24 Oct Acupuncture Following Head and Neck Cancer Treatment
Richard C. Niemtzow, MD, PhD, MPH
Xerostomia
Xerostomia or dry mouth is caused by a disturbance of the salivary glands. This is especially prevalent among head and neck oncology patients who have experienced chemotherapy, radiation and surgery for their head and neck malignancy. Cancer therapy can cause damage to both the serous and mucous cells that compose the salivary glands. Patients who are treated with radioactive iodine for thyroid cancer also experience reduction in saliva and taste.
Damage to the Salivary Glands
The major glands that produce the saliva are found in the sublingual, submaxillary, and parotid glands. Radiation and chemotherapy are most damaging to the serous cells that produce the thin and watery composition of saliva. The mucous cells are more robust and resistant to the impact of cancer therapies. The mucous cells are the thick and sticky components of saliva that manifest due to injury of serous glands in the first few weeks of radiation and/or chemotherapy. The fluid-like dilution of saliva from the damaged serous cells are mostly absent. The patient complains of having a thick saliva that has a sensation of accumulating and gagging in the back of the throat and is difficult to spit out. Patients are forced to drink water to help keep their mouth moist, improve swallowing, eating and talking. Further modifications in taste also begins shortly after the saliva alteration. The changes can be slight to severe. Some patients even say that “water is not wet.” But most often the combined deficit in saliva and its consistency plus the change in taste can heavily impact on the quality of life. Food may have a bland or aggerated taste and is no longer a source of enjoyment. Lack of satisfaction with eating can add to unintentional weight loss. Patients who are treated with radioactive iodine for thyroid cancer also experience disturbances in saliva and taste by the same mechanism.
Other Dry Mouth Consequences
The impact of dry mouth is even more devastating. Because there is no longer a natural rinse of the teeth and gums from the saliva, an increase in caries and periodontal disease occurs with a significant financial burden. Carbohydrate metabolism that begins in the mouth is affected by the saliva’s poor dilution and breakdown of carbohydrate nutrients and as result, leads to a higher incidence of gastric ulcers. Social interaction becomes compromised as talking turns into a social handicap as the dry mouth necessitates frequent sips of water and degrades speech.
Avoiding the Damage to the Salivary Glands
The use of medical radiation protectors has been advocated to protect the salivary glands from the radiation. For example, Ethyol (amifostine), is a recent new radiation protector approved by the FDA. It is also possible to specifically target the tumor cells and avoid healthy tissue by specialized radiation techniques. Even various techniques of radiation scheduling may prevent some destruction of the salivary glands. Unfortunately, it is beyond the scope of this article to provide details on the radiotherapy. Surgical transposition of the salivary glands outside of the radiation field may be considered and then the glands restored to their proper anatomical location. There are some protocols geared for tumors caused by the human papillomavirus (HPV) that may permit reduction of the radiation and chemotherapy dosages. Proton beam therapy may be more healthy tissue sparing than conventional radiotherapy. Despite the many attempts to spare the salivary glands, many patients still suffer from saliva and taste deficiencies.
Failure of Artificial Saliva
There are a multitude of saliva aids on the commercial market that help keep the mouth moist. Although these are artificial remedies, many patients find them helpful in combatting dry mouth. Other patients do not benefit from artificial saliva with complaints that their dry tongue “sticks” to the roof of their mouth upon awakening. There still remains the constant difficulty in eating and swallowing that requires frequently use of water with every mouthful of food.
Acupuncture
Patients inquire whether acupuncture can be effective in improving the xerostomia. The author has treated xerostomia since 1999 to the satisfaction of many patients with a self-styled acupuncture procedure. How does acupuncture work and what are the results? There are few and questionable scientific acupuncture theories. Despite the fact that acupuncture has been around for over 5000 years, little evidence supports acupuncture points or meridians; nevertheless, for centuries, people have been placing needles into these mysterious meridians and points and demonstrated that beneficial physiological effects occur.
My self-styled acupuncture technique
At this point I would like to elaborate on my self-styled acupuncture technique. I presented a dry mouth acupuncture technique as a poster demonstration at an acupuncture symposium held by the American Academy of Medical Acupuncture in 1999. In the early 2000s, I demonstrated the technique at MD Anderson Cancer Center in Houston, Texas. Many months later I accompanied my colleagues from MD Anderson to the Cancer Center at Fudan University, Shanghai to further validate this technique on Chinese head and neck cancer patients. I conducted a clinical trial at the Naval Medical Center, San Diego, California while I was on active duty and published in the International Journal of Radiation Oncology and Biophysics. The dry mouth acupuncture technique has made its “rounds” in military and civilian hospitals. The majority of patients that seek my care are oncology patients with dry mouth. I taught the technique to many acupuncturists in this country and overseas. The teaching is still on-going. Many patients state that it is a life changer as the acupuncture technique increases the saliva. The treatment requires 2 sessions; one right after the other so it is a perfect weekend treatment. Saliva usually starts within ten minutes. The treatment does not always work. But in the vast majority of cases, the acupuncture proves helpful. There are quite a few patients who have achieved 10 years of maintaining a saliva flow. Patients who have been dry over many years, may be salvaged. I find this quite surprising as some patients with no saliva for over 15 years have been successfully treated. This is quite curious as the saliva glands remain dormant despite having been damaged for such a long time and the acupuncture treatment “wakes them up.”
The therapy consists of needles on the outside of the ears and in the index fingers. The acupuncture needles in the ear are placed in points named Shen Men that means spirit gate, point zero and salivary gland 2’. The first two points are well known points and help very much with the process. The classical salivary gland point did not seem to work well, so I slowly moved it toward the orifice of the external ear canal such that the needle just abutts the canal at the 6 o’clock position. I call it salivary gland 2’.
Trial and error have demonstrated that this maximizes the production of saliva. Next, needles are also placed near the tip of the index finger about ½ way toward the nail bed in the fleshy tissue. The other two needles are then placed in areas of the index finger on the distal interphalangeal and proximal interphalangeal joint areas. These index needles align on the “Large Intestine” acupuncture meridian but have nothing to do with our large intestines.
Acupuncturists will question the fact that the needles are not located on acupuncture points. This is a result that the meridians may act as a conductor and needles do not have to be placed just on the acupuncture points to bring about a physiological effect. I always have the patient dissolve a sugar-less mint at the beginning of the treatment to start a parasympathetic saliva stimulation. This aids in the production of the saliva. How long does the treatment take? I usually keep the needles in place for at least 1 to 1½ hours. Considering that the treatment may last for many months to several years, this is very acceptable. Many patients ask about taste. Taste is even more difficult to resolve than the saliva. In many cases taste is improved but never fully. I have had some patients tell me that their taste had become normal, but this is certainly the exception.
In a clinical trial, 18 patients were treated with my acupuncture technique. 9 patients had a robust secretion of saliva and the others had various degrees of lesser secretion. This is very encouraging and as the years have gone by the technique has certainly become refined and the success rate and refinement of the technique has improved. Practice makes perfect. Several years ago, I co-authored an article with my colleagues surveying xerostomia in the research literature. Here are the findings. “Acupuncture may be a helpful adjunct to cancer care for treatment and/or prevention of xerostomia in patients with head and neck cancer, but studies to date have been limited by small sample size and/or lack of blinding. Large phase III trials are currently underway.” It is interesting to note that other reviews in the medical acupuncture literature for dry mouth are inconclusive. There are some trials that are suggestive of a positive effect. I looked at several reviews and there was no mention of the acupuncture technique employed. This is very important as you would not expect positive results if the technique was not optimized.
Where Can You Find an Acupuncturist that Treats Dry Mouth?
The easiest way is to “google.” Some acupuncturists state on their web site medical conditions that are treated. A good source of finding a medical acupuncturist in your area is a service by the American Academy of Medical Acupuncture that is found on the initial page of their web site “Find an Acupuncturist Near You.”
Final Remarks from a Head and Neck Cancer Patient
I too am a cancer survivor having had thyroid cancer treated with radiation. I experienced the dry mouth and loss of taste and appreciate the complaints of my patients. I can truthfully say as a previous practicing radiation oncologist and as a patient, dry mouth and loss of taste is debilitating. Fortunately for me my wife is an acupuncturist and she treated me with my own technique. It does work! What would I do without it?
Many of you may be skeptical in trying acupuncture, but as the recipient of my own treatment I have no doubts of its benefit. I do believe that many cancer treatments centers should offer acupuncture treatments to their patients even for other medical challenges. A patient from England who I treated with acupuncture was so pleased with the results on himself that he started a dry mouth foundation in London. The foundation pays for any patient who cannot financially afford the payment in England. Need I say more?
The opinions and assertions of this article are the private views of the author and are not to be construed as official or as reflecting the views of the United States Air Force Medical Corps, the Air Force at Large, or the Department of Defense. The author indicates that he does not have any conflicts of interest or financial interests.
Editors Note: Richard C Niemtzow, M.D., PhD, MPH is a graduate of the Faculte de Medecine, Universite de Montpellier, France 1976 and completed a residency in radiation oncology at the University of Texas Medical Branch Galveston, Texas 1980. Graduate of the UCLA /Helms Medical Acupuncture Course in 1995. He has been practicing medicine for over 41 years. He is responsible for initiating the first full time acupuncture clinic in the Armed Forces that today is the Air Force Acupuncture and Integrative Medicine Center at Joint Base Andrews, where he is current director.
Editor in Chief of the journal Medical Acupuncture for 20 years and Senior Military Editor of the Journal of Alternative and Complementary Medicine for 12 years. Former President of the American Academy of Medical Acupuncture and the Maryland Medical Acupuncture Society.
Military Service: Retired from the United States Air Force in April 2010 obtaining the rank of Colonel after almost 30 years of active duty service. First full time medical acupuncturist in the Armed Forces. Consultant for Integrative Medicine for the United States Air Force Surgeon General. He was the Assistant Secretary of Defense for Health Affairs’ representative to the National Institutes of Health, National Center for Complementary and Integrative Health Advisory Council from 2004 to 2017. Represented the United States Air Force as a NATO committee member on Integrative Medicine. Assistant Professor at the Uniformed Services University of the Health Sciences. “Point of Contact,” Moderator and Co-Author of a $5.4 million Army, Navy, Air Force and Veterans Administration Joint Incentive Fund to teach Battlefield Acupuncture (Niemtzow). Designer of many acupuncture techniques such as Battlefield Acupuncture, dry mouth resolution in cancer head and neck patients, a concussion headache protocol and acupuncture for degenerative retinal disease (phase 3 study).