Response to Sun, Zang, and Chen

To the Editor, We thank DrSun et al.1 for reading and taking interest in our work. Their comments align with issues already discussed in our article. Building on their observations regarding gaps in the field, we take this opportunity to further reflect on key limitations and potential research directions for acupuncture in oncology. Despite its methodological value in blinding and controlling for nonspecific effects,2 sham acupuncture faces significant challenges. Inadequate physiological research has led to the use of inappropriate controls that may compromise trial validity3 and, as noted in The British Medical Journal, even underestimate true efficacy due to inherent design difficulties and specific effects.4 Currently, recognized standards for sham acupuncture procedures and reporting are still lacking. Consequently, designing a sham control that is both physiologically inactive and indistinguishable from true treatment remains a key problem awaiting a solution. These methodological gaps, briefly discussed in the EAGER trial’s limitations regarding sham design, highlight the need for robust controls. To address this, our ongoing trial (NCT07098949) employs a sham-acupuncture control, with disease-free survival as the primary endpoint and quality of life as a secondary endpoint, to determine whether the observed effects of acupuncture are beyond a placebo response.