New ASCO guideline recommends integrative interventions to manage cancer pain

A new joint practice guideline from the Society for Integrative Oncology (SIO) and the American Society of Clinical Oncology (ASCO) used 227 relevant studies to provide evidence-based recommendations on integrative medicine approaches to pain management in cancer patients.¹

The directive, published in Journal of Clinical Oncology, gives a moderate strength of recommendation for the use of acupuncture for joint pain associated with aromatase inhibitors and may recommend it along with reflexology or acupressure for general cancer pain or musculoskeletal pain. In addition, hypnosis may be recommended to patients experiencing pain during procedures and massage is recommended to patients experiencing pain during their palliative or hospice care.

According to the joint panel, the recommendations were based on a moderate level of evidence, but the benefits of these practices outweighed the risks to patients. However, they noted that the evidence supporting mind-body interventions or natural products such as yoga, omega-3 fatty acids, music therapy, or topical pure emu oil was insufficient to recommend for or against these interventions. In addition, they did not have enough evidence to recommend interventions for pain in patients with pediatric cancer.

“Pain is a clinical challenge for many oncology patients and clinicians, and there is growing evidence that integrative therapies can be useful in pain management. But to date, there has been no clear clinical guidance on when and when not to use these approaches,” said Heather Greenlee, ND, PhD, co-chair of the SIO Clinical Practice Guideline Committee, in an SIO press release.²

To develop this practice guide, an international multidisciplinary panel of experts was formed between the two groups, including a patient advocate and a health research methodologist. The recommendations were then developed through a systematic review of 1,346 articles from PubMed (1990-2021) and the Cochrane Library (1990-2021), examining whether the study population included adult and pediatric patients who were at any stage in their cancer treatment pain had trajectory; integrative interventions that included acupuncture, acupressure, mind-body therapies, and natural products; no comparisons within the study; Outcomes that included pain intensity, reduction or change in symptoms reported as the primary outcome in the manuscript.

After screening the articles for the criteria, 227 articles remained and formed the basis for the guideline recommendations. While the panel noted that many of the primary studies included in the review suffered from flaws and limitations in their study design. Therefore, they used the systemic reviews to identify the relevant primary studies. Other shortcomings included the lack of blinding in the study design, incomparable control arms, small sample sizes and/or high failure rates, and limited statistical power, which reduced confidence in the results of some of the interventions.

Acupuncture was the most frequently identified intervention with 51 items compared to massage with 14 items. In patients with general cancer pain or musculoskeletal pain, a study of 360 patients randomized 2:1:1 to receive either electroacupuncture, ear acupuncture, or usual care. Electroacupuncture reduced pain by 1.9 points on a 0-10 numerical pain rating scale and ear acupuncture reduced pain by 1.6 points compared to usual treatment. These results were also durable at 6 months and associated with minimal toxicities, so the panel recommended these interventions for patients with general cancer pain.

“Guidelines of practice are a critical way to ensure healthcare providers are using treatments based on high-quality evidence from scientific studies that have demonstrated the efficacy and safety of the treatment,” said Scott T. Tagawa, MD, MS, in the press release. “The guidelines focus on important concerns in patient care that have a strong impact on quality of life and will help equip the oncology community with the essential knowledge needed to manage integrative therapy approaches.”

Integrative oncology is a patient-centred and evidence-based field of cancer treatment that uses interventions for pain such as mind and body practices, natural products, and lifestyle changes from different traditions alongside conventional treatments. Given such a broad field, the panel believes there is a need to provide recommended guidelines that are evidence-based and enable oncologists to make informed decisions.

Within the guidelines, they also note that the guidelines exist within a framework of health care that has differences between patient groups and note that many patients may have limited access to medical care. For example, race and ethnicity, age, socioeconomic status, sexual orientation and gender identity, geographic location, immigration status, and access to insurance affect how much integrative patients may be able to receive. The panel therefore recommends working on patient care in these interventions and breaking down structural barriers to care.

“This is the first of three evidence-based guidelines for adults that SIO and ASCO are co-developing, combining the strengths of both organizations,” added Linda E. Carlson, PhD, President of SIO, in the press release. “The goal of this important collaboration is to educate as many clinicians and patients as possible where the evidence lies for integrative therapies to support the best possible clinical outcomes for all cancer patients. And we believe this new policy achieves that.”

_REFERENCES:

_{1. Mao J, Ismaila N, Bao T, et al. Integrative medicine for pain management in oncology: Society for Integrative Oncology – ASCO guideline. J Clin Oncol. September 19, 2022. doi:10.1200/JCO.22.01357}

_{2. New SIO/ASCO pain guidelines released. Hannah Hayden. September 19, 2022. Accessed September 22, 2022. https://bit.ly/3C7I8N7}