Society of Integrative Oncology Updates Guidelines on Using Complementary Therapies During and After Breast Cancer Treatment

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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 an addition to conventional medicine. Because complementary therapies can be combined or integrated with conventional medical treatment, they’re also called "integrative therapies."

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 up to 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 updated its guidelines.

The updated guidelines were published online on April 24, 2017 by CA: A Cancer Journal for Clinicians. Read “Clinical practice guidelines on the evidence-based use of integrative therapies during and after breast cancer treatment.”

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 update 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 Cancer Center, and other institutions in the United States and Canada, analyzed studies on complementary medicine used to treat people diagnosed with breast cancer published between Jan. 1, 2014 and Dec. 31, 2015 to see which integrative treatments appear to be most effective and safe for patients. They evaluated more than 80 different therapies.

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 had the strongest evidence supporting its use, and received an A grade for reducing anxiety, treating symptoms of depression, and improving quality of life. Music therapy, yoga, and massage received a B grade for the same symptoms, as well as for providing benefits to breast cancer patients. Yoga received a B grade for improving quality of life based on two recent trials. Yoga and hypnosis received a C for fatigue.

"The routine use of yoga, meditation, relaxation techniques, and passive music therapy to address common mental health concerns among patients with breast cancer is supported by high levels of evidence," said Debu Tripathy, M.D., chair of breast oncology at the University of Texas MD Anderson Cancer Center and a past president of the Society for Integrative Oncology. "Given the indication of benefit coupled with the relatively low level of risk, these therapies can be offered as a routine part of patient care, especially when symptoms are not well controlled."

Acupressure and acupuncture received a B grade as an addition to medicine to reduce nausea and vomiting caused by chemotherapy. In general, there was a lack of strong evidence supporting the use of dietary supplements and botanical natural products as part of supportive cancer care and to manage treatment-related side effects.

More than 10 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.

Four 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.
  • Meditation (grade A), including mindfulness-based stress reduction, yoga (grade A), and stress management programs (grade B) are recommended to reduce longer-term anxiety both during and after treatment.
  • Acupuncture (grade C) and relaxation (grade C) can be considered for reducing anxiety.

Depression and mood

  • Meditation (grade A), particularly mindfulness-based stress reduction, is recommended for improving mood and easing depression.
  • Yoga (grade B) and relaxation (grade A) are recommended for improving mood and easing depression.
  • Music therapy (grade B) and massage (grade B) are recommended to improve mood.
  • Acupuncture (grade C), healing touch (grade C), and stress management (grade C) can be considered to improve mood and ease depression.

Fatigue

  • Hypnosis (grade C) and ginseng (grade C) can be considered to ease fatigue.
  • Acupuncture (grade C) and yoga (grade C) can be considered to improve fatigue after treatment is completed.
  • 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) can be considered for people having trouble sleeping.

Quality of life

  • Meditation (grade A) and yoga (grade B) are recommended for improving quality of life.
  • Acupuncture (grade C), mistletoe (grade C), Qigong (grade C), reflexology (grade C), and stress management (grade C) can be considered to improve quality of life.

Nausea/vomiting caused by chemotherapy

  • Acupressure (grade B), electroacupuncture (grade B), ginger (grade C), and relaxation (grade C) can be considered as an addition to anti-nausea medicines to control 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

  • Acupuncture (grade C), healing touch (grade C), hypnosis (grade C), and music therapy (grade C) can be considered to manage pain.

Neuropathy

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

Lymphedema

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

Hot flashes

  • Acupuncture (grade C) can be considered to ease hot flashes.
  • Soy products (grade D) are NOT recommended to treat hot flashes because no studies show these products help.

Skin irritation from radiation therapy

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

"Clinicians and patients need to be cautious about using therapies that received a grade of C or D and fully understand the potential risks of not using a conventional therapy that may effectively treat cancer or help manage side effects associated with cancer treatment," said Lynda Balneaves, R.N., Ph.D., associate professor of nursing at the Rady Faculty of Health Sciences and president-elect of the Society for Integrative Oncology.

"Patients are using many forms of integrative therapies with little or no supporting evidence and that remain understudied," said Heather Greenlee, Ph.D., assistant professor of epidemiology at Columbia University. "This paper serves as a call for further research to support patients and healthcare providers in making more informed decisions that achieve meaningful clinical results and avoid harm."

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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