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COMPANION ARTICLES
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ARTICLE CITATION
DOI: 10.1200/JCO.22.01357 Journal of Clinical Oncology - published online before
print September 19, 2022
PMID: 36122322
INTEGRATIVE MEDICINE FOR PAIN MANAGEMENT IN ONCOLOGY: SOCIETY FOR INTEGRATIVE
ONCOLOGY–ASCO GUIDELINE
Jun J. Mao , MD, MSCE1
x
Jun J. Mao
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; Nofisat Ismaila , MD, MSc2
x
Nofisat Ismaila
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; Ting Bao , MD1
x
Ting Bao
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; Debra Barton , PhD3
x
Debra Barton
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; Eran Ben-Arye , MD4
x
Eran Ben-Arye
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; Eric L. Garland, PhD5
x
Eric L. Garland
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; ...Heather Greenlee , ND, PhD6
x
Heather Greenlee
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; Thomas Leblanc , MD7
x
Thomas Leblanc
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; Richard T. Lee , MD8
x
Richard T. Lee
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; Ana Maria Lopez , MD9
x
Ana Maria Lopez
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; Charles Loprinzi , MD10
x
Charles Loprinzi
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; Gary H. Lyman , MD, MPH6
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Gary H. Lyman
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; Jodi MacLeod , BA11
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Jodi MacLeod
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; Viraj A. Master, MD, PhD12
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Viraj A. Master
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; Kavitha Ramchandran, MD13
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Kavitha Ramchandran
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; Lynne I. Wagner , PhD14
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Lynne I. Wagner
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; Eleanor M. Walker, MD15
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Eleanor M. Walker
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; Deborah Watkins Bruner , PhD12
x
Deborah Watkins Bruner
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; Claudia M. Witt , MD, MBA16
x
Claudia M. Witt
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; and Eduardo Bruera , MD17
x
Eduardo Bruera
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1Memorial Sloan Kettering Cancer Center, New York, NY
2American Society of Clinical Oncology, Alexandria, VA
3University of Michigan School of Nursing, Ann Arbor, MI
4Lin & Carmel Medical Centers, Clalit Health Services; Technion Faculty of
Medicine, Haifa, Israel
5College of Social Work, University of Utah, Salt Lake City, UT
6Fred Hutchinson Cancer Research Center, Seattle, WA
7Duke University School of Medicine Durham, NC
8City of Hope Comprehensive Cancer Center, Duarte, CA
9Thomas Jefferson. Sidney Kimmel Cancer Center, Philadelphia, PA
10Mayo Clinic, Rochester, MN
11Patient Representative, Memorial Sloan Kettering Integrative Medicine Service,
New York, NY
12Winship Cancer Institute of Emory University, Atlanta, GA
13Stanford University, Palo Alto, CA
14Wake Forest School of Medicine, Winston-Salem, NC
15Henry Ford Hospital, Detroit, MI
16University Hospital Zurich, Zurich, Switzerland
17MD Anderson Cancer Center, Houston, TX
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*J.J.M. and E.B. were expert panel cochairs.
https://doi.org/10.1200/JCO.22.01357
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ABSTRACT
Section:
ChooseTop of pageAbstract <<INTRODUCTIONGUIDELINE
QUESTIONSMETHODSRESULTSRECOMMENDATIONSEVIDENCE SUMMARY OF
INTER...DISCUSSIONPATIENT AND CLINICIAN COM...HEALTH DISPARITIESGUIDELINE
IMPLEMENTATION ...OPEN COMMENT REVIEWLIMITATIONS OF THE RESEAR...FUTURE
DIRECTIONSADDITIONAL RESOURCESREFERENCES
PURPOSE
The aim of this joint guideline is to provide evidence-based recommendations to
practicing physicians and other health care providers on integrative approaches
to managing pain in patients with cancer.
METHODS
The Society for Integrative Oncology and ASCO convened an expert panel of
integrative oncology, medical oncology, radiation oncology, surgical oncology,
palliative oncology, social sciences, mind-body medicine, nursing, and patient
advocacy representatives. The literature search included systematic reviews,
meta-analyses, and randomized controlled trials published from 1990 through
2021. Outcomes of interest included pain intensity, symptom relief, and adverse
events. Expert panel members used this evidence and informal consensus to
develop evidence-based guideline recommendations.
RESULTS
The literature search identified 227 relevant studies to inform the evidence
base for this guideline.
RECOMMENDATIONS
Among adult patients, acupuncture should be recommended for aromatase
inhibitor–related joint pain. Acupuncture or reflexology or acupressure may be
recommended for general cancer pain or musculoskeletal pain. Hypnosis may be
recommended to patients who experience procedural pain. Massage may be
recommended to patients experiencing pain during palliative or hospice care.
These recommendations are based on an intermediate level of evidence, benefit
outweighing risk, and with moderate strength of recommendation. The quality of
evidence for other mind-body interventions or natural products for pain is
either low or inconclusive. There is insufficient or inconclusive evidence to
make recommendations for pediatric patients. More research is needed to better
characterize the role of integrative medicine interventions in the care of
patients with cancer.
Additional information is available at
https://integrativeonc.org/practice-guidelines/guidelines and
www.asco.org/survivorship-guidelines.
INTRODUCTION
Section:
ChooseTop of pageAbstractINTRODUCTION <<GUIDELINE
QUESTIONSMETHODSRESULTSRECOMMENDATIONSEVIDENCE SUMMARY OF
INTER...DISCUSSIONPATIENT AND CLINICIAN COM...HEALTH DISPARITIESGUIDELINE
IMPLEMENTATION ...OPEN COMMENT REVIEWLIMITATIONS OF THE RESEAR...FUTURE
DIRECTIONSADDITIONAL RESOURCESREFERENCES
Pain is one of the most common, disabling, and feared symptoms experienced by
patients diagnosed with cancer.1,2 Among patients with advanced cancer, pain can
be a result of tumor burden or invasion of bones, muscles, or nerves. In
addition, many conventional cancer treatments such as surgery, chemotherapy,
radiotherapy, immunotherapy, or hormonal therapy can result in both acute and
chronic pain conditions such as aromatase inhibitor (AI)–induced joint pain or
chemotherapy-induced peripheral neuropathy (CIPN) pain.3,4 With improved
oncologic treatment, many patients diagnosed with advanced cancer now live
longer with symptomatic illness and ongoing oncologic treatment. Additionally,
increasing numbers of patients experience remission and join the 16.9 million
cancer survivors in the United States alone.5 Many survivors, however, continue
to experience chronic pain resulting from their cancer treatment that not only
negatively affects their quality of life, but also their daily functions.6
Chronic pain may also lead to nonadherence to oncologic treatment such as
hormonal therapies,7,8 thus, potentially compromising overall survival.
Therefore, effective pain management is of critical importance throughout the
cancer care trajectory.
THE BOTTOM LINE
Integrative Medicine for Pain Management in Oncology: Society for Integrative
Oncology—ASCO Guideline
Guideline Questions
1. What mind-body therapies are recommended for managing pain experienced by
adult and pediatric patients diagnosed with cancer?
2. What natural products are recommended for managing pain experienced by adult
and pediatric patients diagnosed with cancer?
Target Population
Patients of any age diagnosed with any cancer who are experiencing pain during
any stage of their cancer care trajectory.
Target Audience
Clinicians who provide care to patients with cancer, cancer survivors, and
family caregivers.
Methods
An Expert Panel was convened to develop clinical practice guideline
recommendations on the basis of a systematic review of the health literature.
Recommendations
The following recommendations are evidence-based, informed by randomized trials
and systematic reviews, and guided by clinical experience. The recommendations
were developed by a multidisciplinary group of experts.
NOTE:
The following set of recommendations are for adults with cancer. Although many
of the recommendations are weak and based on low-quality evidence, the
interventions do have clinical relevance, with a favorable benefit-to-harm
ratio, and this is the basis for making the recommendations. There is
insufficient or inconclusive evidence to make recommendations for pediatric
patients with cancer.
Aromatase inhibitor–related joint pain.
Recommendation 1.1.
Acupuncture should be offered to patients experiencing AI-related joint pain in
breast cancer (Type: Evidence based, benefits outweigh harms; Evidence quality:
Intermediate; Strength of recommendation: Moderate).
Recommendation 1.2.
Yoga may be offered to patients experiencing AI-related joint pain in breast
cancer (Type: Evidence based, benefits outweigh harms; Evidence quality: Low;
Strength of recommendation: Weak).
General cancer pain or musculoskeletal pain.
Recommendation 1.3.
Acupuncture may be offered to patients experiencing general pain or
musculoskeletal pain from cancer (Type: Evidence based, benefits outweigh harms;
Evidence quality: Intermediate; Strength of recommendations: Moderate).
Recommendation 1.4.
Reflexology or acupressure may be offered to patients experiencing pain during
systemic therapy for cancer treatment (Type: Evidence based, benefits outweigh
harms; Evidence quality: Intermediate; Strength of recommendation: Moderate).
Recommendation 1.5.
Massage may be offered to patients experiencing chronic pain following breast
cancer treatment (Type: Evidence based, benefits outweigh harms; Evidence
quality: Low; Strength of recommendation: Moderate).
Recommendation 1.6.
Hatha yoga may be offered to patients experiencing pain after treatment for
breast or head and neck cancers (Type: Evidence based, benefits outweigh harms;
Evidence quality: Low; Strength of recommendation: Weak).
Recommendation 1.7.
Guided imagery with progressive muscle relaxation may be offered to patients
experiencing general pain from cancer treatment (Type: Evidence based, benefits
and harms not assessable; Evidence quality: Low; Strength of recommendation:
Weak).
Chemotherapy-induced peripheral neuropathy.
Recommendation 1.8.
Acupuncture may be offered to patients experiencing chemotherapy-induced
peripheral neuropathy from cancer treatment (Type: Evidence based-informal
consensus, benefits outweigh harms; Evidence quality: Low; Strength of
recommendation: Weak).
Recommendation 1.9.
Reflexology or acupressure may be offered to patients experiencing
chemotherapy-induced peripheral neuropathy from cancer treatment (Type: Evidence
based, benefits outweigh harms; Evidence quality: Low; Strength of
recommendation: Weak).
Procedural or surgical pain.
Recommendation 1.10.
Hypnosis may be offered to patients experiencing procedural pain in cancer
treatment or diagnostic workups (Type: Evidence based, benefits outweigh harms;
Evidence quality: Intermediate; Strength of recommendation: Moderate).
Recommendation 1.11.
Acupuncture or acupressure may be offered to patients undergoing cancer surgery
or other cancer-related procedures such as bone marrow biopsy (Type: Evidence
based-informal consensus, benefits outweigh harms; Evidence quality of: Low;
Strength of recommendation: Weak).
Recommendation 1.12.
Music therapy may be offered to patients experiencing surgical pain from cancer
surgery (Type: Evidence based, benefits outweigh harms; Evidence quality of:
Low; Strength of recommendation: Weak).
Pain during palliative care.
Recommendation 1.13.
Massage may be offered to patients experiencing pain during palliative and
hospice care (Type: Evidence based; benefits outweigh harms; Evidence quality:
Intermediate; Strength of recommendation: Moderate).
Please refer to the treatment algorithm in Figure 2 for the visual
representation of these recommendations.
Additional Resources
Definitions for the quality of the evidence and strength of recommendation
ratings are available in Appendix Table A1 (online only). More information,
including a supplement with additional evidence tables, slide sets, and clinical
tools and resources, is available at
https://integrativeonc.org/practice-guidelines/guidelines and
www.asco.org/survivorship-guidelines. The Society for Integrative Oncology
Clinical Practice Guidelines Committee's Standard Operating Procedures
(available at https://integrativeonc.org/practice-guidelines/guidelines-sops)
and the Methodology Manual (available at www.asco.org/guideline-methodology)
provide additional information about the methods used to develop this guideline.
Patient information is available at
https://integrativeonc.org/knowledge-center/patients and www.cancer.net.
Society for Integrative Oncology and ASCO believe that cancer clinical trials
are vital to inform clinical decisions and improve cancer care, and that all
patients should have the opportunity to participate.
As pain in patients and survivors of cancer is complex with different etiologies
(eg, tumor burden, treatment-related, and non–cancer-related) and varying
presentations (eg, neuropathic and musculoskeletal) and duration (eg, acute and
chronic), pain management requires an interdisciplinary approach and should
include both pharmacologic and nonpharmacologic treatments, where appropriate.2
Integrative medicine, defined as the coordinated use of evidence-based
complementary practices and conventional care treatments,9 includes
interventions such as acupuncture, massage, meditation, and yoga, which are
increasingly available in cancer centers and are recommended for symptom and
pain management.10,11 An estimated 40% of patients with cancer use integrative
medicine on an annual basis.12-14 The key guiding principle of integrative
medicine is to use these interventions along with conventional pain management
approaches (eg, medications, radiation, injections, and physical therapies) and
it is not intended to replace conventional interventions.9
Patients often seek integrative medicine because they perceive that conventional
medical treatment is not completely meeting their needs, fear side effects from
pharmacotherapies, prefer a holistic approach, or because it has been
recommended by their family or health care providers.15-18 A growing number of
well-conducted randomized controlled trials (RCTs) have found that interventions
such as acupuncture or massage can alleviate pain in patients and survivors of
cancer.19-21 However, for many other interventions, trials are small and are
often limited by a lack of methodologic rigor. Ideally studies should not only
report the statistical significance of their findings but also the clinically
meaningful change in pain severity (a two-point reduction on a 0-10 scale).
To guide a patient-centered and evidence-based approach to pain management
incorporating integrative medicine interventions for appropriate
indications,9,22 clinicians and patients need to be equipped with knowledge of
the current evidence base of these therapies for pain management in cancer care.
The purpose of this guideline is to systematically appraise the evidence from
randomized controlled clinical trials, systematic reviews (SRs), and
meta-analyses, and to provide guidance to clinicians on the effectiveness of
integrative medicine treatment options for pain in adults and children with a
cancer diagnosis.
GUIDELINE QUESTIONS
Section:
ChooseTop of pageAbstractINTRODUCTIONGUIDELINE QUESTIONS
<<METHODSRESULTSRECOMMENDATIONSEVIDENCE SUMMARY OF INTER...DISCUSSIONPATIENT AND
CLINICIAN COM...HEALTH DISPARITIESGUIDELINE IMPLEMENTATION ...OPEN COMMENT
REVIEWLIMITATIONS OF THE RESEAR...FUTURE DIRECTIONSADDITIONAL
RESOURCESREFERENCES
This clinical practice guideline addresses two overarching clinical questions:
(1) What mind-body therapies are recommended for managing pain experienced by
adult and pediatric patients diagnosed with cancer? (2) What natural products
are recommended for managing pain experienced by adult and pediatric patients
diagnosed with cancer?
METHODS
Section:
ChooseTop of pageAbstractINTRODUCTIONGUIDELINE QUESTIONSMETHODS
<<RESULTSRECOMMENDATIONSEVIDENCE SUMMARY OF INTER...DISCUSSIONPATIENT AND
CLINICIAN COM...HEALTH DISPARITIESGUIDELINE IMPLEMENTATION ...OPEN COMMENT
REVIEWLIMITATIONS OF THE RESEAR...FUTURE DIRECTIONSADDITIONAL
RESOURCESREFERENCES
Guideline Development Process
Both the Society for Integrative Oncology (SIO) and ASCO regularly engage in the
development and dissemination of clinical practice guidelines. SIO's mission is
to advance evidence-based, comprehensive, integrative health care to improve the
lives of people affected by cancer. ASCO's mission is to conquer cancer through
research, education, and promotion of the highest-quality, equitable patient
care. For this guideline, SIO and ASCO joined efforts to develop a guideline
focused on the use of integrative therapies to manage oncology-related pain to
provide evidence-based recommendations to patients and clinicians to inform
clinical decisions. This guideline builds upon the existing ASCO guidelines on
pain management, the growing body of research in this area, and the emphasis
from the Centers for Disease Control and Prevention to use nonpharmacologic
approaches for pain management.2,23,24
This SR-based guideline product was developed by an international
multidisciplinary Expert Panel, which included a patient representative and a
health research methodologist (Appendix Table A2, online only). The Expert Panel
met via video conferences and corresponded through e-mail. Based upon the
consideration of the evidence, the authors were asked to contribute to the
development of the guideline, provide critical review, and finalize the
guideline recommendations. The guideline recommendations were sent for an open
comment period of two weeks allowing the public to review and comment on the
recommendations after submitting a confidentiality agreement. These comments
were taken into consideration while finalizing the recommendations. Members of
the Expert Panel were responsible for reviewing and approving the penultimate
version of the guideline, which was then submitted to the Journal of Clinical
Oncology (JCO) for editorial review and consideration for publication. All
SIO-ASCO guidelines are ultimately reviewed and approved by the Expert Panel,
the SIO Clinical Practice Guidelines Committee, and the ASCO Evidence Based
Medicine Committee before publication. All funding for the administration of the
project was provided by SIO.
The recommendations were developed by using a SR of evidence identified through
online searches of PubMed (1990-2021) and Cochrane Library (1990-2021) of RCTs,
SRs, and meta-analyses. Articles were selected for inclusion in the SR on the
basis of the following criteria:
* Population: Adults and pediatric patients experiencing pain during any stage
of their cancer care trajectory
* Interventions: Integrative interventions for pain management, including
acupuncture, acupressure, mind-body therapies, and natural products (note:
see details in the Data Supplement, online only; therapies focused on pain
prevention were not included)
* Comparisons: No intervention, waitlist, usual care (UC) or standard care,
guideline-based care, active control, attention control, placebo, or sham
interventions
* Outcomes: Pain intensity, reduction, or change in symptoms reported as the
primary outcome in published manuscript
* Sample size: Minimum total sample size of 20
Articles were excluded from the SR if they were (1) meeting abstracts not
subsequently published in peer-reviewed journals; (2) editorials, commentaries,
letters, news articles, case reports, and narrative reviews; or (3) published in
a non-English language. The guideline recommendations were crafted, in part,
using the Guidelines Into Decision Support methodology and the accompanying
BRIDGE-Wiz software program.25 In addition, a guideline implementability review
was conducted. On the basis of the implementability review, revisions were made
to the draft to clarify recommended actions for clinical practice. Ratings for
type and strength of the recommendation, and evidence quality are provided with
each recommendation. The quality of the evidence for each outcome was assessed
using the Cochrane Risk-of-Bias tool26 by the project methodologist in
collaboration with the Expert Panel cochairs and reviewed by the full Expert
Panel.
The SIO and ASCO Expert Panel and guidelines staff will work with cochairs to
keep abreast of any substantive updates to the guideline. On the basis of formal
review of the emerging literature, SIO will determine the need to update the
guideline. The SIO Guidelines Methodology Manual (available at
https://integrativeonc.org/practice-guidelines/sio-guidelines-guidelines-methodology)
provides additional information about the guideline process.
Guideline Disclaimer
The Clinical Practice Guidelines and other guidance published herein are
provided by the SIO and the ASCO to assist health care providers in clinical
decision making. The information herein should not be relied upon as being
complete or accurate, nor should it be considered as inclusive of all proper
treatments or methods of care or as a statement of the standard of care. With
the rapid development of scientific knowledge, new evidence may emerge between
the time information is developed and when it is published or read. The
information is not continually updated and may not reflect the most recent
evidence. The information addresses only the topics specifically identified
therein and is not applicable to other interventions, diseases, or stages of
diseases. This information does not mandate any particular course of medical
care. Further, the information is not intended to substitute for the independent
professional judgment of the treating clinician, as the information does not
account for individual variation among patients. Recommendations specify the
level of confidence that the recommendation reflects on the net effect of a
given course of action. The use of words like “must,” “must not,” “should,” and
“should not” indicate that a course of action is recommended or not recommended
for either most or many patients, but there is latitude for the treating
clinician to select other courses of action in individual cases. In all cases,
the selected course of action should be considered by the treating clinician in
the context of treating the individual patient. Use of the information is
voluntary.
SIO and ASCO do not endorse third-party drugs, devices, services, therapies,
apps, or programs used to diagnose, treat, monitor, manage, or alleviate health
conditions. Any use of a brand or trade name is for identification purposes
only. SIO and ASCO provide this information on an “as is” basis and make no
warranty, express or implied, regarding the information. SIO and ASCO
specifically disclaim any warranties of merchantability or fitness for a
particular use or purpose. SIO and ASCO assume no responsibility for any injury
or damage to persons or property arising out of or related to any use of this
information, or for any errors or omissions.
Guideline and Conflicts of Interest
The Expert Panel was assembled in accordance with SIO's and ASCO's shared
Conflict of Interest Policy Implementation for Clinical Practice Guidelines
(“Policy,” found at
https://integrativeonc.org/practice-guidelines/guidelines-sops and
https://www.asco.org/guideline-methodology). All members of the Expert Panel
completed SIO's disclosure form, which requires disclosure of financial and
other interests, including relationships with commercial entities that are
reasonably likely to experience direct regulatory or commercial impact as a
result of promulgation of the guideline. Categories for disclosure include
employment; leadership; stock or other ownership; honoraria, consulting, or
advisory role; speaker's bureau; research funding; patents, royalties, other
intellectual property; expert testimony; travel, accommodations, expenses; and
other relationships. In accordance with the Policy, the majority of Expert Panel
did not disclose any relationships constituting a conflict under the Policy.
RESULTS
Section:
ChooseTop of pageAbstractINTRODUCTIONGUIDELINE QUESTIONSMETHODSRESULTS
<<RECOMMENDATIONSEVIDENCE SUMMARY OF INTER...DISCUSSIONPATIENT AND CLINICIAN
COM...HEALTH DISPARITIESGUIDELINE IMPLEMENTATION ...OPEN COMMENT
REVIEWLIMITATIONS OF THE RESEAR...FUTURE DIRECTIONSADDITIONAL
RESOURCESREFERENCES
Characteristics of Studies Identified in the Literature Search
A total of 1,346 articles were identified in the literature search. After
applying the eligibility criteria, 227 articles remained, forming the
evidentiary basis for the guideline recommendations.
TABLE 1. Studies on Interventions With Sufficient Evidence to Inform
Recommendations
View larger version (302K)
The identified trials were published between 1990 and 2021. The trials compared
various integrative therapies to standard of care, placebos, sham interventions,
other interventions, or active controls. The primary outcome for most of the
studies included pain severity, pain reduction, and change in pain symptoms,
which were measured with commonly used standardized tools such as the Visual
Analog Scale (VAS), Brief Pain Inventory scale (BPI), Numerical Rating Scale
(NRS), etc. Characteristics of the included studies are in the Data Supplement,
and Figure 1 presents the Preferred Reporting Items for Systematic Reviews and
Meta-Analyses flow diagram for the SR. Table 1 includes a breakdown of the
included studies by integrative therapies and pain indication, and Table 2
includes studies on interventions with insufficient or inconclusive evidence to
inform recommendations.
FIG 1. Systematic review flow diagram. RCT, randomized controlled trial; SR,
systematic review.
TABLE 2. Studies on Interventions With Insufficient or Inconclusive Evidence to
Inform Recommendations
View larger version (651K)
Study Quality Assessment
Study design aspects related to individual study quality, quality of evidence,
strength of recommendations, and risk of bias were assessed for the 227
intervention studies identified. SRs and meta-analyses were assessed for quality
using the assessment of multiple systematic reviews (AMSTAR) tool.252 Design
elements, such as blinding, allocation concealment, sufficient sample size,
intention-to-treat, and funding sources, were assessed for RCTs using the
Cochrane Risk-of-Bias tool.26 Overall, the included SRs were conducted using
established methods; however, many of the primary studies included in these
reviews suffered from flaws and/or limitations in study design. Ultimately, we
used the SRs as one of the means to identify relevant primary studies.
Additional RCTs identified and included in this guideline ranged from low to
high overall risk of bias in one or more key domains. Some of the flaws in the
study design included lack of blinding; incomparable control arms, small sample
sizes and/or high attrition rates; and limited statistical power, all of which
lowered the confidence in the findings. The included studies were also
heterogeneous with respect to patient populations, sample size, methodologic
quality, treatment duration, and outcome measures. The primary outcomes varied
across studies and, in most cases, were not directly comparable because of
different outcomes, measurements, and instruments used at different time points.
This diversity precluded a quantitative analysis and, as such, only a
descriptive review was performed. Refer to the Data Supplement for quality
rating scores and the Methodology Manual for more information and for
definitions of ratings for overall potential risk of bias.
RECOMMENDATIONS
Section:
ChooseTop of pageAbstractINTRODUCTIONGUIDELINE
QUESTIONSMETHODSRESULTSRECOMMENDATIONS <<EVIDENCE SUMMARY OF
INTER...DISCUSSIONPATIENT AND CLINICIAN COM...HEALTH DISPARITIESGUIDELINE
IMPLEMENTATION ...OPEN COMMENT REVIEWLIMITATIONS OF THE RESEAR...FUTURE
DIRECTIONSADDITIONAL RESOURCESREFERENCES
Aromatase Inhibitor–Related Joint Pain
Recommendation 1.1.
Acupuncture should be offered to patients experiencing AI-related joint pain in
breast cancer (Type: Evidence based, benefits outweigh harms; Evidence quality:
Intermediate; Strength of recommendation: Moderate).
Literature review.
Four SRs and five RCTs were conducted in the area of acupuncture and AI-related
joint and muscle pain.19,27-30,44-47 The most definitive evidence is from a
phase III sham-controlled RCT conducted among 226 patients with moderate to
severe AI-related joint pain.19 After 6 weeks, true acupuncture reduced pain
significantly more than sham acupuncture and standard of care (waitlist control;
2.05, 1.07, and 0.99 points, respectively, on a 0-10 point NRS). After 6 weeks,
there were more responders who had a clinically meaningful change in pain (a
two-point reduction on a 0-10 scale)253 in the true acupuncture group compared
with the sham and waitlist control groups (58%, 33%, and 31% respectively).
Recommendation 1.2.
Yoga may be offered to patients experiencing AI-related joint pain in breast
cancer (Type: Evidence based, benefits outweigh harms; Evidence quality: Low;
Strength of recommendation: Weak).
Literature review.
In one RCT (N = 142),254 a 4-week yoga intervention was compared with a waitlist
control among breast cancer survivors currently receiving hormone therapy
(including AIs or tamoxifen) and who reported moderate to severe pain, muscle
aches, and body aches (> 2 on 0-4 scale) at baseline. Compared with women
randomly assigned to wait-list control, a significantly greater proportion of
women randomly assigned to yoga had reductions in total body aches (yoga 88.0% v
control 56.7%; P = .02), while there was a trend for pain (yoga 57.1% v control
37.1%; P = .09). Limitations of this trial include the analysis of pain as a
secondary outcome as the parent trial was powered for insomnia.254
Clinical interpretation.
Since AI-related joint pain affects up to 50% of women on this class of drugs
and negatively affects quality of life and adherence to hormonal treatment, we
recommend that acupuncture should be used for management of this painful
condition. Our recommendation is based on the available evidence for managing
this challenging condition and clinical importance of this issue. Many studies
showed joint pain results in nonadherence to AIs7,8 and such behavior can lead
to increased recurrence and mortality for women with breast cancer.255 Funding
to study nonpharmacologic approaches to pain and symptom management is highly
limited partly because of the lack of industry support. To date, only
acupuncture, duloxetine,256 and supervised exercise257 have been found to
improve AI-induced pain in large RCTs258 but only one large definitive trial for
each intervention has been conducted. Despite the recommendation, the decision
to use acupuncture with other treatments for AI-related pain needs to be based
on patient preference, benefit versus risk for each therapy, and availability of
and access to the treatment modality. Yoga, other mind-body therapies, and
natural products require additional well-conducted RCTs to increase the quality
of evidence to inform a change in the level of recommendation, if warranted.
General Cancer Pain or Musculoskeletal Pain
Recommendation 1.3.
Acupuncture may be offered to patients experiencing general pain or
musculoskeletal pain from cancer (Type: Evidence based, benefits outweigh harms;
Evidence quality: Intermediate; Strength of recommendation: Moderate).
Literature review.
Eight RCTs investigated the effect of acupuncture on general cancer pain or
general musculoskeletal pain among patients with cancer.20,48-54 Among them,
only one RCT had a large sample size,20 with 360 patients allocated in a 2:1:1
ratio into electroacupuncture (EA), auricular acupuncture (AA), and UC. It
showed that EA reduced pain by 1.9 points on a 0-10 NRS, and AA reduced pain by
1.6 points compared with UC at the end of treatment. In addition, the treatment
effects were durable at six months from random assignment. Both EA and AA were
associated with minimal toxicities, although more patients withdrew early from
the AA group because of ear pain.20 Given the large sample size and large effect
size, although there was no blinded sham control, the committee determined that
patients may consider using acupuncture to manage chronic musculoskeletal pain.
Recommendation 1.4.
Reflexology or acupressure may be offered to patients experiencing pain during
systemic therapy for cancer treatment (Type: Evidence based, benefits outweigh
harms; Evidence quality: Intermediate; Strength of recommendation: Moderate).
Literature review.
There were seven randomized trials, evaluating the effectiveness of reflexology
to reduce pain during systemic therapy (chemotherapy, chemoradiotherapy,
targeted, and/or hormonal therapy) with six trials showing significantly less
pain in the intervention group compared with the controls.92-96,98 These studies
included patients with different cancer types and used different methods to
implement the reflexology intervention that was provided (provided by a
reflexologist,92,93,95-97 administered by a trained caregiver94,98). Four trials
included fewer than 50 patients per arm, but three trials included more than 90
patients per arm.94,97,98 The type of control varied between trials (attention
control,94,98 usual or standard care,95-97 and other active treatment such as
relaxation) and two trials94,97 blinded patients to the group assignments.
Recommendation 1.5.
Massage may be offered to patients experiencing chronic pain following breast
cancer treatment (Type: Evidence based, benefits outweigh harms; Evidence
quality: Low; Strength of recommendation: Moderate).
Literature review.
In a SR and meta-analysis,101 five randomized trials with a total of 127
patients with chronic musculoskeletal pain after breast cancer treatment were
included. Three studies were of high methodologic quality and in one study,
patients were blinded for the intervention. The trial interventions included
myofascial induction, myofascial release, classic massage, ischemic compression
of trigger points, and myofascial therapy. Controls used in the trials included
an educational session, physical therapy, or sham control. In the massage
therapy group, the pain was decreased by a small to moderate effect size
(standardized mean difference [SMD] 0.32) compared with the controls. On the
basis of the available data, massage may be offered to decrease pain intensity
in women who have completed surgical treatment, chemotherapy, and/or radiation
therapy for breast cancer.
Recommendation 1.6.
Hatha yoga may be offered to patients experiencing pain after treatment for
breast or head and neck cancers (Type: Evidence based, benefits outweigh harms;
Evidence quality: Low; Strength of recommendation: Weak).
Literature review.
Two RCTs evaluated hatha yoga for musculoskeletal pain among patients'
postcancer treatment: One RCT for musculoskeletal pain associated with head and
neck cancer76 (N = 40) and the second evaluated hatha yoga for musculoskeletal
pain among patients with breast cancer (N = 42).77 Both trials had small sample
sizes, and follow-up assessments were completed at similar intervals (8 weeks,
2.5 months). In one trial, statistically significant differences were observed
among patients with head and neck cancer on the BPI (short form), including in
patterns of change in pain (P < .001, SMD = 0.90), and pain interference with
activities of daily living (BPI Interference, P = .005, SMD = 0.67). In the
second trial among patients with breast cancer, the yoga group demonstrated
significant improvement in shoulder and arm pain severity from baseline to
post-treatment (P = .01 and P = .01, respectively). Pain reduction was
maintained at 2.5 months post-treatment (P = .01 and P = .01, respectively).
However, the control group demonstrated no significant difference between
pretreatment and post-treatment pain levels. These findings provide preliminary
evidence supporting the efficacy of hatha yoga for pain after head and neck or
breast cancer treatment, although given the small sample sizes and lack of
attention controls, the quality of the evidence is low.
Recommendation 1.7.
Guided imagery with progressive muscle relaxation (PMR) may be offered to
patients experiencing general pain from cancer treatment (Type: Evidence based,
benefits and harms not assessable; Evidence quality: Low; Strength of
recommendation: Weak).
Literature review.
Four RCTs were identified for evaluation of guided imagery and PMR for patients
experiencing pain because of a cancer diagnosis.80,81,125,126 These studies
included multiple types of cancers, and two of these studies included
intervention arms that included only 20 participants.81,125 One included an
intervention arm of approximately 100 participants.126 The largest and one of
the smaller studies reported decreased pain levels with the intervention
compared with the control. One of the studies used audio recorded instruction of
PMR and mental imagery as well as live instruction and a control group. Blinding
of participants, health professionals, data collectors, and data analysts was
inconsistent. These factors adversely affected study quality overall. With only
some favorable findings, overall lack of safety data, and quality concerns,
guided imagery and PMR may be offered to patients experiencing cancer-related
pain, but the strength of the recommendation is weak.
Clinical interpretation.
General cancer pain and musculoskeletal pain are common among patients with
cancer and can persist even years after cancer treatment. Management of pain
requires an interdisciplinary approach that includes pharmacologic treatments
(both nonopioid and opioid drugs depending on the severity), physical therapy,
and psychotherapy. There is moderate evidence that acupuncture can be used to
manage general cancer pain or chronic musculoskeletal pain. In addition,
reflexology can be incorporated into systemic cancer treatment. The other
integrative medicine interventions, despite some demonstrating promising
preliminary results, have low level of evidence because of limited research and
methodologic challenges; therefore, more rigorous research is needed.
Chemotherapy-induced Peripheral Neuropathy
Recommendation 1.8.
Acupuncture may be offered to patients experiencing CIPN from cancer treatment
(Type: Evidence based-informal consensus, benefits outweigh harms; Evidence
quality: Low; Strength of recommendation: Weak).
Literature review.
There were two SRs31,32 and seven RCTs56-62 with small sample sizes
investigating the effect of acupuncture on CIPN. No major toxicities were
reported in any studies, and most studies showed a benefit of acupuncture for
CIPN pain. In a phase II trial (N = 75), acupuncture was associated with
significant reduction in CIPN pain, whereas sham acupuncture and UC were not
(1.75, 0.91, and 0.19 points, respectively, on a 0-10-point NRS). However, the
small sample sizes and high or unclear risk of biases in the studies resulted in
low level of evidence.62
Recommendation 1.9.
Reflexology or acupressure may be offered to patients experiencing CIPN from
cancer treatment (Type: Evidence based, benefits outweigh harms; Evidence
quality: Low; Strength of recommendation: Weak).
Literature review.
Two small RCTs with approximately 30 patients per arm evaluated the
effectiveness of reflexology for reducing CIPN symptoms, including pain,
compared with the control.99,100 One trial in patients with multiple cancers
compared the effects of reflexology foot massage twice a day for 20 minutes over
6 weeks to standard hospital care.99 This study found improvement in sensory
functions in the reflexology group compared with the control group but no group
differences for peripheral neuropathy-related pain severity and incidence. The
second study was in patients with gynecologic cancers and tested a self-care
reflexology approach.100 Patients in the intervention group were trained to
perform aromatherapy self-foot reflexology (three times a week, for 15 minutes
on each foot, 18 sessions over a period of 6 weeks) and were compared with a
waitlist control. The intervention group showed lower levels of peripheral
neuropathy symptoms, less interference with daily activities, and higher
peripheral skin temperature level. In addition, the self-foot massage seemed to
have had a positive effect on mood symptoms. Furthermore, side effects were not
reported in either study or, therefore, the potential benefits likely outweigh
the potential harms.
Clinical interpretation.
CIPN is a highly common, persistent, and debilitating toxicity that not only
negatively decreases quality of life but also increases risk for falls.259
Duloxetine provides modest effect for CIPN pain,23 but it has side effects
poorly tolerated by some patients. On the basis of preliminary efficacy and
favorable risk-benefit ratio, acupuncture may be recommended. A phase III
acupuncture for CIPN trial is ongoing and will help more definitively clarify
the role of acupuncture for this debilitating painful condition
(ClinicalTrials.gov identifier: NCT04917796). In addition, albeit with low
levels of evidence, aromatherapy self-foot-reflexology may be considered part of
self-care for some patients for CIPN pain to improve patients' self-efficacy and
to empower them to be more active participants during their cancer care; larger
trials would be needed for evidence-based recommendations.
Surgical or Procedural Pain
Recommendation 1.10.
Hypnosis may be offered to patients experiencing pain during cancer treatment
procedures or diagnostic workups (Type: Evidence based, benefits outweigh harms;
Evidence quality: Intermediate; Strength of recommendation: Moderate).
Literature review.
Five studies have evaluated the use of hypnosis during procedures,87-91
including three with methodologic weaknesses and two well-designed studies with
an attention control as well as a standard-of-care arm.88,91 The two most
rigorous trials with more than 200 randomly assigned participants each evaluated
hypnosis for large core breast biopsies91 and tumor embolization or
radiofrequency ablation.88 Both studies demonstrated significantly lower pain
ratings compared with control arms with a median reduction of ≥ 2 (0-10 point
scale) reported during the procedure. On the basis of these two trials, hypnosis
may be recommended to help manage pain during procedures. Importantly, both
studies involved hypnosis provided throughout the procedure, not just for a
short time before the procedure.
Clinical interpretation.
Procedures such as biopsy or tumor embolization play an important role in
diagnosis and treatment of cancer. However, they are associated with acute pain
and frequently require management with intravenous or oral pain medications that
have a few side effects. There is moderate evidence for self-hypnosis to be
taught and used to prevent treatment procedure-related pain. However, for the
other interventions such as mindfulness-based interventions, music therapy, and
virtual reality–based imagery interventions, despite their appeal and potential
effect, research is very much needed to establish a robust evidence base.
Recommendation 1.11.
Acupuncture or acupressure may be offered to patients undergoing cancer surgery
or other cancer-related procedures such as bone marrow biopsy (Type: Evidence
based-informal consensus, benefits outweigh harms; Evidence quality: Low;
Strength of recommendation: Weak).
Literature review.
There were 12 RCTs assessing the effect of acupuncture or acupressure in
reducing pain associated with surgery or procedure.64-75 They are all limited by
small sample sizes and an unclear or high risk of bias. Among them, two involved
acupressure for bone marrow aspiration and biopsy pain,64,65 one was on
acupuncture and mastectomy pain,66 and nine were on postoperative pain.67-75 The
two acupressure and bone marrow aspiration and biopsy pain RCTs showed that
acupressure significantly reduced the proportion of patients who experienced
severe pain than sham acupressure (2.7% v 20%, P = .03),64 and acupressure
resulted in the lowest procedural pain score when compared with sham acupressure
or sham (P = .001).65 A trial of acupuncture for mastectomy pain (N = 30) showed
that acupuncture significantly reduce pain, nausea, and anxiety in the first 2
postoperative pain days when compared with UC.66 Among the nine RCTs on
acupuncture versus control groups to reduce postoperative pain, six trials
showed no statistical difference between the two groups, and three showed
acupuncture treatment resulted in lower pain score.68-70 Adequately powered and
well-designed trials are needed to establish the definitive efficacy of
acupuncture. Although the quality of evidence was deemed low, the benefit seems
to outweigh the risk; therefore, the panel determined that patients may explore
use of acupuncture or acupressure to reduce surgical and procedure-related pain.
Recommendation 1.12.
Music therapy may be offered to patients experiencing surgical pain from cancer
surgery (Type: Evidence based, benefits outweigh harms; Evidence quality: Low;
Strength of recommendation: Weak).
Literature review.
Although all the three studies in this section demonstrated a significant effect
of music therapy to improve surgical pain scores more than UC, quality of
evidence is low as two trials showed high risk of bias117,118 and one was a
small study to test the hypothesis.116 A trial of 60 patients undergoing lung
cancer resection indicated potential association between music therapy and the
need for less analgesic medication, including opioid drugs.118 The smallest
study of 30 mastectomy patients used a high-dose (4 hours of recorded music)
music therapy intervention and found the music therapy group experienced a 41.4%
less increase in pain from time 1 (preoperative) to time 2 (postoperative)
compared with women in the control.116 Similarly, a trial of 120 women with
breast cancer undergoing radical mastectomy surgery in China found a
statistically significant improvement in the primary end point (change in Pain
Rating Index scores from baseline [the first day after radical mastectomy
(pretest)]) for the music therapy group compared with the control group (–2.38
(95% CI, –2.80 to –1.95), P < .001) at the first post-test (evaluation on the
day before discharge from hospital). This improvement remained significant,
although the difference narrowed, at the third post-test (evaluation on the day
of admission for second chemotherapy session).
Clinical interpretation.
Cancer surgery is associated with acute pain and can also lead to chronic pain.
The primary mode of pain management during the perioperative or postoperative
periods involves anesthesia, opioid, and nonopioid drugs. Despite the
preliminary evidence and potential value of several integrative medicine
interventions such as acupuncture, music therapy, or massage, the quality of
research evidence is low and insufficient. Adequately powered clinical trials
evaluating the effectiveness of these interventions in the perioperative or
postoperative settings are needed to guide further recommendations.
Pain During Palliative Care
Recommendation 1.13.
Massage may be offered to patients experiencing pain during palliative and
hospice care (Type: Evidence based, benefits outweigh harms; Evidence quality:
Intermediate; Strength of recommendation: Moderate).
Literature review.
A SR from 2009 assessing 14 low-quality trials concluded (on the basis of four
trials) that there is encouraging evidence that massage can alleviate pain in
palliative cancer patients with various types of cancers.103 A more recent SR
from 2020 included three RCTs evaluating the effectiveness of massage for pain
in patients receiving palliative treatment, all of them showing favorable
results for massage.40 Although two studies included smaller samples (10-20
patients per arm), the third trial was a high-quality large multicenter trial21
that was also included in the previous SR. A total of 380 adults with various
types of advanced cancers who were experiencing moderate-to-severe pain were
included (90% were enrolled in hospice) and randomly assigned to massage or
simple touch sessions (six 30-minute sessions over 2 weeks). The intervention
included gentle gliding stroke; squeezing, rolling, and kneading the muscles;
and trigger point release, while the control group received simple touch.
Immediate outcomes were obtained just before and after each treatment session on
a 0- to 10-point scale (Memorial Pain Assessment Card), and sustained outcomes
(including BPI) were obtained at baseline and weekly for 2 weeks. Massage seems
to have an immediate beneficial effect on pain reduction (mean difference, 0.90;
P < .001), and no side effects were observed. No between-group mean differences
occurred over time in the sustained measurements of pain. On the basis of the
available favorable data from multiple trials, massage may be offered to
patients experiencing pain during palliative and hospice care.
Clinical interpretation.
Effective pain management is a central component in providing high-quality
palliative care. On the basis of moderate evidence, massage can be incorporated
into palliative and hospice setting to provide short-term pain relief and
enhance coping for patients living with advanced cancer. The research is very
limited in both quantity and quality for other interventions to make sound
recommendations for pain management in this population. Chronic pain management
in cancer survivorship is also essential for improving quality of life and
functional recovery. With the ongoing opioid epidemic in the United States,
Canada, and other countries, rigorous research and appropriate implementation
and integration of nonpharmacologic interventions (eg, acupuncture, yoga, and
massage) even as first-line pain management is needed for the growing population
of cancer survivors.
Figure 2 provides a visual representation of these recommendations in the
treatment algorithm. Table 3 shows the breakdown of the summary of
recommendations.
FIG 2. Treatment algorithm. CIPN, chemotherapy-induced peripheral neuropathy.
TABLE 3. Summary of Recommendations
View larger version (548K)
EVIDENCE SUMMARY OF INTERVENTIONS WITH INSUFFICIENT OR INCONCLUSIVE EVIDENCE TO
INFORM AN ACTIONABLE RECOMMENDATION
Section:
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QUESTIONSMETHODSRESULTSRECOMMENDATIONSEVIDENCE SUMMARY OF INTER...
<<DISCUSSIONPATIENT AND CLINICIAN COM...HEALTH DISPARITIESGUIDELINE
IMPLEMENTATION ...OPEN COMMENT REVIEWLIMITATIONS OF THE RESEAR...FUTURE
DIRECTIONSADDITIONAL RESOURCESREFERENCES
Adult Population
Natural products for AI-related joint pain.
There is insufficient evidence to recommend for or against use of omega-3 fatty
acids, Yi Shen Jian Gu granules, or topical pure emu oil to manage AI-related
pain. Four trials tested the effects of natural products on the treatment of
AI-induced pain in patients with breast cancer. Two randomized,
placebo-controlled trials tested the effects of omega-3 fatty acids on the
prevention and treatment of AI-induced musculoskeletal pain.191,192 The first
trial was a large multisite trial that tested the effects of omega-3 fatty acids
on reducing AI-induced musculoskeletal pain in women with a history of breast
cancer (N = 262).192 In this trial, improvements were observed in both the
omega-3 fatty acid and placebo (soybean or corn oil) arms with no differences
between groups. The second trial was a smaller pilot and feasibility trial,
again testing the effects of omega-3 fatty acids on preventing AI-induced
arthralgias in patients with breast cancer (N = 44) and found no differences in
pain severity between groups.191 One trial tested the effects of a combination
of Chinese herbal formulation Yi Shen Jian Gu granules,203 while another tested
topical pure emu oil.204 The emu oil did not yield differences compared with the
placebo. However, the women who received Yi Shen Jian Gu (n = 40) appeared to
have improved pain at 12 and 24 weeks. Given that there was only one trial of
each treatment intervention with relatively small sample sizes, there are
insufficient data to make a clinical recommendation.
General cancer pain.
Music therapy.
There is insufficient evidence to recommend for or against the use of music
therapy for patients experiencing general cancer pain. Of the three studies
identified, only two trials specified pain as a primary outcome and were,
therefore, reviewed.114,115 These two trials did not contribute evidence of
music therapy as effective for generalized oncology pain because of methodologic
flaws. One RCT compared one-time 30-minute sedative music therapy, instrumental
intervention versus UC for 126 inpatient oncology patients experiencing levels
of pain rated three and greater on a 0-10 numerical rating scale.114 The music
therapy intervention included self-selected music styles intended for relaxation
or distraction. The other study compared music therapy (passive listening to
instrumental music) to poetry (listening to spoken-word poetry) in a three-arm
trial with the control group receiving usual inpatient care.115 Use of opioid
analgesics and nonsteroidal anti-inflammatory drugs were reported for both
groups, with no significant difference of use between groups. Primary outcomes
were changes in daily pain levels over the 3 days during which music or poetry
was offered. Both intervention groups showed statistically significant
improvements in perceptions of pain, which may indicate that it was the
distraction provided by the interventions that was sufficient to decrease
perception of pain, and not effects specific to music therapy.
Herbal products.
There is insufficient evidence to recommend for or against the use of Xiao Zheng
Zhitong paste, Jinlongshe granule, Shuangbai San paste, or Xiao-Ai-Tong
decoction for general cancer pain. Four trials tested the effects of Chinese
herbal preparations on treating general cancer pain, including Xiao Zheng
Zhitong paste in patients with a range of different cancer types,207 Jinlongshe
granules in patients with gastric cancer,208 Shuangbai San paste in patients
with liver cancer,209 and Xiao-Ai-Ton decoction with and without morphine in
patients with a range of different cancer types.206 Given that there was only
one trial of each treatment intervention, variability in quality of the trials,
there are insufficient data to make a clinical recommendation.
Chemotherapy-induced peripheral neuropathy.
Natural products.
There is insufficient evidence to recommend for or against the use of omega-3
fatty acids, and glutamine to patients experiencing CIPN from cancer treatment.
A single moderate-size randomized, double-blind, placebo-controlled trial (N =
69) tested the effects of omega-3 fatty acid on reducing the incidence and
severity of peripheral neuropathy in patients with breast cancer receiving
paclitaxel chemotherapy.194 Trial results showed that patients receiving the
omega-3 fatty acids were less likely to develop peripheral neuropathy, but there
were no differences in severity of neuropathy and motor nerve conduction
measurements. Although the trial results are intriguing, subsequent trials need
to replicate and confirm these findings before a clinical recommendation can be
made.
Two RCTs tested the effects of glutamine on the incidence and severity of
peripheral neuropathy.186,187 The first trial was a moderate-size (N = 86) trial
comparing oral levo-glutamine compared with no intervention in patients with
colorectal cancer receiving oxaliplatin.186 Patients who received levo-glutamine
had lower incidence and severity of peripheral neuropathy symptoms; however, the
trial did not control for placebo effects. The second smaller trial (N = 43)
compared oral glutamate to placebo in women with ovarian cancer receiving
paclitaxel.187 There were no differences between groups in incidence of
peripheral neuropathy; patients who received glutamate reported lower pain
severity. No clinical recommendations can be made on the basis of these results
because of low study quality and/or small sample size.
Surgical or procedural pain.
Meditation-based interventions.
There is inconclusive evidence to recommend for or against the use of
meditation-based interventions to patients with breast cancer experiencing
procedural pain. Four RCTs evaluated meditation or mindfulness-based
interventions for patients experiencing procedural pain for breast
cancers.127-130 Two studies examined loving-kindness meditation versus music
intervention versus UC, and showed loving-kindness meditation's superiority to
UC, but not to music.129,130 The third study examined guided meditation plus
massage versus massage alone, and showed no significant difference between study
arms.128 The fourth study was composed of three arms comparing guided
mindfulness-based meditation to guided focused breathing and standard of care in
women scheduled for stereotactic breast biopsy.127 The result of this study was
also negative. All four studies were relatively small in size (n < 50 per arm).
The mixed findings suggest that meditation-based therapies are not superior to
active control conditions, but it is likely that these studies were
underpowered. In the absence of fully powered trials, there are no clear
indications for meditation-based therapies for patients experiencing procedural
pain for breast cancers.
Music therapy.
There is inconclusive evidence to recommend for or against the use of music
therapy to patients experiencing procedural pain. The five trials
reviewed119-123 showed either no effect119,123 or suffered from various
methodologic flaws, including weak music therapy interventions,122 high risk of
bias in trial methodology,121 inadequate assessment and reporting of pain
scores,121,122 and inconsistent tracking of analgesic or anxiolytic medication
provided during the intervention period.120,121 These studies, therefore,
yielded results insufficient to determine the effect of music therapy on
procedural pain.
Reflexology.
There is insufficient evidence to recommend for or against the use of
reflexology for pain associated with surgery or procedure. There is only one
small, randomized trial138 (n = 31 patients per arm) in patients with gastric or
liver cancer who received major abdominal surgery evaluating the effectiveness
of foot reflexology compared with a control. The foot reflexology was provided
at least 24 hours after surgery by a trained reflexologist (10 minutes on each
foot for 3 consecutive days). The control group received routine care. The
results were inconclusive; although there was no significant group difference
for the McGill Pain Questionnaire, the VAS showed a difference in favor of the
intervention group. The present data are insufficient to recommend the use of
reflexology for pain associated with cancer-related surgery or procedures.
Hypnosis.
There is inconclusive evidence to recommend for or against the use of hypnosis
in treating surgical pain in patients with cancer. Two studies evaluated
hypnosis for surgical pain with inconsistent results.84,85 Montgomery et al85
randomly assigned 200 patients with breast cancer scheduled for excisional
biopsy or lumpectomy to 15-minute hypnosis intervention before surgery versus an
attention control. Subjects in the hypnosis group reported less pain intensity
(means = 22.43 v 47.83; difference = 25.40; 95% CI, 17.56 to 33.25) and pain
unpleasantness (means = 21.19 v 39.05; difference = 17.86; 95% CI, 9.92 to
25.80). Hypnosis also led to decreased utilization of propofol and lidocaine
compared with controls. The second study allocated 150 patients with breast
cancer scheduled for minor breast surgery to hypnosis (≤ 15 minutes) versus UC
control.84 The study found increased mean pain in the hypnosis arm (2.63,
standard deviation 1.62) versus control (1.75, standard deviation 1.59; P =
.004) on a pain VAS (0-10). Despite the large and well-designed clinical trials,
the inconsistent results make any conclusions impossible at this time.
Massage.
There is inconclusive evidence to recommend for or against the use of massage
for peri-postoperative pain from major surgical procedures in breast and
gynecologic cancer. There were two RCTs evaluating the effectiveness of massage
for pain reduction after major surgical procedures in patients with breast
cancer. A small trial with 19 patients per arm undergoing autologous tissue
reconstruction showed no extra benefits in the massage group compared with
controls.128 Another trial with 30 patients per arm undergoing lymph node
dissection evaluated the effectiveness of postsurgical arm massage provided by
the patient's significant other.139 The intervention group reported less pain in
the immediate postoperative period than the control group that received no
massage. A three-armed trial analyzed 35 women per arm with gynecologic cancers
and compared Swedish massage with vibration and UC as additional treatment to
postoperative pain medication.141 The interventions were applied for 3
consecutive days after surgery. Massage showed only minor effects on short-term
sensory and affective pain. On this basis, the data are inconclusive to
recommend massage for peri-postoperative pain following major surgical
procedures in patients with breast and gynecologic cancer.
There is also insufficient evidence to recommend for or against the use of
massage for pain from minor surgical procedures. There are very little data
evaluating the effectiveness of massage to improve pain from minor surgical
procedures. In a pilot trial with 2:1 random assignment, 40 patients received a
20-minute massage before and after the surgical placement of a vascular access
device (port) and 20 patients received attention control.140 No relevant
differences in postsurgical pain were observed between both groups. The
available data are insufficient to recommend massage for pain following minor
surgical procedures.
Pain from survivorship and palliative care.
Meditation-based interventions.
There is inconclusive evidence to recommend for or against the use of
meditation-based interventions to patients experiencing pain after treatment or
survivorship for breast cancers. Three RCTs evaluated meditation-based
interventions for patients experiencing pain after treatment or survivorship for
breast cancer or bone cancer.131-133 One study was relatively small (n < 50 per
arm),133 reporting superiority of Mindfulness-Based Stress Reduction (MBSR) plus
music therapy over a waitlist control for reducing pain intensity in
osteosarcoma. The other two studies were moderately large (n > 50 per
arm),131,132 with one study demonstrating the superiority of Mindfulness-Based
Cognitive Therapy over a waitlist control for reducing late post-treatment pain
intensity in women with breast cancer.132 By contrast, the other trial (the
largest meditation-based intervention trial evaluated in this review, N = 322)
showed no effect of MBSR over a waitlist control for chronic pain in breast
cancer survivors who completed treatment.131 The null effect in this trial may
be associated with low baseline pain or the high heterogeneity of the sample
(women had completed treatment between 2 weeks to 2 years before study
enrollment). Adverse events were not reported for all four studies. Given these
mixed findings, and the lack of safety data, there are no clear indications for
meditation-based intervention for patients experiencing pain following treatment
or survivorship for breast or bone cancers.
Hypnosis.
There is inconclusive evidence to recommend for or against the use of hypnosis
in treating pain in cancer survivors (active treatment and post-treatment
survivors). Studies of hypnosis during cancer survivorship were limited because
of significant methodologic issues. Two studies combined hypnosis with another
intervention—support group135 or cognitive behavioral therapy.134 These studies
generally reported positive benefits; however, interpretation is limited because
of the combination approach. A study randomly assigned patients receiving a bone
marrow transplant to hypnosis training, cognitive behavioral coping, therapist
contact, and UC.136 The patients in the hypnosis arm attended two prehospital
sessions and then received taped recordings for daily practice while in the
hospital. Descriptive results showed lower oral pain in the hypnosis group but
were limited by the small numbers in each group (10-12 in each arm). Therefore,
this area could benefit from more research with large sample sizes.
Music therapy.
There is insufficient evidence to recommend for or against the use of music
therapy in treating palliative or chronic pain in patients with cancer. There
was only one study reviewed for music therapy for pain in patients receiving
palliative care.124 This trial was conducted as an RCT, but the group designated
as control received an effective intervention (MBSR involving deep breathing,
visual imagery, and muscle relaxation). Although the study was well designed and
blinded, pain scores did not change significantly and both groups improved in
relaxation and well-being scores. The dose for the music therapy intervention
was low, consisting of the availability of 45 minutes of prerecorded music on a
cassette tape player, which most participants in the music therapy group
reported listening to only 2-4 times per week. The music therapist met once with
each intervention group participant to choose the type of music they preferred.
The study, therefore, does not support the use of this music therapy
intervention for pain during palliative care.
Virtual reality.
There is insufficient evidence to recommend for or against the use of virtual
reality imagery and relaxation in treating palliative or chronic pain in
patients with cancer. Only two studies were identified for the use of virtual
reality imagery and relaxation interventions in adults, both for pain during
palliative care.142,143 The first study investigated female patients with breast
cancer experiencing pain and receiving analgesic painkillers (intravenous or
oral) in a palliative care setting.142 This trial did not specify the primary
outcome, and although both pain and anxiety were assessed, conclusions were that
an immersive virtual reality imagery and relaxation intervention is acceptable
in an Arab culture (study is from Jordan), and that virtual reality holds
promise as an effective distraction intervention for managing pain and anxiety
among this study population.142 The second trial also only studied female
patients with breast cancer who had undergone breast cancer surgery.143 Both
intervention and control groups received upper-extremity physiotherapy, with the
intervention group adding an Xbox 360 Kinect technology-based gamification of
physiotherapy for weeks 2 through 5 in addition to some additional physiotherapy
exercises. Both groups experienced statistically significant improvement over
time with no differences between groups.
Pain during radiation therapy and/or oral mucositis.
Hypnosis.
There is inconclusive evidence to recommend for or against the use of hypnosis
in treating radiotherapy-induced pain in patients with cancer. For radiotherapy,
only one study has been published.137 This study randomly assigned 68 patients
with head and neck cancer receiving radiotherapy to a single 20-minute session
of hypnosis or UC. The hypnosis treatment demonstrated significantly lower pain
scores –1.966 (95% CI, –2.260 to –1.673; P < .001) compared with controls. This
study should be considered hypothesis-generating.
Honey.
There is inconclusive evidence to recommend for or against the clinical use of
honey for oral mucositis. Nineteen trials tested the effects of honey on the
prevention and/or treatment of oral mucositis.148-166 The results across trials
are inconsistent and, thus, it is not possible to make a conclusive
recommendation. Study populations included patients with head and neck cancer
receiving radiation (some of whom also received chemotherapy),149-159,165
patients with acute myeloid leukemia receiving chemotherapy,160 patients with
chemotherapy-induced oral mucositis,163 patients with radiation therapy-induced
oral mucositis,164 and patients with lung cancer receiving chemotherapy and
radiation therapy.166 No two trials used the same honey preparation, dose, mode,
and/or timing of delivery. Some studies did suggest that the studied honey
preparation did provide some benefit, although the size and quality of the
studies limit the ability to draw definitive conclusions. The largest and most
rigorously designed trial was a three-arm trial conducted within the National
Clinical Trials Network NRG Oncology clinical trial network that tested the
effects of standard supportive care, liquid manuka honey, and manuka honey
lozenges in preventing radiation esophagitis in patients with lung cancer.
Neither honey arm was superior to supportive care in preventing radiation
esophagitis; however, the honey preparation in this trial was irradiated, which
may have inhibited the beneficial effect of bacteria within the honey. Because
of the heterogeneity of interventions and outcomes, the data are inconclusive on
the use of honey to prevent or treat oral mucositis.
Other natural products.
There is insufficient evidence to recommend for or against the clinical use of
chamomile, propolis, glutamine, curcumin, teas, mouthwashes, and other herbal
combinations. Multiple trials tested a variety of botanical and natural products
to prevent and/or treat mucositis in a range of different cancer types receiving
different chemotherapy and/or radiation therapy
treatments.167-174,188,189,195-202,211-229 Interventions included
chamomile,167,168 propolis,169-171 glutamine,172-185 curcumin,188-190 botanical
teas,195,196 mouthwashes,197-202 and other natural products (Data
Supplement).211-229 No two trials used the same formulation. Although some
trials suggested that there might be some benefit, most trials did not have
clearly defined end points and were not clearly powered to detect differences.
Thus, there are insufficient data to make clinical recommendations on the use of
these natural products for the prevention and/or treatment of oral mucositis.
Oral mucositis pain represents a challenging toxicity associated with radiation
and some chemotherapy agents. The current management often involves topical
local anesthetics, opioids, and liquid diets, and in many cases, patients
require a gastric tube for adequate nutrition. Despite tremendous unmet needs,
the research evidence for integrative medicine (both mind-body and natural
products) is low and requires thoughtful investigation to make evidence-informed
recommendations.
Pediatric Population
Although we sought out to evaluate the evidence of integrative medicine for pain
in pediatric population, there were very few trials in this population. Several
small RCTs focused on procedural pain: hypnosis,240-243 music therapy,245 and
virtual reality246,247 were conducted. Despite showing acceptability,
feasibility, and promising effect in some trials, these studies had substantial
methodologic flaws such as lack of appropriate control groups and small sample
size; therefore, there is insufficient evidence to support the use of hypnosis,
music therapy, and virtual reality in treating procedural pain in pediatric
patients with cancer. A number of RCTs evaluated various natural products for
oral mucositis pain with honey.148,161,162 The study populations included
pediatric patients receiving methotrexate,162 and other children receiving
chemotherapy and/or radiation therapy.148,161 The results from these studies
were inconsistent. Natural products (eg, vitamin E, Traumeel S, pine bark
extract, andiroba gel, and propolis) were evaluated in clinical trials as
treatment of chemotherapy-induced oral mucositis in children with
cancer226,248-251; however, these trials were early phase and had limited sample
size and poor control groups; therefore, the risk of bias was high; the evidence
for these therapies were insufficient or inconclusive.
Pain in children or infants with cancer is common during medical or surgical
treatment; however, because of the limited research in this area, no
recommendations can be made to incorporate integrative medicine intervention for
pain management. Research in alleviating pediatric pain and other symptoms is
particularly challenging because of the difficulty in assessing and measuring
children's pain, the involvement of parents, which adds complexity, and small
sample sizes. However, to provide evidence-informed integrative treatment for
children with cancer, novel research methods, carefully developed interventions,
and rigorous study design and conduct are needed for children with cancer and
their parents.
DISCUSSION
Section:
ChooseTop of pageAbstractINTRODUCTIONGUIDELINE
QUESTIONSMETHODSRESULTSRECOMMENDATIONSEVIDENCE SUMMARY OF INTER...DISCUSSION
<<PATIENT AND CLINICIAN COM...HEALTH DISPARITIESGUIDELINE IMPLEMENTATION ...OPEN
COMMENT REVIEWLIMITATIONS OF THE RESEAR...FUTURE DIRECTIONSADDITIONAL
RESOURCESREFERENCES
Pain remains a challenging clinical issue for both patients with cancer and
health care providers. Effective pain management requires careful consideration
of the research evidence for both pharmacologic and nonpharmacologic
interventions. On the basis of reviewing 198 RCTs and 26 SRs and meta-analyses,
several integrative medicine interventions can be considered for management of
pain in oncology settings, using rigorous criteria for the basis of
recommendations. Acupuncture should be recommended to manage AI-related joint
pain. Acupuncture and reflexology or acupressure may be recommended for general
cancer pain and musculoskeletal pain. Hypnosis may be recommended for patients
undergoing painful procedures, and massage may be recommended for patients
receiving palliative or hospice care. These recommendations were based on at
least intermediate quality of evidence and overall appraisal of benefits
outweighing potential harms. The use of other integrative medicine interventions
for other types of pain currently has low quality of evidence. This guideline
provides the evidence base for integrating selected integrative medicine
approaches into a comprehensive pain management strategy to improve symptom
control and quality of life for patients with cancer and survivors. In addition,
the review highlights the gaps in evidence that should inspire future research.
PATIENT AND CLINICIAN COMMUNICATION
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DIRECTIONSADDITIONAL RESOURCESREFERENCES
Effective communication between health care providers and their patients is
essential for patient-centered pain management. It is well documented that
physicians rarely inquire about the use of integrative medicine, and patients
often do not disclose such use.260 Health care providers need to have a
knowledge base to engage in meaningful communication with their patients about
integrative medicine use and provide answers to their questions.261 The results
of a large survey suggest that lack of knowledge about integrative medicine is
often the biggest barrier to use by patients, particularly among racial and
ethnic minorities and among those with less education.262,263 Patients with
positive beliefs about natural health approaches, higher treatment expectancy,
lower barriers, and with family endorsement are likely to prefer integrative
medicine over pharmacology to manage pain.17,263 Facilitating open communication
and acknowledging patient values and preferences will enable shared decision
making about selecting the most appropriate pain management approach to ensure
high-quality care. For recommendations and strategies to optimize
patient-clinician communication, see Patient-Clinician Communication: American
Society of Clinical Oncology Consensus Guideline.264
HEALTH DISPARITIES
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DIRECTIONSADDITIONAL RESOURCESREFERENCES
Although SIO-ASCO clinical practice guidelines represent expert recommendations
on the best practices in disease management to provide the highest level of
cancer care, it is important to note that many patients have limited access to
medical care or receive fragmented care. Demographic factors such as race and
ethnicity, age, socioeconomic status, sexual orientation and gender identity,
geographic location of residence, immigrant status, insurance access, and other
social determinants are known to affect cancer care outcomes.265 The impact of
intersectionality is often cumulative and more than simply additive,17 resulting
in knowledge gaps, limited availability to high-quality primary and specialty
care, and transportation barriers. These demographic elements are bolstered by
structural factors that maintain health inequities in marginalized communities
in the United States and other countries. In countries without universal health
care, for many patients, the quintessential barrier to health care is access to
health insurance, whether uninsured or underinsured. Since integrative medical
care generally is not covered by health insurance, and many countries with
universal health care do not provide routine integrative medical care, its
access is often limited to those who can pay the out-of-pocket costs.
This clinical practice guideline should be considered in the context of existing
health inequities and structural barriers to access to care. Health care
professionals should strive to deliver the highest level of cancer care to all
populations including those who have traditionally been marginalized and
underserved. Future trials should critically evaluate inclusion and exclusion
criteria to avoid, when possible, excluding patients with comorbid conditions,
usually more prevalent among minority patients, to avoid systematically
excluding patients traditionally under-represented in clinical trials.266
Thoughtful design with regard to inclusion and exclusion criteria and
recruitment procedures will enhance sample representativeness and maximize
generalizability to diverse and under-represented patients. Moreover, trial
participation often systematically disadvantages marginalized individuals as
participation often requires frequent clinic visits, only offers interventions
during work hours, and does not provide funding for transportation, parking,
and/or childcare. Additionally, stakeholders should work toward achieving health
equity by ensuring equitable access to both high-quality cancer care and
research and addressing the structural barriers that uphold inequities in health
and health care.265
GUIDELINE IMPLEMENTATION AND POTENTIAL BARRIERS
Section:
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QUESTIONSMETHODSRESULTSRECOMMENDATIONSEVIDENCE SUMMARY OF
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IMPLEMENTATION ... <<OPEN COMMENT REVIEWLIMITATIONS OF THE RESEAR...FUTURE
DIRECTIONSADDITIONAL RESOURCESREFERENCES
SIO-ASCO guidelines are developed for implementation across oncology care
settings. Patient, provider, and health system barriers exist for the
implementation of this guideline. First, patients and health care providers
often lack the knowledge and awareness of the evidence base of integrative
medicine for pain. Second, despite the recent growth of integrative medicine
programs in comprehensive cancer centers,11 these clinical services may not be
as available in community hospitals, especially hospitals serving low income,
racial, or ethnic minority populations.267 Third, oncology patients often have
medical complexity (such as neutropenia, thrombocytopenia, or presence of tumor
or surgical wound), which community integrative health providers (eg,
acupuncturists and massage therapists) may not have the necessary knowledge of
or competency to ensure safe and effective care.268 Finally, although many
nonpharmacologic integrative medicine interventions have relatively low cost,
they generally are not covered by health insurance.269
The 2012 National Health Interview Survey in the United States found that most
adults who saw a practitioner for acupuncture or massage therapy did not have
health insurance coverage for these interventions, and those with coverage were
more likely to have costs only partly covered.270 Given the financial toxicity
experienced by many patients with cancer,271 additional out-of-pocket expenses
represent significant barriers to implementation of these recommendations. The
guideline Bottom Line Box was designed to facilitate implementation of
recommendations. This guideline will be distributed widely through the SIO and
ASCO guideline information networks. Joint SIO and ASCO guidelines are posted on
the SIO and ASCO websites and are published in the Journal of Clinical Oncology.
OPEN COMMENT REVIEW
Section:
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QUESTIONSMETHODSRESULTSRECOMMENDATIONSEVIDENCE SUMMARY OF
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IMPLEMENTATION ...OPEN COMMENT REVIEW <<LIMITATIONS OF THE RESEAR...FUTURE
DIRECTIONSADDITIONAL RESOURCESREFERENCES
The draft recommendations were released to the public for open comment from
November 10 through November 23, 2021, with invitations sent out to 24
organizations. There were eight respondents in total representing medical
oncology (3), integrative oncology (2), surgical oncology (1), family medicine
(1), and nursing (1). Response categories of “Agree as written,” “Agree with
suggested modifications” and “Disagree. See comments” were captured for every
proposed recommendation with 42 written comments received. A total of 80%-91% of
the responses either agreed or agreed with slight modifications to the
recommendations, while 9% of responses disagreed. Expert Panel members reviewed
comments from all sources and determined whether to maintain original draft
recommendations, revise with minor language changes, or consider major
recommendation revisions. All changes were incorporated before the SIO Clinical
Practice Guidelines Committee and ASCO Evidence Based Medicine Committee review
and approval.
LIMITATIONS OF THE RESEARCH
Section:
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QUESTIONSMETHODSRESULTSRECOMMENDATIONSEVIDENCE SUMMARY OF
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DIRECTIONSADDITIONAL RESOURCESREFERENCES
The methodologic rigor is limited in some of the studies included. For mind-body
interventions, adequate blinding is often difficult, if not impossible. In
addition, the interventions often vary in dosing and format, and fidelity of the
interventions is not always monitored. For natural product interventions, the
quality of products is often not well characterized, and the dosing is rarely
standardized. The methods used to assess pain are often inconsistent among
trials, which created difficulties in interpreting the data.269 Because many
integrative medicine intervention studies do not receive funding from industry,
a large RCT of a specific intervention (eg, acupuncture) for a specific outcome
(eg, AI-related joint pain, or massage for pain in palliative care setting) is
often limited to one large trial, which does not allow for adequate replication
of data. Additionally, most of the studies failed to report any adverse events
from these interventions. Furthermore, our guideline methodology excluded
nonrandomized pragmatic studies, which may be more reflective of real-life
integrative oncology practice.272
FUTURE DIRECTIONS
Section:
ChooseTop of pageAbstractINTRODUCTIONGUIDELINE
QUESTIONSMETHODSRESULTSRECOMMENDATIONSEVIDENCE SUMMARY OF
INTER...DISCUSSIONPATIENT AND CLINICIAN COM...HEALTH DISPARITIESGUIDELINE
IMPLEMENTATION ...OPEN COMMENT REVIEWLIMITATIONS OF THE RESEAR...FUTURE
DIRECTIONS <<ADDITIONAL RESOURCESREFERENCES
SIO and ASCO believe that cancer clinical trials are vital to inform clinical
decisions and improve cancer care, and that all patients should have the
opportunity to participate in these trials. As this guideline has identified
scientific gaps in a number of mind-body interventions (eg, meditation, yoga,
and music) for pain management in specific populations (eg, postsurgical,
radiation, and pediatric), careful intervention development, testing, and
well-designed and executed RCTs are needed to increase the evidence base. Where
the results were mixed (eg, meditation for post-treatment survivorship pain),
additional large-scale trials and meta-analyses are needed to resolve ambiguity
stemming from the presence of both positive and negative trials. Despite
tremendous patient interest, no herbs or natural supplements can currently be
recommended for treatment of pain; thus, well-designed, placebo-controlled phase
I-III trials are needed to establish the safety and efficacy of high-quality
natural products for pain.
For treatments such as acupuncture, massage, or reflexology where there is an
existing evidence base, there is a need for hybrid trials using appropriate
implementation research frameworks and measures to determine optimal
implementation and integration of these interventions into community oncology
practices. It is particularly important to conduct trials that address the needs
of underserved patients with cancer and survivors (eg, racial and/or ethnic
minority, rural, older, pediatric, adolescent, and young adult).
Patient-centered outcomes research, comparative effectiveness trials, and
real-world trials are especially beneficial for comparing the relative benefits
and harms of different integrative medicine treatments and other appropriate
pharmacologic, behavioral, or rehabilitative treatments, so patients and
clinicians can choose among evidence-based approaches to manage pain.
Finally, with advances in omics technology, wearable sensors, behavioral and
neuroscience, big data, and novel trial designs, research needs to guide
precision integrative pain management so that the right patient receives the
right treatment to improve their pain and related outcomes.
Society for Integrative Oncology and ASCO believe that cancer clinical trials
are vital to inform clinical decisions and improve cancer care, and that all
patients should have the opportunity to participate.
ADDITIONAL RESOURCES
Section:
ChooseTop of pageAbstractINTRODUCTIONGUIDELINE
QUESTIONSMETHODSRESULTSRECOMMENDATIONSEVIDENCE SUMMARY OF
INTER...DISCUSSIONPATIENT AND CLINICIAN COM...HEALTH DISPARITIESGUIDELINE
IMPLEMENTATION ...OPEN COMMENT REVIEWLIMITATIONS OF THE RESEAR...FUTURE
DIRECTIONSADDITIONAL RESOURCES <<REFERENCES
More information, including a supplement with additional evidence tables, slide
sets, and clinical tools and resources, is available at
www.asco.org/survivorship-guidelines and
https://integrativeonc.org/practice-guidelines/guidelines. Patient information
is available at www.cancer.net and
https://integrativeonc.org/knowledge-center/patients.
RELATED SOCIETY FOR INTEGRATIVE ONCOLOGY AND ASCO GUIDELINES
* Clinical practice guidelines on the evidence-based use of integrative
therapies during and after breast cancer treatment273
(https://acsjournals.onlinelibrary.wiley.com/doi/full/10.3322/caac.21397)
* Complementary therapies and integrative medicine in lung cancer: Diagnosis
and management of lung cancer, 3rd ed: American College of Chest Physicians
evidence-based clinical practice guidelines274
(https://pubmed.ncbi.nlm.nih.gov/23649450/)
* Evidence-Based Clinical Practice Guidelines for Integrative Oncology:
Complementary Therapies and Botanicals275
(https://integrativeonc.org/docman-library/docs/65-sio-guidelines-2009/file)
* Patient-Clinician Communication264
(http://ascopubs.org/doi/10.1200/JCO.2017.75.2311)
* Integrative Therapies During and After Breast Cancer Treatment276
(https://ascopubs.org/doi/10.1200/JCO.2018.79.2721)
* Management of Chronic Pain in Survivors of Adult Cancers2
(https://ascopubs.org/doi/10.1200/JCO.2016.68.5206)
* Prevention and Management of Chemotherapy-Induced Peripheral Neuropathy in
Survivors of Adult Cancers23 (https://ascopubs.org/doi/10.1200/JCO.20.01399)
© 2022 by American Society of Clinical Oncology
Society for Integrative Oncology Clinical Practice Guidelines Committee
approval: May 6, 2022.
ASCO Evidence Based Medicine Committee approval: May 20, 2022.
EDITOR'S NOTE
This joint Society for Integrative Oncology (SIO) and ASCO Clinical Practice
Guideline provides recommendations, with comprehensive review and analyses of
the relevant literature for each recommendation. Additional information,
including a supplement with additional evidence tables, slide sets, clinical
tools and resources, and links to patient information, is available at
https://integrativeonc.org/knowledge-center/patients and www.cancer.net,
https://integrativeonc.org/practice-guidelines/guidelines and
www.asco.org/survivorship-guidelines.
SUPPORT
Supported by a generous grant from the Samueli Foundation to the Society for
Integrative Oncology to develop clinical practice guidelines.
AUTHOR CONTRIBUTIONS
Conception and design: All authors
Collection and assembly of data: All authors
Data analysis and interpretation: All authors
Manuscript writing: All authors
Final approval of manuscript: All authors
Accountable for all aspects of the work: All authors
AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST
Integrative Medicine for Pain Management in Oncology: Society for Integrative
Oncology–ASCO Guideline
The following represents disclosure information provided by authors of this
manuscript. All relationships are considered compensated unless otherwise noted.
Relationships are self-held unless noted. I = Immediate Family Member, Inst = My
Institution. Relationships may not relate to the subject matter of this
manuscript. For more information about ASCO's conflict of interest policy,
please refer to www.asco.org/rwc or ascopubs.org/jco/authors/author-center.
Open Payments is a public database containing information reported by companies
about payments made to US-licensed physicians (Open Payments).
Jun J. Mao
Research Funding: Tibet Cheezheng Tibetan Medicine Co Ltd (Inst)
Nofisat Ismaila
Employment: GlaxoSmithKline (I)
Stock and Other Ownership Interests: GlaxoSmithKline (I)
Ting Bao
Research Funding: Merck
Eric L. Garland
Consulting or Advisory Role: BehaVR LLC
Patents, Royalties, Other Intellectual Property: I am a licensor to BehaVR LLC,
I have licensed my Mindfulness-Oriented Recovery Enhancement intervention to
BehaVR so the company could develop a virtual reality version of the therapy. I
receive royalties for this license.
Other Relationship: Myself
Thomas Leblanc
Honoraria: AbbVie, Astellas Pharma, Agilix
Consulting or Advisory Role: Pfizer, AbbVie/Genentech, AstraZeneca, Flatiron
Health, Bristol Myers Squibb/Celgene, GlaxoSmithKline, Astellas Pharma, Blue
Note Therapeutics
Speakers' Bureau: Agios, AbbVie, Bristol Myers Squibb/Celgene
Research Funding: AstraZeneca (Inst), Jazz Pharmaceuticals (Inst), Bristol Myers
Squibb (Inst)
Patents, Royalties, Other Intellectual Property: UpToDate Inc, royalty
Travel, Accommodations, Expenses: Agios, AbbVie/Genentech, Bristol Myers
Squibb/Celgene
Richard T. Lee
Research Funding: Merck (Inst), Incyte (Inst), Yivia (Inst)
Uncompensated Relationships: Grow Ohio Pharmaceuticals
Ana Maria Lopez
Research Funding: Bristol Myers Squibb
Charles Loprinzi
Consulting or Advisory Role: PledPharma, Metys Pharmaceuticals, Disarm
Therapeutics, OnQuality Pharmaceuticals, NKMax, Mitsubishi Tanabe Pharma,
Veloxis, Hengrui Pharmaceutical, Osmol Therapeutics, Grunenthal, Neuropathix,
Denali Therapeutics
Research Funding: Bristol Myers Squibb (Inst)
Other Relationship: Cynosure/Hologic
Gary H. Lyman
Honoraria: Sandoz, Partners Healthcare, Squibb, Seattle Genetics, Teva, Jazz
Pharmaceuticals
Consulting or Advisory Role: G1 Therapeutics, Samsung Bioepis, BeyondSpring
Pharmaceuticals, MSD, Fresenius Kabi
Research Funding: Amgen (Inst)
Viraj A. Master
Honoraria: Ethicon
Kavitha Ramchandran
Consulting or Advisory Role: Drishti, Group Well, Varian Medical Systems
Lynne I. Wagner
Stock and Other Ownership Interests: Johnson & Johnson (I), Lilly (I), Gilead
Sciences (I)
Consulting or Advisory Role: Celgene, Athenex
Travel, Accommodations, Expenses: Celgene
Deborah Watkins Bruner
Employment: Emory University
Stock and Other Ownership Interests: AbbVie, Altria, Bristol Myers Squibb,
GlaxoSmithKline, Johnson & Johnson, Pfizer, Procter & Gamble, Stryker, Viatris,
Walgreens Boots Alliance
Honoraria: American Society of Radiation Oncology (ASTRO), Oncology Nursing
Society, Memorial Sloan-Kettering Cancer Center, Alliance, Wilmont Cancer Center
Consulting or Advisory Role: Flatiron Health, Alliance for Clinical Trials in
Oncology, University of Rochester
Claudia M. Witt
Research Funding: CERES (Inst), Newsenselab (Inst)
Eduardo Bruera
Research Funding: PharmaCann Inc (Inst)
No other potential conflicts of interest were reported.
APPENDIX
TABLE A1. Recommendation Rating Definitions
View larger version (689K)
TABLE A2. Society for Integrative Oncology–ASCO Integrative Medicine for Pain
Management in Oncology Guideline Expert Panel Membership
View larger version (641K)
ACKNOWLEDGMENT
The Expert Panel wishes to thank the ASCO EBMC reviewers Drs Elise Kohn and
Michele Halyard, the ASCO Evidence Based Medicine Committee, and the SIO
Clinical Practice Guideline Committee for their thoughtful reviews and
insightful comments on this guideline.
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Section:
ChooseTop of pageAbstractINTRODUCTIONGUIDELINE
QUESTIONSMETHODSRESULTSRECOMMENDATIONSEVIDENCE SUMMARY OF
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DIRECTIONSADDITIONAL RESOURCESREFERENCES <<
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DOI: 10.1200/JCO.22.01357 Journal of Clinical Oncology
Published online September 19, 2022.
PMID: 36122322
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5. Neoadjuvant Chemotherapy, Endocrine Therapy, and Targeted Therapy for Breast
Cancer: ASCO Guideline
Larissa A. Korde et al., J Clin Oncol, 2021
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Picked up by 5 news outlets
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Picked up by 5 news outlets
Blogged by 2
Tweeted by 99
On 4 Facebook pages
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