Acupuncture for Xerostomia

M. D. Anderson Cancer Center
Date: January 25, 2009

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Acupuncture for Xerostomia

Lorenzo Cohen, Ph.D., director, and Kay Garcia, LAc, Dr.P.H., clinical nurse specialist, both in M. D. Anderson's Integrative Medicine discuss how acupuncture can be used to help relieve some of the side effects accompanying cancer treatment.

Lisa Garvin:

Welcome to Cancer Newsline, a weekly podcast series from the University of Texas MD Anderson Cancer Center. Cancer Newsline helps you stay current with the news on cancer research, diagnosis, treatment and prevention providing the latest information on reducing your family's cancer risk. I am your host Lisa Garvin. Today, we have two guests Dr. Lorenzo Cohen who is the director of MD Anderson's Integrative Medicine Program, and Kay Garcia who is a doctor of public health also with the Integrative Medicine Program at MD Anderson. Welcome to you both and today we are going to be talking about acupuncture and its uses for xerostomia, which is a fancy word for dry mouth which is a fairly common side effect of cancer treatment. I guess I will start with you Dr. Garcia. First of all, let us talk about xerostomia, how common is it, it is a fairly common side effect of cancer treatment and how serious can it be?

Dr. Kay Garcia:


It is a fairly common treatment of radiation to the head and neck area. Patients who have oropharyngeal cancers or cancers of the head and neck area that receive radiation often suffer from the destruction of the salivary glands which can result in problems from a variety of areas. They often get into nutritional deficits, they suffer from dry mouth, they suffer from dental problems that are sometimes irreversible.

Lisa Garvin:

What is the most common treatment for xerostomia today? I know a lot of its health care like blending your foods and eating only soft foods and sucking on candies or so, are there any medical treatments for xerostomia?

Dr. Kay Garcia:

There have been studies looking at particular medications, pilocarpine, amifostine to help stimulate salivary glands. And sometimes patients suffer from side effects related to those medications and sometimes patients then aren't compliant with the medication regimen. There are other procedures with IMRT which is a specific form of radiation, Intensity Modulated Radiation Treatment that specifically targets only the area of the tumor to help preserve salivary glands. But, again all patients are not able to receive IMRT and so there are still a very great difficulty and many patients still suffer from radiation-induced xerostomia that often ends up in long term chronic problems that may be irreversible.

Garvin:

How did we make the leap to acupuncture for treating xerostomia and either one of you can answer this, was there a literature before or was this just a bright idea or how did it come about?

Garcia:

There are original studies conducted in Europe looking at acupuncture to reverse the effects of radiation-induced xerostomia that got positive effects. Follow-up studies then in the United States also got positive effects, but these are for the most part small nonrandomized trials. At MD Anderson then we conducted a small nonrandomized pilot study a few years ago that also got positive results and interestingly, most of the patients who participated in that study had received IMRT, had received the Intensity Modulated Radiation Therapy, yet still suffered from xerostomia. This was a treatment trial and patients received two treatments a week for four weeks, so a maximum of eight treatments and we did see a positive result from that trial. And so, as a result then we have developed placebo controlled randomized trials and are looking both at treatment, acupuncture to treat xerostomia, as well as acupuncture to prevent xerostomia.

Garvin:

And Dr. Cohen, you said that there was a randomized trial going on with our sister institution in Shanghai?

Dr. Lorenzo Cohen:

Yes, we actually recently completed a study with our colleagues at the Fudan University Cancer Hospital, which was focused on prevention of xerostomia. So, patients were recruited for the study who is going to be undergoing head and neck radiation, prior to starting radiation and either receive acupuncture three days a week, throughout the 7-week course of their radiation treatment or they were assigned to a group that did not receive acupuncture. So, we did not have a placebo control group, but the usual care comparison group, and we collected data across the course of their radiation, as well as one month after the end of radiation. And we see differences from their self reported measures on xerostomia related symptoms, as well as actually their overall general quality of life. Group differences emerged as early as three weeks into radiation showing that there was less severe development of xerostomia if they were receiving acupuncture. And the effects became stronger over time and in fact, remain significant even one month after radiation had ended. And we also measured a more objective outcome where we actually looked at saliva flow and this is a very standardized technique for measuring saliva flow over a five minute period of time. Saliva flow was dramatically higher in the patients who were receiving the acupuncture throughout their radiation. They all developed xerostomia to some degree, but much lesser if they were receiving the acupuncture.

Garvin:

Was this a surprising finding? I do not know much about acupuncture as a whole, as a preventative therapy. Is this something new in the field of acupuncture as far as using it to prevent things before they happen?

Dr. Lorenzo Cohen:

Well, certainly in the world of xerostomia research, and as you heard there has been a fair number of trials now looking at acupuncture for xerostomia, nobody has looked at it for preventing the development of xerostomia and due to radiation of the head and neck. It has been focused on treating it after it develops. So, it is an important first step at looking at the benefits of acupuncture to prevent the development of that particular syndrome. What is going to be interesting and important to do is two things, one is how long will the effect last because there is the concern that some of the damage will continue even beyond one month. So, we are collecting data on that initial study six months out, but we also have proposed this study and hopefully we will receive funding to do a much larger version of the same study which would also include a placebo control group. So, we would really know, is it something unique to the use of those acupuncture points, which is the critical next step to really document authoritatively that acupuncture can help to prevent xerostomia.

Garvin:

So this next study will be with you, with MD Anderson and Fudan University, it will be a multi-center trial?

Cohen:

Exactly, so what will be interesting about the study is in one sense to look at some of the cultural differences, but also to compare different types of head and neck cancers. So, in Shanghai they have mainly nasopharyngeal carcinoma, almost a hundred percent and so we will just be recruiting nasopharyngeal carcinoma patients in Shanghai. And then at MD Anderson other head and neck cancer patients, so to be able to see if there is also differences along those lines. And the other study that we are doing and will hopefully be starting soon is the one that Dr. Garcia mentioned where we will be looking at the treatment of xerostomia and of course including the all important placebo control group as well.

Garvin:

Dr. Garcia as a licensed acupuncturist, where are the pressure points for xerostomia prevention and or treatment?

Garcia:

The points that we are using for our trial are primarily on the ear, although we do have points in the arms and points in the legs. Most of the ones for this trial are based on a study that was conducted by the Navy many years ago showing a positive effect with ear points, and so, out of I think there are 13 points, then six of those around the ears and then there is one point on each arm and then points on each leg.

Garvin:

And how long does a typical treatment last? How long do the needles stay in?

Garcia:

The needle stay in for about 20 minutes, 20 to 25 minutes and that is standard in most acupuncture clinical settings.

Garvin:

That sounds like the benefits could be huge. I think as Dr. Cohen was saying earlier up to 80-percent of cancer patients will suffer through xerostomia?

Garcia:

That is correct.

Garvin:

Well it sounds like the potential benefit is huge for these studies both here at MD Anderson and at Shanghai, our sister institution. Do you have any final thoughts Dr. Garcia about acupuncture and xerostomia?

Garcia:

The only final thought would be that if patients are considering it and have concerns that acupuncture and particularly this particular protocol is very, very safe. And so, certainly this is something that they would want to discuss with their physician, but the risks associated with this particular treatment are minimal as long as it is provided by a qualified licensed acupuncturist.

Garvin:

And Dr. Cohen you sound like you are very excited about the potential benefits of acupuncture.

Cohen:

Well, and this is something that is really important for patients to know is, one, that it is safe. And although it does not work for everybody, it is something important to consider and to speak to the healthcare provider about incorporating because you know and particularly these patients who have had xerostomia chronically for years, three years, four years, five years. And some of these patients were in the initial study that we did, the single arm trial they have enhanced saliva flow for years. They had to take a sip of water or eat a candy on a regular basis. They can't go for more than half an hour without taking a sip of water because of discomfort. They have a hard time eating. And they were so thankful of participating in this trial and in some of them the effect was long lasting and there are of course a lot of people who are skeptical about the benefits of acupuncture and in some sense rightly so, because we do not quite understand why it is working. But, when you see these examples and you see some of the data that is starting to come out, there is a real physiological change that is happening in the person. And at the end of the day if that physiological change is due to a placebo, it is still quite remarkable and the person has regained their quality of life that had deteriorated dramatically. And whether that is for nausea or for dry mouth, or for pain or some other symptom, it is really important to give acupuncture a good try because it can help transform somebody's life.

Garvin:

If you have any questions about anything you have heard today on Cancer Newsline, contact askMDAnderson at 1-877-MDA-6789 or online at www.mdanderson.org/ask. Thank you for listening to this episode of Cancer Newsline, tune in next week for the next podcast in our series.

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