Growth of Integrative Medicine at Leading Cancer Centers Between 2009 and 2016: A Systematic Analysis of NCI-Designated Comprehensive Cancer Center Websites

Integrative Therapies in Cancer Care: An Update on the Guidelines

INTRODUCTION

ASCO and the Society for Integrative Oncology have collaborated to develop guidelines for the application of integrative approaches in the management of anxiety, depression, fatigue and use of cannabinoids and cannabis in patients with cancer. These guidelines provide evidence-based recommendations to improve outcomes and quality of life by enhancing conventional cancer treatment with integrative modalities.

METHODS

All studies that informed the guideline recommendations were reviewed by an Expert Panel which was made up of a patient advocate, an ASCO methodologist, oncology providers, and integrative medicine experts. Panel members reviewed each trial for quality of evidence, determined a grade quality assessment label, and concluded strength of recommendations.

RESULTS

Strong recommendations for management of cancer fatigue during treatment were given to both in-person or web-based mindfulness-based stress reduction, mindfulness-based cognitive therapy, and tai chi or qigong. Strong recommendations for management of cancer fatigue after cancer treatment were given to mindfulness-based programs. Clinicians should recommend against using cannabis or cannabinoids as a cancer-directed treatment unless within the context of a clinical trial. The recommended modalities for managing anxiety included Mindfulness-Based Interventions (MBIs), yoga, hypnosis, relaxation therapies, music therapy, reflexology, acupuncture, tai chi, and lavender essential oils. The strongest recommendation in the guideline is that MBIs should be offered to people with cancer, both during active treatment and post-treatment, to address depression.

CONCLUSION

The evidence for integrative interventions in cancer care is growing, with research now supporting benefits of integrative interventions across the cancer care continuum.

Efficacy of acupuncture treatment for breast cancer-related insomnia: study protocol for a multicenter randomized controlled trial

Background

Insomnia is one of the most common symptoms among breast cancer patients, which can be present throughout all stages of breast cancer. As a non-pharmacological alternative treatment, acupuncture has been suggested to improve sleep situations in patients with cancer suffering from insomnia. However, there is a lack of well-designed, high-quality clinical evidence regarding the efficacy of acupuncture in the treatment of breast cancer-related insomnia. This study is conducted to evaluate the efficacy and safety of acupuncture treatment for breast cancer-related insomnia.

Methods

This study was designed as a multicenter, randomized, sham-controlled clinical trial. A total of 264 eligible patients with breast cancer-related insomnia will be randomized into an acupuncture group and a sham acupuncture group in a 1:1 ratio. In the trial, patients in the acupuncture and sham acupuncture groups will receive 12 sessions over a consecutive 4-week period. The primary outcome will be the treatment response rate of Insomnia Severity Index (ISI) at week 4; secondary outcomes include treatment remission rate of ISI, Sleep Efficiency (SE) obtained by the use of Sleep diary, treatment response rate of ISI at 8th and 16th weeks of follow-up, the mean changes of ISI, Generalized Anxiety Disorder Scale (GAD-7), Patient Health Questionnaire-9 (PHQ-9), Quality of Life Questionnaire - Core 30 (QLQ-C30), sleep parameters recorded in Actigraphy and weekly usage of remedial drugs. Adverse events will be recorded throughout the study. All analyses will be based on the ITT principle and performed with SAS 9.4 statistical software.

Discussion

This trial will evaluate the clinical efficacy and safety of acupuncture for breast cancer-related insomnia. If proven effective, acupuncture will provide an effective option for patients with breast cancer-related insomnia, which will play a positive role in helping patients reduce their use of sleeping medications.

Clinical trial registration

ClinicalTrials.gov, identifier NCT05510700.

"You matter": patients perceptions and disparities about cancer care and telehealth during and after COVID-19 pandemic

PURPOSE

Disparities in cancer care have been exacerbated by the COVID-19 pandemic. The aim of this study is to establish how telehealth mitigated the effect of COVID-19 on the healthcare sector and to identify potential disparities in perception and experience with telehealth in cancer care during and after the pandemic.

METHODS

We identified individuals with an established cancer diagnosis who received treatment at a comprehensive academic cancer center with a diverse patient population between 2019 and 2021, during the COVID-19 pandemic. Participants were asked to complete a self-administrated survey intended to collect patient-reported outcomes on socioeconomic and mental health challenges incurred during the pandemic as well as participants' experience with telehealth. The assessment was adapted from a 21-question-based survey applied for mental health. Descriptive statistics were used to summarize participant characteristics and the response to the survey items. Multivariable logistic regression was performed to assess and analyze the contributing factors to the survey responses.

RESULTS

A total of N = 136 participants were included in this analysis. The majority of participants (60.6%) reported increased anxiety, stress, or experience of distress as a direct result of COVID-19. However, among 54.1% of survey responders participated in a telehealth appointment and 84.4% agreed it was an easy and effective experience.

CONCLUSION

Elderly, male, and black participants reported the worst impact related to the pandemic. The majority of patients had a positive experience with telehealth. The results of the study suggest that telehealth services can serve as a tool for patients with cancer during and beyond active treatment to access supportive services.

Establishing an Integrative Oncology Service: Essential Aspects of Program Development

PURPOSE OF REVIEW

Over the last 2 decades, integrative oncology (IO) has seen exponential growth within cancer care. It aims to combine evidence-based complementary therapies with conventional treatments to improve the well-being and quality of life for individuals dealing with cancer. The proliferation of integrative medicine programs in major cancer centers globally reflects varying approaches shaped by cultural, demographic, and resource-based factors.

RECENT FINDINGS

Drawing upon the expertise of leaders in IO from the Society for Integrative Oncology (SIO) Clinical Practice Committee, this manuscript serves as a practical guide for establishing an IO practice. Collating insights from diverse professionals, including oncologists, integrative oncologists, supportive care physicians, researchers, and clinicians, the paper aims to provide a comprehensive roadmap for initiating and advancing IO services. The primary objective is to bridge the gap between conventional cancer care and complementary therapies, fostering a patient-centric approach to address the multifaceted challenges encountered by individuals with cancer. This paper delineates several key sections elucidating different aspects of IO practice. It delves into the core components necessary for an IO service's foundation, outlines the initial medical consultation process, and presents crucial tools essential for successful consultations. By consolidating insights and expertise, this manuscript seeks to facilitate the integration of IO into mainstream cancer care, ultimately enhancing patient outcomes and experiences.

Implementation of Virtual Integrative Oncology Shared Medical Appointment Series (VIOSMAS) Within Mixed Diagnosis Population

BACKGROUND

Integrative oncology [IO] is sought-after by patients, endorsed by clinical guidelines, and valued within National Cancer Institute Centers. Shared Medical Appointments [SMA] leverage health education and social connection to deliver enhanced patient experience, population health, cost-reduction, and clinician well-being. Integrative Oncology Shared Medical Appointments increase access to integrative medicine but delivering these services via telehealth have not been evaluated.

OBJECTIVE

We created, and pilot tested a Virtual Integrative Oncology Shared Medical Appointment Series (VIOSMAS) to assess its feasibility, acceptability, and efficacy at an urban academic teaching hospital.

METHODS

The 7-session hour-long Living Well with and after Cancer series included didactics, multi-disciplinary experiential sessions, and group discussion. Topics included (1) Introduction, (2) Herbs/Botanicals/Fungi, (3) Mindful Movement, (4) Acupuncture, (5) Narratives and Nature, (6) Diet and Culinary Medicine, and (7) Vitamins/Supplements. Virtual visits via telehealth were offered to enhance patient participation during the pandemic. Outcome measures included recruitment, retention, pre/post-series patient survey and qualitative clinician feedback.

RESULTS

Between 9/2021 and 4/2023, 72 unique patients were recruited to 5 cohorts and had a total of 332 VIOSMAS visits. A total of 50 patients (69%) attended 4 or more of the 7-session series; 60 (83% were women); patients ranged in age from 28 to 93 years (median 66); 36 (50%) lived outside the city center; the most common cancer diagnoses were breast, lymphoma, and lung cancer. Patients were from diverse demographics. Pre-program, patients reported desiring assistance in addressing diverse symptoms including fatigue, insomnia, pain, gastrointestinal (GI) symptoms, anxiety, and depression. Post-series, patients reported that the VIOSMAS addressed their goals and symptoms; they also reported incorporating recommended lifestyle changes in diet, exercise, sleep, and stress management; they were satisfied with the number of sessions and telehealth format. The participating clinicians reported high levels of satisfaction with VIOSMAS. Revenue to the institution from VIOSMAS exceeded the revenue potential of equivalent time spent for individual visits while supporting extended physician-patient contact.

CONCLUSION

VIOSMAS is feasible for patients and clinicians, addresses patients' symptoms and questions about lifestyle and complementary therapies, and generates more revenue than individual visits. Larger implementation trials with appropriate comparison groups are recommended.

Acupuncture vs Massage for Pain in Patients Living With Advanced Cancer: The IMPACT Randomized Clinical Trial

Importance

Pain is challenging for patients with advanced cancer. While recent guidelines recommend acupuncture and massage for cancer pain, their comparative effectiveness is unknown.

Objective

To compare the effects of acupuncture and massage on musculoskeletal pain among patients with advanced cancer.

Design, Setting, and Participants

A multicenter pragmatic randomized clinical trial was conducted at US cancer care centers consisting of a northeastern comprehensive cancer center and a southeastern cancer institute from September 19, 2019, through February 23, 2022. The principal investigator and study statisticians were blinded to treatment assignments. The duration of follow-up was 26 weeks. Intention-to-treat analyses were performed (linear mixed models). Participants included patients with advanced cancer with moderate to severe pain and clinician-estimated life expectancy of 6 months or more. Patient recruitment strategy was multipronged (eg, patient database queries, mailings, referrals, community outreach). Eligible patients had English or Spanish as their first language, were older than 18 years, and had a Karnofsky score greater than or equal to 60 (range, 0-100; higher scores indicating less functional impairment).

Interventions

Weekly acupuncture or massage for 10 weeks with monthly booster sessions up to 26 weeks.

Main Outcomes and Measures

The primary end point was the change in worst pain intensity score from baseline to 26 weeks. The secondary outcomes included fatigue, insomnia, and quality of life. The Brief Pain Inventory (range, 0-10; higher numbers indicate worse pain intensity or interference) was used to measure the primary outcome. The secondary outcomes included fatigue, insomnia, and quality of life.

Results

A total of 298 participants were enrolled (mean [SD] age, 58.7 [14.1] years, 200 [67.1%] were women, 33 [11.1%] Black, 220 [74.1%] White, 46 [15.4%] Hispanic, and 78.5% with solid tumors). The mean (SD) baseline worst pain score was 6.9 (1.5). During 26 weeks, acupuncture reduced the worst pain score, with a mean change of -2.53 (95% CI, -2.92 to -2.15) points, and massage reduced the Brief Pain Inventory worst pain score, with a mean change of -3.01 (95% CI, -3.38 to -2.63) points; the between-group difference was not significant (-0.48; 95% CI, -0.98 to 0.03; P = .07). Both treatments also improved fatigue, insomnia, and quality of life without significant between-group differences. Adverse events were mild and included bruising (6.5% of patients receiving acupuncture) and transient soreness (15.1% patients receiving massage).

Conclusions and Relevance

In this randomized clinical trial among patients with advanced cancer, both acupuncture and massage were associated with pain reduction and improved fatigue, insomnia, and quality of life over 26 weeks; however, there was no significant different between the treatments. More research is needed to evaluate how best to integrate these approaches into pain treatment to optimize symptom management for the growing population of people living with advanced cancer.

Trial Registration

ClinicalTrials.gov Identifier: NCT04095234.

Knowledge and attitudes towards medicinal cannabis and complementary and integrative medicine (CIM): a survey of healthcare professionals working in a cancer hospital in Australia

PURPOSE

We investigated attitudes and practices of healthcare professionals (HCPs) to medicinal cannabis (MC) and complementary and integrative medicine (CIM), including individual therapies, such as acupuncture, massage, herbs, dietary supplements, nutrition and exercise. We explored whether healthcare occupation influenced attitudes to CIM and MC; referral pathways for advice on CIM; and interest in a pharmacy service to evaluate herbs and supplements.

METHODS

Cross-sectional survey. All clinical staff at a comprehensive cancer hospital were invited to complete an anonymous questionnaire about CIM and MC. We used descriptive analysis to describe the respondent's knowledge and attitudes, and Fisher's exact test to test for differences by occupation, length of time at the hospital and age.

RESULTS

Most of the 116 HCPs respondents supported integrating CIM into cancer care (94.8%) and wanted to learn more (90%) and to understand benefits and contraindications. Most respondents believed that CIM (87.9%) could benefit patients with cancer, and MC could benefit those with advanced cancer (49-51%). Whilst just over half (52.6%) felt confident discussing CIM with patients, only 10% felt they had sufficient knowledge to discuss MC. Most felt they did not have sufficient knowledge to specifically discuss mind and body practices (63.8%) or herbs and supplements (79%). HCPs (63%) would be more inclined to allow use of herbs and supplements with cancer treatment if a pharmacy service was available to evaluate interactions. Occupation, length of time at hospital and age influenced confidence and knowledge about CIM.

CONCLUSIONS

The integration of evidence-based CIM and MC into cancer care is hampered by a lack of knowledge of benefits and contraindications, and gaps in education. Effective and safe integration may require targeted development of services such as pharmacy to evaluate the safety of herbs and supplements, and inclusion of cancer specialists who have received training in individual CIM therapies and MC.

Retrospective Outcomes of a New Acupuncture Service at a Comprehensive Cancer Center

Introduction: Among cancer centers, patients' interest in acupuncture is growing, in addition to clinical research in the intervention. Their National Cancer Institute-designated comprehensive cancer center piloted an acupuncture service. Their aim was to assess whether acupuncture impacted patient self-reported symptoms as delivered clinically and discuss their implementation strategy. Methods: Patients undergoing acupuncture at a comprehensive cancer center from June 2019 to March 2020 were asked to complete a modified Edmonton Symptom Assessment Scale (ESAS) before and after each session. The authors evaluated symptom changes after acupuncture in both outpatient and inpatient settings. A change of ≥1 U, on the 0-10 scale, was considered clinically significant. Results: Three hundred and nine outpatient and 394 inpatient acupuncture sessions were provided to patients at the comprehensive cancer center during this period, of which surveys from 186 outpatient (34 patients) and 124 inpatient (57 patients) sessions were available for analysis. The highest pretreatment symptoms reported by outpatients were neuropathy (5.78), pain (5.58), and tiredness (5.59). Outpatients receiving acupuncture reported clinically significant improvements in pain (ESAS score change of -2.97), neuropathy (-2.68), decreased lack of well-being (-2.60), tiredness (-1.85), nausea (-1.83), anxiety (-1.56), activities of daily living issues (-1.32), depression (-1.23), anorexia (-1.19), insomnia (-1.14), and shortness of breath (-1.14). The most severe pretreatment symptoms reported by inpatients were pain (6.90), insomnia (6.16), and constipation (5.44). Inpatients receiving acupuncture reported clinically significant improvements in anxiety (-3.69), nausea (-3.61), insomnia (-3.26), depression (-2.98), pain (-2.77), neuropathy (-2.68), anorexia (-2.20), constipation (-1.95), and diarrhea (-1.26). Conclusion: Both outpatient and inpatient participants in this pilot acupuncture program reported clinically significant improvements in symptoms after a single acupuncture treatment. Some differences between the outpatient and inpatient settings warrant further investigation.

Integrative Oncology Care of Symptoms of Anxiety and Depression in Adults With Cancer: Society for Integrative Oncology-ASCO Guideline

PURPOSE

To provide evidence-based recommendations to health care providers on integrative approaches to managing anxiety and depression symptoms in adults living with cancer.

METHODS

The Society for Integrative Oncology and ASCO convened an expert panel of integrative oncology, medical oncology, radiation oncology, surgical oncology, palliative oncology, social sciences, mind-body medicine, nursing, methodology, and patient advocacy representatives. The literature search included systematic reviews, meta-analyses, and randomized controlled trials published from 1990 through 2023. Outcomes of interest included anxiety or depression symptoms as measured by validated psychometric tools, and adverse events. Expert panel members used this evidence and informal consensus with the Guidelines into Decision Support methodology to develop evidence-based guideline recommendations.

RESULTS

The literature search identified 110 relevant studies (30 systematic reviews and 80 randomized controlled trials) to inform the evidence base for this guideline.

RECOMMENDATIONS

Recommendations were made for mindfulness-based interventions (MBIs), yoga, relaxation, music therapy, reflexology, and aromatherapy (using inhalation) for treating symptoms of anxiety during active treatment; and MBIs, yoga, acupuncture, tai chi and/or qigong, and reflexology for treating anxiety symptoms after cancer treatment. For depression symptoms, MBIs, yoga, music therapy, relaxation, and reflexology were recommended during treatment, and MBIs, yoga, and tai chi and/or qigong were recommended post-treatment.

DISCUSSION

Issues of patient-health care provider communication, health disparities, comorbid medical conditions, cost implications, guideline implementation, provider training and credentialing, and quality assurance of natural health products are discussed. While several approaches such as MBIs and yoga appear effective, limitations of the evidence base including assessment of risk of bias, nonstandardization of therapies, lack of diversity in study samples, and lack of active control conditions as well as future research directions are discussed.Additional information is available at www.asco.org/survivorship-guidelines.

Complementary and alternative medicine in oncology: knowledge, attitude and practice among Tunisian healthcare workers

PURPOSE

Over the past years, there has been a considerable increase in complementary and alternative medicine (CAM) use among cancer patients. However, guidance from health care workers (HCWs) is not always provided. We aimed to determine the knowledge, attitude and practice of Tunisian HCWs regarding the use of CAM in cancer patients.

METHODS

We conducted a multicenter cross-sectional study over 5 months from February to June 2022 among HCWs caring for cancer patients in the Tunisian center region. Data were collected using a self-administered questionnaire developed by our investigators.

RESULTS

The level of knowledge about CAM was declared limited by 78.4% of our population. The best known CAM therapies were herbal medicine and homeopathy while chiropractic and hypnosis where the least. HCWs who had sought information on CAM represented 54.3% of our sample and the main source of information was the Internet (37.1%). A positive attitude towards the use of CAM was found in 56% of HCWs. The integration of CAM into supportive care in oncology was approved by 78% of HCWs. Concerning training on CAM, 78% declared its necessity for HCWs and 73.3% expressed a desire to have it. A personal use of CAM was found in 53% of HCWs while 38.8% had previously used CAM in the treatment of their cancer patients.

CONCLUSION

The majority of HCWs had a positive attitude towards the use of CAM in oncology despite their poor knowledge about it. Our study emphasizes the need to train HCWs dealing with cancer patients on CAM.

Kidney Cancer Integrative Oncology: Possible Options for Care

PURPOSE OF REVIEW

This study aims to review how complementary and integrative medicine (CIM), defined as therapies utilizing nutrition, physical activity, herbs, supplements, mind-body therapies, homeopathy, and other non-traditional therapies, can address the prevention, treatment, side effects, and recurrence of kidney cancer. This review discusses advances and discoveries in research, gaps in research, current debates on the subject, and directions for future research. We queried Ovid MEDLINE and PubMed databases using the search terms kidney cancer, integrative medicine, integrative oncology, nutrition, supplements, treatment, prevention, and therapy. Searches were limited to integrative medicine and integrative oncology. We reviewed CIM therapies related to prevention, treatment, side effect mitigation, and recurrence of kidney cancers.

RECENT FINDINGS

Search results yielded 211 studies, of which 87 were relevant to this review. Studies related to CIM and kidney cancer were clustered into themes, including nutrition, physical activity, supplements, mind-body therapies, and alternative therapies. This review provides a foundation for utilizing the principles of integrative medicine in the prevention of and care for patients with kidney cancer and the need for further focused research on the effectiveness of CIM in kidney cancers.

Benefit of inhalation aromatherapy as a complementary treatment for stress and anxiety in a clinical setting – A systematic review

OBJECTIVE

The purpose of this systematic review is to ascertain the impact of inhalation aromatherapy on stress and anxiety in clinical settings.

METHODS

A search strategy was developed using various databases. Randomised Controlled Trials (RCTs) as well as single and double-blind pilot clinical studies (non-RCT) using inhalation aromatherapy with an essential oil blend or a single essential oil were examined. All studies included a control intervention and use of a validated measurement tool. The time period under review was years 2000-2021. Due to the high level of heterogeneity and element of bias, a narrative synthesis was conducted.

RESULTS

The search strategy initially retrieved 628 studies and through application of the selection criteria and the removal of duplicates, 76 studies were selected for review with a total of 6539 patients. In 42% of the RCTs, physiological measures including vital signs and/or salivary cortisol were used in addition to questionnaires. Over 70% of the studies reported a positive effect on anxiety levels in the aromatherapy intervention groups compared with the control. However, in many cases this is limited by the absence of safety data, imprecise reporting of plant species and dosage of essential oil.

CONCLUSION

Inhalation aromatherapy has the potential to reduce stress and anxiety with data emerging to further support this result across a wide modality of clinical treatments. However, there is a clear need for the development of standard protocols for research in this area, generating measurable results which will create the opportunity for more rigorous evidence-based outcomes.

Integrative Oncology and the Clinical Care Network: Challenges and Opportunities

Integrative oncology is a new and growing field of cancer care. Integrative oncology is a patient-centered, evidence-based field of comprehensive cancer care that utilizes integrative therapies such as mind-body practices, acupuncture, massage, music therapy, nutrition, and exercise in collaboration with conventional cancer treatments. Patient interest and utilization has been growing over the past two decades. Clinical research has shown the benefits of these approaches to improving symptom management and quality of life, and is now being incorporated into national guidelines from the National Comprehensive Cancer Network (NCCN) and American Society for Clinical Oncology (ASCO). The availability of these services at cancer centers is growing, although the structure and implementation of integrative oncology remains highly variable. This article discusses the benefits of integrative oncology and provides an overview of the current state of integrative oncology programs nationwide. Current challenges and opportunities for cancer centers to provide integrative services is reviewed in the areas of programmatic structure, clinical service, education, and research.

How to Make Evidence-Based Integrative Medicine a Part of Everyday Oncology Practice

Integrativety oncology (IO) is a "patient-centered, evidence-informed field of comprehensive cancer care that utilizes mind-body practices, natural products, and lifestyle modifications from different traditions alongside conventional cancer treatments." There is an urgent need to educate oncology health care providers on the fundamentals of evidence-based IO to meet the needs of people with cancer. In this chapter, we aim to provide oncology professionals with actionable guidance on the basis of the Society for Integrative Oncology (SIO)-American Society of Clinical Oncology (ASCO) guidelines on integrative medicine use during oncology visits to help alleviate symptoms and side effects in people with cancer during and after treatment.

Virtual acupressure for symptom management in cancer populations during COVID-19: a retrospective analysis

OBJECTIVE

Following the outbreak of COVID-19, access to in-person oncology acupuncture service was temporarily disrupted at Dana-Farber Cancer Institute, a National Cancer Institute (NCI)-designated cancer center. During this period, a virtual acupuncturist-guided session of patient self-acupressure was implemented to provide continuity of supportive care for cancer patients. We provide preliminary findings on the feasibility and potential impact of remotely delivered acupressure on patient-reported symptom burden in cancer populations.

METHODS

This is a retrospective chart review of cancer patients who received virtual acupressure service at a single academic cancer center from May 11 to December 31, 2020. Each telehealth session consisted of a one-on-one appointment between the patient and acupuncturist. A semi-standardized set of acupoints were used, including Yintang, ST36, GB20, PC6, and HT7 as well as Relaxation Point on the ear. At the start of each session, Edmonton Symptom Assessment System (ESAS) was used to collect patient-reported symptom burden. For patients with at least one follow-up within 14 days of the baseline visit, paired t-test was used to analyze changes in ESAS scores from baseline to first follow-up.

RESULTS

A total of 102 virtual acupressure sessions were administered to 32 patients. Most patients were females (90.6%) and white (84.4%), and the mean age was 55.7 (range = 26-82; SD = 15.7). The most common cancer diagnosis was breast (53.1%), followed by pancreatic (12.5%) and lung (9.4%). Baseline ESAS Total, Physical, and Emotional scores were 21.5 (SD = 11.1), 12.4 (SD = 7.5), and 5.2 (SD = 3.8), respectively. Of 32 patients, 13 (41%) had a second acupressure session within 14 days. For these 13 patients, there was a statistically significant reduction in Total symptom burden (-4.9 ± 7.6; p = 0.04) and in Physical (-3.5 ± 5.4; p = 0.04) and Emotional (-1.2 ± 1.8; p = 0.03) subscales from baseline to follow-up.

CONCLUSION

Virtual acupressure was associated with significant reduction in symptom burden among cancer patients from their baseline to follow-up visits. Larger scale randomized clinical studies are needed to confirm these findings and better understand the impact of virtual acupressure on symptom burden in cancer populations.

Integrative medicine in multiple myeloma and plasma cell disorders

INTRODUCTION

Integrative Medicine (IM) use and efficacy is poorly defined in those with plasma cell disorders (PCD). A 69-question survey on the subject was hosted on HealthTree.org for 3 months.

METHOD

The survey included questions about complementary practice use, PHQ-2 score, quality of life, and more. Mean outcome values were compared between IM users and non-users. Proportions of supplement users and IM patients were compared between patients currently on myeloma specific treatment and patients not currently on treatment.

RESULTS

The top 10 IM modalities reported among 178 participants were aerobic exercise (83 %), nutrition (67 %), natural products (60 %), strength exercise (52 %), support groups (48 %), breathing exercises (44 %), meditation (42 %), yoga (40 %), mindfulness-based stress reduction (38 %), and massage (38 %). The survey showed most patients participated in IM modalities, though they felt uncomfortable discussing them with their oncologist. Participant characteristics were compared between groups (users and non-users) using two-sample t-tests and chi-square tests. Use of vitamin C (3.6 vs. 2.7; p = 0.01), medical marijuana (4.0 vs. 2.9; p = 0.03), support groups (3.4 vs. 2.7; p = 0.04), and massage (3.5 vs. 2.7; p = 0.03) were associated with a higher quality of life scores on MDA-SI MM. There were no other significant associations between supplement use or IM practices and the MDA-SI MM, brief fatigue inventory, or PHQ-2.

CONCLUSION

This study provides a foundation in the understanding of IM use in PCD, but more research is needed to evaluate individual IM interventions and their efficacy.

Bibliometric Analysis of Acupuncture Therapy for Cancer Pain Over the Past 10 Years

Purpose

Cancer pain is a common symptom of cancer patients and greatly affects quality of life. Acupuncture has certain curative effects on cancer pain. The aim of this study was to analyze and visualize the current status and research trend of acupuncture treatment for cancer pain over the last 10 years and provide directions for future development.

Methods

A search of the Web of Science Core Collection from 2012-01-01 to 2022-08-20 was performed to collect studies related to acupuncture therapy for cancer pain. CiteSpace was used to conduct bibliometric analysis and visualization from the perspective of the volume of annual publications, journals, nations, institutions, authors, keywords, and references.

Results

A total of 302 studies were included in the analysis. The number of publications increased steadily with some fluctuations over the past decade. Integrative Cancer Therapies was the journal with the most relevant publications, and the Journal of Clinical Oncology was the most frequently cited journal. China had the highest volume of publications, and the USA contributed most to international collaboration. The most prolific institution was Memorial Sloan Kettering Cancer Center. The most productive author was Mao JJ, and the most influential author was Lu WD. "Acupuncture" was the top keyword in frequency and centrality. The references with the highest frequency and centrality were published by HE, Y, and Ting Bao, respectively.

Conclusion

A stable development trend has formed in this field. The overall collaborative network needs to be strengthened. Breast cancer and multiple myeloma, electroacupuncture and bee venom acupuncture, postoperative pain, peripheral neuropathic pain syndrome, and aromatase inhibitors-associated arthralgia syndrome are research hotspots in this field. Randomized controlled trials (RCTs), evidence-based evaluations and mechanisms (cancer-induced bone pain) are research trends and frontiers.

"A Pain Deep in Your Soul (Being) that is Not Physical:" Assessing Spiritual Pain in Integrative Oncology Consultations

CONTEXT

Spiritual pain contributes to the suffering of cancer patients. However, it is unclear whether patients seen outside of palliative care report spiritual pain and its relationship with symptom burden.

OBJECTIVES

Characteristics of patients reporting spiritual pain were examined, as well as the association of spiritual pain with symptom burden and how spiritual pain affected the factor structure of the Edmonton Symptom Assessment System (ESAS).

METHODS

A retrospective chart review was conducted of integrative oncology patients who completed the PROMIS10 and a modified ESAS (ESAS-FS) including financial distress and spiritual pain (pain deep in your soul/being that is not physical). Multiple logistic regression was used to assess associations between demographics and spiritual pain. T-tests compared ESAS-FS symptoms and global health for patients endorsing spiritual pain (0 vs. ≥1). Principal component analyses (oblique rotation) were also used to determine ESAS-FS symptom clusters.

RESULTS

The sample (N = 1662) was mostly women (65%) and 39% endorsed spiritual pain at least ≥one. Men and older individuals were less likely to endorse spiritual pain (ps < 0.05). Presence of spiritual pain was associated with worse symptoms on the ESAS-FS and global health (ps < 0.001). The ESAS-FS had two symptom clusters, with the psychological factor including depression, anxiety, wellbeing, sleep, financial distress, and spiritual pain (Cronbach's alpha 0.78).

CONCLUSION

Assessing spiritual pain and understanding the effects of its presence or absence in the context of other physical and psychosocial symptoms may provide additional opportunities for preventing exacerbation of symptoms, improving quality of life, and enhancing overall experience of care.

Demographic and Clinical Characteristics Associated With Familiarity, Interest, and Use of Integrative Therapies Among Patients With Breast Cancer

BACKGROUND

Integrative therapies reduce side effects from cancer treatment, though remain underutilized. There is a paucity of data on factors associated with familiarity, interest, and use of these therapies among breast cancer patients.

METHODS

A survey on familiarity, interest, and use of acupuncture, massage, meditation, music therapy, and yoga was conducted in patients enrolled in the Chicago Multiethnic Epidemiologic Breast Cancer Cohort. Familiarity and interest were assessed using a five-point Likert scale, and modeled using proportional odds regression. Use was per self-report, modeled using logistic regression. Adjusted odds ratios (aOR) and 95% confidence intervals (95% CI) were calculated.

RESULTS

Of 1300 study participants, 59.6% were familiar with massage, 47.2% acupuncture, 46.9% meditation, 46.5% yoga, and 34.5% music therapy; 63.3% were interested in massage, 50.2% yoga, 47.9% meditation, 44.2% acupuncture, and 41.4% music therapy. Only 41.3% had used massage, 25.8% acupuncture, 18.7% yoga, 18.5% meditation, and 7.4% music therapy. Older age and lower education level were associated with lower familiarity and interest. Black patients were more likely than White patients to be interested. Patients' interest increased significantly when certain symptoms were treated. In the adjusted models, patients ages 40 to 65 were less likely than those ages <40 to have used massage (aOR 0.55, 95% CI: 0.31-0.98), yoga (aOR 0.52, 95% CI: 0.27-0.99), or meditation (aOR 0.47, 95% CI: 0.25-0.90). Patients with high school education were less likely than those with a graduate degree to have used acupuncture (aOR 0.42, 95% CI: 0.24-0.72), massage (aOR 0.39, 95% CI: 0.25-0.62), or meditation (aOR 0.26, 95% CI: 0.12-0.58). Having received chemotherapy was associated with increased interest in yoga (aOR 1.36, 95% CI: 1.07-1.73), massage (aOR 1.27, 95% CI: 1.01-1.59), or meditation (aOR 1.26, 95% CI: 1.01-1.57). Receipt of hormone therapy was not associated with interest or use.

CONCLUSION

In this racially diverse cohort of patients, familiarity and interest of integrative therapies were high, while use was low. Older age and lower education level were associated with lack of interest and use. Chemotherapy was associated with interest, but hormone therapy was not. Strategies to promote the benefits and use of integrative therapies among breast cancer patients are needed.

Practice Patterns on the Incorporation of Integrative Medicine Into the Oncologic Care of Patients With Cancer

BACKGROUND

With rising interest in complementary approaches to symptom management, awareness of real-world practice patterns in the incorporation of integrative oncology (IO) into cancer care is limited. Therefore, we examined the reasons for referral, symptom burdens, and clinical outcomes for cancer patients who underwent initial IO consultations.

METHODS

The records of adult patients with cancer who underwent initial outpatient IO consultations at our cancer center for a representative 10-day period at the start of each month for 12 months starting January 1, 2017, were reviewed retrospectively. Patient demographic and medical characteristics and outpatient IO consultation details, including patient-reported outcome measures of symptom burden, were extracted. Descriptive summary statistics and logistic regression were used to analyze the data.

RESULTS

Among the 473 study patients, 71% were women, breast cancer (42%) was the most common cancer type, and 31% had metastatic cancer. Referring clinicians listed an integrative approach (57%) as the most common reason for referral, followed by diet (26%), pain (19%), discussion of herbs and supplements (18%), and stress (18%). In comparison, patients listed their primary concerns as diet (16%), pain (15%), and an integrative approach to overall health (11%). After the IO consultations, the highest likelihood of subsequent recommendations were acupuncture for hot flashes (odds ratio [OR], P = .002) or peripheral neuropathy (OR = 6.59, P < .001), oncology massage for pain (OR = 3.04, P < .001), psychology referral for patient's self-reported anxiety (OR = 2.35, P < .001), and mind-body therapies for stress (OR = 2.57, P < .001).

CONCLUSION

Cancer patients' top concerns regarding IO consultation may not always match providers' reasons for referral. Longitudinal data analysis is needed to determine the effect of integrative interventions on symptom burden.

Integrative Medicine for Pain Management in Oncology: Society for Integrative Oncology-ASCO Guideline

PURPOSE

The aim of this joint guideline is to provide evidence-based recommendations to practicing physicians and other health care providers on integrative approaches to managing pain in patients with cancer.

METHODS

The Society for Integrative Oncology and ASCO convened an expert panel of integrative oncology, medical oncology, radiation oncology, surgical oncology, palliative oncology, social sciences, mind-body medicine, nursing, and patient advocacy representatives. The literature search included systematic reviews, meta-analyses, and randomized controlled trials published from 1990 through 2021. Outcomes of interest included pain intensity, symptom relief, and adverse events. Expert panel members used this evidence and informal consensus to develop evidence-based guideline recommendations.

RESULTS

The literature search identified 227 relevant studies to inform the evidence base for this guideline.

RECOMMENDATIONS

Among adult patients, acupuncture should be recommended for aromatase inhibitor-related joint pain. Acupuncture or reflexology or acupressure may be recommended for general cancer pain or musculoskeletal pain. Hypnosis may be recommended to patients who experience procedural pain. Massage may be recommended to patients experiencing pain during palliative or hospice care. These recommendations are based on an intermediate level of evidence, benefit outweighing risk, and with moderate strength of recommendation. The quality of evidence for other mind-body interventions or natural products for pain is either low or inconclusive. There is insufficient or inconclusive evidence to make recommendations for pediatric patients. More research is needed to better characterize the role of integrative medicine interventions in the care of patients with cancer.Additional information is available at https://integrativeonc.org/practice-guidelines/guidelines and www.asco.org/survivorship-guidelines.

"What Should I Eat?"-Addressing Questions and Challenges Related to Nutrition in the Integrative Oncology Setting

PURPOSE OF REVIEW

This review aims to assess how nutrition can be addressed in the integrative oncology setting, taking into account cancer patients' unmet needs as they relate to nutrition in cancer care and the evidence-based information that is available on this topic.

RECENT FINDINGS

During and after cancer treatment, nutrition is an important component of supportive care, for patients and their family members. Current scientific data consistently show that poor nutrition can reduce survival and decrease adherence to cancer treatments. Unfortunately, the limited availability of dietitians makes access to individualized nutrition counseling challenging, and many cancer patients still do not receive adequate nutritional support. As a result, one of the main unmet needs of patients and their families through the whole cancer trajectory is accessible and up-to-date evidence-based nutritional counseling that emphasizes basic healthy nutrition. The popularity of complementary and integrative medicine among patients with cancer makes the integrative oncology setting an excellent avenue for providing such support. A suggested simple approach that utilizes World Cancer Research Fund/American Institute for Cancer Research and American Cancer Society basic information is described. This approach can be easily incorporated into integrative oncology settings, while reserving the role for the registered dietician to address underweight patients, patients with malnutrition, and patients with more complicated dietary situations. The integrative oncology setting is in a unique place in oncology that can be utilized for enhancing dissemination of healthy nutrition information and addressing the unmet needs expressed by patients and families.

Acupuncture in hematologic malignancies and hematopoietic cell transplantation

Acupuncture is an integrative medicine modality that has been used historically and studied recently for managing various symptoms and diseases. Patients with hematological malignancies often experience a high symptom burden including pain, fatigue, nausea, vomiting, and insomnia. Pharmacological interventions are the mainstay of managing these symptoms, although they may not provide adequate control or are not well tolerated due to side effects. There have been many randomized controlled trials of acupuncture on reduction of these symptoms. In this review, we will summarize the current evidence on the effect of acupuncture on the management of common symptoms experienced by patients with hematological malignancies and the current understanding of acupuncture's mechanism of action. The evidence is the strongest for reducing pain and nausea vomiting, less strong for symptoms such as peripheral neuropathy, fatigue, constipation, insomnia, night sweat, and pruritus.

On Being a Stranger in a Foreign Land: Providing Integrative Oncology Therapies to COVID-19 Medical Professionals

This narrative describes an innovative program using integrative medicine therapies to improve the well-being of patients and providers in a hospital’s COVID-19 departments.

Acupuncture versus massage for pain in patients living with advanced cancer: a protocol for the IMPACT randomised clinical trial

INTRODUCTION

Pain, comorbid fatigue and sleep disturbances are common and distressing symptoms for patients with advanced cancer, negatively impacting their quality of life. Clinical guidelines recommend non-pharmacological interventions, including acupuncture and massage, for pain management in adult patients with cancer in adjunct to conventional care. However, high-quality evidence about the comparative effectiveness and long-term durability of these therapies for symptom management is limited.

METHODS AND ANALYSIS

We describe the design of a two-arm, parallel group, multicentre randomised controlled trial that investigates the use of acupuncture versus massage for musculoskeletal pain among 300 patients with diverse types of advanced cancer. The primary aim is to evaluate the long-term effectiveness (26 weeks from randomisation) of acupuncture vs massage for pain (primary outcome) and comorbid symptoms (fatigue, sleep disturbance and quality of life). The secondary aim is to identify patient-level demographic characteristics (eg, sex, race, age), clinical factors (eg, insomnia, pain severity) and psychological attributes that are associated with a greater reduction in pain for either acupuncture or massage. Patients will receive weekly acupuncture or massage treatments for 10 weeks, followed by monthly booster sessions up to 26 weeks. The primary endpoint will be the change in worst pain intensity score from baseline to 26 weeks. We will collect validated patient-reported outcomes at multiple time points over 26 weeks.

ETHICS AND DISSEMINATION

The Institutional Review Board at Memorial Sloan Kettering Cancer Center in New York approved this protocol. Results will be disseminated via peer-reviewed scientific journals and conference presentations. Our findings will help patients and healthcare providers make informed decisions about incorporating non-pharmacological treatments to manage pain for patients with advanced cancer.

TRIAL REGISTRATION NUMBER

NCT04095234.

Acupuncture as a Complementary Therapy for Cancer-Induced Bone Pain: A Systematic Review and Meta-Analysis

Background

Cancer-induced bone pain (CIBP) is a special type of cancer pain and lacks safe and effective treatments. Acupuncture is a potentially valuable treatment for CIBP, studies evaluating the effect of acupuncture on CIBP have increased significantly, but the safety and efficacy of acupuncture to control CIBP remains controversial.

Objective

To provide the first meta-analysis to evaluate the safety and efficacy of acupuncture in CIBP management.

Data Sources

CNKI, CBM, Wanfang, VIP Database, PubMed, Embase, and Cochrane Library were searched from their inception until 1 June 2022.

Study Selection

RCTs with primary bone tumor patients or other types of primary cancer companied by bone metastases as the research subjects and to evaluate the efficacy of acupuncture treatment alone or combined with the control treatment were included. Meanwhile, RCTs should choose the pain score as the primary outcome and pain relief rate, frequency of breakthrough pain, analgesic onset time, analgesia duration, quality of life, and adverse events as reference outcomes.

Data Collection and Analysis

We designed a data-extraction form that was used to extract key information from the articles. Data extraction study evaluation was conducted independently by two reviewers, and a third reviewer would resolve any disagreements. The risk of bias was assessed by the Cochrane Collaboration's tool for assessing the risk bias. The quality of the evidence for main outcomes was evaluated by the GRADE system. Mean differences (MD), relative risk (RR), and 95% confidence intervals (CIs) were calculated. The forest plots were performed using the Review Manager Software (5.3 version). Subgroup analysis was used to investigate the possible sources of potential heterogeneity. Descriptive analysis was performed in case of unacceptable clinical heterogeneity.

Results

Thirteen RCTs (with 1,069 patients) were included, and all studies were at high risk of bias owing to lack of blinding or other bias. Eleven studies evaluated the effectiveness of acupuncture as a complementary therapy, and showed that acupuncture plus control treatment (compared with control treatment) was connected with reduced pain intensity (MD = −1.34, 95% CI −1.74 to −0.94; Q &lt; 0.1; I2 = 98%, P &lt; 0.01). Subgroup analyses based on acupoints type partly explain the potential heterogeneity. The results also showed that acupuncture plus control treatment (compared with control treatment) was connected with relieving pain intensity, increasing the pain relief rate, reducing the frequency of breakthrough pain, shortening analgesic onset time, extending the analgesic duration, and improving the quality of life. We have no sufficient evidence to prove the effectiveness of acupuncture alone. Four RCTs reported only adverse events related to opioids' side effects. Evidence was qualified as “very low” because of low methodological quality, considerable heterogeneity, or a low number of included studies.

Conclusion

Acupuncture has a certain effect as a complementary therapy on pain management of CIBP, which not only mitigates the pain intensity but also improves the quality of life and reduces the incidence of opioids' side effects, although the evidence level was very low. In future, a larger sample size and rigorously designed RCTs are needed to provide sufficient evidence to identify the efficacy and safety of acupuncture as a treatment for CIBP.

Patients' lived experiences and recommendations for enhanced awareness and use of integrative oncology services in cancer care

BACKGROUND

Consuming educational content, adhering to treatment plans and managing symptoms and side-effects can be overwhelming to new oncology patients.

OBJECTIVE

The purpose of this study is to engage patients in conceptualization of enhanced clinic processes and digital health tools to support awareness and use of integrative oncology services.

PATIENT INVOLVEMENT

We engaged patients in participatory design to understand lived experiences surrounding use of integrative oncology services during and after conventional cancer treatment.

METHODS

Ten participatory design sessions were held with individual participants. Sessions began with patient story telling regarding diagnosis and paths to awareness and use of integrative oncology services. We then reviewed prototype mobile app screens to solicit feedback regarding digital health functionality to support patient navigation of symptom-alleviating options.

RESULTS

Oncology patients are active participants in the management of symptoms and side effects. Patients who utilize yoga, acupuncture, and massage report a need for earlier patient education about these services. Patients express interest in digital health tools to match symptoms to options for relief, provide access to searchable information, and facilitate streamlined access to in-person and remote services.

DISCUSSION

Patients co-produce wellbeing by seeking solutions to daily challenges and consuming educational content. Clinics can collaborate with patients to identify high priority needs and challenges.

PRACTICAL VALUE

Active collaboration with patients is needed to identify unmet needs and guide development of clinic processes and digital health tools to enhance awareness and use of IO services in conventional cancer care.

FUNDING

The principal investigator was supported by the U.S. Agency for Healthcare Research and Quality (AHRQ K12HS026370). The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of AHRQ. The sponsor had no role in the study design, data collection, analysis, report writing, or decision to submit for publication.

The Provision of Complementary, Alternative, and Integrative Medicine Information and Services: a Review of World Leading Oncology Hospital Websites

BACKGROUND

Many cancer patients use complementary, alternative, and integrative medicine (CAIM) to improve their psychological and functional health. However, there is little known about the extent of CAIM information and services provided on oncology hospital websites.

METHODS

This study reviewed public-facing websites to determine the degree of CAIM information provided and services offered by the world's leading cancer hospitals in 2021; this ranking was informed by a large survey of medical professionals led by Newsweek and Statista. Nine authors extracted data from hospital websites individually and in triplicate, prior to meeting to revise data extractions. Data analysis was then performed by two authors to determine how many hospitals provided CAIM descriptions and offered CAIM services, and the extent of CAIM information provided.

RESULTS

A total of 131 hospitals were included in this study. Of the eligible hospitals, 50.38% (n = 66) provided a theoretical description of CAIM; 48.09% (n = 63) provided a description of one or more CAIM therapies; 63.36% (n = 83) offered one or more CAIM therapies to cancer patients. The most common therapies described were the same as the most common therapies offered. These therapies are massage, special foods and diets, acupuncture, meditation, yoga, and creative outlets. While CAIM therapies were commonly offered, information surrounding the benefits and side effects associated with these therapies varied.

CONCLUSIONS

Due to the lack of CAIM standardization worldwide, there is a need for increased CAIM information provision on hospital websites to better inform and empower patients to make well-informed decisions about their health.

Operational definition of complementary, alternative, and integrative medicine derived from a systematic search

BACKGROUND

Identifying what therapies constitute complementary, alternative, and/or integrative medicine (CAIM) is complex for a multitude of reasons. An operational definition is dynamic, and changes based on both historical time period and geographical location whereby many jurisdictions may integrate or consider their traditional system(s) of medicine as conventional care. To date, only one operational definition of "complementary and alternative medicine" has been proposed, by Cochrane researchers in 2011. This definition is not only over a decade old but also did not use systematic methods to compile the therapies. Furthermore, it did not capture the concept "integrative medicine", which is an increasingly popular aspect of the use of complementary therapies in practice. An updated operational definition reflective of CAIM is warranted given the rapidly increasing body of CAIM research literature published each year.

METHODS

Four peer-reviewed or otherwise quality-assessed information resource types were used to inform the development of the operational definition: peer-reviewed articles resulting from searches across seven academic databases (MEDLINE, EMBASE, AMED, PsycINFO, CINAHL, Scopus and Web of Science); the "aims and scope" webpages of peer-reviewed CAIM journals; CAIM entries found in online encyclopedias, and highly-ranked websites identified through searches of CAIM-related terms on HONcode. Screening of eligible resources, and data extraction of CAIM therapies across them, were each conducted independently and in duplicate. CAIM therapies across eligible sources were deduplicated.

RESULTS

A total of 101 eligible resources were identified: peer-reviewed articles (n = 19), journal "aims and scope" webpages (n = 22), encyclopedia entries (n = 11), and HONcode-searched websites (n = 49). Six hundred four unique CAIM terms were included in this operational definition.

CONCLUSIONS

This updated operational definition is the first to be informed by systematic methods, and could support the harmonization of CAIM-related research through the provision of a standard of classification, as well as support improved collaboration between different research groups.

Exploring the Feasibility of a Mindfulness-Music Therapy Intervention to Improve Anxiety and Stress in Adolescents and Young Adults with Cancer

CONTEXT

Adolescent and young adults (AYAs) with cancer experience significant psychological distress due to cancer treatment that can persist long after treatment. However, little is known regarding optimal interventions to support the psychosocial needs of AYAs with cancer.

OBJECTIVE

The overall objective of this single arm, longitudinal, pilot study was to determine the feasibility of implementing a mindfulness-based music therapy intervention to improve anxiety and stress in AYAs receiving cancer treatment.

METHODS

AYAs (15 - 39 years old) who were to receive cancer treatment for ≥ eight weeks were recruited from the pediatric, melanoma, sarcoma, breast, lymphoma, and leukemia oncology outpatient centers at Dana-Farber Cancer Institute. The music therapy intervention included four sessions of individual mindfulness-based music therapy in-person or using Zoom over twelve weeks. Prior to-and after the intervention period, participants completed the Patient-Reported Outcomes Measurement Information Anxiety 4a and Perceived Stress Scale. Changes in patient-reported outcomes are compared using Wilcoxon signed-rank tests.

RESULTS

Over ∼14 months, 37 of 93 eligible AYAs were enrolled to the study (39.8% consent rate). Overall, 27 of 37 (73%) participants (Median age=32; 56.8% Female) completed at least two music therapy sessions and the baseline measures and end of study measures. Participation in the mindfulness-based music therapy sessions resulted in significant pre-to-posttest improvements in perceived stress (median change: -4.0, P = 0.013) and non-significant changes in anxiety (median change: -1.9, P = 0.20). Satisfaction and acceptability were highly rated.

CONCLUSIONS

The delivery of a four-session mindfulness-based music therapy intervention to AYAs receiving chemotherapy was feasible and significantly improved perceived stress. These preliminary findings should be confirmed in a randomized controlled trial.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03709225.

Integrative oncology: Addressing the global challenges of cancer prevention and treatment

The increase in cancer incidence and mortality is challenging current cancer care delivery globally, disproportionally affecting low- and middle-income countries (LMICs) when it comes to receiving evidence-based cancer prevention, treatment, and palliative and survivorship care. Patients in LMICs often rely on traditional, complementary, and integrative medicine (TCIM) that is more familiar, less costly, and widely available. However, spheres of influence and tensions between conventional medicine and TCIM can further disrupt efforts in evidence-based cancer care. Integrative oncology provides a framework to research and integrate safe, effective TCIM alongside conventional cancer treatment and can help bridge health care gaps in delivering evidence-informed, patient-centered care. This growing field uses lifestyle modifications, mind and body therapies (eg, acupuncture, massage, meditation, and yoga), and natural products to improve symptom management and quality of life among patients with cancer. On the basis of this review of the global challenges of cancer control and the current status of integrative oncology, the authors recommend: 1) educating and integrating TCIM providers into the cancer control workforce to promote risk reduction and culturally salient healthy life styles; 2) developing and testing TCIM interventions to address cancer symptoms or treatment-related adverse effects (eg, pain, insomnia, fatigue); and 3) disseminating and implementing evidence-based TCIM interventions as part of comprehensive palliative and survivorship care so patients from all cultures can live with or beyond cancer with respect, dignity, and vitality. With conventional medicine and TCIM united under a cohesive framework, integrative oncology may provide citizens of the world with access to safe, effective, evidence-informed, and culturally sensitive cancer care.

"Part of the Conversation": A Qualitative Study of Oncology Healthcare Professionals' Experiences of Integrating Standardized Assessment and Documentation of Complementary Medicine

Introduction:

The use of complementary medicine (CM) among individuals with cancer is common, however, it is infrequently assessed or documented by oncology healthcare professionals (HCPs). A study implementing standardized assessment and documentation of CM was conducted at a provincial cancer agency. The purpose of this study was to understand the perspectives and experience of oncology HCPs who took part in the study, as well as withdrew, regarding the feasibility and the challenges associated with assessment and documentation of CM use.

Methods:

An interpretive descriptive study methodology was used. A total of 20 HCPs who participated, managed staff, or withdrew from the study were interviewed. Interviews were recorded and transcribed verbatim. Thematic, inductive analysis was used to code and analyse themes from the data.

Results:

Oncology HCPs who participated in the study felt that CM use was common among patients and recognized it went underreported and was poorly documented. Facilitating factors for the implementation of standardized assessment and documentation of CM use included having a standard assessment form, embedding assessment within existing screening processes, and leveraging self-report by patients. Barriers included limited time, perceived lack of knowledge regarding CM, hesitancy to engage patients in discussion about CM, and lack of institutional support and resources. Recommendations for future implementation included having explicit policies related to addressing CM at point-of-care, leveraging existing electronic patient reporting systems, including the electronic health record, and developing information resources and training for HCPs.

Conclusions:

With the high prevalence of CM use among individuals with cancer, oncology HCPs perceive addressing CM use to be feasible and an essential part of high-quality, person-centered cancer care. Institutional and professional challenges, however, must be overcome to support the assessment, documentation and discussion of CM in patient-HCP consultations.

Acupuncture for Quality of Life in Gastric Cancer Patients Undergoing Adjuvant Chemotherapy

CONTEXT

Patients with gastric cancer experience health-related quality of life (HRQOL) decline during adjuvant chemotherapy following gastrectomy.

OBJECTIVES

This pilot study aimed to evaluate the preliminary effect and feasibility of electro-acupuncture (EA) for HRQOL and symptom burden in these patients.

METHODS

In this open-label, multicenter, parallel controlled trial, gastric cancer patients who planned to receive adjuvant chemotherapy were randomly assigned to receive high-dose EA (seven times each chemotherapy cycle for three cycles), low-dose EA (three times each chemotherapy cycle), or usual care only. The acupoints prescription consisted of bilateral ST36, PC6, SP4, and DU20, EX-HN3, and selected Back-shu points. Patients completed the Functional Assessment of Cancer Therapy-Gastric (FACT-Ga) weekly, and the Edmonton Symptom Assessment System (ESAS). The primary outcome was the difference among the groups on the gastric cancer subscale (GaCS) of the FACT-Ga.

RESULTS

Of the 66 randomized patients, 58 were analyzed according to intention-to-treat principle, and 45 were in the per-protocol set (PPS). The average scores in PPS of GaCS were 52.12±9.71, 51.85±12.36, and 45.37±8.61 in high-dose EA, low-dose EA, and control groups, respectively. EA was significantly associated with improved average GaCS scores when compared with control group (51.98±10.91 vs. 45.37±8.61, P = 0.039). EA treatment also produced ESAS relief at the end of intervention (14.36 ± 12.28 vs. 23.91 ± 15.52, P = 0.027). Participants in EA groups had fewer grade ≥3 leukopenia (0% vs. 15.79%, P = 0.031) and neutropenia (2.56% vs. 26.31%, P = 0.012).

CONCLUSION

EA showed promising effects in improving HRQOL, controlling symptom burden, and reducing toxicity during adjuvant chemotherapy in gastric cancer patients. Future adequately powered trials are feasible and needed to confirm the specific effect of EA.

Comparison of Depressive Symptom Outcomes in Hospitalized Adult Cancer Patients Receiving Music Therapy or Massage Therapy

CONTEXT

Depressive symptoms are prevalent and associated with greater healthcare utilization among hospitalized adults with cancer. Music therapy and massage therapy are available at many National Cancer Institute (NCI)-Designated Cancer Centers and recommended by the American Society of Clinical Oncology for depressive symptoms, but a paucity of studies have compared these two therapies.

OBJECTIVES

We conducted a retrospective, multi-method program evaluation of single, first-time music therapy and massage therapy sessions delivered to hospitalized adults with cancer.

METHODS

The study was conducted at an NCI-Designated Comprehensive Cancer Center between February 2018 and October 2019. We assessed depressive symptoms with the Edmonton Symptom Assessment Scale (ESAS) depression item. We also invited patients to provide free-text comments describing their treatment experience.

RESULTS

Among 1764 patients (61.2% women, 72.7% white), 350 received music therapy and 1414 received massage therapy; music therapy was associated with a 0.4 point greater reduction (95% 0.3 to 0.6, P < 0.001) in the ESAS depression score relative to massage therapy. When analyses were restricted to the 452 (25.6%) patients with moderate-to-severe depressive symptoms (ESAS score ≥ 4), music therapy was associated with a 1.2 point greater reduction (95% CI 0.7 to 1.7, P < 0.001) relative to massage therapy, a clinically meaningful difference. In free-text comments, music therapy was described as energizing, uplifting, and evocative, whereas massage therapy was described as calming and relaxing.

CONCLUSION

Among hospitalized adult cancer patients, both music therapy and massage therapy were associated with reduced depressive symptoms, but music therapy was associated with a greater reduction than massage therapy.

A Multi-step Approach to Adapting a Mind-Body Resiliency Intervention for Fear of Cancer Recurrence and Uncertainty in Survivorship (IN FOCUS)

BACKGROUND

For cancer survivors, there is a paucity of fear of recurrence (FOR) interventions that integrate empirically supported mind-body and psychological skills for managing FOR and are delivered in scalable formats.

OBJECTIVE

To adapt an evidence-based resiliency intervention to address FOR among cancer survivors.

METHODS

A multidisciplinary team of researchers, clinicians, and patient stakeholders followed an iterative intervention adaptation process (ORBIT). In Step 1, we sought to define key FOR management skills through a literature review and feedback from stakeholders. In Step 2, we integrated findings into a treatment manual and refined procedures for in-person delivery to groups of cancer survivors, defined as adults who had completed primary cancer treatment for non-metastatic cancer. In Step 3, we conducted a single arm trial to assess initial acceptability and change in FOR severity with 23 cancer survivors (N=4 intervention groups). In Step 4, we conducted additional qualitative interviews with 28 cancer survivors (N=6 focus groups stratified by FOR severity, N=15 individual interviews) to define adaptive and maladaptive strategies for coping with FOR and to identify preferences for delivery. In Step 5, we refined the treatment manual and procedures for testing in a future pilot randomized feasibility trial.

RESULTS

We identified critical feedback using a combination of qualitative and quantitative methods. The single arm trial suggested preliminary feasibility and sustained reductions in FOR severity, yet need for refinement (i.e., eligibility, delivery modality), prompting additional qualitative interviews for further targeting. The resulting intervention (IN FOCUS) is comprised of virtual, synchronous, group-delivered sessions that offer an integrated approach to FOR management by teaching cognitive-behavioral techniques, meditation, relaxation training, adaptive health behaviors, and positive psychology skills. Sessions are targeted by applying skills to FOR and associated healthcare engagement.

CONCLUSIONS

IN FOCUS is a targeted intervention for teaching mind-body resiliency skills to groups of cancer survivors with elevated FOR. Next steps are testing feasibility in a pilot randomized trial.

Awareness, Use and Outlook of Complementary and Alternative Medicine (CAM) Options in an Underserved, Uninsured Minority Cancer Patient Population

Integrative oncology aims to coordinate the delivery of conventional medicine and evidence-supported complementary and alternative medicine (CAM) to patients receiving cancer care. This field developed out of an increased interest in CAM usage among cancer patients. However, CAM use among medically underserved cancer patients remains to be well characterized. We evaluated CAM awareness as well as prevalence and characteristics of CAM use in 170 consecutive, medically underserved cancer patients presenting to a large, academic, inner-city cancer clinic, using a survey tool. Fifty-three participants declined participation and 17 survey results were incomplete. Therefore, 100 survey results were included in the final analysis. There were 65 males and 35 females in the survey with a mean age of 64.2 years. About 98% of the respondents were African American while 2% identified themselves as Hispanic. About 45% of patients had metastatic cancer, 24% had early-stage disease while 31% of patients were not aware of the stage of their cancer. About 55% patients had elementary school or lower level of education while only 16% had a college degree or higher. About 92% of respondents were unemployed. Some knowledge of CAM was reported by 22% of patients, while CAM use was reported in only 16% of patients. Female sex and college degree were significantly associated with CAM use. The most commonly used CAM modality was meditation (56%), followed by herbal remedies (31%), yoga (31%), and acupuncture (12%). Among CAM users, a majority used multiple CAM therapies. All users reported benefit from CAM use. Emotional wellbeing was the most common benefit followed by improvement in treatment related adverse effects, chemotherapy related symptoms, pain, and sleep. Even though the majority of our surveyed patients never used CAM, 90% of non-users were interested in gaining more information about the various CAM options and exploring its use and potential benefits. The majority (70%) wanted their primary oncologist to provide information about CAM options and discuss its safety and potential complementary benefit in management of their cancer and associated symptoms.

Enhancing Access to Yoga for Older Male Veterans After Cancer: Examining Beliefs About Yoga

BACKGROUND

Yoga is an effective clinical intervention for cancer survivors. Most studies of the positive effects of yoga on cancer patients report on predominantly middle-aged women with breast cancer. Less is known about the use of yoga in older adults, veterans, and those from diverse racial or ethnic backgrounds.

METHODS

We examined strategies to enhance access to yoga in older veterans after cancer, focusing on education (study 1) and intervention (study 2). Study 1 included 110 participants with a median (SD) age of 64.9 (9.4) years who were mostly male (99%) cancer survivors who were interviewed 12 months after their cancer diagnosis. Study 2 included 28 participants with a median (SD) age of 69.2 (10.9) years who were mostly male (96%) cancer survivors who participated in a yoga program within 3 years of their cancer diagnosis. Standardized interviews assessed interest in and barriers to yoga while self-reporting assessed health-related quality of life and beliefs about yoga.

RESULTS

In study 1, interest in yoga increased from 5.5 to 31.8% (χ 2 = 22.25, P < .001) following education. In open-ended questions 4 themes related to negative beliefs or barriers emerged: lack of knowledge or skepticism, disinterest or dislike, physical health barriers, and logistical barriers. In study 2, beliefs were more positive following intervention for expected benefits (t = 4.44, P < .001), discomfort (t = 4.92, P < .001), and social norms (t = 4.38, P < .001) related to yoga. Physical function improved after participation in a yoga class, especially for those with higher beliefs in yoga prior to class. Age was not associated with beliefs about yoga in either sample.

CONCLUSIONS

A portion of older veterans who are cancer survivors were interested in yoga but faced access barriers. Implications for practice and research include increasing knowledge about yoga benefits and addressing physical health and logistical barriers to enhance access to yoga for older veterans.

"Moving Forward": Older Adult Motivations for Group-Based Physical Activity After Cancer Treatment

Background

Engagement in physical activity (PA) post-treatment can improve health outcomes and quality of life among cancer survivors. The purpose of this study is to explore United States (US) older adult cancer survivors’ (OACS) reasons for engaging in group-based PA classes, to identify themes supporting exercise motivations in the context of cancer recovery.

Methods

OACS participating in a fitness program at a large US comprehensive cancer center completed semi-structured interviews. Transcripts were analyzed using modified grounded theory, and demographic data were analyzed descriptively.

Results

Modified grounded theory analysis (n = 25; age M = 70.92, SD = 10.82; 9 cancer types) identified individual rationales for exercise grounded in collective experience. Participants’ internal motivations for PA are shaped by the desire for control over an uncertain future and post-treatment body, obtained by literally “moving forward” post-cancer; this is supported by external motivations for social connections that present a positive model of survivorship, within a setting that instills confidence and safety.

Conclusions

Exercise can be a way for older adults to tap into internal and external motivations that support cancer survivorship. Interventions that make explicit connections between exercise and cancer recovery, facilitate interpersonal interaction, and promote a sense of safety may be the most effective. The concepts identified in this study can inform the development of future interventions to improve long-term behavior change among OACS and evaluate existing PA programs.

Effects of Center-Based Delivery of Tai Chi and Qi Gong Group Classes on Self-Reported Symptoms in Cancer Patients and Caregivers

Background: There is increasing interest in complementary approaches such as Tai Chi (TC) and Qi Gong (QG) in oncology settings. We explored the effects of TC/QG delivered in group classes at a comprehensive cancer center. Methods: Patients and caregivers who participated in TC or QG completed assessments before and after an in-person group class. Assessments included questions about expectancy/satisfaction and common cancer symptoms (Edmonton Symptom Assessment Scale [ESAS]). ESAS distress subscales analyzed included global (GDS), physical (PHS), and psychosocial (PSS). Results: Three hundred four participants (184 patients, 120 caregivers) were included in the analysis. At baseline, caregivers had a greater expectancy for change in energy level as a result of class participation compared with patients (22.9% vs 9.9%). No significant difference was observed between baseline patient and caregiver PSS. Clinically significant improvement in well-being was observed among patients in TC classes (1.0) and caregivers in QG classes (1.2). For fatigue, patients (1.4) and caregivers (1.0) participating in QG experienced clinically significant improvement. Both TC and QG classes were associated with clinically significant improvements (ESAS GDS decrease ≥3) in global distress for patients (TC = 4.52, SD= 7.6; QG = 6.05, SD = 7.9) and caregivers (TC = 3.73, SD = 6.3; QG = 4.02, SD = 7.8). Eighty-nine percent of participants responded that their expectations were met. Conclusions: Patients and caregivers participating in TC or QG group classes were satisfied overall and experienced significant improvement in global distress. Additional research is warranted to explore the integration of TC and QG in the delivery of supportive cancer care.

Availability of Integrative Medicine Therapies at National Cancer Institute-Designated Comprehensive Cancer Centers and Community Hospitals

Introduction: The authors compared the availability of integrative medicine therapies in National Cancer Institute-Designated Comprehensive Cancer Centers and community hospitals. Methods: The authors reviewed 51 Comprehensive Cancer Center and 100 community hospital websites and collected race and median household income data for community hospital populations. Results: Availability of acupuncture (56% vs. 76.5%, p = 0.01), meditation (63% vs. 82.4%, p = 0.02), and music therapy (55% vs. 74.5%, p = 0.02) was significantly lower at community hospitals compared with Comprehensive Cancer Centers. Integrative medicine availability was also significantly lower in community hospitals serving lower-income populations. Conclusion: Equitable access to evidence-based integrative medicine in community hospitals is needed.

Insight into the characteristics of research published in traditional, complementary, alternative, and integrative medicine journals: a bibliometric analysis

BACKGROUND

Traditional, complementary, alternative and integrative medicine (TCAIM) can be described as diverse medical and healthcare interventions, practices, products, or disciplines that are not considered as part of conventional medicine. Inherent in its definition, TCAIMs are comprised of a wide variety of therapies with highly variable safety and effectiveness evidence profiles. Despite this, the use of many TCAIMs is highly prevalent among patients globally. The present study consists of a bibliometric analysis of TCAIM journals.

METHODS

A single search of all International Standard Serial Number (ISSNs) of all journals categorized as "complementary and alternative medicine" (code 2707) based on the All Science Journal Classification (ASJC) was run on Scopus on April 17, 2021. All publication types were included; no further search limits were applied. The following bibliometric data were collected: number of publications (in total and per year), authors and journals; open access status; journals publishing the highest volume of literature and their impact factors; language, countries, institutional affiliations, and funding sponsors of publications; most productive authors; and highest-cited publications. Trends associated with this subset of publications were identified and presented. Bibliometric indicators of production were calculated, and bibliometric networks were constructed and visualized using the software tool VOSviewer.

RESULTS

A total of 172,466 publications (42,331 open access), were published by 219,680 authors in 143 journals from 1938 to 2021. Since the 1940s, an upward trend with respect to the volume of publications can be observed, with a steep increase observed between the mid-2000s and mid-2010s. The journal that published the largest number of publications was the Journal of Natural Products (n = 15,144). The most productive countries included China (n = 45,860), the United States (n = 29,523), and Germany (n = 10,120); a number of the most common institutional affiliations and funding sponsors also originated from these three countries.

CONCLUSIONS

The number of publications collectively published in TCAIM journals follows an upward trend. Given a high prevalence of TCAIM use among patients, increased acceptance of TCAIM among conventional healthcare providers, and growing interest in the research of TCAIM, future work should continue to investigate and track changes in the publication characteristics of the emerging research on this topic.

Patient Perspectives on Active vs. Passive Music Therapy for Cancer in the Inpatient Setting: A Qualitative Analysis

CONTEXT

Music therapy (MT) is a nonpharmacologic therapy where licensed therapists provide active (e.g., singing, playing songs) or passive (e.g., listening) music-based interventions. Both active and passive MT are effective techniques for treating cancer-related symptoms. However, the influence of active vs. passive MT techniques on patient-reported perceptions and experiences of care have yet to be explored.

OBJECTIVES

To understand how active and passive MT is perceived and experienced by patients with cancer.

METHODS

We conducted a retrospective analysis of semistructured interviews collected as part of a quality improvement study (n = 20) with patients in the inpatient setting who had received active or passive MT within the past 24 hours. Transcripts were analyzed using thematic content analysis.

RESULTS

Four themes emerged: 1) Different articulations of benefit for recipients of active vs. passive MT; 2) patient choice as a form of empowerment; 3) changed perception of hospital experience; and 4) differing recommendations for future MT. Recipients of active MT emphasized the session's interactive elements, finding the sessions stimulating by providing opportunities for joyous social interaction not centered on their diagnosis. Passive MT recipients focused on the calming therapeutic effect of the session, easing anxieties through focus and reflection on the music itself.

CONCLUSION

This analysis builds on current MT literature by providing insights specifically from oncology patients treated in the inpatient setting. Patients experience active and passive MT in different ways and perceived unique benefits for coping with cancer from each technique. Our findings can inform development of specific MT for symptom control in hospital settings.

Acupuncture for Cancer-Related Anorexia: a Review of the Current Evidence

PURPOSE OF REVIEW

Loss of appetite/anorexia is extremely common among cancer patients, affecting as many as half of newly diagnosed patients and 70% of patients with advanced disease. Effective management of this disabling symptom of cancer remains a major challenge in the field of oncology. We conducted a systematic review of the current evidence on acupuncture and/or moxibustion as an intervention for cancer-related anorexia.

RECENT FINDINGS

Acupuncture, as a part of traditional Chinese medicine practice, has demonstrated effectiveness in managing many cancer- and treatment-related symptoms, especially chemotherapy-induced or postoperative nausea. However, the efficacy of acupuncture in treating cancer-related anorexia/loss of appetite is not clear. The current level of evidence is insufficient to make a definitive conclusion on the benefit of acupuncture/moxibustion for treating chronic cancer-related anorexia/appetite problems. Future large randomized controlled trials of high methodological quality are needed.

Barriers and Facilitators to Integrative Oncology Services in Australia: A Changed Mind Set Required

Objectives: This study aimed to explore barriers and facilitators to integrative oncology (IO) service provision and access in Australia. Design: The study design was mixed method with two substudies: a cross-sectional national cancer service survey of public and private sectors; and focus group interviews and an online survey of cancer survivors. Triangulation analysis of qualitative and quantitative data was used to identify and interrogate meta-themes. Subjects: The cancer service response rate was 93.2% (n = 275/295); 71/275 (25.8%) provided IO. Thirty-three cancer survivors from Anglo-European, Arabic, Vietnamese, and Chinese backgrounds were interviewed, and 121 survivors answered the online survey. Results: IO gaps were substantial, with no services in many regions and cities; a lack of diversity and availability of therapeutic options, including culturally appropriate services; and a mismatch between the high use of natural health products by survivors and types of IO services provided. Two overlapping meta-themes were identified: "barriers and facilitators" and "peoples and institutions"; each with four subthemes, respectively, "access/provision, affordability/funding, information/evidence, and culture/values" and "cancer survivors, healthcare professionals, organizations, and policies." While affordability/funding was the greatest barrier to survivors and providers, solutions varied (e.g., building a stronger evidence-base, business model advice) and often conflicted (e.g., public verses private sector funding). The most insidious barrier was professional/corporate cultures and values that influenced hospital policies (or lack thereof), conceptions of evidence and the therapeutic alliance. Survivors called for a change of mindset in the culture of medicine and value-based health care. Conclusions: The barriers and facilitators to IO services were more complex than building the evidence-base and demonstrating value to justify funding. To achieve a better alignment of patients' preferences with service provision, providers require more guidance on clinical governance, business models, local service gaps, and interprofessional collaboration. National strategies and funding models are needed to ensure appropriate, equitable IO service provision.

The use of complementary and integrative therapies as adjunct interventions during radiotherapy: a systematic review

PURPOSE

Literature supporting the efficacy of complementary and integrative medicine (CIM) alongside radiotherapy is fragmented with varying outcomes and levels of evidence. This review summarizes the available evidence on CIM used with radiotherapy in order to inform clinicians.

METHODS

A systematic literature review identified studies on the use of CIM during radiotherapy. Inclusion required the following criteria: the study was interventional, CIM therapy was for human patients with cancer, and CIM therapy was administered concurrently with radiotherapy. Data points of interest were collected from included studies. A subset was identified as high-quality using the Jadad scale. Fisher's exact test was used to assess the association between study results, outcome measured, and type of CIM.

RESULTS

Overall, 163 articles met inclusion. Of these, 68 (41.7%) were considered high-quality trials. Articles published per year increased over time (p < 0.01). Frequently identified therapies were biologically based therapies (47.9%), mind-body therapies (23.3%), and alternative medical systems (13.5%). Within the subset of high-quality trials, 60.0% of studies reported a favorable change with CIM while 40.0% reported no change. No studies reported an unfavorable change. Commonly assessed outcome types were patient-reported (41.1%) and provider-reported (21.5%). Rate of favorable change did not differ based on type of CIM (p = 0.90) or outcome measured (p = 0.24).

CONCLUSIONS

Concurrent CIM may reduce radiotherapy-induced toxicities and improve quality of life, suggesting that physicians should discuss CIM with patients receiving radiotherapy. This review provides a broad overview of investigations on CIM use during radiotherapy and can inform how radiation oncologists advise their patients about CIM.