Acupressure on Xerostomia in Head and Neck Cancer Patients

Official title

Effect of Self-administered Acupressure for Improving Xerostomia in Head and Neck Cancer Patients: a Randomized Controlled Trial

Overview

This is a randomized controlled trial aimed to1) examine the effect of a self-administered acupressure intervention on head and neck cancer patients with xerostomia (primary outcome) relative to oral health education control; 2) examine the effect of self-administered acupressure on secondary outcomes, including quality of life and severity of symptoms of head and neck cancer patients; 3) evaluate patients' expectancy of acupressure; 4) explore the acceptability of self-administered acupressure for head and neck cancer patients with xerostomia. Hypothesis: self-administered acupressure has better effect on xerostomia for head and neck cancer patients comparing to oral health education. Acupressure will also benefit head and neck cancer patients on quality of life and severity of symptoms. Head and neck cancer patients may have good acceptability of self-administered acupressure.

Detailed description

Xerostomia is defined as "the subjective sensation of dryness of the mouth". It is common in patients with acute/chronic medical conditions, especially in patients with cancer. Results from observational studies reported 40% to 75% prevalence of xerostomia among cancer patients. Head and neck cancer patients, as the seventh most common type of cancer, reported an even higher prevalence (80%) of xerostomia after treatment compared with other cancer types. Despite the high prevalence of xerostomia, it is often underrecognized by patients and healthcare providers.

Xerostomia in head and neck cancer patients is largely induced by radiation in the head and neck region, which can damage salivary glands, and thereby change the volume, consistency, and pH of their saliva. Besides, xerostomia may be caused or exacerbated by the concomitant or sequential use of chemotherapy agents and other drugs (e.g., opioid). Consistent lacking saliva in cancer patients can lead to increased risk of oral fungal infection, caries, swallowing problems, sleep problems, depression, fatigue and altered taste, which may even result in poor nutritional status. Furthermore, xerostomia may become a chronic and even irreversible side effect.

Current therapies for xerostomia in cancer patients include both pharmacological and non-pharmacological treatments. Pharmacotherapy has been considered as a general treatment for stimulating saliva secretion in alleviating xerostomia for head and neck cancer patients. However, the evidence of pharmacological interventions (e.g., pilocarpine, bethanechol, amifostin, cevimeline and palifermin) on xerostomia is insufficient, and the use of pharmacotherapy may cause some common adverse effects, including nausea, sweating, nervousness, and urinary frequency. Non-pharmacological treatments such as saliva stimulants (e.g. citric and malic acids, chewing gum, toothpaste and lozenges) and saliva substitute (e.g. liquids, gels and sprays) have also been suggested to treat xerostomia, but neither with sufficient evidence of significant effect, and may also lead to adverse effects (e.g., nausea, unpleasant taste, diarrhea, and tooth mineralization). Some patients may find regular sips of water useful, but only for temporary benefit, because saliva is a complex substance with irreplaceable functions (antibacterial and immunologic protection). Therefore, an evidence-based effective strategy with few adverse events is warranted for head and neck cancer patients with xerostomia.

Both acupressure and acupuncture aim to improve health and cure illnesses by improving energy flow through stimulating meridian points. Acupressure is a non-invasive technique of activating acupoints using hands, fingers, or thumbs along the meridians, while acupuncture involves the use of needles. Stimulation on acupoints may increase the flow of blood and qi along the related meridians, as well as stimulate the local blood flow around the salivary glands, thereby increasing salivary secretion. Also, acupressure/acupuncture may stimulate the parasympathetic nervous system, hence indirectly stimulate salivary glands secretion. Besides, microcirculation may be promoted through the release of sensory neuropeptides, so as to increase the tissue oxygenation and metabolism. Some studies had demonstrated positive effect of acupuncture on xerostomia for head and neck cancer patients, while none examined acupressure. Based on the same meridian theory, both acupuncture and acupressure were widely applied to the symptom management (e.g. fatigue, nausea, pain) for cancer patients, effectively with good adherence. Compared to acupuncture, acupressure can be administered by patients themselves after training. The purpose of this study is to examine the effect of self-administered acupressure on xerostomia for head and neck cancer patients.

Interventions

• Behavioral Self-administered acupressure
  The participants should perform self-administered acupressure 12 weeks after training
• Other Oral health education
  The participants should perform general oral care by themselves after the oral health education relating to xerostomia

Primary outcome measures

• Xerostomia Questionnaire [Time frame: Baseline, 4 weeks, 12 weeks, and 24 weeks]

Secondary outcome measures (6)

• Saliva flow [Time frame: baseline, 12 weeks and 24 weeks]
• Quality of life for head and neck cancer patients [Time frame: baseline, 12 weeks and 24 weeks]
• Symptom severity [Time frame: baseline, 12 weeks and 24 weeks]
• Sociodemographic characteristics [Time frame: Baseline]
• Acceptability [Time frame: 12 week]
• Acupressure Expectancy Scale [Time frame: Baseline]

Eligibility criteria

Inclusion criteria

• age ≥18 years;
• able to give informed consent;
• diagnosed with head and neck cancer (cancers in the head and neck region, e.g. oral cancer, nasopharyngeal cancer, oropharyngeal cancer, hypopharyngeal cancer, laryngeal cancer, sinus cancer, salivary gland cancer);
• completed radiation therapy or chemoradiotherapy for at least 2 weeks;
• complains of xerostomia after the treatment;
• able to communicate in Cantonese or Mandarin.

Exclusion criteria

• history of xerostomia prior to head and neck cancer treatment (e.g., Sjögren Syndrome);
• practiced acupressure or received acupuncture in the last 3 months;
• having contraindications to acupressure, e.g. blood system disease (e.g., leukemia); pregnancy; lactating; upper or lower extremity deformities; infection or injuries at the acupoints.

Those who are taking medications/alternative substances to treat xerostomia on a fixed dosage regimen in the past one month will not be excluded.

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Criteria are shown verbatim from the registry (in English). Final eligibility is always assessed by the study center.

Healthy volunteers: No

Study design

Allocation

Randomized

Model

Parallel assignment

Masking

Open label

Primary purpose

Treatment

Study locations

Hong Kong · 1 center

• Queen Mary Hospital — Hong Kong

Publications

• Davies AN. A comparison of artificial saliva and chewing gum in the management of xerostomia in patients with advanced cancer. Palliat Med. 2000 May;14(3):197-203. doi: 10.1191/026921600672294077. PMID 10858827
• Eisbruch A, Kim HM, Terrell JE, Marsh LH, Dawson LA, Ship JA. Xerostomia and its predictors following parotid-sparing irradiation of head-and-neck cancer. Int J Radiat Oncol Biol Phys. 2001 Jul 1;50(3):695-704. doi: 10.1016/s0360-3016(01)01512-7. PMID 11395238
• Jensen SB, Pedersen AM, Vissink A, Andersen E, Brown CG, Davies AN, Dutilh J, Fulton JS, Jankovic L, Lopes NN, Mello AL, Muniz LV, Murdoch-Kinch CA, Nair RG, Napenas JJ, Nogueira-Rodrigues A, Saunders D, Stirling B, von Bultzingslowen I, Weikel DS, Elting LS, Spijkervet FK, Brennan MT; Salivary Gland Hypofunction/Xerostomia Section, Oral Care Study Group, Multinational Association of Supportive Ca PMID 20237805
• Mercadante S, Calderone L, Villari P, Serretta R, Sapio M, Casuccio A, Fulfaro F. The use of pilocarpine in opioid-induced xerostomia. Palliat Med. 2000 Nov;14(6):529-31. doi: 10.1191/026921600701536273. No abstract available. PMID 11219883
• Garcia-Chias B, Figuero E, Castelo-Fernandez B, Cebrian-Carretero JL, Cerero-Lapiedra R. Prevalence of oral side effects of chemotherapy and its relationship with periodontal risk: a cross sectional study. Support Care Cancer. 2019 Sep;27(9):3479-3490. doi: 10.1007/s00520-019-4650-6. Epub 2019 Jan 24. PMID 30675665
• Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, Bray F. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin. 2021 May;71(3):209-249. doi: 10.3322/caac.21660. Epub 2021 Feb 4. PMID 33538338
• Nathan CO, Asarkar AA, Entezami P, Corry J, Strojan P, Poorten VV, Makitie A, Eisbruch A, Robbins KT, Smee R, St John M, Chiesa-Estomba C, Winter SC, Beitler JJ, Ferlito A. Current management of xerostomia in head and neck cancer patients. Am J Otolaryngol. 2023 Jul-Aug;44(4):103867. doi: 10.1016/j.amjoto.2023.103867. Epub 2023 Mar 28. PMID 36996514
• Dirix P, Nuyts S, Vander Poorten V, Delaere P, Van den Bogaert W. The influence of xerostomia after radiotherapy on quality of life: results of a questionnaire in head and neck cancer. Support Care Cancer. 2008 Feb;16(2):171-9. doi: 10.1007/s00520-007-0300-5. Epub 2007 Jul 6. PMID 17618467

Identifiers

NCT: NCT06465628 · UW 24-233

Primary sources (government registries)

• ClinicalTrials.gov (US NIH)

View this study on ClinicalTrials.gov ↗