Oncological and functional outcome after laryngectomy for laryngeal and hypopharyngeal cancer: a population-based analysis in Germany from 2001 to 2020.

Prognostic factors for overall survival (OS), percutaneous endoscopic gastrostomy (PEG) dependency, and long-term speech rehabilitation via voice prosthesis (VP) after laryngectomy for laryngeal or hypopharyngeal cancer were investigated in a retrospective population-based study in Thuringia, Germany. A total of 617 patients (68.7% larynx; hypopharynx; 31.3%; 93.7% men; median age 62 years; 66.0% stage IV) from 2001 to 2020 were included. Kaplan-Meier and Cox multivariable regression analyses were performed. 23.7% of patients received a PEG. 74.7% received a VP. Median OS was 131 months. Independent factors for lower OS were stage IV (compared to stage II; hazard ratio [HR] = 3.455; confidence interval [CI] 1.395-8.556) and laryngectomy for a recurrent disease (HR = 1.550; CI 1.078-2.228). Median time to PEG removal was 7 months. Prior partial surgery before laryngectomy showed a tendency for independent association for later PEG removal (HR = 1.959; CI 0.921-4.167). Postoperative aspiration needing treatment was an independent risk factor (HR = 2.679; CI 1.001-7.167) for later definitive VP removal. Laryngectomy continuously plays an important role in a curative daily routine treatment setting of advanced laryngeal or hypopharyngeal cancer in Germany. Long-term dependency on nutrition via PEG is an important issue, whereas use of VP is a stable long-term measure for voice rehabilitation.

Prioritization and resource allocation in the context of the COVID-19 pandemic. Recommendations for colorectal and pancreatic cancer in Germany.

In the context of the COVID-19 pandemic, there has been a scarcity of resources with various effects on the care of cancer patients. This paper provides an English summary of a German guideline on prioritization and resource allocation for colorectal and pancreatic cancer in the context of the pandemic. Based on a selective literature review as well as empirical and ethical analyses, the research team of the CancerCOVID Consortium drafted recommendations for prioritizing diagnostic and treatment measures for both entities. The final version of the guideline received consent from the executive boards of nine societies of the Association of Scientific Medical Societies in Germany (AWMF), 20 further professional organizations and 22 other experts from various disciplines as well as patient representatives. The guiding principle for the prioritization of decisions is the minimization of harm. Prioritization decisions to fulfill this overall goal should be guided by 1. the urgency relevant to avoid or reduce harm; 2. the likelihood of success of the diagnostic or therapeutic measure advised; and 3. the availability of alternative treatment options. In the event of a relevant risk of harm as a result of prioritization, these decisions should be made by means of a team approach. Gender, age, disability, ethnicity, origin and other social characteristics, such as social or insurance status, as well as the vehemence of a patient's treatment request and SARS-CoV-2 vaccination status should not be used as prioritization criteria. The guideline provides concrete recommendations for 1. diagnostic procedures, 2. surgical procedures for cancer, and 3. systemic treatment and radiotherapy in patients with colorectal or pancreatic cancer within the context of the German healthcare system.

Spirituality in Oncology: Relations between Spirituality, Its Facets, and Psychological and Demographic Factors in Cancer Patients in Germany.

INTRODUCTION: Cancer diagnoses are constantly increasing in clinical practice. Therefore, more and more patients are interested in how they can actively participate in the process of treatment. Spirituality represents a hidden issue of the population, which counts as a branch of complementary and alternative treatment. Therefore, the aim of our study was to investigate whether there are associations between spirituality and demographic and psychosocial factors, as well as religious beliefs, in cancer patients. METHODS: We conducted a survey with 451 participants in 10 oncology centers between March and July 2021. A composition of the following 9 different questionnaires was used to collect data on spirituality, demographics, resilience, self-efficiency, life satisfaction, and sense of coherence: Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being (FACIT-Sp12), General Life Satisfaction Short Scale (L-1), Resilienzskala Kurzform (RS-13), Sense of Coherence Scale - Leipziger Kurzform (SOC-L9), Allgemeine Selbstwirksamkeit Kurzskala (AKSU), Adolescent Food Habits Checklist, Likert-Scale of daily activities, questionnaire of the Working group Prävention und Integrative Onkologie (PRiO), and personal opinion on the cause of the disease. Calculated data and analyzed group differences using ANOVA Bonferroni were used to test associations between spirituality and the variables studied. For more detailed examination of spirituality, we took a closer look at the different components of spirituality - peace, meaning, and faith - and their relation to each other (three-factor spirituality analyses). RESULTS: Higher spirituality scores in total as well as meaning, peace, and faith were each associated with higher levels of resilience and life satisfaction. Higher religious belief was found to be associated with higher spiritual attitudes. High personal self-efficiency was found in people with higher spiritual beliefs in general as well as higher meaning and peace. Meaning and peace emerge as essential components of spiritual well-being and show a stronger association with expressions of general spirituality than faith. CONCLUSION: Spirituality takes a crucial role among the resources of life-threatening diseases. As such, further research is needed to expand and integrate patient options into a modernized concept of care. Our data indicate that higher spiritual well-being is associated with a more tolerant approach to illness. Thus, addressing spiritual needs in therapy is associated with better psychological adjustment to the individual situation and reduces negative distress. To promote spiritual needs in the future, cognitive as well as affective components of spirituality should be emphasized.

Impact of nutrition counseling on nutrition status in patients with head and neck cancer undergoing radio- or radiochemotherapy: a systematic review.

PURPOSE: In this systematic review, we included randomized controlled trials from 2004 to 2021 to determine the effect of individual dietary counseling for patients with head and neck cancer, specifically, nutritional outcome, morbidity, and quality of life (QOL), during and after chemo- and chemoradiotherapy. METHODS: In October 2023, a systematic search was conducted searching five electronic databases (Embase, Cochrane, PsychInfo, CINAHL, and Medline) to find studies concerning the use and effectiveness of intensive nutritional care on head and neck cancer patients. RESULTS: From all 2565 search results, 6 studies with 685 head and neck cancer patients were included in this systematic review. The patients were treated with radiotherapy or radiochemotherapy. The therapy concepts include intensive nutritional support from a dietician. Outcomes were nutritional status, body composition, quality of life, and adverse effect. All studies had low quality, high risk of bias, and reported heterogeneous results: some studies reported significant improved nutrition status, body composition and quality of life, while other studies did not find any changes concerning these endpoints. CONCLUSION: Due to the very heterogeneous results and methodical limitations of the included studies, a clear statement regarding the effectiveness of intensive nutritional therapy of head and neck cancer patients is not possible. Further well-planned studies are needed.

Impact of Human Papillomavirus-Negative Dominance in Oropharyngeal Cancer on Overall Survival: A Population-Based Analysis in Germany from 2018 to 2020.

The impact of the relation of human papillomavirus (HPV) and smoking status of oropharyngeal squamous cell carcinoma (OPSCC) on overall survival (OS) was investigated in a retrospective population-based study in Thuringia, Germany. A total of 498 patients with OPSCC (76.9% men; mean age 62.5 years) from 2018 to 2020 were included. OPSCC cases were 37.3% HPV-positive (+) (31.2% smokers; mean incidence: 2.91/100,000 population) and 57.8% HPV-negative (63.5% smokers; mean incidence: 4.50/100,000 population). Median follow-up was 20 months. HPV+ patients had significantly better OS than HPV-negative (-) patients (HPV+: 2-year OS: 90.9%; HPV-: 2-year OS: 73.6%; p < 0.001). In multivariable analysis, HPV- patients (hazard ratio (HR) = 4.5; 95% confidence interval (CI): 2.4-8.6), patients with higher N classification (N2: HR = 3.3; 95% CI: 1.71-6.20; N3: HR = 3.6; 95% CI: 1.75-7.31) and with a higher cancer staging (III: HR = 5.7; 95% CI: 1.8-17.6; IV: HR = 19.3; 95% CI: 6.3-57.3) had an increased hazard of death. HPV- smokers formed the majority in Thuringia. Nicotine and alcohol habits had no impact on OS. Optimizing OPSCC therapeutic strategies due to the dominance of HPV- is more important than discussing de-escalation strategies for HPV+ patients.

The quality of German - language patient decision aids for oncological patients on the internet.

BACKGROUND: Previous studies have already shown that decision aids are a suitable tool for patient decision-making. The aim of this work is to conduct an online search for freely available, German-language patient decision aids (PDAs) for cancer patients, followed by an assessment of their quality. For this purpose, a rating tool that is as manageable as possible was developed on the basis of already existing quality criteria. METHODS: A simulated patient online search was conducted via the four most frequently used search engines in Germany. A quality assessment tool was created utilizing international and national guidelines, with a focus on practicality and manageability. Subsequently, the identified PDAs were rated by 4 raters based on the rating tool. RESULTS: The number of German-language oncology PDAs is low (n = 22 of 200 URLs) with limited variability regarding rare cancers. Most originate from non-profit organizations. The overall quality is low, as indicated by an average of 57.52% of the maximum evaluation points of the developed quality assessment tool. Reference values used to assess quality were related to e.g. support/effectiveness, adaptation, layout, etc. No qualitative differences were found regarding different publishers. Quality differed between PDAs of different length, with longer PDAs achieving better results. CONCLUSION: Overall, the supply and quality of German-language PDAs is not satisfactory. The assessment tool created in this study provides a solid, but more manageable basis, for developing and identifying high-quality PDAs. PRACTICE IMPLICATIONS: PDAs should be increasingly used by physicians in practice. For this, a quick qualitative assessment of PDAs in everyday life must be possible. Future research has to investigate especially the aspect of the length of a PDA in more detail.

Psychosocial effects of the corona pandemic on people with cancer: a qualitative study.

INTRODUCTION: The Corona pandemic caused far-reaching changes since 2020. We wanted to find out which factors determined the psycho-social well-being of cancer patients during the pandemic. METHODS: From May to July 2021, structured interviews were conducted concerning lockdown, social limitations, the virus itself, the treatment situation, and opportunities. RESULTS: Twenty people took part in the study (doctors, psychologists, nurses, social workers, patients). One of the most important aspects was the ban on visits. Others were the fear of infection and the possibility of vaccination. Wearing a mask seem to have been worse for the experts. Conflicts in families about the "right" behavior to protect yourself from infection have been a stressful issue for patients, just as the lack of balance and recreation in free time. CONCLUSION: Patients in the third wave of corona have become accustomed to the rules. Especially loneliness and the organization of time at home are psycho-social stress factors.

[Complementary and alternative medicine-An option for chronic pain patients?] / Komplementäre und alternative Medizin ­ eine Option bei chronischen Schmerzpatienten?

The interest of patients with chronic pain in complementary and alternative medicine (CAM) is high. The aim of an accompanying complementary therapy is to strengthen the patient's self-efficacy, the ability to make decisions and the autonomy. The best evidence exists for physical activity and a balanced diet. Exercise combinations of strength and endurance as well as targeted strengthening of the muscles in the area of the pain are particularly suitable. When choosing the form of exercise, low-threshold training options are recommended. There is no reliable evidence for kinesio taping, homeopathy, neural therapy and draining procedures. The extensive data on acupuncture must be interpreted taking methodological limitations into account. Heat applications can support multimodal pain therapy. In the case of anti-inflammatory phytotherapeutic agents, there are good rationales from basic research and reliable empirical knowledge regarding the dosage. The evidence on cannabis is low.

Why We Should Look at Dinner Plates: Diet Changes in Cancer Patients.

OBJECTIVE: Malnutrition is often underestimated in the context of cancer therapy: the dietary trends initiated by patients after diagnosis are usually neither known to nor evaluated by the medical staff. Here, we propose a combined screening instrument evaluating malnutrition and dietary trends. METHODS: The validated screening tool NRS-2002 was combined with a four-item questionnaire assessing whether (1) patients preferred certain foods, (2) avoided certain foods, (3) used dietary supplements or followed a special diet since the time of cancer diagnosis. The screening tool was routinely used by cancer patients in the daily practice of three oncological departments. The presented analysis was performed retrospectively and anonymized. RESULTS: Overall, 102 cancer patients undergoing systemic therapy (CP), 97 undergoing radiation therapy (RP), and 36 head-neck cancer patients (HNP) were screened. The CP cohort showed a higher rate of malnutrition (50.00%) than the HNP (28.13%) or RP (26.80%) cohort. Overall, diet changes were observed in 33.63% of all patients. Avoiding meat, stimulants, or hard and edgy food was often mentioned in free text answers, while patients reported a preference for fruit and vegetables. Nutritional supplements were used by 28.76% of the patients. While dietary changes were common, only 6.64% of the patients mentioned adhering to a specific cancer diet. CONCLUSION: Malnutrition is still underestimated nowadays. Diet trends, especially avoiding certain foods, are common in cancer patients, while adhering to a specific cancer diet is an exception. Diet trends should be assessed and addressed to avoid or aggravate malnutrition.

Umbrella review: Summary of findings for acupuncture as treatment for radiation-induced xerostomia.

Acupuncture is a common part of complementary medicine. However, traditional Chinese acupuncture has been built on concepts which are not in accordance with science-based medicine. Our aim was to critically assess the evidence presented in systematic reviews (SRs) and meta-analyses (MAs) about the effectiveness of acupuncture on radiotherapy induced xerostomia. A systematic search was conducted in February 2022. We evaluated all SRs/MAs using the AMSTAR-2 instrument. Eight SRs, with 12 controlled studies were included. All SRs summarize that the methodological drawbacks do not allow to give a clear statement about the effectiveness of acupuncture. While objective assessments in most SRs/MAs reported no difference between real and sham acupuncture, some favorable effects on subjective xerostomia symptoms are found. No clinical meaningful effectiveness of acupuncture on xerostomia has been proven so far, but positive subjective findings need to be explored more. While most SRs recommend further studies, studies involving patients with a serious cancer diagnosis are ethically questionable.

"I do not hear you!": hearing-impaired cancer patients report their communication experiences.

PURPOSE: Hearing impairment has a high impact on communication between cancer patients and their oncologists. What is the patient's perspective on this problem and how can physicians draw lessons from it? METHODS: Together with otorhinolaryngologists and hearing-impaired patients, we developed a questionnaire including the sections: WHO (Five) Well-Being Index (5 items), Abbreviated Profile of Hearing Aid Benefit (APHAB) as established self-estimation of hearing function (24 items), use of hearing aid (4 items) as well as patients' experiences (15 items), difficulties (9 items) and wishes (7 items) regarding the communication with physicians. The experiences, difficulties, wishes, and life satisfaction of cancer patients were analyzed between groups based on participants' APHAB scores, well-being and use of hearing aids. A total of 104 cancer survivors (median age 76.5 years, range 32-90 years) were included. RESULTS: Between the groups of subjectively hearing-impaired and normal hearing participants, we registered a significant difference in difficulties in conversation, wishes for physician-patient communication and psychological well-being. Depending on participants' well-being, wishes and difficulties differed. Differences were also found between participants with and without hearing aids in terms of difficulties in conversation, but not in terms of their wishes and well-being. A large proportion of participants classified as subjectively hearing-impaired according to APHAB already had a hearing aid. CONCLUSIONS: Cancer patients with hearing loss are very restricted in their understanding of given information and hearing aid use cannot completely compensate for this. Consequently, communication guidelines should be considered and specific educational tools need to be developed for these groups.

[Mortality risk for oral and oropharyngeal carcinomas in Thuringia: a population-based analysis]. / Sterberisiko für Mundhöhlen- und Oropharynxkarzinome in Thüringen: eine bevölkerungsbasierte Analyse.

OBJECTIVE: This population-based study investigates the impact of HPV association on overall survival (OS) of oral cavity (OSCC) and oropharyngeal squamous cell carcinoma (OPSCC) in Thuringia and the incidence of HPV-positive (HPV+) and HPV-negative (HPV-) tumors. METHODS: A total of 308 patients (83.4% men; mean age 57.6 years) with a primary diagnosis of OSCC (38%) or OPSCC (62%) from 2008 were included in the study. Descriptive statistics were obtained for the variables. According to Ang's risk classification, patients were classified as low risk of death (HPV+, nonsmokers), intermediate risk (HPV+, smokers) and high risk of death (HPV-smokers). Kaplan-Meier analyses and Cox multivariable regression analysis were performed to examine OS. RESULTS: 22.5% of OPSCC was HPV+ (incidence: 1.89/100,000 population; thereof 80.1% smokers). The proportion of OSCC with HPV+ was 8.5% (incidence: 0.44/100,000; thereof 78.6% smokers). The median follow-up was 31 months. HPV+ patients had significantly better 5-year OS than HPV- patients (81% vs. 49%; p < 0.001). In multivariable analysis lower OS were associated with: HPV-patients (hazard ratio (HR) = 3.2; 95% confidence interval (CI) = 1.6-6.4; p = 0.001), high risk of death according to Ang (HR = 2.3; 95% CI = 1.0-5.4; p = 0.049), older age (HR = 1.7; 95% CI = 1.1-2.4; p = 0.01), T3/T4-classification (HR = 2.1; 95% CI = 1.3-3.2; p = 0.001) and the presence of distant metastases (HR = 2.7; 95% CI = 1.6-4.4; p < 0.001). CONCLUSIONS: HPV+ non-smokers were minority in Thuringia. The majority of HPV+ patients had an intermediate risk of death due to cigarette smoking.

Usage of Complementary and Alternative Methods, Lifestyle, and Psychological Variables in Cancer Care.

BACKGROUND/AIM: People who are undergoing cancer treatment often ask themselves what they can do in addition to conventional medical therapy with regard to nutrition, activity, and complementary methods. However, we know little about the motivation why people opt for one or the other measure. The aim of this study was therefore to examine the extent of physical activity (PA), healthy nutrition, and the use of complementary methods in relation to both demographic and psychological data. MATERIALS AND METHODS: A questionnaire was used to collect data on demographic data, resilience, coherence, self-efficacy, spirituality, satisfaction, and complementary and alternative medicine (CAM) behavior, PA, and diet. Between March and July 2021, data from 446 patients were collected. Regression models and correlation analyzes were used to examine the associations between CAM use, diet and PA with the other variables surveyed. RESULTS: CAM usage could only be predicted based on the patient's spirituality. Women used CAM more often and ate more healthily. Healthy eating was also related to younger age, shorter medical history, resilience, satisfaction, and coherence. In addition, the results showed that daily PA was related to the level of resilience, spirituality, and self-efficacy. CONCLUSION: Which people or why patients use CAM remains a question to be further investigated. Our data suggest that CAM seeks to address similar needs that others find in spirituality. In order to promote a healthy diet and PA in cancer patients in the future, various psychological variables seem conceivable. Resilience stands out, which is related to an overall healthier lifestyle.

[Essential trace elements, vitamins, and selected electrolytes in complementary medicine for cancer patients]. / Essentielle Spurenelemente, Vitamine und ausgewählte Elektrolyte in der Komplementärmedizin für Tumorpatienten.

OBJECTIVE: Are there any evidence-based medicine (EBM)-supported treatment approaches of complementary and alternative medicine (CAM) methods for urological oncologists? METHODS: We reviewed the actual German S3 guidelines "Supportive Care" and "Complementary Medicine" as well as the online-tool Onkopedia for recommendations about essential trace elements (Zn, Se, Mn, Fe), vitamins (A, B, C, D, E), and electrolytes (Mg, Ca). Furthermore, we added results of randomized trials to present potential future developments. RESULTS: Each therapy with micronutrients should be based on laboratory observation of a deficit. There are selected guideline recommendations for selenium, iron and vitamin D. Potential indications were registered for manganese, vitamin A derivates, and vitamin C. No benefit was observed for vitamin B, zinc, and vitamin E. CONCLUSION: Micronutrients should be substituted in the case of deficit. General supplementation of daily nutrition is not recommended for cancer patients.

Decision-making by cancer patients and the role of a counselling facility for complementary and alternative medicine: a cohort study.

OBJECTIVE: The aim of this cohort study was to gain insight on influencing factors on the decision-making process in conventional medicine compared to complementary and alternative medicine (CAM). METHODS: A standardized questionnaire was distributed among cancer patients who attended the counselling facility for CAM of a German university hospital in 2020. RESULTS: Fifty patients (30.3%) returned the questionnaire. After counselling on CAM, most patients made a decision in CAM but also in conventional medicine. Thus, the focus on informed decision-making during counselling on CAM had a strong effect on the decision-making process in conventional medicine. Patients reporting good support also reported making decisions together with physicians and relatives. Moreover, after counselling on CAM, patients reported being more satisfied with their decision in both settings afterwards. CONCLUSION: Information on CAM which focuses on informed decision-making, supports patient's ability to understand and weigh risks and benefits of treatments, supports shared decision-making and enables patients to transfer these competences also to decisions on conventional medicine. So counselling on CAM may further decision-making competences in cancer patients. This encourages patients to engage in shared decision-making and increases patient's satisfaction with decisions.

Can Cancer Education Programs Improve Health Literacy Among Deaf and Hard of Hearing Patients: a Systematic Review.

Patients affected from hearing loss face many problems when visiting oncologists. We conducted a systematic review to survey if cancer education programs can promote health literacy among deaf and hard of hearing (DHH) patients. The authors searched two databases for RCTs, and cohort studies with interventions promoting cancer health literacy for adult DHH patients. Risk of bias was assessed with SIGN Methodology Checklist for RCTs, and cohort studies. Significance of mean changes over time, and mean differences between comparison groups were used to present outcomes of each study. Surveyed interventions addressed three domains: cancer knowledge, coping skills, and cancer screening. Key information was gathered and synthesized providing a juxtaposition of the content and presenting important effects in detail. Nine RCTs and seven cohorts with 1865 participants were included. In total, 13 studies showed that cancer health literacy interventions improved mean scores significantly from pre- to post-test measures. There are hints that captioning and written texts may be sufficient for milder forms of hearing loss. Three studies showed that resiliency skill training promotes various domains of well-being. Three studies indicated that educational interventions encourage cancer screening practices. Educational programs are an effective way to promote cancer health literacy among DHH patients to facilitate communication with oncologists. As extent of hearing loss was not assessed, the authors cannot say the degree to which results are applicable to all degrees of hearing loss. To obtain hard data, further studies with more diverse populations, various cancer entities, different methods, and exact hearing loss assessments are required.

[Complementary and Alternative Medicine Offers of Teaching Practices for General Medicine]. / Komplementär- und alternativmedizinische Angebote von Lehrpraxen für Allgemeinmedizin.

OBJECTIVE: Germany's new medical licensure act has increased the importance of general practice in academic medical education. This study gives an overview of complementary and alternative medicine in general teaching practices in Germany and their adherence to evidence-based criteria which is required in order to qualify as a teaching practice. METHODS: After a systematic search for German teaching practices, we assessed their diagnostic and therapeutic offers via their websites. We calculated the various frequencies of treatments and differentiated between evidence-based complementary medicine and alternative medicine with little to no evidence. RESULTS: Of 4102 practices, more than half offered complementary and/or alternative treatment. Most of those were treatments approved of by the German medical association. Alternative medicine was offered by 18.2% of the practices. CONCLUSION: Collective terms and conflicting evidence complicate the classification of treatments. Teaching practices offering non-evidence-based treatment raise the question whether recruitment of additional teaching practices stands at odds with the quality of medical education. Explicit offers of alternative treatment should disqualify a teaching practice as such. Controversial treatment may be taught academically and during residency with a focus on evidence-based guidelines and communication skills in order to prepare young medical practitioners for talks with their patients about the subject.

Methodological Review: Summary of Findings for Acupuncture as Treatment for Cancer Therapy-induced Xerostomia.

BACKGROUND/AIM: With a rapidly growing number of studies, systematic reviews (SRs) and meta-analyses (MAs) on acupuncture, the level of evidence seems to be high. Yet, traditional Chinese acupuncture is built on concepts which are not in accordance with science-based medicine. Accordingly, our aim was to critically assess the evidence presented in SRs and MAs on xerostomia induced by treatment of head and neck cancer with radiotherapy. MATERIALS AND METHODS: In February 2022, a systematic search of five electronic databases (Embase, Cochrane, PsychInfo, CINAHL and Medline) was conducted to find SRs/MAs on acupuncture use against cancer-treatment induced xerostomia. We evaluated all SRs/MAs using the AMSTAR instrument, comparing the assessment of the individual studies included and the conclusions drawn by the authors. In case of heterogeneity between the SRs, we evaluated the controversial items of the assessments directly from the studies. RESULTS: Finally, eight SRs/MAs were included. Most of them show methodological drawbacks in several domains of the AMSTAR instrument, which influences the credibility of the results. CONCLUSION: The evidence on the use of acupuncture as treatment for radiotherapy-induced xerostomia is low. Present SRs/MAs mainly summarize results of a few and mostly small studies. Even though the included studies greatly overlap, the quality of the presentation and interpretation of the authors differs greatly. Therefore, a high quality and conclusive summary of the present evidence on the use of acupuncture to treat radiotherapy induced xerostomia is still missing.