Purpose <p>Fatigue is one of the most common and troublesome symptoms in cancer survivors and is strongly correlated with pain. We evaluated the effect of acupuncture versus usual care for fatigue among cancer survivors with chronic pain.</p> Methods <p>We analyzed data from a randomized clinical trial comparing the effect of electro-acupuncture (EA) or battlefield acupuncture (BFA) versus waitlist control (WLC) for chronic musculoskeletal pain in cancer survivors. Analysis included participants who reported moderate or severe fatigue at baseline. Interventions were delivered over 10&#xa0;weeks. Fatigue severity was measured using the Brief Fatigue Inventory (BFI).</p> Results <p>Among 274 participants (mean age 61.0&#xa0;years [standard deviation (SD)] 12.8; 73.0% women), the baseline BFI worst fatigue score was 7.1 (SD 1.7). EA and BFA were associated with reductions in worst fatigue score of 2.4 points (95% confidence interval [CI]: − 2.9 to − 1.9) and 2.0 points (95% CI: − 2.5 to − 1.5) from baseline to week 12. There was no significant between-group difference. A higher proportion of patients in both EA and BFA experienced clinically meaningful fatigue improvement compared to WLC (61.2% and 51.6% vs. 37.3%, <i>p</i> = 0.019). Fatigue reductions persisted at week 24 (EA: −2.1 points [95% CI: −2.6 to −1.7]; BFA: −2.2 points [95% CI: −2.8 to −1.7]).</p> Conclusion <p>Cancer survivors with chronic pain experienced clinically meaningful and durable fatigue reductions when receiving either EA or BFA.</p> Implications for cancer survivors <p>These findings support the clinical utility of acupuncture as an evidence-based option for managing fatigue in cancer survivors with pain.</p> Trial registration <p>ClinicalTrials.gov Identifier: NCT02979574; November 30, 2016.</p>