Preventing xerostomia

Stimulated by Menezes et al 2021.[1]

Photo by Craig Cameron on Unsplash.

RIX – radiation induced xerostomia
PROM – patient reported outcome measure
XI – Xerostomia Inventory
XQ – Xerostomia Questionnaire
BAI – Beck Anxiety Inventory

key to acronyms

I was a bit late to pick up this paper, perhaps because the title is long, and I didn’t really notice the word prevent. There is quite a lot of research on treating xerostomia,[2] especially after radiotherapy of head and neck cancer, but I think this is the first report with prevent in the title, and the first to include objective outcomes, although it is not the first to perform acupuncture during a course of radiotherapy.

I was pleased to see the absence of a sham group in this trial, and a reasonable number randomised (n=107). If you recall there has been some controversy of late over the effect of sham acupuncture in this condition and how it differs between China and the US (see my previous blog: RIX sham and cultural differences).[3]

The main differences between this trial and the larger (n=240), two centre, three arm, sham controlled trial I reported on previously are the use of lots of points on the face and the measurement of salivary flow as an outcome.

Garcia et al used a single point on the face
Menezes et al used 8

Garcia et al only used a single point on the face (CV24) along with body and ear points but performed treatment 3 times a week during the 6 or 7 week course of radiotherapy. Menezes et al used 8 points on the face plus two more on the head as well as 8 peripheral points and the weekly application of ear seeds, but only applied the treatment once a week, and we are not told how long the radiotherapy lasted in this case.

Unstimulated salivary flow was recorded before and after radiotherapy in Menezes et al, and this is the most interesting outcome, although subjective outcomes (PROMs) were also used. They used the Xerostomia Inventory (XI; score range 11 to 55)) and the Beck Anxiety Inventory (BAI). Unfortunately, Garcia et al used the XQ (score range 0 to 80), so there is no direct comparison between the trials.

Sialometry – the measurement of salivary flow

Sialometry is mentioned once in the paper by Garcia et al, but I can find no record of any results in the paper or supplements.

In Menezes et al we are told that the baseline measures are no different, although I cannot find the data in the paper, but we are presented with the post radiotherapy data. The acupuncture group appears to produce twice the amount of saliva in 5 minutes as the untreated group, and I estimate that it corresponds to 0.4 to 0.5ml per minute, which according to a paper in the Journal of Medicine and Life,[4] is entirely normal. The untreated group managed about 0.2ml per minute, which is below normal, but not as bad as it could be after radiotherapy. Salivary density was also significantly greater, and pH was no different.

The XI score was significantly lower in the group receiving acupuncture alongside their radiotherapy, and anxiety during radiotherapy was markedly lower in this group.

Addendum

I have just realised I forgot to mention a study I was involved with for the past 7 years that involved acupuncture provided with a radiotherapy department. The report of the feasibility study has finally been published,[5] but my main involvement was in training a small group of radiographers in 2014, and in developing protocols for use in the study with a group of experts.[6] The study showed it was both feasible and acceptable to patients and staff, but the treatment course was probably insufficient to measure significant benefits in the mixed cancer population selected.

References

1          Menezes AS da S, Sanches GLG, Gomes ESB, et al. The combination of traditional and auricular acupuncture to prevent xerostomia and anxiety in irradiated patients with HNSCC: a preventive, parallel, single-blind, 2-arm controlled study. Oral Surg Oral Med Oral Pathol Oral Radiol Published Online First: 27 February 2021. doi:10.1016/j.oooo.2021.02.016

2          Ni X, Tian T, Chen D, et al. Acupuncture for Radiation-Induced Xerostomia in Cancer Patients: A Systematic Review and Meta-Analysis. Integr Cancer Ther 2020;19:153473542098082. doi:10.1177/1534735420980825

3          Garcia MK, Meng Z, Rosenthal DI, et al. Effect of True and Sham Acupuncture on Radiation-Induced Xerostomia Among Patients With Head and Neck Cancer: A Randomized Clinical Trial. JAMA Netw Open 2019;2:e1916910. doi:10.1001/jamanetworkopen.2019.16910

4          Iorgulescu G. Saliva between normal and pathological. Important factors in determining systemic and oral health. J Med Life 2009;2:303–7.

5          Hughes J, Gyertson K, Carballo L, et al. A feasibility trial of acupuncture in cancer patients undergoing radiotherapy treatment. Complement Ther Clin Pract 2021;43:101372. doi:10.1016/j.ctcp.2021.101372

6          Hughes J, Cummings M, Filshie J, et al. Ensuring model validity in a feasibility study of acupuncture to improve quality of life in cancer patients undergoing radiotherapy treatment. Eur J Integr Med 2018;21:50–2. doi:10.1016/j.eujim.2018.06.010


Declaration of interests MC