for Cancer-Related Pain Using Quality-Adjusted Life Years in a Noninferiority Trial. J Altern Complement Med. 2021;27(5):390\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1089/acm.2020.0386\u003c/span\u003e\u003cspan address=\"10.1089/acm.2020.0386\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAsprey A, Paterson C, White A. All in the same boat: A qualitative study of patients\u0026rsquo; attitudes and experiences in group acupuncture clinics. Acupunct Med. 2012;30(3):163\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1136/acupmed-2012-010150\u003c/span\u003e\u003cspan address=\"10.1136/acupmed-2012-010150\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTofthagen C, Boses S, Healy G, Jooma N. Evaluation of Group Acupuncture for Cancer-Related Symptoms: A Retrospective Analysis. J Palliat Med. 2015;18(10):878\u0026ndash;80. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1089/jpm.2015.0143\u003c/span\u003e\u003cspan address=\"10.1089/jpm.2015.0143\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ede Valois B, Young T, Thorpe P, Degun T, Corbishley K. Acupuncture in the real world: evaluating a 15-year NADA auricular acupuncture service for breast cancer survivors experiencing hot flushes and night sweats as a consequence of adjuvant hormonal therapies. Support Care Cancer. 2022;30(6):5063\u0026ndash;74. https://doi.org/10.1007%2Fs00520-022-06898-7\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSimcock R, Fallowfield L, Jenkins VA. Group Acupuncture to Relieve Radiation Induced Xerostomia: A Feasibility Study. Acupunct Med. 2009;27:109\u0026ndash;13. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1136/aim.2009.000935\u003c/span\u003e\u003cspan address=\"10.1136/aim.2009.000935\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReed EN, Landmann J, Oberoi D, Piedalue K-AL, Faris P, Carlson LE. Group versus Individual Acupuncture (AP) for Cancer Pain: A Randomized Noninferiority Trial. Evidence-based Complement Altern Med. 2020. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1155/2020/7209548\u003c/span\u003e\u003cspan address=\"10.1155/2020/7209548\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcKee MD, Nielsen A, Anderson B, Chuang E, Connolly M, Gao Q, et al. Individual vs. Group Delivery of Acupuncture Therapy for Chronic Musculoskeletal Pain in Urban Primary Care\u0026mdash;a Randomized Trial. J Gen Intern Med. 2020;35(4):1227\u0026ndash;37. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s11606-019-05583-6\u003c/span\u003e\u003cspan address=\"10.1007/s11606-019-05583-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDe Valois B, Young TE, Robinson N, Mccourt C, Maher EJ. NADA ear acupuncture for breast cancer treatment-related hot flashes and night sweats: An observational study. Med Acupunct. 2012;24(4):256\u0026ndash;68. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1089/acu.2012.0897\u003c/span\u003e\u003cspan address=\"10.1089/acu.2012.0897\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChuang E, Hashai N, Buonora M, Gabison J, Kligler B, McKee MDi. \u0026lsquo;it\u0026rsquo;s Better in a Group Anyway\u0026rsquo;: Patient Experiences of Group and Individual Acupuncture. J Altern Complement Med. 2018;24(4):336\u0026ndash;42. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1089/acm.2017.0262\u003c/span\u003e\u003cspan address=\"10.1089/acm.2017.0262\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOberoi D, Reed EN, Piedalue K-A, Landmann J, Carlson LE. Exploring patient experiences and acceptability of group vs. individual acupuncture for Cancer-related pain: a qualitative study. BMC Complement Med Ther Med Ther. 2022;22(155). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12906-022-03600-6\u003c/span\u003e\u003cspan address=\"10.1186/s12906-022-03600-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNational Institute for Health and Care Excellence. NICE real-world evidence framework [Internet]. 2022 [cited 2023 Feb 28]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e\u003c/span\u003e\u003cspan address=\"http://www.nice.org.uk/corporate/ecd9\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBritish Acupuncture Council. Who we are [Internet]. [cited 2023 Nov 2]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://acupuncture.org.uk/\u003c/span\u003e\u003cspan address=\"https://acupuncture.org.uk/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBritish Acupuncture Council. About Acupuncture [Internet]. [cited 2023 May 6]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://acupuncture.org.uk/about-acupuncture/\u003c/span\u003e\u003cspan address=\"https://acupuncture.org.uk/about-acupuncture/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePaterson C, Dieppe P. Characteristic and incidental (placebo) effects in complex interventions such as acupuncture. BMJ. 2005;330(7501):1202\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1136/bmj.330.7501.1202\u003c/span\u003e\u003cspan address=\"10.1136/bmj.330.7501.1202\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAoyama N, Fujii O, Yamamoto T. Efficacy of Parietal Acupoint Therapy: Scalp Acupuncture for Neck/Shoulder Stiffness with Related Mood Disturbance. Med Acupunct. 2017;29(6):383\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1089/acu.2017.1250\u003c/span\u003e\u003cspan address=\"10.1089/acu.2017.1250\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLan Y, Wu X, Tan HJ, Wu N, Xing JJ, Wu FS, et al. Auricular acupuncture with seed or pellet attachments for primary insomnia: A systematic review and meta-analysis. BMC Complement Altern Med. 2015;15(1):1\u0026ndash;14. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12906-015-0606-7\u003c/span\u003e\u003cspan address=\"10.1186/s12906-015-0606-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbbate S. An Overview of the Therapeutic Application of Moxibustion. J Chinese Med. 2002;(69):5\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMacPherson H, Thomas K. Self-help advice as a process integral to traditional acupuncture care: implications for trial design. Complement Ther Med. 2008;16(2):101\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ctim.2008.02.010\u003c/span\u003e\u003cspan address=\"10.1016/j.ctim.2008.02.010\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHui KK, Nixon EE, Vangel MG, Liu J, Marina O, Napadow V, et al. Characterization of the \u0026lsquo;deqi\u0026rsquo; response in acupuncture. BMC Complement Altern Med. 2007;7:1\u0026ndash;16. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/1472-6882-7-33\u003c/span\u003e\u003cspan address=\"10.1186/1472-6882-7-33\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSeers HE, Gale N, Paterson C, Cooke HJ, Tuffrey V, Polley MJ. Individualised and complex experiences of integrative cancer support care: Combining qualitative and quantitative data. Support Care Cancer. 2009;17(9):1159\u0026ndash;67. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00520-008-0565-3\u003c/span\u003e\u003cspan address=\"10.1007/s00520-008-0565-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIBM. IBM SPSS software [Internet]. [cited 2023 Nov 2]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ibm.com/spss\u003c/span\u003e\u003cspan address=\"https://www.ibm.com/spss\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBraun V, Clarke V. Reflecting on reflexive thematic analysis. Qual Res Sport Exerc Heal. 2019;11(4):589\u0026ndash;97. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/2159676X.2019.1628806\u003c/span\u003e\u003cspan address=\"10.1080/2159676X.2019.1628806\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCreswell JW. A Concise Introduction to Mixed Methods Research. Los Angeles: SAGE Publications Inc.; 2015. 155 p.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTonkin-Crine S, Anthierens S, Hood K, Yardley L, Cals JWL, Francis NA, et al. Discrepancies between qualitative and quantitative evaluation of randomised controlled trial results: Achieving clarity through mixed methods triangulation. Implement Sci. 2016;11(1):1\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s13012-016-0436-0\u003c/span\u003e\u003cspan address=\"10.1186/s13012-016-0436-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHo RST, Ho FF, Adams J, Cramer H, Leung B, Ward L, et al. Patients\u0026rsquo; perceptions on non-specific effects of acupuncture: Qualitative comparison between responders and non‐responders. Integr Med Res. 2022;11(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.imr.2021.100771\u003c/span\u003e\u003cspan address=\"10.1016/j.imr.2021.100771\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcCambridge J, Kypri K, Elbourne D. Research participation effects: A skeleton in the methodological cupboard. J Clin Epidemiol. 2014;67(8):845\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jclinepi.2014.03.002\u003c/span\u003e\u003cspan address=\"10.1016/j.jclinepi.2014.03.002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStringer J, Ryder WD, Mackereth PA, Misra V, Wardley AM. A randomised, pragmatic clinical trial of ACUpuncture plus standard care versus standard care alone FOr Chemotherapy Induced peripheral Neuropathy (ACUFOCIN). Eur J Oncol Nurs. 2022;60. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ejon.2022.102171\u003c/span\u003e\u003cspan address=\"10.1016/j.ejon.2022.102171\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWhite P, Bishop FL, Prescott P, Scott C, Little P, Lewith G. Practice, practitioner, or placebo? A multifactorial, mixed-methods randomized controlled trial of acupuncture. Pain. 2012;153(2):455\u0026ndash;62. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.pain.2011.11.007\u003c/span\u003e\u003cspan address=\"10.1016/j.pain.2011.11.007\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLewith G, Brien S, Barlow F, Eyles C, Flower A, Hall S, et al. The meaning of evidence: Can practitioners be researchers? Forsch Komplementarmed. 2009;16(5):343\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ctim.2003.12.004\u003c/span\u003e\u003cspan address=\"10.1016/j.ctim.2003.12.004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWhite P, Prescott P, Lewith G. Does needling sensation (de qi) affect treatment outcome in pain? Analysis of data from a larger single-blind, randomised controlled trial. Acupunct Med. 2010;28(3):120\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1136/aim.2009.001768\u003c/span\u003e\u003cspan address=\"10.1136/aim.2009.001768\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNCA. NCA: Research Integrity Statement [Internet]. [cited 2023 Nov 2]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://nca.ac.uk/research/integrity-statement\u003c/span\u003e\u003cspan address=\"https://nca.ac.uk/research/integrity-statement\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"supportive-care-in-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jscc","sideBox":"Learn more about [Supportive Care in Cancer](https://www.springer.com/journal/520)","snPcode":"520","submissionUrl":"https://submission.nature.com/new-submission/520/3","title":"Supportive Care in Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"acupuncture, group acupuncture, integrative oncology, patient experience, cancer care, mixed methods","lastPublishedDoi":"10.21203/rs.3.rs-4435751/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4435751/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eAcupuncture for cancer care is safe and effective and can be provided in group or individual settings. Previously, group acupuncture (GA) has been compared with individual acupuncture (IA) for specific cancer-related symptoms or patient experience, but has not correlated symptoms with patient experience between GA and IA. This service evaluation, using a mixed-methods design, aimed to compare GA with IA for symptom-related outcomes and patient experience and explore their inter-relationships, in order to inform future development of the service.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eCancer patients referred to the acupuncture service in a UK NHS hospital received six treatments of GA or IA. Outcomes were gathered using Measure Yourself Concerns and Wellbeing (MYCaW) questionnaires pre- and post-treatment. Experience of acupuncture was gathered post-treatment using a questionnaire and analysed using reflexive thematic analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e48 participants\u0026rsquo; data were analysed. There were statistically significant improvements in outcomes overall, with no difference between GA and IA. Most participants had a positive experience; IA participants focused more on the relationship with their acupuncturist whilst GA participants focused more on environmental factors. For a few GA participants, the group experience was negative, but data synthesis revealed this did not impact symptom-related outcomes.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eIn both GA and IA arms, symptom-related outcomes mostly improved alongside a positive experience. For those participants for whom GA was not an ideal setting, there was no effect on symptom-related outcomes. These results may be of relevance when establishing acupuncture services in supportive cancer care settings.\u003c/p\u003e","manuscriptTitle":"Evaluating the Outcomes and Patient Experience of Group and Individual Acupuncture in an NHS Cancer Care Setting: A Mixed Methods Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-07 23:17:13","doi":"10.21203/rs.3.rs-4435751/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-01-08T17:32:53+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-31T13:56:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"225771048144575776145048038214501774502","date":"2024-07-19T08:54:38+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-07-02T02:46:28+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-01T14:11:54+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-05-24T05:39:46+00:00","index":"","fulltext":""},{"type":"submitted","content":"Supportive Care in Cancer","date":"2024-05-17T09:36:54+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"supportive-care-in-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jscc","sideBox":"Learn more about [Supportive Care in Cancer](https://www.springer.com/journal/520)","snPcode":"520","submissionUrl":"https://submission.nature.com/new-submission/520/3","title":"Supportive Care in Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"6fc70d10-d876-46fd-9a61-553754801dee","owner":[],"postedDate":"June 7th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-02-17T16:05:01+00:00","versionOfRecord":{"articleIdentity":"rs-4435751","link":"https://doi.org/10.1007/s00520-025-09226-x","journal":{"identity":"supportive-care-in-cancer","isVorOnly":false,"title":"Supportive Care in Cancer"},"publishedOn":"2025-02-10 15:58:09","publishedOnDateReadable":"February 10th, 2025"},"versionCreatedAt":"2024-06-07 23:17:13","video":"","vorDoi":"10.1007/s00520-025-09226-x","vorDoiUrl":"https://doi.org/10.1007/s00520-025-09226-x","workflowStages":[]},"version":"v1","identity":"rs-4435751","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4435751","identity":"rs-4435751","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}