Society for Integrative Oncology Issues Guidelines on Complementary Therapies

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Complementary medicine is the term used to describe therapeutic techniques that are not part of conventional medicine (also called "regular," "standard," or "mainstream" medicine). Complementary therapies are used as a "complement" or addition to conventional medicine. Because complementary medicine can be combined or integrated with conventional medical treatment, it is also called "integrative medicine."

Complementary medicine includes techniques such as acupuncture, herbal medicine, massage, support groups, and yoga. Sometimes called holistic medicine, complementary medicine typically addresses how disease affects the whole person: physically, emotionally, spiritually, and socially.

Conventional medicine has been proven to be safe and effective by numerous scientific studies. While some studies show that people diagnosed with breast cancer can get benefits from complementary medicine, it's important to know that complementary therapies usually don't undergo the same kinds of rigorous testing as conventional medicine.

Studies have shown that more than 80% of people diagnosed with breast cancer use complementary therapies after being diagnosed. To help doctors and patients understand which complementary therapies are safe and effective for people diagnosed with breast cancer, the Society for Integrative Oncology has put out guidelines.

The guidelines were published in issue 50 of a special monograph of the Journal of the National Cancer Institute. Read “Clinical Practice Guidelines on the Use of Integrative Therapies as Supportive Care in Patients Treated for Breast Cancer” (PDF).

The Society for Integrative Oncology is a nonprofit multidisciplinary organization of professionals dedicated to studying and facilitating the cancer treatment and recovery process through the use of integrative medicine.

To create the guidelines, researchers at Columbia University's Mailman School of Public Health and the Herbert Irving Comprehensive Cancer Center, with colleagues at MD Anderson Cancer Center, University of Michigan, Memorial Sloan Kettering, and other institutions in the United States and Canada, analyzed more than 200 studies done between 1990 and 2013 to see which integrative treatments appear to be most effective and safe for patients. They evaluated more than 80 different therapies.

Dawn Hershman, M.D., M.S., assistant professor of medicine at Columbia University, who also is a member of the Breastcancer.org Professional Advisory Board, helped write the guidelines.

The guidelines give each complementary therapy a letter grade:

  • “A” means the therapy is recommended because there is strong evidence that it offers benefits.
  • “B” means the therapy is recommended because evidence shows that it offers benefits, but probably not as much benefit as therapies with an “A” grade.
  • “C” means the therapy should be recommended selectively to certain people based on patient preferences and the doctor’s judgment; the evidence shows that the therapy offers a small benefit.
  • “D” means the therapy is not recommended because the evidence shows it offers no benefits; doctors should discourage patients from using the therapy.
  • “H” means the therapy is not recommended because research shows that it does more harm than good; doctors should discourage patients from using the therapy.
  • “I” means there isn’t enough research to make a recommendation on the therapy.

Meditation, yoga, and relaxation with imagery were found to have the strongest evidence supporting their use. They received an "A" grade for easing anxiety and other mood disorders that people diagnosed with breast cancer may experience.

The same complementary therapies received a "B" grade for reducing stress, depression, and fatigue.

Acupuncture received a "B" grade for controlling chemotherapy-induced nausea and vomiting.

More than 30 complementary therapies, including some natural products and acupuncture for other conditions, had weaker evidence of benefit due to either small study sizes or conflicting study results and received a "C" grade.

Seven other therapies were deemed unlikely to provide any benefit and are not recommended. One therapy was found to be harmful: acetyl-L-carnitine, which is marketed to prevent chemotherapy-related neuropathy, actually increased the risk of neuropathy.

The guidelines list specific conditions and breast cancer treatment side effects and recommends complementary therapies to help ease them.

Anxiety and stress

  • Music therapy (grade B) is recommended for relieving short-term anxiety during radiation and chemotherapy.
  • Meditation (grade B), including mindfulness-based stress reduction, yoga (grade B), and stress management programs (grade B) are recommended to reduce longer-term anxiety both during and after treatment.
  • Acupuncture (grade C) can be considered for treating anxiety that happens with ongoing fatigue.
  • Relaxation (grade C) and massage therapy (grade C) both can be considered for short-term relief of anxiety during treatment.

Depression and mood

  • Meditation (grade A), particularly mindfulness-based stress reduction, is recommended for improving mood and easing depression during radiation therapy and after treatment.
  • Yoga alone (grade A) and relaxation (grade A) are recommended for improving mood and easing depression during radiation therapy and chemotherapy, as well as for people also experiencing fatigue.
  • Music therapy (grade B) is recommended for newly diagnosed patients to improve mood.
  • Massage (grade B) is recommended for improving mood in survivors who are done with treatment.
  • Stress management (grade C) can be considered to improve mood.
  • Healing touch (grade C) can be considered to improve mood in people getting chemotherapy.
  • Acupuncture (grade C) can be considered to improve mood in women having hot flashes.

Fatigue

  • Energy conservation (grade B) is recommended to manage fatigue.
  • Qigong (grade C) and acupuncture after treatment (grade C) can be considered to manage fatigue.
  • 2,000 mg per day of American ginseng root powder (grade C) can be considered to ease fatigue during chemotherapy and radiation.
  • Acetyl-L-carnitine (grade D) and guarana (grade D) are NOT recommended to treat fatigue, because research shows they have no effect.

Sleep problems

  • Gentle yoga (grade C) and stress management techniques (grade C) can be considered for people having trouble sleeping.

Quality of life and movement/flexibility

  • Meditation (grade A) is recommended for improving quality of life.
  • Relaxation (grade C), guided imagery (grade C), Qigong (grade C), reflexology (grade C), stress management (grade C), and yoga (grade C) can be considered to improve quality of life.
  • Research on acupuncture (grade C) has shown mixed results for improving quality of life, but doesn’t cause harm.
  • Mistletoe (grade C) can be considered for improving quality of life in the short-term, but there is little research on its long-term effects; some research shows high doses of mistletoe can cause liver problems.
  • Exercise programs that include a relaxation/stress management component (grade C) can be considered to help improve movement and flexibility.
  • Exercise programs aimed at energy conservation (grade D) are NOT recommended.

Nausea/vomiting caused by chemotherapy

  • Electroacupuncture (grade B) and progressive muscle relaxation (grade C) can be considered to ease nausea.
  • Ginger (grade C) in combination with anti-nausea medicines can be considered to control short-term nausea right after chemotherapy, but not vomiting or delayed nausea and vomiting; ginger SHOULD NOT be taken with Emend (chemical name: aprepitant) because the two don’t work together and may cause even more vomiting and nausea.
  • Glutamine (grade D) is NOT recommended to treat nausea and vomiting because research has shown it has no effect.

Pain

  • Healing touch (grade C) and sleep enhancement programs (grade C) can be considered to ease pain during chemotherapy.
  • Music therapy (grade C), physical training programs that include a mind-body aspect (grade C), and hypnosis (grade C) can be considered for treating pain from surgery.
  • Acupuncture (grade C) and electroacupuncture (grade C) can be considered to ease joint pain cause by an aromatase inhibitor.

Neuropathy caused by taxane chemotherapy

  • Acetyl-L-carnitine (grade H) is NOT recommended to prevent neuropathy caused by taxane chemotherapy medicines; one large study showed that acetyl-L-carnitine actually increased neuropathy.

Lymphedema

  • Manual lymph drainage (grade C), low-frequency laser therapy (grade C), and electrotherapy (grade C) can be considered to reduce arm volume and improve lymphedema-related quality of life.

Hot flashes

  • Acupuncture (grade C) and electroacupuncture (grade C) can be considered to ease hot flashes in survivors.
  • Soy isoflavone extracts or soy foods (grade D) are NOT recommended to treat hot flashes because no studies show these products help.

Skin irritation from radiation therapy

  • Aloe vera gel (grade D) and hyaluronic acid (grade D) are NOT recommended to prevent or treat skin irritation caused by radiation because no studies how these products help.

"Most breast cancer patients have experimented with integrative therapies to manage symptoms and improve quality of life,” said Heather Greenlee, N.D., Ph.D., assistant professor of epidemiology at Columbia University and president of the Society for Integrative Oncology. “But of the dozens of products and practices marketed to patients, we found evidence that only a handful currently have a strong evidence base. These guidelines provide an important tool for breast cancer patients and their clinicians as they make decisions on what integrative therapies to use and not use. The guidelines clearly demonstrate that clinicians and patients should adopt shared decision-making approaches when assessing the risk-benefit ratio for each therapy. It is important to personalize the recommendations based upon patients' clinical characteristics and values. What's right for one patient may be wrong for another.”

For more information on how to integrate complementary therapies into your breast cancer treatment and recovery plan, including how to find a qualified practitioner, visit the Breastcancer.org Complementary & Holistic Medicine section.


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