The Society for Integrative Oncology (SIO) and the American Society of Clinical Oncology (ASCO) have released a new joint practice guideline on the use of integrative approaches, such as acupuncture and massage therapy, to manage pain related to cancer or its treatment. The recommendations were recently published in the Journal of Clinical Oncology.
“Pain is a clinical challenge for many oncology patients and clinicians, and there’s a growing body of evidence showing that integrative therapies can be useful in pain management. But to date there has not been clear clinical guidance about when and when not to use these approaches,” Heather Greenlee, ND, PhD, cochair of the SIO Clinical Practice Guideline Committee, said in a new release.
Integrative oncology uses mind-body practices, natural products and lifestyle modifications from different traditions along with conventional cancer treatment, according to SIO. Complementary therapies aim to optimize health and quality of life and improve clinical outcomes across the cancer care continuum while empowering people to become active participants in their care.
To develop the guideline, an expert panel performed a literature search for relevant research published between 1990 and 2021. The panel included experts in integrative oncology, medical oncology, radiation therapy, surgery, palliative care, mind-body medicine, social sciences and nursing, as well as patient advocates.
The experts identified 227 relevant studies that looked at complementary therapies used to manage pain during any stage of cancer care, focusing randomized controlled trials—the gold standard of medical research. These therapies were compared against standard care, placebos, sham interventions or other active interventions. Outcomes of interest included pain intensity, symptom relief and adverse events.
“This new guideline takes a deeper dive on the use of integrative therapies, which is important because clinicians and patients need to have access to the latest evidence-based information to make clinical decisions,” said panel cochair Jun Mao, MD, of Memorial Sloan Kettering Cancer Center.
Up to 79% of people with cancer seek integrative approaches to help them cope with cancer, panel cochair Eduardo Bruera, MD, of MD Anderson Cancer Center, told ASCO Daily News. He noted that pain is a concern not only for people currently undergoing cancer treatment but also for those who have finished therapy and been left with chronic pain, for example due to peripheral neuropathy caused by chemotherapy.
The panel members came up with a set of recommendations for adults with cancer that are evidence-based and guided by clinical experience. They acknowledged that some of these are weak recommendations based on low-quality evidence, but the interventions are generally safe and their benefits outweigh their harms.
The recommendations include the following:
- Acupuncture should be offered to patients experiencing joint pain related to aromatase inhibitors used to treat breast cancer.
- Acupuncture may be offered to people experiencing general pain or musculoskeletal pain from cancer.
- Acupuncture may be offered to patients experiencing peripheral neuropathy as a side effect of chemotherapy.
- Acupuncture or acupressure may be offered to patients undergoing cancer surgery or other cancer-related procedures such as bone marrow biopsies.
- Reflexology or acupressure may be offered to patients experiencing pain during systemic therapy for cancer treatment.
- Reflexology or acupressure may be offered to patients experiencing chemotherapy-induced peripheral neuropathy.
- Yoga may be offered to breast cancer patients experiencing aromatase inhibitor-related joint pain.
- Hatha yoga may be offered to patients experiencing pain after treatment for breast cancer or head and neck cancer.
- Massage may be offered to people experiencing chronic pain following breast cancer treatment.
- Massage may be offered to patients experiencing pain during palliative and hospice care.
- Guided imagery with progressive muscle relaxation may be offered to patients experiencing general pain from cancer treatment.
- Hypnosis may be offered to patients experiencing procedural pain during cancer treatment or diagnostic workups.
- Music therapy may be offered to patients experiencing pain from cancer surgery.
The guideline also mentions other complementary approaches, including herbs and supplements, that are potentially relevant to cancer care but need more research. The lack of an endorsement of a particular therapy does not necessarily mean it is ineffective or unsafe, but rather that the panel felt the evidence was insufficient to support a recommendation. There is also not enough evidence to make recommendations for children with cancer.
Many comprehensive cancer centers designated by the National Cancer Institute offer various integrative therapies, but they can be harder to come by in community hospitals and other care settings, where most cancer patients are treated. Racial and ethnic minorities and people with less education are less likely to know about complementary therapies. Lack of insurance coverage for integrative care is also a barrier.
“Clinician uptake of evidence-based treatments is always a concern, which is one of the reasons why we create practice guidelines,” Bruera said. “We are hoping that by showing the growing evidence that is out there, healthcare systems will start hiring these kinds of practitioners and insurance systems will start covering these treatments, because more and more, these are being shown to be effective at managing pain for cancer populations.”