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Hiccups have a curious connection to cancer

Colleen Kennedy, a retired medical assistant, was prepared for the annihilation of chemotherapy and radiation treatment for stage-three lung cancer. She hadn’t expected the hiccup fits that started about halfway through her first treatment round. They left her gasping for air and sent pain ricocheting through her already tender body.  At times, they triggered her gag reflex and made her throw up. After they subsided, she felt tired, sore, breathless—as if she’d just finished a tough workout. They were, Kennedy, now 54, told me, “nothing compared to what we would consider normal hiccups at all.” They lasted for nearly a year.

Hiccups are one of the most common bodily experiences that humans (and rats, squirrels, rabbits, cats, dogs, and horses) have; even fetuses get them. When we hiccup, the diaphragm involuntarily contracts and the vocal cords snap closed, producing the eponymous “hic” sound. These spasms usually disappear within a few minutes. Compared with cancer’s existential threat and the brutal reality of treating it, hiccups are innocuous, banal, and unserious. But these two experiences are, peculiarly, connected. As many as 40 percent of cancer patients deal with bouts of hiccups during their illness. For a smaller subset—about one in 10—those spells last for more than 48 hours.

Chronic hiccups interrupt almost every aspect of life. They disrupt concentration and conversations. They shake a person awake. Eating, drinking, and swallowing can feel like choking. Often, chest aches linger long after a hiccuping fit subsides.

And they are difficult to treat. Doctors have some off-label prescriptions at their disposal, but none has been rigorously tested—none has been proved to work any better than home remedies. Kennedy tried to eradicate her hiccups with deep, forceful inhales and by drinking water from the far rim of a glass; she also trained herself to exhale before drinking or eating to limit the amount of air she swallowed. “Sometimes it worked, but most times it didn’t,” she said. Many try chiropractice or acupuncture. Others recruit household items: sugar, lemons, vinegar, a pencil, a cold spoon. Only one hiccup drug has ever been approved by the Food and Drug Administration.

Hiccups, one of the most basic physiological features of human life, remain deeply mysterious and surprisingly understudied—partly because their fleeting nature makes them hard to examine, partly because they just seem so harmless. But when they’re not, hiccups confront us with how helpless we can be against our own body’s whims.

In popular culture, hiccups are a joke: In a Looney Tunes bit from 1942, Daffy Duck’s hiccups send his hat bouncing. In a 2005 episode of Foster’s Home For Imaginary Friends, Bloo tries everything to cure his hiccups—he pours a box of sugar into his mouth, breathes into a brown paper bag, drinks hot sauce, eats peanut butter, gets scared, takes small sips and big gulps, stands on his head, brushes his teeth while singing, swallows a lemon. Nothing works. In 1937’s Snow White and the Seven Dwarfs, Dopey accidentally swallows a bar of soap and starts hiccuping bubbles. In 1970’s Aristocats, Uncle Waldo gets hiccups from drinking too much. In 1975’s Monty Python and the Holy Grail, a hiccuping guard is commanded by the king to get a drink to rid him of his ailment. In a 1992 episode of The Simpsons, a man who’s been hiccuping for 45 years gives this four-second interview to the local Springfield TV news: “Hic—kill me—hic—kill me—hic—kill me.”

In medicine, hiccups are a conundrum. “There’s really no benefit to a hiccup, as far as anyone knows,” Aminah Jatoi, a Mayo Clinic oncologist who studies hiccups, told me. A transient symptom that appears and disappears randomly, hiccups are nearly impossible to study with rigor. Experiments on treatments are, accordingly, a nightmare to orchestrate. To date, only a handful of randomized, controlled trials have studied pharmacological treatments for hiccups; none recruited more than 40 patients. Most studies rely on storytelling: single-patient case reports, limited case series, and analyses of databases of doctor’s notes.

What we do know: A sudden temperature shift can bring hiccups on, as can drinking alcohol, eating spicy food, and getting excited or stressed. High blood sugar can be to blame. So can low sodium or electrolytes. Many drugs—including steroids, chemotherapy agents, benzodiazepines, opioids, nicotine, antibiotics, anesthesia, and anti-nausea and blood-pressure medicines—are linked with hiccups. Some drugs used to treat intractable hiccups can cause hiccups. In one case study, a patient’s hiccups were incited by a hair brushing against the eardrum; in another, from 1988, the culprit was an ant crawling around the eardrum.

The medical conditions associated with hiccups range the body’s entire upper half: stroke, brain injury, meningitis, multiple sclerosis, ear infection, rhinitis, goiters, sore throat, pneumonia, bronchitis, asthma, tuberculosis, fluid in the lungs or heart, bloating, gas, pregnancy, hernias, ulcers, liver disease, kidney disease. And cancer.

Experts offer two main explanations for the cancer-hiccup connection. In one, cancers that invade the chest, throat, or head (that is, anything along the route of a hiccup) provoke them. In the other, medications prescribed to cancer patients— including chemotherapy drugs, steroids, and opioids—set them off. Regardless of whether cancer itself is to blame or whether they’re a side effect of treatment, hiccups add another layer of misery to the experience.

One study published in 2022 showed that hiccups were a major detriment to the quality of life of about one in 20 of the cancer patients surveyed. Among those with hiccups, almost one in three said they struggled to relax or recreate; a smaller portion said they couldn’t enjoy meals. In another study of 320 cancer patients, hiccups sent one in 10 to the hospital for help. Other research suggests that upwards of three-quarters of hiccup-struck patients deal with the spasms without medical intervention. In a survey of 90 cancer-health-care providers with experience with hiccups, 40 percent rated their patients’ hiccup severity as worse than their nausea and vomiting.

Even so, experts say, hiccups remain an aside for both patients and practitioners.

Given the rapidity of physician visits—on average about 23 minutes, by one measure, for patients with cancer—hiccups may simply fall too low on a list of preoccupations to warrant mention, but “I think part of what happens is patients feel a little embarrassed bringing it up,” Jatoi said. Or “the patient may want to be a ‘good’ patient and not complain,” says Thomas Smith, an oncologist and palliative-medicine specialist at Johns Hopkins—perhaps because they fear their doctors will modify their treatment course if they speak up about any negative side effects.

Oncologists, for their part, don’t consistently or directly ask about hiccups in the way that they screen for pain, nausea, and trouble breathing. “I don’t know of a single symptom-assessment scale in use that has a line for hiccups,” Smith told me. Some brush off patients who do complain of the spasms. “My doctors just shook their heads like I was joking when I told them I got the hiccups all the time,” one patient wrote to Mayo Clinic hiccup researchers.

And so hiccups are relegated to the category of “orphan” symptoms—prevalent, distressing, characteristically unaddressed. Other such symptoms include muscle cramps, itchiness, muscle twitching, restless legs syndrome, loss or distortion of taste, dry mouth, and sweating. The success of palliative care depends on alleviating orphan symptoms: Every hiccup or itch or tingling foot, every flush of sweat or bout of constipation tethers patients to a raw state of awareness. “It’s a common reminder that you have chemotherapy, which is a constant reminder you have cancer, which is a constant reminder you’re facing your mortality,” Smith said. Treating hiccups offers medical relief in the form of escape. “It may make it possible for patients to have a few hours where they don’t think about cancer.”

Jatoi said she often warns patients who are about to start a potentially hiccup-inducing regimen. “That helps patients speak up,”  she said, which is a step toward finding relief.   Oncologists can try prescribing a muscle-spasm treatment, for example, an off-label use that seems to help some patients. They might tweak the chemotherapy regimen to swap in drugs less likely to cause hiccups. The one treatment for hiccups that the FDA has approved—chlorpromazine, an antipsychotic first synthesized 72 years ago—can come with serious side effects, which research has shown to include low blood pressure and delirium.

In the absence of clinically proven solutions, most hiccup sufferers are shepherded toward home remedies—breath-holding; drinking through hard-to-suck straws; swallowing spoonfuls of sugar, peanut butter, or vinegar.  “None of them have been tested to see how effective they are,”  Smith said. But without solid alternatives, he added, they’re worth trying. After all, unlike the hiccups themselves, “they’re completely harmless.”

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