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In September 2022, ASCO and the Society for Integrative Oncology, or SIO, published a joint guideline on using integrative therapies to manage pain in people with cancer. Integrative therapies are treatments and techniques used in addition to standard cancer treatment to help people cope with the side effects of cancer, including cancer-related pain.

In this podcast, Dr. Richard Lee talks to the guideline panel co-chair, Dr. Jun Mao, about these guideline recommendations. They discuss why the guideline was created and the different types of integrative therapies included in these recommendations, including acupuncture, reflexology and acupressure, hypnosis, massage, yoga, guided imagery and progressive muscle relaxation, and music therapy.

Dr. Lee is a clinical professor in the Departments of Supportive Care Medicine and Medical Oncology at City of Hope Comprehensive Cancer Center and serves as the medical director of the Integrative Medicine Program. Dr. Lee is also the 2023 Cancer.Net Associate Editor for Palliative Care. Dr. Mao is chief of the Integrative Medicine Service at Memorial Sloan Kettering Cancer Center and holds the Laurance S. Rockefeller Chair in Integrative Medicine at the institution.

View disclosures for Dr. Lee and Dr. Mao at Cancer.Net.

Dr. Lee: My name is Richard Lee. I'm a clinical professor here at City of Hope Cancer Center. I'm in the Departments of Supportive Care Medicine and Medical Oncology and medical director for the Integrative Medicine Program. I'm honored to be accompanied today by Dr. Jun Mao. He's the chief of the Integrative Medicine Service at Memorial Sloan Kettering and holds the Laurance S. Rockefeller Chair in Integrative Medicine. So we're going to talk about the joint SIO-ASCO guidelines that recently came out in the Journal of Clinical Oncology looking at integrative approaches to cancer pain. And so let me first ask you, Jun, could you talk about what is a clinical practice guideline, and how does it help guide cancer care?

Dr. Mao: The clinical practice guideline is a process bringing multidisciplinary experts to look at the evidence from randomized clinical trials or systematic reviews and meta-analysis and to really evaluate the level of the evidence from research and clinical trials, and also incorporate our clinical expertise, consideration for the benefit and risk. Then, making a set of recommendations for doctors and nurses, health care providers to make informed decisions for patients.

Dr. Lee: Great. And tell us more, what is integrative medicine for those patients who may not have a full understanding what this field is about?

Jun Mao: So integrative medicine is a complex term. Originally, a lot of people may have heard that term of “alternative medicine” or “complementary medicine.” So those terms are referring to using things like herbs or shamanism instead of a conventional cancer treatment. So recognizing the needs of patients who want to explore alternative ways to help them to cope with cancer, and the importance of adhering to conventional surgery, radiation therapy, chemotherapy. So the field of integrative medicine has emerged. Integrative medicine is a field that is based on evidence and acknowledge the patient's wishes to carefully incorporate evidence-based lifestyle interventions, mind-body treatments, and consider for natural products and herbal medicine in a safe and effective way to improve patients' physical, emotional, and spiritual well-being. Also, part of the goal of integrative medicine is to really engage the patient as an active participant to prevent cancer and to really engage in their own care during and beyond their cancer treatment.

Dr. Lee: And for patients who are new to this concept of integrative medicine or integrative therapies, why is it important for us to study this for cancer care?

Dr. Mao: Richard, this is really important because often when a person gets cancer, you get friends and family who really want to be helpful who say, “Do this, try that, use this herb, or this supplement has been used by that.” So there's a lot of anecdote. There's a lot of sort of people just want to be helpful. But in actuality, some of the treatments, without carefully considering actual evidence and potential risks of drug herbal interaction, can induce harm, not only increase the toxicity of the cancer treatment, but may even shorten the lives of cancer patients. Therefore, we often tell patients don't use these treatments as alternative, but to use in an integrated way. And doing research is going to be helpful to understand in what setting for what condition or symptoms. These are helpful, not helpful, are they safe or unsafe?

Dr. Lee: That's really important. That's great to see the research coming along. And so let's talk about ASCO, the American Society for Clinical Oncology, which is the world's leading and largest professional organization for oncologists, as well as Society for Integrative Oncology, SIO. You know, how did they come together to produce this joint guideline on integrative medicine and pain management?

Dr. Mao: So, as you know, ASCO is a world-leading conventional oncology society. It's a multi-discipline, you know, surgeons, medical oncologists, radiation oncologists, a lot of psychosocial supportive care folks are part of this society. Society for Integrative Oncology is a relatively new society, but this year we're celebrating 20th year, so it's not so new anymore. You know, a lot of very passionate physicians, nurses, nutritionists, social workers, we joined together to really help to advocate for evidence-based integrative medicine in the context of care delivery. SIO brings that expertise together with ASCO to formulate a set of guidelines that can be readily implemented into the care setting to help patients and families to deal with pain, a very common and disturbing side effect for cancer and cancer treatment.

Dr. Lee: It's so great to see 2 leading organizations come together to put these guidelines together. So let's jump into the guidelines a little bit, and one of the areas that they covered is acupuncture. So can you let us know and let patients know what is acupuncture, and what types of cancer-related pain has it been shown to be helpful?

Dr. Mao: Acupuncture is a type of therapy that originated from the traditional Chinese medicine. It has been documented over 2,500 years ago. So the way acupuncture works clinically is putting very thin, sterile needles in specific locations of the body to help address symptoms, promote a sense of relaxation and wellness. Often, you need a series between 6 to 10 treatments. I always tell patients it's almost like a physical therapy. You need a few treatments to see the benefit. In animal research, there has been a documented mechanism that acupuncture may help your brain to release endogenous neurotransmitters, like endogenous opiates, serotonin, or dopamine, as a result to reduce pain, increase a sense of relaxation, well-being.

So the ASCO-SIO Joint Clinical Guideline looked at clinical trials, found pretty strong evidence that acupuncture can be used for a type of joint pain that is very common in women with breast cancer taking aromatase inhibitors. Aromatase inhibitors are a class of drug that drop the estrogen level in women with breast cancer as a result of preventing the breast cancer from spreading. Unfortunately, about 50% of women do develop very diffuse joint pain. A lot of time it is in the low back and knees and makes a lot of patients stop this life-saving drug. The committee feels strongly like acupuncture should be recommended as one of the options to treat aromatase inhibitor-related joint pain. In other areas, not as strong, but also in general cancer-related joint pain and musculoskeletal pain. And there are also some weak evidence on acupuncture can be helpful for chemotherapy-induced peripheral neuropathy, as well as to be used in post-surgical related pain. So those are the recommendations we would tell a patient who experienced those pains to try acupuncture.

Dr. Lee: So Jun, you mentioned about the different recommendations around acupuncture, and you're talking a little bit about levels of evidence. Could you explain to patients what you mean by the levels of evidence and the types of recommendations that were put forward by ASCO and SIO?

Dr. Mao: So when expert