Acupuncture for chronic RIX

Stimulated by Cohen et al 2024.[1]

RIX – Radiotherapy-Induced Xerostomia
IF – impact factor
SOH – standard oral hygiene
RTOG – radiation therapy oncology group
XQ – Xerostomia Questionnaire
FACT-G – Functional Assessment of Cancer Therapy – General
QoL – quality of life

– key to acronyms

This paper was published on 13^th May in JAMA Network Open (IF 13.8). It took me a bit by surprise because I had not heard of this trial before, despite it being a large multicentre study and the fact that it has been going on for over 10 years.

It is a 3-arm trial (n=258) of acupuncture plus SOH versus sham plus SOH versus SOH alone. The patients all had grade 2 or 3 RIX 12 months or more following radiotherapy for head and neck cancer. This late RTOG grading refers to moderate to complete dryness of the mouth, but not complete fibrosis of salivary glands, which is grade 4.

Acupuncture was provided twice a week for 4 weeks along with SOH instructions. 14 points were used in both the real and sham groups. The acupuncture group received needling to 3 ear points on each side (Shenmen, Point Zero, Salivary Gland), CV24 (on the chin), LU7, LI1, and KI6. The last 3 were bilateral. That makes 13 points. A non-penetrating needle was used at GB32, presumably only on one side, to make up 14 points. Red handled Seirin needles (0.16x15mm) were used on ear points and blue handled needles (0.20x30mm) were used on body points.

In the sham group 3 points were used on the helix of each ear and non-penetrating needles with the Park sham device were used on ‘inactive’ points close to CV24, TE6, between LI7 & LI8, ST36. One real acupuncture needle was inserted at GB32 and stimulated to achieve de qi sensation.

So, a little bit of a complicated protocol with some needling in both groups, but much more needling in the ‘true’ acupuncture group.

The primary outcome was the XQ, which I described in a previous blog on the same topic: RIX sham and cultural differences. Higher scores on the XQ represent worse symptoms, and a 10 point change is considered clinically significant. They also used the FACT-G and the 4-item Acupuncture Expectancy Scale. Higher scores on these scales represent better QoL or higher expectancy respectively.

After the first 4 weeks of treatment (8 sessions), if there was a minor response (a 10-to-19-point reduction in the XQ), a further 4 weeks of treatment was provided. This included both acupuncture and sham groups. No further treatment was provided for those with no response, partial response (20 point or more decrease in XQ), or complete response (XQ = 0).

The primary outcome was at the 4 week point and this was the only time point at which the true acupuncture group was significantly better than both SOH alone and the sham group. At subsequent time points the difference between the acupuncture and sham groups was minimal, although true acupuncture continued to be significantly better than SOH until 24 weeks (at 24 weeks there was only a trend in favour of acupuncture – p=0.06). Interestingly, the sham group was not significantly better than SOH at the first 3 time points, but at 24 weeks it was, finishing up with the lowest XQ score of all 3 groups. This is likely to be chance, but we cannot completely ignore some impact of the penetrating needling performed in the sham group.

I think this is now good enough evidence to get those involved in cancer survivorship to adopt acupuncture for xerostomia.

Reference

1          Cohen L, Danhauer SC, Garcia MK, et al. Acupuncture for Chronic Radiation-Induced Xerostomia in Head and Neck Cancer: A Multicenter Randomized Clinical Trial. JAMA Netw Open. 2024;7:e2410421.