ASCO Endorses Complementary Therapy Guidelines for Patients With Breast Cancer

Gary H. Lyman, MD, FASCO

In an effort to address strategies that many patients with cancer are adopting, ASCO has endorsed recommendations regarding the use of complementary therapies such as meditation, yoga, and acupuncture to manage symptoms and adverse effects of breast cancer treatment.^1,2

An ASCO expert panel determined that the 2017 guidelines from the Society for Integrative Oncology (SIO) are “clear, thorough, and based on the most relevant scientific evidence.”1 Panel cochair Gary H. Lyman, MD, MPH, codirector of the Hutchinson Institute for Cancer Outcomes Research and a medical oncologist in the Breast Cancer Program at the Seattle Cancer Care Alliance, both in Washington, said in a podcast that the panel wanted to add commentary specifically addressing the ASCO perspective.³

“We know from surveys that these kinds of interventions and therapies are being used. In fact, probably the majority of [patients with] cancer at some point in the course of their disease will engage in some of these [practices],” he said. “While some can cause interaction or harm with other therapies, the biggest harm to consider would be if a patient were to undertake an integrative therapeutic measure rather than traditional therapies.” The panel emphasized that these therapies are complementary and should be used along with conventional anticancer treatment.

Panel cochair Lorenzo Cohen, PhD, the Richard E. Haynes Distinguished Professor in Clinical Cancer Prevention and director of the Integrative Medicine Program at The University of Texas MD Anderson Cancer Center in Houston, is a founding member and past president of the SIO. He defined integrative medicine as a patient-centered, evidence-informed field of care that uses mind and body practices, natural products, and/or lifestyle modifications to improve health, quality of life, and clinical outcomes.

“We are talking about this comprehensive approach [and] looking at different kinds of treatment modalities that can be incorporated alongside conventional care and, importantly, across the cancer care continuum,” he said in the podcast. “This isn’t necessarily just focusing on palliative care or end-of-life care but at any point and any stage of disease.”

Table. ASCO-Endorsed Guidelines for Integrative Therapies¹

Categories of Interventions

The ASCO guideline excluded lifestyle changes that have been extensively written about elsewhere, including diet and exercise, mainstream interventions such as support groups, and practices like attention-restoration therapy that are in the earliest stages of clinical evaluation. Practices such as prayer and spirituality were not considered specifically integrative oncology therapy.The recommendations were categorized by symptom, and the strength of the evidence was graded on a scale of A to I, with “A” representing the strongest findings (Table).¹ Conditions and adverse effects such as fatigue, quality of life and physical functioning, pain, and sleep disturbance were included. “Certainly, the mind—body area was the one that received the most support,” Cohen said. “Yoga received a grade of B, which, of course, is something that would be recommended for depressed mood or mood disturbance, as well as for anxiety and stress reduction.

“Some of the other modalities fell into the category of D. One in particular was aloe vera gel to help with postradiation skin reaction.”

Music therapy and massage received a B and a C, respectively, for treatment of anxiety and depression and general stress reduction. However, the panel decided it could not take a firm position in either direction for hypnosis, acupuncture, and yoga to treat fatigue; these techniques received a C, which means there is moderate certainty of benefit. The panel found some evidence supporting the use of ginseng to address fatigue but added that there are special considerations around ingestibles and injectables.

“There’s a little more concern there because it’s an ingestible, and there’s a specific discussion point that the guidelines committee came up with of some caution around ginseng and the particular kind of ginseng used in some of the large clinical trials that were positive, which was American ginseng,” Cohen said. “Different kinds of ginseng could potentially have different effects in the body, particularly around hormonal regulation, which is relevant for [patients with] breast cancer.

“Mistletoe got a grade of C for quality-of-life improvement,” he said. “That is more concerning when you’re doing subcutaneous injections of substances that are not currently approved by the FDA, so extreme caution is needed there.”

However, negative effects from these integrative therapies are rare, which is one reason Lyman finds them so attractive.

“I found it most interesting as a practicing oncologist that some of the recommendations from the SIO and now endorsed by ASCO have very little downside to them,” he said. “For things like meditation, music therapy, and yoga, some level of evidence of benefit went a long way because there is little conceivable reason for harm, with 1 exception: if a patient [were] to engage in these activities to the exclusion of known, effective traditional therapies.”

Lyman added that there is a “compelling need” for cancer care providers to better understand practices such as qigong, reflexology, and meditation. He said providers need to make sure they are familiar with everything the patient is experiencing or being treated with in case unexpected interactions occur.

Cohen explained that it’s also important to do more research into integrative therapies. There are practices that patients are using safely and effectively, or unsafely and ineffectively, and it is the medical community’s responsibility to provide evidence showing which practices are helpful and which are not. Providers should know when and how to direct patients to effective integrative therapies and away from therapies that don’t work, he said. Ultimately, both physicians would like to see integrative medicine covered by insurance providers. They hope that guidelines like these can make a difference when those coverage decisions are made.

“Medicare and Medicaid don’t cover any of this,” said Cohen. “If there is an evidence base, it should be covered just like conventional treatment. Hopefully, this kind of highlevel endorsement can also influence the payers.”

Lyman added, “When there’s such enormous emphasis on the cost of cancer care, the financial burden of cancer care, it’s critical that patients and their providers [know what works and what doesn’t] when they’re experiencing both [adverse] effects and the financial toxicity associated with cancer care.”

References

1. Lyman GH, Greenlee H, Bohlke K, et al. Integrative therapies during and after breast cancer treatment: ASCO endorsement of the SIO Clinical Practice Guideline [published online June 11, 2018]. J Clin Oncol. doi: 10.1200/JCO.2018.79.2721.
2. Greenlee H, DuPont-Reyes MJ, Balneaves LG, et al: Clinical practice guidelines on the evidence-based use of integrative therapies during and after breast cancer treatment. CA Cancer J Clin. 2017;67(3):194-232. doi: 10.3322/caac.21397.
3. Lyman GH, Cohen L. Integrative therapies during and after breast cancer treatment guideline [podcast]. ASCO Guidelines Podcast Series. 2018. Available at: itunes.apple. com/us/podcast/asco-guidelines-podcast-series/id1348000511?mt=2#episode- Guid=b6dfec2f6d3e86f2f10e8fd2f058569d. Accessed August 20, 2018.