Acupuncture For Dysphagia After Chemoradiation Therapy in HNC

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Integr Cancer Ther. Author manuscript; available in PMC 2011 January 3.
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Published in final edited form as:

Integr Cancer Ther. 2010 September ; 9(3): 284290. doi:10.1177/1534735410378856.
Acupuncture for Dysphagia after Chemoradiation Therapy in

Head and Neck Cancer: A Case Series Report*
Weidong Lu, MB, MPH, PhD1,3, Marshall R. Posner, MD2, Peter Wayne, PhD3, David S.
Rosenthal, MD1, and Robert I. Haddad, MD2
1Leonard P. Zakim Center for Integrative Therapies, Dana-Farber Cancer Institute, Boston, MA
2Head
and Neck Oncology Program, Dana-Farber Cancer Institute, Boston, MA
3Osher
Research Center, Harvard Medical School, Boston, MA
Abstract
BackgroundDysphagia is a common side effect following chemoradiation therapy (CRT) in

head and neck cancer (HNC) patients.
MethodsIn this retrospective case series, ten HNC patients were treated with acupuncture for
radiation-induced dysphagia and xerostomia. All patients were diagnosed with stage III/IV
squamous cell carcinoma. Seven of 10 patients were percutaneous endoscopic gastrostomy (PEG)
tube-dependent when they began acupuncture. Manual acupuncture and electroacupuncture were
used once a week.
ResultsNine of 10 patients reported various degrees of subjective improvement in swallowing
functions, xerostomia, pain and fatigue levels. Six (86%) of 7 PEG tube-dependent patients had
their feeding tubes removed after acupuncture, with a median duration of 114 days (range 49368)
post CRT. One typical case is described in detail.
ConclusionsA relatively short PEG tube duration and reduced symptom severity following
CRT were observed in these patients. Formal clinical trials are required to determine the causality
of our observations.
Keywords
acupuncture; chemoradiation therapy; radiation therapy; head and neck cancer; dysphagia;
percutaneous endoscopic gastrostomy (PEG) tube
Introduction
Head and neck cancer (HNC) accounts for 4% to 5% of all cancer diagnoses, with 42,000
new cases and 12,000 deaths each year in the United States.
*Supported by The National Center for Complementary and Alternative Medicine (NCCAM), Grant Number: 1K01AT004415-01
Address reprint request to Weidong Lu, MB, MPH, PhD, Leonard P. Zakim Center for Integrative Therapies, Dana-Farber Cancer
Institute, 44 Binney Street, Boston, MA 02115, Tel.: (617) 632-4350, Fax: (617) 632-3988; Weidong_lu@dfci.harvard.edu.
Co-authors: Marshall R. Posner, MD, Dana-Farber Cancer Institute, 44 Binney Street, Boston, MA 02115, phone: (617) 632-5718,
Fax: (617) 632-4448, Marshall_Posner@dfci.harvard.edu
Peter Wayne, PhD, Osher Research Center, Harvard Medical School, Landmark Center, 401 Park Dr., Boston, MA 02215, Phone:
(617), Fax: (617) 384-8555, peter_wayne@hms.harvard.edu
David S. Rosenthal, MD, Leonard P. Zakim Center for Integrative Therapies, 44 Binney Street, Boston, MA 02115, Dana-Farber
Cancer Institute, Boston, MA, Phone: (617) 632-3322, Fax: (617) 632-3988, drose@uhs.harvard.edu
Robert I. Haddad, MD, Dana-Farber Cancer Institute, 44 Binney Street, Boston, MA 02115, Phone: (617) 632-5718, Fax: (617)
632-4448, Robert_Haddad@dfci.harvard.edu
Lu et al.
Page 2
Advances in radiation with concomitant chemotherapy, chemoradiation therapy (CRT), have

resulted in significant improvement in survival rate and preservation of organ function in
HNC patients(1,2), and many patients are now cured with aggressive therapy(35).
However, treatment of HNC with CRT is associated with significant toxicity and side
effects. Acute toxicity includes mucositis, nausea/vomiting, dehydration, malnutrition,
weight loss, pain, and leukopenia; long-term side effects are xerostomia (dry mouth),
fibrosis and associated trismus, which all contribute to dysphagia(611). Due to the high
incidence of grade 34 mucositis following CRT, patients are often not able to be fed orally
leading to severe weight loss and malnutrition. Consequently, standard care employs a
percutaneous endoscopic gastrostomy (PEG) tube during radiation for the majority of
patients in order to provide adequate nutritional supply.
Dysphagia, or difficulty with swallowing, is a very common side effect following CRT in
patients with HNC. Dysphagia has been reported to occur in up to 50% of patients after CRT
and this number is considered by some to be underestimated(9,12,13). At 3 and 12 months
following completion of CRT, 73% and 19% of patients are reported to still be PEG
dependent(14). Dysphagia may lead to aspiration, which may significantly impact many
aspects of health and quality of life in patients recovering from CRT. Although swallowing
therapy has been found to improve dysphagia and reduce aspiration rate, many patients still
have significant swallowing problems and remain PEG tube dependent for many months
after completion of CRT(13,15). The reported median PEG tube duration ranges from 178
365 days(1618). The median PEG tube duration following CRT has been reported to be 5
months(14,19). In general, swallowing issues continue to evolve during the first twelve
months after CRT because of the delayed effect of the toxicity of the treatment, which
includes gradual fibrosis of the pharyngeal muscles and soft tissues, persisting xerostomia,
and damaged swallowing muscles. A number of studies suggest that swallowing function for
HNC patients fails to improve 12 months after radiation therapy (15,20,21).
There are 3 published studies from China that have characterized the responses of HNC
patients with dysphagia to acupuncture, including one non-randomized controlled trial
(n=38)(22), and two case series (n=120 and n=11, respectively) in nasopharyngeal and
esophageal cancers(23,24). In addition to HNC-related dysphagia, a significant body of
literature exists that characterizes the efficacy of acupuncture for stroke-related
dysphagia(2528). In this paper, we report a case series of 10 HNC patients treated at DanaFarber Cancer Institute (DFCI) using acupuncture. The results suggest a need to more
definitively evaluate the safety and benefits of acupuncture for HNC patients.
Case Summaries
We report on a group of 10 patients who have been treated with acupuncture for dysphagia
and/or xerostomia at Zakim Center for Integrative Therapies at DFCI from October 2004 to
May 2007.
This group of patients consists of 9 white males and 1 white female, with a mean age of 56
(range 2978). All ten patients were diagnosed with stage III/IV squamous cell carcinoma of
the head and neck. The primary tumor sites were located at the base of the tongue, the floor
of the mouth, or tonsillar area.
Nine out of 10 patients received combined chemoradiation therapy. The chemotherapy was a
carboplatin/Paclitaxel combination in six patients and a cisplatin based protocol in three.
The remaining patient received radiation therapy alone. All 10 patients received radiation
with a median dose of 7,000 cGy (range 60007200). Prior to or following CRT, 4 out of 10
patients had a primary tumor dissection. PEG tubes were needed in 9 of 10 patients during
Lu et al.
Page 3
CRT and 7 were still PEG tube-dependent when they first entered acupuncture. Three out of
10 patients received esophageal dilation procedures due to strictures found by modified
barium swallow (MBS) results. Among these 3 patients, 2 had received 5 and 2 dilations
respectively, before starting acupuncture.
Four of 10 patients started acupuncture while still undergoing CRT and 6 received
acupuncture after the completion of CRT. The median time of initiating acupuncture relative
to the last day of CRT was 27 days (range 44 to 582).
At the first acupuncture visit, all patients complained of a wide range of symptoms including
nausea/vomiting, anxiety, pain, fatigue, dysphagia and xerostomia, with the latter being the
most frequent complaint. Most were undergoing swallowing therapy. All patients received
acupuncture treatments for a median of 13.5 sessions (range 740). A typical visit interval
was once a week or once every two weeks for at least 6 sessions. Manual acupuncture and
electroacupuncture were used based upon the sensitivity and tolerability of the patient
towards acupuncture stimulation. The needling sites of acupuncture were divided into two
stages based on the timing of acupuncture and CRT: for patients who started acupuncture
while undergoing CRT, no radiation field was needled. The needling sites were mostly
located either on the four limbs or on the upper half of the head above the horizontal line of
the eyes. Blood neutrophil, platelet counts and hemoglobin levels were monitored prior to
each acupuncture session. For patients who started acupuncture 30 days post CRT,
additional sites located around ears, neck, check, and jaws were often used: ST36, SP6, LI2,
LI11, GV20, Shenmen/ear, Sanjiao/ear, ST7, ST6, ST5, CV23, GB20, Yintang (Figure 1).
Actual points used on each patient varied based upon specific complaints of each patient at
the time of each visit.
Disposable acupuncture needles (VINCO, Helio Medical Supplies, Inc. USA) 3632
gauge, 11.5 inches (0.200.25 2540 mm) were used. A De Qi sensation, experienced
by the patient as a deep and dull muscle ache at the site of the needle insertion (29), was
attempted but often not necessarily achieved due to the sensitivity of patients.
Electrostimulation sites were at GV20 and Yintang (Model: AWQ-104 L, Mayfair Medical
Supplies Ltd., Hong Kong), with a frequency of 24 Hz. An Infrared heat lamp (Model:
TDP CQ-27, Lhasa OMS, Inc. USA) was often used above the legs of patients during the
session. Needles were retained at sites for 30 minutes in each session. Table 1 shows the
summary table of these patients.
After acupuncture, nine of 10 patients reported various degrees of subjective improvement

in swallowing functions, xerostomia, pain and fatigue levels. Of seven patients with PEG
tubes, one started acupuncture 528 days after CRT and did not respond to acupuncture, as
defined by a PEG tube removal following acupuncture treatment. The patient later received
a tracheotomy and was still PEG tube-dependent at the time of writing this report. The
remaining 6 patients all had their PEG tube removed. Table 2 shows the number of days the
PEG tube remained in place in relationship to the end of CRT and the initiation of
acupuncture treatment. No adverse event related to acupuncture was observed in any patient.
Case Vignette
A 78-year-old white male patient developed a mass on the left side of his neck in September
2005. Examination found a 2 2 cm lesion on the left tongue base extending into the
vallecula and a neck mass measured 1.5 cm in size located at left upper jugulodigastric
region. The biopsy report was consistent with poorly differentiated invasive squamous cell
carcinoma. He was staged as a T2, N1, M0 stage III squamous cell carcinoma of left tongue
base.
Lu et al.
Page 4

On December 1, 2005, the patient underwent concurrent chemoradiation therapy with

carboplatin AUC dose of 1.5 and Paclitaxel at 45 mg/sqm, along with daily radiation
therapy. A PEG tube was placed prior to chemoradiation therapy. The patient received
periodic nutritional consultations as well as speech and swallowing therapy to support
swallowing function and nutritional needs at the beginning of chemoradiation therapy,
which was completed on January 30, 2006. The patient received two esophageal dilation
procedures for dysphagia during the 2nd and 5th month post CRT, respectively. He continued
speech and swallowing therapy until October 11, 2006, 9 months post-chemoradiation
therapy. At that time, the patient was eating small amount of food by mouth three times per
day and taking four cans of liquid food via PEG. He still had significantly decreased
appetite, taste and xerostomia. He was discouraged by the lack of progress in his swallowing
function. The speech and swallowing therapist had concluded that the patient had not shown
significant changes in his swallowing function. His weight was down 2.3 kg during the past
one month. The patient was referred to try acupuncture by the swallowing therapist to
increase saliva and possibly improve his taste and appetite. The acupuncture-naive patient
started the first acupuncture treatment on October 20, 2006. At the initial treatment, he rated
his xerostomia at 5 out of 10, and lack of taste of food at 10 out of 10. The patient was naive
to acupuncture. Therefore, thinner acupuncture needles (Seirin, Japan) (0.16 30 mm)
were used at his first the visit. The following acupuncture points were used: LI2, LI4,
Yintang, ST7, ST5, ST6, Sanjiao/ear, GV 20 and GV 24. At the second visit, the patient
reported a slight improvement in taste of food. During subsequent treatments,
electroacupuncture stimulation was added along with additional acupuncture points: CV23,
ST36, SP9, SP6. The size of acupuncture needles was changed to 0.20 40 mm, with intent
to produce De Qi sensation. The stimulation was administered to Sanjiao/ear and ST5 on the
right side with a low frequency (45 Hz) and a continuous wave pattern at a level that was
well-tolerated by the patient. At the third visit, the patient reported that he could eat more
food with improved swallowing. The patient was encouraged by the improvement he
noticed. He was able to increase varieties of food such as Jelly Stick, Sushi and clam meat.
At the 10th visit, the patient had reduced reliance on liquid food by 50% and gained weight.
During Thanksgiving, 4 weeks after starting acupuncture, he was able to eat "almost
everything" except turkey meat. At the 15th visit, the patient reported a significant increase
of salivary production for which he was able to lick envelopes. He still had some trouble
swallowing meat. He also noted continued improvement in the food taste since beginning
acupuncture. At the 16th visit, January 10, 2007, he reported he could chew and swallow
60%-70% of pork, beef and turkey and discontinued using PEG. On January 22, 2007, at the
follow-up nutrition consult, he weighed 87.5 kilogram and had gained 1.5 kg in three
months. His 18th and final acupuncture session was performed on January 27, 2007. The
PEG tube was removed on February 2, 2007, three months after starting acupuncture. The
patient is still being followed by treating oncologists with a satisfactory swallowing function
and a disease-free status in 2009.
Discussion
In this retrospective case report, head and neck cancer patients undergoing chemoradiation
treatment received multiple sessions of acupuncture treatment aiming to alleviate dysphagia
and xerostomia symptoms. Acupuncture intervention appeared to be well-received and welltolerated by this group of patients. Most patients reported subjective improvement in their
swallowing function with a shorter-than-average PEG tube duration after CRT, based on
previously published reports and our clinical experience. However, without prospective and
comparative studies, the benefits of acupuncture for dysphagia in this population can not be
definitively established.
Lu et al.
Page 5
The entire duration of PEG and the PEG duration post CRT are important indicators of
dysphagia in patients undergoing CRT. Previous studies in a similar population reported
median PEG durations ranging from 178 to 365 days;(1618,30) the reported median postCRT PEG duration ranged from 147 to 150 days(14,19). The median duration of PEG in our
group is slightly lower that what Wiggenraad reported (173 vs. 178 days).(17) However, the
post-CRT PEG duration in our group is much shorter than Nguyens report (median:114 vs.
150 days; mean:145 vs. 240 days)(19). It is possible that the smaller differences in PEG
durations between our cohort and other published reports results from different
chemoradiation protocols. However, a 22% shorter median post-CRT PEG duration in our
acupuncture-treated cases is unlikely to be due only to variations in CRT regimes, and it is
possible that this difference is due in part to acupuncture interventions.
Some preliminary evidence suggests that the mechanism through which acupuncture
impacts dysphagia by improving salivary production, restoring swallowing reflex, and
inhibiting the fibrosis process.
Xerostomia, or dry mouth, is considered a significant factor underlying dysphagia(31).

Several pilot clinical studies suggest that acupuncture may improve xerostomia caused by
radiation therapy in patients with head and neck cancers(3237). Johnstone found that
acupuncture produced a 70% response rate of increasing 10% or more from the baseline as
assessed using the Xerostomia Inventory(32,33). Wong reported a phase I-II study with
transcutaneous electrical stimulation. Forty-six patients were randomized among three
groups with different acupuncture points. After 6 weeks of treatment, for 37 patients who
completed the treatment course, salivation production was statistically significantly
increased from baseline in all three groups at both 3- and 6- months(34,35). A pilot fMRI
study found a relationship between stimulating an acupuncture point, LI-2, located at the
base of index finger, and the activation of the brain function area that is responsible for
salivary production, suggesting a central neural pathway involvement(38).
One study used swallowing electromyography to detect the effect of acupuncture on
swallowing related muscles and evoked potentials in the brainstem in a group of chronic
post-stroke patients with moderate to severe dysphagia(n=30) (39). Acupuncture needles
were inserted into four acupuncture points located around the neck area. The test was
performed 5 min before and 5 min after acupuncture treatment. The study found that the
amplitude and time limit of cricothyroid muscle, and time limit of tongue muscles in the
patients with bulbar palsy significantly decreased after acupuncture. Similar studies have not
yet been conducted in head and neck cancer patients recovering from CRT.
Conclusions
In summary, we report a case series of ten head and neck cancer patients with complaints of
dysphagia and other related symptoms after chemoradiation therapy. All were treated with
multiple sessions of Chinese acupuncture, manual and electro-stimulation at classical
locations of acupuncture. The clinical intentions of the intervention were to reduce local
pain, stimulate salivary production, and stimulate local nerve sensory receptors of related
cranial nerves (namely VII, IX, X, XI and XII nerves).
We observed a short PEG duration following CRT in these patients treated with
acupuncture, along with other subjective improvement in pain, fatigue and xerostomnia
symptoms. However, formal clinical trials are required to determine the causal relationship
between acupuncture and swallowing function in this population. We have initiated a
randomized controlled trial of acupuncture in this population to collect safety, feasibility and
preliminary efficacy data.
Lu et al.
Page 6
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Figure 1.
Acupuncture points used in patients with head and neck cancer

10
46
66
52
73
29
45
58
59
54
78
Age
SCC
SCC
SCC
SCC
SCC
SCC
SCC
SCC
SCC
SCCc
Tumor Type
BOT: base of tongue
TP
TP
TP
BOT
FOMi
unknown primary
BOT
BOT
TPe
BOTd
Primary
Site
T2, N2b
T3, N2c
T1, N2a
T1, N2b
T4, N1
T1,N0
T4, N2b
T1, N2A
T2, N3, M0
T2, N1, M0
Stage
i
FOM: floor of mouth
TPF: Docetaxel, Cisplatin, 5-Fluorouracil
NR: not relevant; PEG was removed before the initiation of acupuncture
f
Days of acupuncture initiated prior to end of RT
e
TP: tonsillar pillar
c
SCC: Squamous cell carcinoma
LDRT: last day of radiation therapy
RT: radiation therapy
Sex
Patient No.
Patient characteristics and acupuncture responses
Cisplatin
Carbo/Paclitaxel
Carbo/paclitaxel
Carbo/Paclitaxel
TPF
None
TPFh
Carbo/Paclitaxel
Carbo/Paclitaxel
Carbo/Paclitaxel
Chemo agents
6400
7200
6996
7000
Unknown
6400
7000
7000
6000
7000
RTa Dose(cGy)
at primary site
(38)
49
49
(34)
238
(44)
582
(26)f
263
Days from
acupuncture
initiation
to LDRTb
49
127
98
127
NR
No PEG used
100
PEG remaining
NRg
368
Days from LDRT

to PEG removal
Improved in anxiety, insomnia, and

xerostomia
Improved in xerostomia,
swallowing, and neck pain
Improved in xerostomia and

swallowing
Transient improvement in fatigue

level
Improved in insomnia, anxiety
Had less than expected toxicity
Had less than expected toxicity
Transient improvement in sleep
Improved in xerostomia
Able to swallow meat
Subjective acupuncture
responses
Table 1
Lu et al.
Page 9

6
6
Post-CRT PEG durationb
PEG duration between

acupuncture and removalc
104
145
206
Mean(days)
42
113
115
SD
96
114
173
Median(days)
49161
49368
98429
range
c
PEG duration between acupuncture and removal: days from first day of acupuncture to the PEG removal
Post-CRT duration: days from last days of CRT to the removal
Total PEG duration: days from initial PEG placement to the removal
Total PEG durationa
Mean and median PEG durations in patients with PEG removed after acupuncture
Table 2
Lu et al.
Page 10

Acupuncture For Dysphagia After Chemoradiation Therapy in HNC

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