Abstract
Introduction
Recent advances in cancer diagnosis and treatments have steadily increased survival rates. Yet, a significant number of patients experience pain throughout the cancer continuum. In addition to negatively impacting the quality of life, pain is also correlated with poor cancer-related outcomes. 1 Therefore, effective pain management strategies are urgently needed.
Accumulating evidence supports the value of Integrative Medicine—a patient-centered approach that selectively incorporates complementary modalities into comprehensive cancer care—for controlling symptoms including pain. 2,3 These therapies are increasingly prevalent with surveys indicating nearly 40% of patients using them annually. 4 –6 Notably, in the wake of the opioid epidemic, the Centers for Disease Control and Prevention began stressing nonpharmacologic options for managing pain since 2016. 7
New Guideline for Cancer Pain Management
The Society for Integrative Oncology (SIO) and the American Society for Clinical Oncology (ASCO) collaborated to formulate the recently published pain management guideline. 8 It is based on the current ASCO recommendations for managing chronic pain in survivors of adult cancers. 9 The new guideline provides recommendations on integrative therapies for controlling pain in individuals affected by cancer.
To develop the guideline, a multidisciplinary group of experts reviewed the extensive evidence base comprising randomized controlled trials, systematic reviews, and meta-analyses (totaling 227 articles published between 1990 and 2021). The studies involved both adult and pediatric cancer populations experiencing pain. In addition, clinical experience and responses from experts in medical oncology, integrative oncology, surgical oncology, family medicine, and nursing as well as patient advocacy, epidemiology, and social sciences representatives helped guide the final recommendations that were based on intermediate-level evidence. The Society for Acupuncture Research (SAR) endorses the following recommendations on acupuncture: Acupuncture should be offered to breast cancer patients with aromatase inhibitor (AI)-related arthralgia. Data from a multicenter trial of breast cancer patients (N = 226) with AI-induced joint pain showed true acupuncture to be more efficacious than sham acupuncture and waitlist control. A greater number of patients in the true acupuncture group experienced clinically meaningful response, defined as at least two-point reduction in pain on a 0–10 scale.
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Joint pain stemming from AI use was also found to make patients AI noncompliant,
11,12
which can lead to greater recurrence and mortality.
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Acupuncture may be recommended to patients experiencing general or musculoskeletal pain. In the largest randomized controlled trial (N = 360) to date of cancer patients with moderate-to-severe chronic musculoskeletal pain, 10 weeks of acupuncture treatments led to durable effects at 6 months postrandomization.
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In addition, acupuncture may be offered to patients experiencing chemotherapy-induced peripheral neuropathy (CIPN); 15 and acupuncture/acupressure may be offered to those undergoing cancer surgery or other cancer-related procedures such as bone marrow biopsy. 16 However, these recommendations are based on low quality of evidence.
Future Research
With the publication of the SIO-ASCO clinical guideline, SAR has a unique role in further shaping the future of oncology acupuncture research with five specific recommendations:
Implementation research to investigate how best to integrate acupuncture into diverse oncology care settings.
Patient-centered comparative effectiveness research to evaluate the relative benefits/harms of different types of acupuncture or care delivery models (e.g., group vs. individual).
Rigorous phase I–III clinical trials to establish the safety and efficacy of acupuncture for pain, such as CIPN, visceral abdominal pain, mucositis pain, and peri- or postoperative pain.
Basic and translational research to inform the mechanisms through which acupuncture may reduce specific types of pain (e.g., CIPN and mucositis).
Health-disparities research to evaluate the role of acupuncture in managing pain in underserved/under-researched populations (e.g., racial/ethnic minorities and children).
Educating Providers About Evidence-Based Integrative Pain Management
Appropriate education of conventional health care providers (e.g., physicians and nurses), acupuncturists, and patients will ensure awareness of guideline recommendations and guide safe/effective use of integrative medicine. Core competencies for integrative oncology providers have been defined 17 and specific training frameworks 18 for oncology physicians to advise their patients were developed and evaluated. 19 The Integrative Medicine Service at Memorial Sloan Kettering (MSK) offers online education courses for providers—including acupuncturists, oncologists, palliative care specialists, and nurse practitioners—on essential guidelines to make personalized recommendations for safe utilization of integrative modalities to their patients. 20 Furthermore, courses developed specifically for acupuncturists educate them on the safety of oncology acupuncture as well as the application of acupuncture to address common cancer symptoms (pain, fatigue, insomnia, and CIPN).
The SAR 2023 conference will have a specific plenary on oncology acupuncture research to present both the research methods and results from several high-impact clinical trials.
Conclusions
Managing cancer pain is challenging for both patients and oncology professionals. This first joint SIO-ASCO guideline on integrative medicine for pain management was produced after a comprehensive review of available evidence. It equips health care providers with the knowledge needed for safely incorporating acupuncture to achieve pain control. Effective dissemination and implementation of this guideline are essential for advancing the field of integrative oncology to greatly improve the quality of life and clinical outcomes of cancer patients across the disease trajectory. Rigorous research is needed to increase the evidence base of acupuncture so it can be appropriately incorporated into guideline development, and ultimately be part of a comprehensive care pathway for people impacted by cancer.
Footnotes
Author Disclosure Statement
Jun J. Mao reports research funding provided to MSK from Tibet Cheezheng Tibetan Medicine Company, Ltd. Claudia M. Witt reports no competing financial interests.