Side-effects of cancer treatment – Brazil 2019

Stimulated by Paim et al and D’Allessandro et al 2019.[1,2]

I selected these trials that were published online on consecutive days last week whilst I was attending a conference in Gramado, Rio Grande do Sul, Brazil. It was only after selecting them that I noticed that both trials were conducted in Brazil. One in Sao Paulo and the other in Porto Alegre – the two cities I had just travelled through on my way to #acugramado2019. Somewhat of a coincidence worth mentioning in a blog I thought. Although I must note that both were worth highlighting in their own right despite this coincidence.

Paim et al studied the potential for TENS applied over the main salivary glands (parotid and submandibular) on each side of the face to improve salivary flow in patients with hyposalivation following radiotherapy for head and neck cancer. Readers will be aware that there has been quite some interest in the use of acupuncture in this condition in recent years, principally resulting from the ARIX trial.[3] Paim et al randomised 68 patients to either TENS or conventional care (benign neglect, ie no treatment). TENS was applied for 20 minutes at 50Hz twice a week for 4 weeks. Stimulated salivary flow (SSF) was the main outcome, and self-perception of salivary flow (SPSF) and quality of life were also measured.

SSF improved from a baseline of 0.16 ml per minute to 0.58 after the course of treatment. There was no improvement in the control group. 30% of patients in the TENS group achieved a flow rate of 0.7 or above, which was determined to be a clinically relevant improvement based on the subjective measures, whilst not reaching a level judged to be normal (>=1ml per minute). SPSF and quality of life improved in line with the salivary flow measures.

ARIX was a larger study (n=144) of group acupuncture (mainly ear points, but also face and hand) compared with oral care education in a cross-over design. Whilst it demonstrated relevant subjective improvements in symptoms, there was no effect on salivary flow rates, either stimulated or unstimulated. ARIX used a different method of stimulation and objective measurement, but the main differences in my opinion were the positioning of stimulation (no needles were placed into or near salivary gland tissue), and the average times from radiotherapy (over 40 months on average in ARIX compared with 4-5 in the current study).

We have a way to go in this research to find the optimal treatment approach, but early treatment directed close to salivary gland tissue seems the most logical.

…early treatment directed close to salivary gland tissue seems the most logical.

So, on to the second paper, this one from Sao Paulo. This one is the second controlled clinical trial (n=33) of acupuncture in chemotherapy induced peripheral neuropathy (CIPN). I noted the first and somewhat larger (n=87) trial in this blog in April this year (CIPN 2019).[4] It is not worth going into great detail in such a small trial, but suffice it to say the results were encouraging, and it adds to the growing interest in the use of acupuncture in CIPN, where conventional treatments are very limited. One difference I noted between the two trials is that this small and more recent trial managed to start treatment somewhat sooner at 2-19 weeks post chemotherapy compared with an average of 15.3 months (>60 weeks) in the previous trial. This is a positive move and getting closer to the prophylactic use I signposted in the CIPN 2019 blog.


1         Paim ÉD, Costa Batista Berbert M, Gonzales Zanella V, et al. Effects of transcutaneous electrical nerve stimulation (TENS) on the salivary flow of patients with hyposalivation induced by radiotherapy in the head and neck region – a randomized clinical trial. J Oral Rehabil Published Online First: 28 June 2019. doi:10.1111/joor.12851

2         D’Alessandro EG, Nebuloni Nagy DR, de Brito CMM, et al. Acupuncture for chemotherapy-induced peripheral neuropathy: a randomised controlled pilot study. BMJ Support Palliat Care Published Online First: 29 June 2019. doi:10.1136/bmjspcare-2018-001542

3         Simcock R, Fallowfield L, Monson K, et al. ARIX: a randomised trial of acupuncture v oral care sessions in patients with chronic xerostomia following treatment of head and neck cancer. Ann Oncol  Off J Eur Soc Med Oncol 2013;24:776–83. doi:10.1093/annonc/mds515

4         Molassiotis A, Suen LKP, Cheng HL, et al. A Randomized Assessor-Blinded Wait-List-Controlled Trial to Assess the Effectiveness of Acupuncture in the Management of Chemotherapy-Induced Peripheral Neuropathy. Integr Cancer Ther 2019;18:1534735419836501. doi:10.1177/1534735419836501

Declaration of interests MC