New ASCO Guideline Recommends Integrative Interventions to Manage Cancer Pain

Pain is a clinical challenge for many oncology patients and clinicians, and there's a growing body of evidence showing that integrative therapies can be useful in pain management, according to Heather Greenlee, ND, PhD.

A new joint practice guideline from the Society for Integrative Oncology (SIO) and the American Society of Clinical Oncology (ASCO) used 227 relevant studies to provide evidence-based recommendations on integrative medicine approaches to managing pain in patients being treated for cancer.1

The guideline, published in the Journal of Clinical Oncology, gives a moderate strength of recommendation to the use of acupuncture for aromatase inhibitor–related joint pain, and may recommends it, along with reflexology or acupressure, for general cancer pain or musculoskeletal pain. Moreover, hypnosis may be recommended to patients who experience procedural pain, and massage is recommended to patients experiencing pain during their palliative or hospice care.

According to the joint panel, the recommendations were based on an intermediate level of evidence, but the benefits of these practices outweighed the risks for patients. However, they determined that the evidence for mind-body interventions or natural products, such as yoga, omega-3 fatty acids, music therapy, or topical pure emu oil, were not sufficient to recommend in favor or not in favor of these interventions. Moreover, they did not have enough evidence to recommend interventions for pain in patients with pediatric cancer.

“Pain is a clinical challenge for many oncology patients and clinicians, and there's a growing body of evidence showing that integrative therapies can be useful in pain management. But to date, there has not been clear clinical guidance about when and when not to use these approaches,” said Heather Greenlee, ND, PhD, co-chair of the SIO Clinical Practice Guideline Committee, in a press release from the SIO.2

To develop this practice guideline an international multidisciplinary expert panel was formed between the two groups, which included a patient representative and health research methodologist. The recommendations were then developed using a systematic review of 1,346 articles from PubMed (1990-2021) and the Cochrane Library (1990-2021) looking at if the population of the study included adults and pediatric patients experiencing pain during any stage of their cancer care trajectory; integrative interventions that included acupuncture, acupressure, mind-body therapies, and natural products; no comparisons within the trial; outcomes that included pain intensity, reduction, or change in symptoms reported as the primary outcome in the manuscript.

After reviewing the articles for the criteria 227 articles remained and made up the basis for the guideline recommendations. While the panel noted that many of the primary studies included in the review suffered from flaws and limitations in their study design. Therefore, they used the systemic reviews to identify the relevant primary studies. Other flaws included the lack of blinding in the study design, incomparable control arms, small sample sizes and/or high attrition rates, and limited statistical power, which lowered the confidence in the findings for some of the interventions.

Acupuncture was the most identified intervention at 51 articles compared with massage in 14 articles. In patients with general cancer pain or musculoskeletal pain one study with 360 randomized patients 2:1:1 to either receive electroacupuncture, auricular acupuncture, or usual care. Electroacupuncture reduced pain by 1.9 points on a 0-10 numeric pain rating scale and auricular acupuncture reduced pain by 1.6 points compared with usual care. These results were also durable at 6 months and associated with minimal toxicities, therefore, the panel recommended these interventions for patients with general cancer pain.

“Practice guidelines are a critical way to ensure healthcare providers use treatments that are based on quality evidence from scientific studies that have shown the treatment to be effective and safe,” said Immediate Past Chair of the ASCO Evidence-Based Medicine Committee, Scott T. Tagawa, MD, MS, in the press release. “The guidelines focus on important concerns in patient care that greatly impact quality of life and will help equip the oncology community with the essential knowledge needed to manage integrative therapy approaches.”

Integrative oncology is a patient-centered and evidence informed field of cancer care that utilizes interventions for pain such as mind and body practices, natural products, and lifestyle modifications from various traditions alongside conventional treatments. With such a wide-ranging field, the panel feels the need to provide recommended guidelines that are based on evidence allowing oncology professionals to make informed choices.

Within the guidelines, they also note that the guidelines exist within a healthcare framework that has disparities among patient groups and notes that many patients may have limited accesses to medical care. For example, race and ethnicity, age, socioeconomic status, sexual orientation and gender identity, geographic location of residence, immigrant status, and insurance access impact how much integrative patients may be able to receive. Therefore, the panel recommends working in these interventions to the patient care and taking down structural barriers to care.

“This is the first of 3 evidence-based guidelines for adults that SIO and ASCO are developing together, which combines the strengths of these two organizations,” Linda E. Carlson, PhD, President of SIO added in the press release. “The goal of this important collaboration is to inform as many clinicians and patients as possible about where the evidence for integrative therapies lies to support the best clinical outcomes possible for all cancer patients. And we believe this new guideline accomplishes that.”


1. Mao J, Ismaila N, Bao T, et al. Integrative Medicine for Pain Management in Oncology: Society for Integrative Oncology–ASCO Guideline. J Clin Oncol. September 19th, 2022. doi: 10.1200/JCO.22.01357

2. New SIO/ ASCO Pain Guidelines Released. Hanna Hayden. September 19th, 2022. Accessed: September 22, 2022.

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