Integrative Therapies for Cancer-Related Pain, with Richard T. Lee, MD, and Jun Mao, MD, MSCE

ASCO: You’re listening to a podcast from Cancer.Net. This cancer information website is produced by the American Society of Clinical Oncology, known as ASCO, the voice of the world's oncology professionals. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guests’ statements on this podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Cancer research discussed in this podcast is ongoing, so data described here may change as research progresses. 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 experts review evidence from clinical trials, if you have several large clinical trials producing very consistent findings that a therapy is beneficial with very low risk, that will give you a high level, strong quality of evidence with strong recommendation. Unfortunately, in the field of integrative medicine, often there's a lack of funding for this type of research. So what you do see is there are maybe only 1 trial showing that it's very beneficial and maybe there are some smaller trials to show some signal, then we will give an intermediate quality of evidence and moderate strength of recommendation. And then you have therapies that are being used by patients, but there's very little trials or the trials, the sample size are very small. Sample size means how many patients participate. Then you see some promising signals overall, but it's kind of, you know, we don't have a strong confidence in the result. That's where we give low quality of evidence and weak strength of recommendation. Dr. Lee: That's really helpful and it's, I think, important since integrative medicine is really based on evidence-based approaches that we are looking at the levels of evidence. So thank you for explaining that. Let's move on to some other therapies that were mentioned within the guidelines. You talk about reflexology and acupressure. Can you talk about what these types of therapies are and what have they been shown to help? Dr. Mao: So reflexology acupressure, so this is a very similar sort of a principle of treatment, but instead of putting needles, it's actually a therapist will put hands on or teach the patient to press specific acupuncture or pressure points as a result to reduce pain or induce relaxation. So here is where you see some intermediate quality of evidence with moderate strength of recommendation for general cancer pain or musculoskeletal pain as the patient is receiving treatment. One common area you would see that is sometimes when a patient's getting chemotherapy, they will have these muscle aches and joint pain. It's not long lasting, but it's very annoying for a number of days. So in those settings, you can try that.   Dr. Lee: So for patients who might have a needle phobia and are very hesitant, would it be reasonable for them to think about reflexology and acupressure as another modality? Dr. Mao: Oh, absolutely. And also I want to clarify reflexology often is done on the feet. So a lot of patients may not necessarily like general massage. Some people love it, but other people just don't want people to touch their whole body. Then the reflexology just focusing on massaging the feet or lower legs can be a really good option. Dr. Lee: Yeah, great to see there are options for patients, depending on their preferences. Let's move on to another therapy in the guidelines that mention hypnosis. And so a lot of patients may not be familiar with what is hypnosis and where can that be applied for patients with cancer? Dr. Mao: Hypnosis is really about changing a state of awareness and a sense of increased relaxation that often allows for improved focus or concentration. But when you talk about hypnosis in a health care setting, it is often done by a provider with verbal repetition, provided with some mental images. Often during hypnosis, patients can be taken to a different mental place and feel a sense of relaxation and calm. And where you see some evidence is actually for procedural pain. This is derived from a large, randomized trial for biopsy, as well as some interventional procedure showing that hypnosis produces benefit for pain reduction, more of acute pain relief. Again, it makes sense physiologically, right? You take your mind and consciousness to a different place rather than focus on the procedure and pain. So this is where we give intermediate quality of evidence and moderate strengths of recommendation. Dr. Lee: Mm-hmm, good. And let's talk a little bit more about massage. You mentioned that a little bit when you were talking about reflexology. Can you tell us about what situations might massage be helpful for the patients? Dr. Mao: So massage, many people know is really applying pressure in a specific body area. And certainly, for oncology massage, people need to have some specific training to be safe, make sure people don't put pressure in where the tumor is or where there may be fracture risk for bone metastasis as well as in where their medical port is. So I would advise patients work with people who have specialized oncology training. With that said, I think we find really good evidence, particularly in the area of use in palliative care. So there was a large trial with over 300 people randomized to either massage or just gentle touch. Massage reduced pain and improved mental health. So I would say massage to be utilized in patients living with advanced cancer or for patients in a hospice setting can be a really beneficial tool. Where there is a slightly, sort of a weaker evidence I would say, is in the area of a general musculoskeletal pain as the patient is experiencing treatment or in survivorship. There, we give a low quality of evidence, but a moderate strength of recommendation. The reason we give a moderate strength of evidence is the risk is really minimal, right? Like even though we don't have a good amount of research, but even say massage produces some temporary relief, it can still be very beneficial for the patients. Dr. Lee: And let's shift gears a little bit to something called yoga, which many of us may know from your local gym. Can you talk a little bit about yoga and what does that mean for patients who have cancer, and how can that help with cancer-related pain? Dr. Mao: Yoga, as many of you know, originated from India, maybe even as old as 5,000 years ago. So yoga practices, it really combines breath work with meditative work with posture, right, specific postures. So often we know in routine, just health industry, yoga can be really good for physical balance, for flexibility, for induced sense of relaxation. So less is known about the use of that for pain management. So there were some small studies to show that yoga showed really good potential benefit in addressing aromatase inhibitor-related joint pain. The reason we give it a low quality of evidence and weak strength of recommendation is because the research is not as developed in this area. Also, in one of the trials, the pain was the secondary outcome rather than the primary outcome. So it was not the outcome they hypothesized to find, although they did find some benefits. So with that, we do feel like given how yoga is relatively low risk, it’s very accessible. So it could be considered for women with breast cancer experiencing aromatase inhibitor-related joint pain. Dr. Lee: And then, Dr. Mao, could you comment a little bit about--there's so many different styles of yoga. Some of them are very physical, like the kind of hot yoga versus other styles might be more gentle. Can you comment a little bit about that and in terms of what style patients might want to consider? Dr. Mao: There's also a national organization to help to train yoga instructors to work with cancer survivors. So as you look out for those programs, you should really look at people who have those experiences. And I would say most of the studies use more of a hatha type of, more gentle yoga rather than the probably rigorous sort of yoga. Particularly, I would say for women with breast cancer on hormonal drugs, there's higher risk for osteoporosis. So it's important to consider the risks. And I would work with highly experienced instructors rather than trying very risky moves that potentially can cause musculoskeletal injuries or fractures. Dr. Lee: Good things to keep in mind as you think about these different therapies. Let's focus more on these kinds of what some consider mind-body techniques: guided imagery, progressive muscle relaxation. Can you talk about these types of therapies, and can the 2 techniques be used in combination to help with cancer pain? Dr. Mao: So these are very common techniques in the realm of mind-body and relaxation technique. Often you will listen to words and the words will guide you to imagine you're on a beach or hiking in the green meadows. And often there's nice music along with the verbal suggestions. And with progressive muscle relaxation, sometimes we’ll ask you to squeeze certain muscle and then release, squeeze and release. By doing that, it also causes a sense of relaxation. So where the application for this is where you see in general cancer pain or musculoskeletal pain. So in those settings, this can definitely be elements to help you improve the coping of pain, it’s almost in the realm of self-care. So patients can potentially do that at home. However, I would say the evidence still very low. So the quality of evidence we give is a low quality of evidence and weak strength of recommendation. Although this therapy is very intuitive, they cause relaxation, which should help with pain. But I would say they by themselves may not be... the primary mode to manage pain, but rather than improve the coping of pain. Dr. Lee: And let's shift gears a little bit to other techniques. One that was mentioned was music therapy. And of course, a lot of people listen to music on the radio or on the way to work. Can you talk about  what is music therapy? Is that the same as just turning on the radio, and where can that be helpful for pain management?   Dr. Mao: So I'm so glad you're asking this question because music therapy is not just music. Music therapy is working with a specialized trained therapist to use music as an avenue to allow patients to develop a very meaningful therapeutic report to induce relaxation, to manage specific physical and emotional symptoms such as pain, depressive symptoms, anxiety. So often, you know, either through playing an instrument, creating sounds, and sometimes by passive listening and passive relaxation. So it's a very sort of an involved process. Where I think there are currently some weak levels of evidence is music therapy for post-operative for surgical pain. That's where there are some research, but because of the trial, the sample size and the control, so unfortunately we can only give a low quality of evidence and weak strength of recommendation. There's much more knowledge about the use of music therapy to reduce anxiety and depression. So, and often those psychological symptoms go hand in hand with a patient with pain. So I do think when we talk about pain management, we shouldn't be so reductionist to just think of a person with pain. Often you have pain, you have anxiety, then you feel depressed about the pain, right? So I think music therapy can play a role to improve the mental coping with pain. Dr. Lee: I think you bring up a really great point, Dr. Mao, about for patients who are being evaluated for pain to really work with their medical team to explore all the potential factors that might be contributing to the pain. Not only their cancer or the treatment, but their mood or how they're sleeping might play a factor. Dr. Mao: Rich, as you know, I'm an integrative medicine specialist. So when we work with patients, we really take a comprehensive history to really understand what are the symptoms. Often, I have never seen patients just presenting with one symptom, right? So then you'll understand their symptoms and needs and then help them to prioritize what matters the most for them and which therapies potentially have the biggest bang for the buck to improve the things they want to help the most. And then often those therapies will produce some, what I call the “side benefit,” say by improving pain, also improve your sleep, improve your anxiety. So the mechanism may be slightly different, and also patients may have different preference. Some people love yoga, other people would never try it. So you got to really, this is what the beauty is about integrative oncology, to give that choice and control back to the patients. But really, as physicians, we provide them with the evidence to help them to make informed decisions. Dr. Lee: And what do you think are the kind of key takeaway points a patient should think about based on these guidelines? Dr. Mao: I think the key takeaway is when you experience pain, don't just think about drugs. Really think about, there are evidence-based non-pharmacological interventions that can really potentially help you reduce pain, improve your emotional and physical coping with the pain. So talk to your doctors and nurses. Are there those therapies available in your cancer center or clinical practice? Or connect you with the qualified community providers and be a strong advocate for your own health. Dr. Lee: And for patients who really want to dive deep and learn more about these, where would you suggest they go to learn more about integrative therapies for cancer-related pain? Dr. Mao: Yeah, as a patient as well as a family member, it's really important to go to websites that are credible for reliable information. So, ASCO has Cancer.Net. It provides incredibly valuable information for patients and families impacted by cancer. American Cancer Society will be a good resource as well. National Cancer Institute also have monographs for integrative therapy, so those can be really valuable. Other places like a Society for Integrative Oncology website or Memorial Sloan Kettering Cancer Center website also have a lot of information about integrative therapies. Dr. Lee: So this has been wonderful. I really want to thank Dr. Mao for a great overview regarding the ASCO-SIO joint guidelines on pain management. And you mentioned a lot of great websites, including Cancer.Net, in which you can learn more about these guidelines as well as other therapies to help with your care. Dr. Mao: Dr. Lee, thank you so much for doing this really important podcast. I do think as one of the co-chairs for this committee, our group really aspired to use this set of ASCO-SIO clinical guidelines to make integrative therapies part of comprehensive pain management for patients impacted by cancer. And together, we can move closer to allow cancer patients to have lower symptom burden, high quality of life. Dr. Lee: I really congratulate you and Dr. Bruera for a job well done, co-chairing this really large effort. It took a lot of time. We're looking forward to additional guidelines coming out from ASCO and SIO looking at different symptoms. ASCO: Thank you, Dr. Lee and Dr. Mao. Learn more about integrative medicine at www.cancer.net/integrative. Cancer.Net Podcasts feature trusted, timely, and compassionate information for people with cancer, survivors, and their families and loved ones. Subscribe wherever you listen to podcasts for expert information and tips on coping with cancer, recaps of the latest research advances, and thoughtful discussions on cancer care. And check out other ASCO Podcasts to hear the latest interviews and insights from thought leaders, innovators, experts, and pioneers in oncology. 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