Complementary and Integrative Approaches for Cancer Symptoms and Treatment Side Effects:
What the Science Says

Mind and Body Approaches

Evidence suggests that some mind and body approaches, such as acupuncture, massage therapy, mindfulness-based stress reduction, and yoga may help to manage some symptoms of cancer and side effects of treatment. The Society for Integrative Oncology 2009 clinical practice guidelines in for the use of complementary therapies and botanicals in integrative oncology, recommends mind and body modalities as part of a multidisciplinary approach for reducing anxiety, mood disturbance, and chronic pain and for improving quality of life in people with cancer. In 2014 the Society for Integrative Oncology issued guidelines on the use of integrative therapies as supportive care in patients treated for breast cancer. The American College of Chest Physicians issued guidelines in 2013 on complementary therapies and integrative medicine in lung cancer. Specific recommendations from these guidelines are noted below.

Acupuncture

There is some evidence that acupuncture can help manage chemotherapy-induced nausea and vomiting in patients. There isn’t enough evidence to determine whether acupuncture relieves cancer pain or other symptoms such as fatigue, hot flashes, and xerostomia.

The Evidence Base

• Several clinical practice guidelines from the Society for Integrative Oncology based on systematic reviews of many randomized controlled trials, as well as guidelines from the American College of Chest Physicians report there is some demonstrated efficacy for acupuncture for relief of some cancer-related symptoms and treatment side effects.

Efficacy

• Clinical practice guidelines issued in 2009 by the Society for Integrative Oncology recommends acupuncture as a complementary therapy when pain is poorly controlled, when side effects associated with other treatments are significant, when nausea and vomiting associated with chemotherapy or surgical anesthesia are poorly controlled, or when reducing the amount of pain medicine becomes a clinical goal. The benefits of acupuncture for other symptoms, including fatigue or hot flashes has not been established.
• Guidelines on complementary therapies and integrative medicine for lung cancer patients issued in 2013 by the American College of Chest Physicians suggests acupuncture as an adjunct treatment option for nausea or vomiting from either chemotherapy or radiation therapy. The guidelines also suggest acupuncture as an adjunct option in patients with cancer-related pain and peripheral neuropathy with inadequate control of these symptoms.
• A 2013 Cochrane review of nine studies of participants with xerostomia, including four studies of participants undergoing radiotherapy for oral cancers, concluded that there is some low quality evidence that acupuncture results in a small increase in saliva production in patients with dry mouth following radiotherapy.
• A 2015 reported randomized trial of 70 participants found comparable efficacy between acupuncture and ondansetron in the prevention of delayed chemotherapy-induced nausea and vomiting. Participants in the acupuncture group appeared to have fewer adverse events and improved quality of life.

Safety

• Complications from acupuncture are rare, as long as the acupuncturist uses sterile needles and proper procedures. Because chemotherapy and radiation therapy can induce immunosuppression, acupuncturists should follow strict clean-needle procedures when treating these patients.

Massage

Studies suggest that massage therapy may help to relieve cancer-related symptoms such as pain, nausea, anxiety, and depression. However, investigators haven’t reached any conclusions about the effects of massage therapy because rigorous research in this field is lacking.

The Evidence Base

• The evidence base on efficacy of massage for cancer-related symptoms or treatment side effects consists of several clinical practice guidelines from the Society for Integrative Oncology based on systematic reviews of many randomized controlled trials, as well as guidelines from the American College of Chest Physicians.

Efficacy

• Clinical practice guidelines issued in 2009 by the Society for Integrative Oncology recommends considering massage therapy delivered by an oncology-trained massage therapist as part of a multimodality treatment approach in patients experiencing anxiety or pain.
• Guidelines issued by the Society for Integrative Oncology in 2014 on the use of integrative therapies as supportive care in patients treated for breast cancer recommend massage for improving mood disturbance in post-treatment breast cancer patients, giving the modality a grade of “B,” which states “there is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.”
• In clinical practice guidelines issued by the American College of Chest Physicians in 2013, massage therapy is suggested as part of a multi-modality cancer supportive care program for lung cancer patients whose anxiety or pain is not adequately controlled by usual care.
• A 2014 reported meta-analysis of 12 studies involving 559 participants examined the effects of massage therapy for cancer patients experiencing pain. Conclusions for these studies suggest that massage helps reduce pain, especially post-operative pain.

Safety

• To avoid possible adverse effects, the massage therapist should not use deep or intense pressure without the health care providers’ approval and may need to avoid certain sites, such as areas directly over a tumor or a known thrombus, or areas where the skin may be sensitive following radiation therapy.

Mindfulness-Based Stress Reduction

There is evidence that mindfulness-based stress reduction, a type of meditation training, can help cancer patients relieve anxiety, stress, fatigue, and sleep disturbances and improve general mood, thus improving their quality of life. Most participants in mindfulness studies have been patients with early-stage cancer, primarily breast cancer, so the evidence favoring mindfulness training is strongest for this population.

The Evidence Base

• The evidence base on efficacy of mindfulness-based stress reduction for cancer symptoms or treatment side effects consists of several clinical practice guidelines from the Society for Integrative Oncology based on systematic reviews of many randomized controlled trials.

Efficacy

• 2009 reported clinical practice guidelines from the Society for Integrative Oncology recommend mind and body modalities, including mindfulness-based stress reduction, as part of a multidisciplinary approach to reduce anxiety, mood disturbance, chronic pain, and improve quality of life.
• Clinical practice guidelines issued in 2014 by the Society for Integrative Oncology on the use of integrative therapies as supportive care in patients with breast cancer recommends meditation, particularly mindfulness-based stress reduction, for improving mood and depression during radiation therapy and posttreatment, as well as improving quality of life. The guidelines give mindfulness-based stress reduction a grade of “A,” noting that “there is high certainty that the net benefit is substantial.”
• These guidelines also recommend mindfulness-based stress reduction to reduce longer term anxiety both during and after treatment, giving the modality a grade of “B,” which states “there is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.”
• A 2013 reported randomized controlled trial of 172 women diagnosed with early-stage breast cancer and undergoing radiotherapy examined the effects of an 8-week mindfulness-based stress reduction program compared with a nutrition education intervention and usual care. Women who were undergoing radiotherapy while participating in the mindfulness program had a significant improvement in many psychosocial variables, such as quality of life, psychosocial coping, depression, and anxiety.
• A 2013 reported meta-analysis of nine studies examined evidence of efficacy of mindfulness-based stress reduction on mental health of breast cancer patients and found that mindfulness-based stress reduction shows a moderate to large positive effect in improving stress, depression, and anxiety in this population.

Safety

• Meditation is generally considered to be safe for healthy people. However, people with physical limitations may not be able to participate in certain meditative practices involving movement.
• There have been rare reports that meditation could cause or worsen symptoms in people with certain psychiatric condition such as anxiety disorders and depression.

Yoga

Preliminary evidence indicates that yoga may help to improve anxiety, depression, and emotional distress, and relieve stress in people with cancer. It also may help to lessen fatigue in breast cancer patients and survivors. However, only a small number of studies have examined the effects of yoga in cancer patients. Some of these studies were not conducted with necessary rigor to draw meaningful conclusions.

The Evidence Base

• The evidence base on efficacy of yoga for cancer symptoms or treatment side effects consists of several clinical practice guidelines from the Society for Integrative Oncology based on systematic reviews of several randomized controlled trials, as well as guidelines from the American College of Chest Physicians.

Efficacy

• In 2013 guidelines from the American College of Chest Physicians, yoga is suggested as part of a multidisciplinary approach to reduce fatigue and sleep disturbance while improving mood and quality of life in patients with lung cancer.
• 2009 clinical practice guidelines from the Society for Integrative Oncology recommend mind and body modalities, including yoga, as part of a multidisciplinary approach to reduce anxiety, mood disturbance, chronic pain, and improve quality of life.
• In 2014 guidelines issued by the Society for Integrative Oncology on the use of integrative therapies as supportive care in patients with breast cancer, yoga is recommended for reducing anxiety in patients undergoing radiation and chemotherapy and is suggested for fatigued patients.
• A 2015 reported secondary analysis on data from a randomized controlled trial assessed the effects of a 4-week yoga intervention on overall cancer-related fatigue in 97 cancer survivors 60 years of age, or older. Participants in the yoga intervention reported significantly lower cancer-related fatigue, physical fatigue, mental fatigue, and global side-effect burden than participants receiving standard care.
• A 2014 reported randomized controlled trial of 60 women with nonmetastatic breast cancer undergoing adjuvant chemotherapy evaluated the effects of an 8-week yoga program on depression, anxiety, and fatigue. Participants in the yoga intervention had a reduction in overall fatigue, but no significant improvement in depression or reduction in anxiety.
• A 2014 Cochrane review of a single trial with 39 participants examined the effects of yoga on emotional distress, fatigue, anxiety, depression, and quality of sleep in people with hematological malignancies. The review concluded that there are not enough data to determine how effective yoga is in the management of symptoms in patients with hematological malignancies.

Safety

• Because yoga involves physical activities, before they start it’s important  for cancer patients to speak with  their health care providers  about  whether any aspects of yoga might be unsafe.  

Natural Products

A 2008 review on botanicals and cancer concluded that although several herbs have shown promise for managing side effects and symptoms such as nausea and vomiting, pain, fatigue, and insomnia, the evidence is limited, and many studies are not well designed. Use of herbs for managing symptoms also raises concerns about potential interactions with conventional cancer treatments. It’s possible that a botanical supplement could negatively impact the effectiveness of some medications used to treat cancer.  Potential for herb-drug interactions should be discussed with, and evaluated by a health care provider.

Ginger

Ginger is an herb that may help to control nausea related to cancer chemotherapy when used as adjunctive therapy to conventional anti-nausea medication.

The Evidence Base

• A few randomized controlled trials have demonstrated efficacy of ginger for controlling chemotherapy-induced nausea.

Efficacy

• A reported randomized, double blind, multicenter trial  with 576 cancer patients examined the effects of ginger supplementation on chemotherapy-induced nausea.  The study found that ginger supplementation administered twice daily starting 3 days before the start of chemotherapy reported significantly reduced severity of acute chemotherapy-induced nausea.
• A 2011 reported randomized, double blind study with 31 children and young adults (8 to 21 years of age) with bone sarcoma evaluated the anti-emetic effect of ginger root powder compared to placebo during 60 cycles of chemotherapy. It was observed that ginger root powder significantly reduced the severity of both acute and delayed chemotherapy-induced nausea and vomiting, when given as additional therapy to ondansetron and dexamethasone.

Safety

• Few side effects are linked to ginger when taken in small doses. Side effects most often reported include gas, bloating, heartburn, and nausea. These effects are most often associated with powdered ginger.

Other Natural Products

• Some people with cancer may have altered circadian rhythmicity. Although the herbs valerian and St. John’s wort may improve sleep, St. John’s wort has been shown to interact with chemotherapeutic agents such as irinotecan and antiretroviral agents such as indinavir. A few studies have examined the effects of other botanicals on sleep, including chamomile and lavender, in non-cancer populations, but there is little evidence to support their use for any condition.
• Two large-scale studies found evidence that supplements containing beta-carotene increased the risk of lung cancer among smokers.

References