The use of acupuncture in radiation-induced complications among cancerpatients

The use of acupuncture in radiation-induced complications among cancer patients

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Complementary Medicine: Education and Research

Vol.1, No. 1, pp. 14-29, Feb 2024

Received Sep 5, 2023; Revised Nov 24, 2023; Accepted Dec 20, 2023

Published by Chinese Medicine and Acupuncture Association of Africa. This is an open access article under the CC BY-NC-ND license.

The use of acupuncture in radiation-induced complications among cancer patients: Narrative review

Kelley Sue Joubert[1]

1. Affiliation: Department of Complementary Medicine, University of Johannesburg, Doornfontein, Johannesburg, South Africa

[1] Corresponding author: Department of Complementary Medicine, University of Johannesburg, Doornfontein, Johannesburg, South Africa. Email: info@drjoubert.co.za Postal address: Health Hub Langham's, 1st Floor, Unit 2A, 1 Tamchele Ave, Beverley Fourways, Johannesburg, South Africa.

To cite this article:

Joubert, K.S. (2024). The use of acupuncture in radiation-induced complications among cancer patients. Complementary Medicine: Education and Research, 1(1), 14-29. https://doi.org/10.62415/VMIJ7249

ABSTRACT

Background: Radiation-induced complications commonly occur among patients who receive radiation therapy. Various research reports that acupuncture treatment significantly reduces radiation-induced complications experienced by patients undergoing radiation therapy. However, there is a lack of review on the use of acupuncture in the treatment of radiation-induced complications among cancer patients.

Aim: The aim of this study was to conduct a narrative review on the use of acupuncture in the treatment of radiation-induced complications among cancer patients.

Methodology: A narrative review was conducted using extensive databases including PubMed, EBSCO host, and Science Direct. Studies included in this review had to meet inclusion criteria based on the date of publication and relevance to acupuncture in treatment for radiation-induced complications. A total of 16 studies met the inclusion criteria for this narrative review on the radiation-induced side-effects, which included mucositis (n= 3), stomatitis (n= 1), xerostomia (n= 6), nausea and emesis (n= 3), and dysphagia (n=3), treated with acupuncture.

Results: Studies observing acupuncture in the treatment of stomatitis, mucositis and xerostomia all showed positive results with significant improvement experienced in patients treated with acupuncture compared to those treated with sham-acupuncture and control groups, with one study for mucositis using a combined therapy of acupuncture and cooling herbs. Studies included for nausea and emesis demonstrated mixed results of no improvement (n= 2) and improvement (n= 1).

Conclusion: Acupuncture demonstrates a significant ability to reduce the severity of common radiation-induced complications caused by radiation therapy among some cancer patients. This study was limited to the small sample size due to the limited research on this topic. More studies on the use of acupuncture treatment to reduce radiation-induced complications among other cancer patients are recommended to strengthen the evidence.

Keywords: acupuncture; radiation therapy; cancer; complementary medicine.

1. Introduction

Radiation therapy is used for its high-dose radiation function of targeting cancer cells in more than half of patients diagnosed with cancer (Baskar et al., 2012). Cancer, a disease theorised to develop from a dysregulation of checkpoint controls during cellular proliferation, has become one of the most notable causes of death worldwide (Meyerson & Pellman, 2011). As of 2017, it was estimated that cancer accounted for 8% of total deaths in South Africa, with incident rates of 156,5 and 148,7 in women and men per 100 000 people, respectively (Made et al, 2017). Despite the significance of radiation therapy in cancer treatments, it can induce severe complications (Chowdhury & Saheda, 2020). Some of the common complications include fatigue, dermatitis, oesophagitis, enteritis, mucositis, pulmonary fibrosis and cardiotoxicity (Hanania et al, 2019; Soumarova & Rusinova, 2020). The types and severity of complications vary from individuals. Choi et al. (2016) point out that insomnia is a common complication, with as many as 52% of patients complaining of sleep difficulties (Choi et al, 2016). Patients treated for head and neck cancer may experience symptoms such as odynophagia (painful swallowing), xerostomia (lack of saliva), orofacial pain and dysphagia (difficulty swallowing). These symptoms can further lead to more complications such as dehydration and inadequate nutrition intake, which can hinder the treatment process (Brook, 2021).

Acupuncture is a complementary treatment modality that falls under the category of Traditional Chinese Medicine (TCM). Acupuncture has been used in practice for over 2000 years (Hu & Venketsamy, 2022). Asadpour et al. (2016) state that the use of acupuncture has increased in popularity among patients undergoing radiation therapy due to its benefits in reducing complications experienced by cancer patients. However, latest research findings have yet to be summarised on the effectiveness of common radiation-induced complications, such as xerostomia, mucositis, stomatitis, emesis, nausea and dysphagia. This narrative review was intended to summarise the latest research findings relating to the use of acupuncture therapy in the treatment of complications experienced by cancer patients with radiation therapy.

2. Methodology

The study was a descriptive study in form of a narrative review. The review was conducted to identify the use of acupuncture in radiation induced side-effects in cancer patients, which included a search of published literature available from databases, including EBSCO host, PubMed and Science Direct. A range of additional sources of information including scientific reports were consulted. The following Boolean search phrases were used; ‘acupuncture AND radiation therapy’, ‘acupuncture AND stomatitis’, ‘acupuncture AND mucositis’, ‘acupuncture AND xerostomia’, ‘acupuncture AND nausea’, ‘acupuncture AND emesis’, ‘radiation therapy’, ‘acupuncture AND dysphagia’, ‘radiation therapy side-effects’, ‘radiation’, ‘TCM’, ‘Traditional Chinese Medicine’, ‘acupuncture therapy’, ‘acupuncture AND radiation treatment’. The databases were searched between the dates of 23 February to 30 August 2022. A full list of sources reviewed is provided in the references section. Table 1 below illustrated an outline of the literature consulted.

Inclusion criteria

· Articles must be published in peer-reviewed journal;

· Studies must be published between 2012-2022; and

· Studies must focus on the use of acupuncture on radiation-induced complications among cancer patients.

Exclusion criteria

· Studies were published before the year of 2012;

· Articles published in non-peer reviewed journals; and

· Studies did not focus on radiation-induced complications among cancer patients.

Complications	Title of Study	Type of Study and sample size	Source
Stomatitis and Mucositis	Prioritizing Chinese Medicine clinical research questions in cancer palliative care from patient and caregiver perspectives	Qualitative 17 Participants (cancer survivors (n=6), Caregivers (n=6) and patients with cancer (n=5)	Wong et al. (2021)
Glossitis treated with acupuncture: Case series	Case report series 5 cases	Noh et al. (2016)
Clinical effect of acupuncture and moxibustion therapy with Chinese herbal preparation in patients undergoing radiotherapy for nasopharyngeal carcinoma	RCT 100 participants, treatment group (n=60), control group (n=40)	Wang & Wang (2015)
Reduction of opioid use by acupuncture in patients undergoing hematopoietic stem cell transplantation: Secondary analysis of a randomized, sham-controlled trial	RCT 60 participants (acupuncture group n=15), sham-acupuncture group (n=20), opioid group (n=20)	Deng et al. (2020)
Xerostomia	Randomized controlled trial of acupuncture for prevention of radiation-induced xerostomia among patients with nasopharyngeal carcinoma	RCT 40 participants	Meng et al. (2012)
Sham-controlled, randomised, feasibility trial of acupuncture for prevention of radiation-induced xerostomia among patients with nasopharyngeal carcinoma	RCT 23 participants (real acupuncture group (n=11), sham acupuncture group (n=12)	Meng et al. (2012)
Effect of true and sham acupuncture on radiation induced xerostomia among patients with head and neck cancer: A randomised clinical trial	RCT 339 (true acupuncture group (n=112), Sham-acupuncture group (n=115), control (n=112)	Garcia et al. (2019)
Phase II results of RTOG 0537: A Phase II/III study comparing acupuncture-like transcutaneous electrical nerve stimulation versus pilocarpine in treating early radiation-induced xerostomia	Phase 2 clinical trial 35 participants	Wong et al. (2012)
Improvement of radiation-induced xerostomia with acupuncture: A retrospective analysis	Pilot study 16 participants	Homb et al. (2014)
ARIX: A randomised trial of acupuncture V oral care sessions in patients with chronic xerostomia following treatment of head and neck cancer	RCT 145 participants	Simcock et al. (2013)
Nausea and Emesis	Acupuncture compared with placebo acupuncture in radiotherapy induced nausea- A randomized controlled study	RCT 215 participants (sham-acupuncture group (n=106) and acupuncture group (n=109)	Enblom et al. (2012)
Emesis in patients receiving acupuncture, sham acupuncture of standard care during chemo-radiation: A randomized controlled study	RCT 68 participants (verum acupuncture group (n=28) and sham acupuncture group (n=29), control (n=11)	Widgren & Enblom (2017)
A feasibility trial of acupuncture in cancer patients undergoing radiotherapy treatment	RCT 101 participants (acupuncture group (n=50) and standard care group (n=50)	Hughes et al. (2021)
Dysphagia	Study on effect of Zeng Ye Bai Hu Tang (Humour-increasing White Tiger Concoction) combined with pulse-taking acupuncture on dysphagia after radiotherapy for nasopharyngeal carcinoma and its influence to VCA-IgA, Rat-IgG antibody and SA Levels	RCT 83 participants (combination group (n=41) and control group (n=42)	Zhao et al. (2021)
Acupuncture for chemoradiation therapy-related dysphagia in head and neck cancer: A pilot random sham-controlled trial	Two-arm sham-controlled randomized Trial 42 participants (acupuncture group (n=21), sham acupuncture group (n=21)	Lu et al. (2016)
Effect of acupuncture in pain management of head and neck cancer radiotherapy: Prospective randomized unicentric study	Randomised open-label trial 62 participants (control arm (n=32), acupuncture arm (n=30)	Dymackova et al. (2021)

Table 1: An outline of the literature consulted in this study.

Data Analysis

The collation of this information as well as the analysis of related information was completed by using search word phrases relating solely to the use of acupuncture and radiation therapy as well as commonly experienced radiation-induced complications. The author thereafter employed content analysis approach to analyse the raw data (Venketsamy et al., 2021). Validity was addressed by identifying peer-reviewed journals, RCTs, cross- checking of references used, and the inclusion of both positive as well as negative findings relating to the outcomes experienced by patients utilising acupuncture therapy in the treatment of radiation-induced complications (Venketsamy & Hu, 2022).

3. Results

EBSCOhost, PubMed and ScienceDirect were consulted to acquire studies that contained the identified keywords. The studies were screened by the author to determine if they met the inclusion criteria. A total of 16 studies were recruited for the data analysis. This narrative review has included and analysed a total of 12 RCTs, 1 phase-2 clinical trial, 1 qualitative study, 1 pilot study and 1 case report series (total n= 16) focusing on the effects of acupuncture treatment in commonly experienced radiation-induced complications. The results were presented according to the complications, namely stomatitis, mucositis, xerostomia, nausea, emesis and dysphagia.

Stomatitis and Mucositis

A qualitative study conducted by Wong (2021) explored cancer patients and their caregivers undergoing palliative care about their experiences of acupuncture in the treatment of stomatitis. In this study, caregivers and patients mentioned that acupuncture was an effective form of treatment to relieve the discomfort experienced with stomatitis when given in combination with Loperamide. Positive views and experiences were expressed by cancer patients and their caregivers. his study however did not include exactly which acupuncture protocols and acupoints were used. On the contrary, Wang and Wang (2015) conducted a post radiotherapy study using a combination of ST6, ST7 and ST36, and Chinese herbal medicine, which focused on nourishing yin, tonifying qi and clearing heat. In the acupuncture treatment, acupoints were utilised bilaterally, which retain for a period of 15 minutes. The frequency of the treatment was five times a week continuously for two weeks. Wang ang Wang (2015) reported an improvement in patients receiving acupuncture with herbal formulae as compared to the control group which received no treatment (p<0.05).

A case report series published in 2016 focused on five separate cases of stomatitis and glossitis (a sub-category of stomatitis) treated with acupuncture. All five cases demonstrated the trend of heat syndrome which was specifically affecting the heart meridian. Noh et al (2016) therefore targeted treatment to points on the heart and kidney meridians. Acupoints used included HT3, HT8, KI2 and KI10. A strong manipulation was applied to these acupoints after needles were inserted, and needles were retained for a total of 15 minutes. Respondents reported a significant reduction in swelling, pustules, ulcers, and pain after acupuncture treatment. In their study, Deng et al (2020) studied the effectiveness of bilateral needling of acupoints ST36, KI3, PC6, SP6, LV3, GV20, EX-HN3, Ear Shen Men and HT7 compared to sham-acupuncture in head and neck cancer patients experiencing mucositis. Participants in the sham-acupuncture group were not penetrated by needles, but instead had the needles taped to the surface of their skin. The results of the study concluded that participants who had received acupuncture treatment demonstrated a significant improvement in pain relief as compared to those in the sham-acupuncture group (p<0.006).

Xerostomia

Meng (2012) conducted a RCT whereby 40 participants were treated three times a week on the same day of receiving radiotherapy. Results of this RCT supported a significant improvement in patients who received acupuncture treatment between the third week and 6 months (p<0.001). Part of the related findings included increased flow of saliva treated with acupuncture in the seventh week (p<0.0001). In a separate study conducted by Meng (2012) further compared the therapeutic differences amongst patients receiving “sham-acupuncture” and those receiving “true acupuncture”. The findings of this study concluded that participants who received true-acupuncture demonstrated a significant improvement in xerostomia as compared to those who received sham-acupuncture treatment (p<0.001). In their study, Garcia et al (2019) revealed a significant improvement in xerostomia after 1 year of treatment as compared to those treated in the sham-acupuncture group (p<0,001) from an RCT. The acupoints selected in this study were RN24, LU7, KI6, LI2, LI4, ST6 and SP6. On a similar vein, Wong et al. (2012) reported positive results from their study using electro acupuncture on SP6, CV24, ST36 and LI4. The treatment was applied two 20-minute sessions per week over a period of 12 weeks.

Homb et al., (2014) selected ST3, ST4, ST5, ST6, ST7, SI18,SI19, GB2, GB3, LI 4, LI11, SP6, DU20, RN23, RN24, Er Shen Men and Point Zero were used in patients struggling with post-radiation induced xerostomia. The first acupuncture session included auricular and manual acupuncture and all subsequent sessions included additional electroacupuncture. Electroacupuncture was applied to ST5, ST6 and ST7 bilaterally for 15-20 minutes. Auricular needles were retained in the ear acupoints for 3 days. Results of this study demonstrated a significant improvement in dry mouth symptoms (p<0.001) and pain (p<0.05) (Homb et al, 2014). Moveover, Simcock et al (2013) conducted a RCT on participants with chronic xerostomia post-treatment for head and neck cancer, and included acupoints LI2, LI20, auricular point Salivary gland 2, Modified point zero and Ear Shen Men. All points were needled bilaterally, and needles manually manipulated for 10 minutes. Sessions lasted for a total of 20 minutes and took place every week for a period of 8 weeks. Results concluded that patients who received acupuncture treatment experienced a significant reduction in symptoms of xerostomia (p<0.031).

Nausea and Emesis

A RCT comparing the effects of patients treated with true-acupuncture to those who were treated with sham-acupuncture, included participants receiving radiation therapy for rectal, pancreatic, testicular and stomach cancers. Those treated with acupuncture were administered treatment sessions of 30-minute duration, three times weekly for two weeks, which was then followed by radiation therapy administered twice per week. PC6 was administered bilaterally at a depth of half cun. Results demonstrated no statistical significance between participants treated with true- versus sham- acupuncture points. It was further concluded that on a basis of scientific findings and statistical analyses that penetrating acupuncture of PC6 demonstrated no effect on nausea relief (Enblom et al, 2012). In another study, Widgren and Enblom (2017) compared to sham-acupuncture in its effectiveness in assisting patients experiencing nausea and emesis in radiotherapy. PC6 was needled with twirling and lifting manipulation at a rate of three times per session. Sham acupuncture was applied by making use of a needle which did not pierce the skin or produce sensation of “de qi”. Upon cross-sectional analysis, it was identified that participants who received verum acupuncture were less likely to require antiemetics (p<0,049). However, there was no significant difference in levels of nausea as compared to the sham-acupuncture group (p<0,074) (Widgren & Enblom, 2017).

Hughes et al (2021) conducted a RCT and made use of PC6 bilaterally together with CV21, LI4, LV3, SP6 and ST36. Participants received 3- 8 weekly acupuncture treatments, and this was determined by the number of prescribed radiotherapy treatments. Reports from radiographers who administered acupuncture treatments included a noticeable improvement in patients who received acupuncture treatment. Participants mentioned a complete alleviation in their nausea while others mentioned their relief was short-lived.

Dysphagia

A study conducted by Zhao et al (2021) made use of administering acupuncture treatments to patients experiencing dysphagia after receiving radiotherapy for nasopharyngeal carcinoma. Acupoints were selected based on “pulse-taking” acupuncture theory, to differentiate between Yin and Yang syndrome patient categories. Participants who fell into the Yin category were treated with acupoints SP9, KI7, KI6 and KI3 whereas participants in the Yang category were treated with acupoints ST9, LI18 and EX-HN1. Chief acupoints used in conjunction with the afore-mentioned points included GB20, DU20, DU16, GB2, RN23, SJ17, EX-HN12, EX-HN13, ST36, SP9, GB34, RN6 and RN12. Needles were retained for 30 minutes, and treatment continued at a frequency of every other day for a total of 4 weeks. Those in the Yang category received acupuncture with reducing method, whereas participants in the yin category were treated with reinforcing technique. Zhao et al (2021) further divided study participants into two groups: one group which received acupuncture only and a second group which received a combination of acupuncture and herbal formulation Zheng Ye Bai Hu Tang. This study found that a combination of acupuncture and Zheng Ye Bai Hu Tang demonstrated a significantly higher improvement in symptoms as compared to participants who only received acupuncture treatment (P<0.05).

A two-arm sham-controlled randomised trial conducted by Lu et al (2016) compared the effects of sham acupuncture and active acupuncture in patients treated with radiotherapy for head and neck cancer. Participants in the active acupuncture group were treated with acupoints ST36, SP9, LI2, LI11, KI3, GB20, GB24, ST5, ST7, CV24, CV23, GB20, EX-HN3 and SI16. Needles were inserted to a depth of 5-10 mm depending on the patient’s body build and stimulated until the arrival of qi was felt. Electroacupuncture was thereafter applied to EX-HN3 and GB20 at 30-minute intervals. Treatments were conducted at a frequency of once a week every two weeks over a period of 24 weeks. The sham-acupuncture group were treated with shallow insertion, thin acupuncture needles and no manipulation was conducted. Results of this study found that symptoms improved in both the active and sham acupuncture groups (Acupuncture: +7,9; Sham-acupuncture +13,9; p=0,044, p<0,001).

Dymackova et al (2021) conducted a randomised open-label trial to identify the effects of using acupoints LU7, LI4, ST36 and KI7 at a frequency of 1-3 times weekly for 10-20 minutes at a time during radiotherapy sessions. The findings of this study concluded that pain associated with dysphagia was significantly reduced in patients who received acupuncture therapy, as compared to those who did not (p<0,001). Table 2 below provided a summary of acupoints as well as auxiliary approaches adopted in the above studies.

Complications	Acupoints selected	Auxiliary approaches	Outcome
Stomatitis and Mucositis	HT3, HT8, KI2 and KI10		Positive
ST6, ST7 and ST36	Cooling and tonifying traditional Chinese Herbs	Positive
Er Shen Men, EX-HN3 GV20, HT7, KI3, LV3, PC6, SP6 and ST36		Positive
Xerostomia	Er Shen Men, KI6, Larynx, LU7, Point Zero, RN24 and Salivary Gland-2 Prime		Positive
KI6, LI2, LI4, LU7, RN24, SP6, ST36 and ST6		Positive
CV24, LI4, SP6 and ST36	Acupuncture-like transcutaneous electrical nerve stimulation applied to the listed acupuncture points	Positive
DU20, Er Shen Men, GB2, GB3, LI11, LI4, Point Zero RN23, RN24, SI19, SP6, ST3, ST4, ST5, ST6 and ST7		Positive
	Auricular point Salivary gland 2, Er Shen Men, LI2, LI20 and modified Point Zero		Positive
Nausea and Emesis	PC6		Negative
PC6		Positive
CV21, LI4, LV3, PC6		Negative
Dysphagia	DU16, DU20, EX-HN1, EX-HN12, EX-HN13, GB2, GB20, GB24, KI3, KI6, KI7, LI18, RN12, RN23, RN6, SJ17, SP9, ST36 and ST9	Zheng ye Bai Hu Tang	Positive
CV23, CV24, GB20, GB24 KI3, LI11, LI2, SI16, SP9 ST36, ST5, ST7 and EX-HN3		Positive
KI7, LI4, LU7 and ST36		Positive

Table 2: A summary of acupoints and auxiliary approaches adopted in the above studies.

4. Discussion

Acupuncture has been used in practice to treat various disease for over 2000 years (Okada et al., 2020). The efficacy of acupuncture treatments profoundly depends on the physical state of the patient and severity of disease. Furthermore, needling techniques, such as needle insertions, correct selections of acupoints, depth of the insertion, retention period of the treatment and the frequency of treatments, significantly influence the outcomes of the treatment (Grant et al, 2015). Selections of meridian systems and appropriate acupoints play important roles in treatment planning, which should be based on a patient’s individual presentation of their symptoms (Noh et al, 2016). Acupoints are categorised based on various functions, with some of these points falling under the category of “extraordinary”, points which possess therapeutic properties, and “A-shi” points which are points with no fixed location but represent as a reflexive point in pain syndromes (Liao et al, 2013).

In TCM, there are various syndromes which are considered in cases of disease. A syndrome in TCM is a term collectively given to a particular group of symptoms and signs demonstrating the clinical phenotypes of the stages of a particular disease and is often used as a means of identifying various patterns in the human body and guiding the correct selection of TCM treatments (Chen & Wang, 2012). In patients with cancer, there is often an associated depletion of qi and yin which can lead to deficiency syndromes or heat syndromes. The main area of focus in treatment for such patients should involve the strengthening of qi and elimination of evil qi (Ji et al, 2016). It is of utmost importance to consider a TCM treatment principle which states that “the same disease may be treated by different therapies, or different diseases may be treated by the same therapy”, when considering creating a treatment plan for each patient (Hu, 2022). The diagnosis of a syndrome involves taking into consideration the symptoms, lifestyle, habits, and medical history of the patient along with assessing the colour of their skin, the shape, colour and body of their tongue and it’s coating and the 12 radial pulses (Stone et al, 2012).

Radiation therapy consumes the yin and qi of the body, which thus leading to the development of a fire/heat syndrome. Common symptoms of yin deficiency include dry mouth and throat, tidal fever, night sweats, red tongue with scanty coating and a thready pulse. Yin deficiency can further affect the skin and body fluids, resulting in dry and red skin. In such cases, treatment should be focused on clearing the heat from the body and nourishing the patient’s yin and qi (Hsu et al., 2016; Park et al., 2013). Yin meridians include the Lung, heart and pericardium meridians of the hand, and the liver, kidney and spleen meridians of the foot (Chang et al, 2019).

Stomatitis and Mucositis

Stomatitis and mucositis, conditions often occurring intercurrently, are common complications in patients receiving high-dose radiation therapy for head and neck cancers shape (Chen et al, 2022). These conditions are often recognised by symptoms such as inflammation of the oral mucous membranes, impaired intake of nutrients and severe oral pain (Lalla et al, 2019). The lesions observed in cases of stomatitis can often be described as painful, circumscribed with a grey-yellow coloured floor and ovoid in shape (Chen et al, 2022). The acupoints used in the treatment of stomatitis and mucositis across the RCTs and case reports included HT3, HT7, HT8, KI2, KI3, KI10, ST6, ST7, ST36, PC6, SP6, LV3, GV20, EX-HN3 and Er Shen Men (Deng et al, 2020; Noh et al, 2016; Wang & Wang, 2015; Wong et al, 2021). These studies demonstrated a common theme of positive results in participants who received acupuncture treatment as opposed to those who did not receive treatment. In TCM theory, stomatitis has been described as originating with issues of the heart and the spleen. The most common syndromes which cause stomatitis include qi and blood deficiency and fire and yin deficiency (Zhang et al 2018). In this instance, the heart is related to the Sanjiao, as it is located in the upper jiao, and pertains to the function of Yang with its element being fire. The Kidney is located in the lower Jiao and its main element is water, and the kidney functions in balancing the heart fire. The heart and kidney share a close relationship in zang-fu theory of Chinese medicine and treatment of a disorder of one organ will require a combined treatment of the other to achieve therapeutic benefit (Dong et al, 2017). From observing the points used in the treatment of stomatitis and comparing them to TCM theory, the points correlate to one another to create a therapeutic benefit, hence explaining the favourable results seen in the studies analysed.

Xerostomia

Dysfunction of the salivary glands is referred to as “heat toxin” in Chinese medicine theory and can fall under the category of being either an excess syndrome (as a result of Blood-heat, lung-heat, or excess heat toxin) or a deficiency syndrome (Stomach-yin deficiency, Qi-yin deficiency or Yin deficiency) (Zhu & Wang, 2018). Acupoints used in the treatment of Xerostomia included RN23, RN24, LU7, KI6, Auricular point zero, Salivary gland 2, Larynx, LI2, LI4, LI11, ST6, SP6, ST36, ST3, St4, ST5, ST7, SI19, GB2, GB3 and DU20. All studies focused mainly on using the Ren and Stomach meridians along with auricular points and showed positive results (Garcia et al, 2019; Homb et al, 2014; Meng et al, 2012; Simcock et al, 2013; Wong et al, 2012). The acupoints located on the face (ST3, ST4, ST5, ST7, ST6, GB2, GB3 and SI19) are located along the cutaneous branches of the trigeminal and facial nerves (Zhou & Benharash, 2014). The facial nerve supplies the sublingual and submandibular glands, which are responsible for the production of saliva. Treatment success of xerostomia is dependent on an appropriate production of saliva (Ami & Wolff, 2010). It can be hypothesised that the positive results observed in all of the above studies could be attributed to the ability to stimulate the facial nerve and therefore improve salivation (Garcia et al, 2019; Homb et al, 2014; Simcock et al, 2013). It would be interesting to see future studies which focus on observing if this is indeed the case.

Nausea and Emesis

The common acupoint used in studies identifying the effectiveness of acupuncture treatment in nausea and emesis was PC6 (Enblom et al, 2012; Hughes et al, 2021; Widgren & Enblom, 2017). PC6 can be utilised to regulate gastric function and maintains the internal organs of the body and has further demonstrated an ability to promote gastric digestive function recovery. Additional acupoints usually considered in the treatment of nausea and emesis include RN12, which is a local point described as one of the most important points on the abdomen due to its combined nature of being a meridian, special and local point. PC6, ST36 and RN12 have an important combined function when used together to restore gastrointestinal integrity and reduce associated symptoms of gastrointestinal dysfunction (Zhang, et al 2021). One theory behind the mechanism of action of these points, is for their ability to activate the dorsal reticular nucleus of the medulla oblongata (Ji et al, 2009). Two studies (Enblom et al, 2012; Hughes et al, 2021) out of the three studies included in this narrative review demonstrated no improvement in symptoms, however it is worth noting that these studies made use of PC6 on its own, without ST36 and RN12 which could be a reason behind the lack of improvement in symptoms.

Dysphagia

In the case of dysphagia, threee RCTs met the inclusion criteria for this narrative review (Dymackova et al, 2021; Lu et al, 2016; Zhao et al, 2021). All three of these RCTs reported positive result when compared to the placebo group. The commonly used acupoints in these studies included KI7 and ST36. As mentioned previously, the kidney has a close relationship with the heart in TCM theory, and ST36 is important for supporting the entire gastrointestinal system and tonifying. What is important to note, is that in the clinical trial conducted by Zhao et al (2021) it was the participants who received both the herbal concoction Zheng Ye Bai Hu Tang and acupuncture treatment that demonstrated improved symptoms. The difference in acupoints used in the studies conducted by Zhao et al (2021) and Dymackova et al (2021) is the selection of LU7 and LI4 in addition to KI7 and ST36. In TCM theory, the Lung meridian has a special function in assisting with disorders of the throat and governs the qi of the body (Chang et al, 2019). Participants in the Lu et al (2016) study showed improvement in symptoms in both the sham-acupuncture and acupuncture groups. A potential explanation of this could relate back to above mentioned information relating to “a-shi” points, which are points that are tender to the touch and still have therapeutic properties based on the patient. However, further studies are a necessity to exclude the potential placebo effect in patients treated with sham-acupuncture.

5. Conclusion and recommendations

Radiation therapy is used for its high-dose radiation function of targeting cancer cells in more than half of patients diagnosed with cancer (Baskar et al, 2012). Whilst this form of treatment is effective, it can induce painful and severe side effects, which have a large effect on the quality of life for most patients (Chowdhury & Saheda, 2020; Jacob et al, 2022). Acupoints are considered entities which are pathologically dynamic, and their sensitivity is largely affected by changes to the individual’s homeostasis, and patients who have more tender sensation by acupoints would require more treatments as opposed to those who do not experience any tender sensation by the acupoints. The reason for this being that those with more sensitive points depict an impaired self-healing capability (Zhou & Benharash, 2014). The author thereafter is of the opinion that it is important to consider the vitality of a patient when prescribing acupuncture prescriptions.

It is therefore important to consider individualised needle manipulation methods in RCT participants based on their disease presentation, vitality and sensation at the acupoints in order to achieve optimal results. In studies where there were no therapeutic effects observed or if the benefit was equivalent to that seen in sham-acupuncture groups, it is important to reflect on if the needle was manipulated appropriately, the needle depth was correct and if the point was accurately located. Acupuncture therapy could be an important inclusion in assisting patients receiving radiation therapy. There is an urgent need to design and conduct clinical trials with high-quality and suitable methodologies relating to radiation-induced complications. This will provide a more careful and comprehensive evaluation of acupuncture effectiveness in management of radiation-induced complications. Based on the results and discussion, the author thereafter recommends:

· It is recommended that future studies focus on the importance of establishing individualised acupuncture treatments for patients. Because current studies lack the inclusion of individualised treatments which is of vital importance in TCM theory of syndromes.

· Study groups should be separated in accordance with their TCM syndrome diagnosis along with sham-acupuncture and control groups.

· Consideration of depth, length and frequency of treatments should be adjusted in accordance with patient vitality and TCM syndrome diagnosis.

Acknowledgement

N/A.

Author’s Disclosure Statement

The study wasn’t funded by any organization or institution. The author declared that she had no financial or personal relationships that might have inappropriately influenced her in writing this article.

Declaration

The author declared no conflicts of interest.

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