Complementary Therapies and Integrative Oncology in Lung Cancer: ACCP Evidence-Based Clinical Practice Guidelines (2nd Edition)

doi:10.1378/chest.07-1389

Chest

Volume 132, Issue 3, Supplement, September 2007, Pages 340S-354S

https://doi.org/10.1378/chest.07-1389 Get rights and content

Background

This chapter aims to differentiate between “alternative” therapies, often promoted falsely as viable options to mainstream lung cancer treatment, and complementary therapies, adjunctive, effective techniques that treat symptoms associated with cancer and its mainstream treatment, and to describe the evidence base for use of complementary therapies.

Methods and design

A multidisciplinary panel of experts in oncology and integrative medicine evaluated the evidence for complementary (not alternative) therapies in the care of patients with lung cancer. Because few complementary modalities are geared to patients with only a single cancer diagnosis, symptom-control research conducted with other groups of patients with cancer was also included. Data on complementary therapies such as acupuncture, massage therapy, mind-body therapies, herbs and other botanicals, and exercise were evaluated. Recommendations were based on the strength of evidence and the risk-to-benefit ratio.

Results

Patients with lung and other poor-outlook cancers are particularly vulnerable to heavily promoted claims for unproved or disproved “alternatives.” Inquiring about patients' use of these therapies should be routine because these practices may be harmful and can delay or impair treatment. Mind-body modalities and massage therapy can reduce anxiety, mood disturbance, and chronic pain. Acupuncture assists the control of pain and other side effects and helps reduce levels of pain medication required. Trials of acupuncture for chemotherapy-induced neuropathy and postthoracotomy pain show promising results. Herbal products and other dietary supplements should be evaluated for side effects and potential interactions with chemotherapy and other medications.

Conclusions

Complementary therapies have an increasingly important role in the control of symptoms associated with cancer and cancer treatment.

Section snippets

Detailed Methodology

A multidisciplinary panel of experts in oncology was gathered to prepare this chapter. The team included the following: thoracic medical oncologist Jorge E. Gomez, MD, at Memorial Sloan-Kettering Cancer Center (MSKCC); radiation oncologist and acupuncturist Peter A. S. Johnstone, MD, at Emory University School of Medicine; Gary E. Deng, MD, PhD, an internist specializing in integrative oncology at MSKCC; Nagi Kumar, PhD, a nutritionist/researcher at the Moffitt Cancer Center; Andrew Vickers,

Limitations: Gaps in Research

Despite the long history of most complementary modalities, rigorous scientific research on these therapies is a recent phenomenon. The research is further limited by lack of sufficient funding, lack of qualified investigators, and methodologic and ethical issues unique to studying complementary therapies. Therefore, gaps in research are the norm rather than the exception in this field, and these gaps represent the major limitation. Many complementary therapies derived from complete traditional

Recommendations and Discussion

The recommendations are organized according to modalities. Within each modality, recommendations supported by a strong level of evidence are made and discussed first (grade A and B). Recommendations are presented in text boxes for easy recognition. Selected topics where only grade C recommendations can be made are then discussed. These topics are selected based on their clinical significance. Such selectiveness is necessary because of the nascent nature of research in this area. For many issues

Recommendation

1. It is recommended that all patients with lung cancer be asked specifically about the use of CAM. Grade of recommendation, 1C

Rationale and Evidence: The most comprehensive and reliable findings on Americans' use of CAM in general come from the National Center for Health Statistics 2002 National Health Interview Survey. The National Center for Health Statistics is an agency of the Centers for Disease Control and Prevention.⁵ Of 31,044 adults surveyed, 75% used some form of CAM. When prayer

Recommendation

2. It is recommended that all patients with lung cancer be given guidance about the advantages and disadvantages of complementary therapies in an open, evidence-based, and patient-centered manner by a qualified professional. Grade of recommendation, 1C

Rationale and Evidence: Surveys show that most cancer patients rely on friends and family members, the media, and the Internet, rather than health-care professionals as top sources of CAM information.13, 14 Information obtained from these

Recommendation

3. In lung cancer patients, mind-body modalities are recommended as part of a multidisciplinary approach to reduce anxiety, mood disturbance, or chronic pain. Grade of recommendation, 1B

Rationale and Evidence:

Mind-body modalities, including meditation, hypnosis, relaxation techniques, cognitive-behavioral therapy, biofeedback, and guided imagery are increasingly becoming part of mainstream care over the years. A survey found that 19% of American adults used at least one mind-body therapy in a

Meditation

Meditation focuses attention on increasing mental awareness and clarity of mind (concentrative meditation) or opens attention to whatever goes through the mind and to the flow of sensations experienced from moment to moment (mindfulness meditation). In a randomized wait-list control study²³ of 109 cancer patients, participation in a 7-week mindfulness-based stress reduction program was associated with significant improvement in mood disturbance and symptoms of stress. A single-arm study²⁴ of

Yoga

Yoga, which combines physical movement, breath control, and meditation, improved sleep quality in a trial of 39 patients with lymphoma. Practicing a form of yoga that incorporates controlled breathing and visualization significantly decreased sleep disturbance when compared to wait-list control subjects.²⁵ Mindfulness-based stress reduction techniques must be practiced to produce beneficial effects.²⁶

Hypnosis

Hypnosis is an artificially induced state of consciousness in which a person is highly receptive to suggestions. A trancelike state (similar to deep daydreaming) can be achieved by first inducing relaxation and then directing attention to specific thoughts or objects. For best results, the patient and the therapist must have a good rapport with a level of trust; the environment must be comfortable and free from distractions; and the patient must be willing to undergo the process and must desire

Relaxation Techniques

Relaxation techniques were shown in randomized controlled trials to ameliorate anxiety and distress significantly. A randomized study of relaxation therapy vs alprazolam showed that both approaches significantly decreased anxiety and depression, although the effect of alprazolam was slightly quicker for anxiety and stronger for depressive symptoms.³⁴ Relaxation achieves the effect without side effects and at a lower cost. A randomized trial³⁵ of 82 radiation therapy patients found significant

Recommendations

4. In lung cancer patients experiencing anxiety or pain, massage therapy delivered by a massage therapist trained in oncology is recommended as part of a multimodality treatment approach. Grade of recommendation, 1C

5. The application of deep or intense pressure is not recommended near cancer lesions or anatomic distortions such as postoperative changes, as well as in patients with a bleeding tendency. Grade of recommendation, 2C

Rationale and Evidence:

The many types of body-based practices have

Recommendation

6. For lung cancer patients, therapies based on manipulation of putative bioenergy fields are not recommended. Grade of recommendation, 1C

Rationale and Evidence:

Energy therapies are based on the theory that manipulation of “energy fields” around a patient has therapeutic value. Two types of energy fields are involved: biofield and electromagnetic field.

Biofield therapies are intended to affect energy fields that purportedly surround and penetrate the human body. Because no convincing scientific

Recommendations

8. Acupuncture is recommended as a complementary therapy when nausea and vomiting associated with chemotherapy are poorly controlled. Grade of recommendation, 1B

9. Electrostimulation wristbands are not recommended for managing chemotherapy-induced nausea and vomiting. Grade of recommendation, 1B

Rationale and Evidence:

Acupuncture helps lessen chemotherapy-induced nausea and vomiting.⁶⁰ In one study,⁶¹ 104 breast cancer patients receiving highly emetogenic chemotherapy were randomized to receive

Recommendation

10. When the patient with lung cancer does not stop smoking despite use of other options, a trial of acupuncture is recommended to assist in smoking cessation. Grade of recommendation, 2C

Rationale and Evidence:

Smoking cessation has the largest impact in preventing lung cancer. Educational, behavioral, and medical interventions are the mainstay for smoking cessation. The effect of acupuncture has been studied with mixed results. A metaanalysis⁶⁹ of 22 studies concluded that acupuncture is no

Recommendation

11. In patients with lung cancer with symptoms such as dyspnea, fatigue, chemotherapy-induced neuropathy, or postthoracotomy pain, a trial of acupuncture is recommended. Grade of recommendation, 2C

Rationale and Evidence:

Lung cancer patients with advanced disease almost always experience dyspnea attributable to parenchymal tumor burden or pleural effusion. Oxygen and opioids remain the mainstay of symptomatic treatment, although confusion and constipation are common side effects. An uncontrolled

Recommendation

12. In patients with a bleeding tendency, it is recommended that acupuncture be performed by qualified practitioners and used cautiously. Grade of recommendation, 1C

Rationale and Evidence:

Acupuncture needles are regulated as medical device in the United States. They are filiform, sterile, single use, and very thin (28 to 40 gauge). Insertion of acupuncture needles causes minimal or no pain and less tissue injury than phlebotomy or parenteral injection. Acupuncture performed by experienced,

Diet and Dietary Supplements Including Herbal Products

Many epidemiology studies demonstrate an association of diet and cancer incidence. Other than smoking cessation, a healthy diet is perhaps the most important lifestyle change a person can make to help prevent cancer, as well as cardiovascular disease and diabetes. However, aside from interventions to counter specific protein, calorie, vitamin, or mineral nutritional deficits, special dietary regimens do not have any significant role in cancer treatment. Some dietary regimens have been promoted

Recommendations

13. It is recommended that dietary supplements, in particular herbal products, be evaluated for side effects and potential interaction with other drugs. Those that are likely to interact with other drugs, such as chemotherapeutic agents, should not be used concurrently during chemotherapy or radiation, or before surgery. Grade of recommendation, 1B

14. In lung cancer patients who either do not respond to or decline antitumor therapies, it is recommended use of botanical agents occur only in the

Recommendation

15. It is recommended that patients be advised to avoid therapies promoted as “alternatives” to mainstream care. Grade of recommendation, 1A

Rationale and Evidence:

Alternative therapies that claim to improve survival have largely been demonstrated to be ineffective in clinical trials.¹⁰⁶ Randomized trials have shown no benefit or, in some cases, shorter survival for high-dose vitamin C,107, 108 shark cartilage,¹⁰⁹ hydrazine sulfate,110, 111, 112, 113 and mistletoe extracts.114, 115, 116, 117

Research Priorities

We view the following as high-priority areas of research: effectiveness of complementary therapies in the management of symptoms or disease processes for which our current treatment options are not satisfactory; mechanisms of action as explained by contemporary biomedical science; definitive database of drug-supplement interactions; and new cancer therapies derived from botanicals or other supplements or their synergistic effect with conventional medicine.

Conclusion

The use of CAM is common among cancer patients. These therapies are very diverse in their origin, theory, practice, safety, and efficacy. Some of the therapies have been shown in studies to be helpful in reducing symptoms experienced by cancer patients. These complementary therapies (used as adjuncts to mainstream cancer treatment) are increasingly integrated into regular oncologic care, leading to integrative oncology. Dietary supplements, herbs, and other botanicals can be problematic because

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Citation Excerpt :
Participants stated that practitioners need to consider the client's goals, the best available evidence, and their own clinical experience when creating treatment plans. This description meets the definition for evidence-based practice in the field of massage therapy as well as other health professions (Baskwill, 2011; Brosseau et al., 2012a; Cassileth et al., 2007; Dryden and Moyer, 2012; Kerner, 2008; Li et al., 2014; Nutbeam, 1996). Treatment here is simply a term for the hands-on portion of massage therapy; the planned and patterned soft-tissue manipulation (Kennedy et al., 2015).
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The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml)

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DIAGNOSIS AND MANAGEMENT OF LUNG CANCER: ACCP GUIDELINES (2ND EDITION)Complementary Therapies and Integrative Oncology in Lung Cancer: ACCP Evidence-Based Clinical Practice Guidelines (2nd Edition)

Background

Methods and design

Results

Conclusions

Section snippets

Detailed Methodology

Limitations: Gaps in Research

Recommendations and Discussion

Recommendation

Recommendation

Recommendation

Meditation

Yoga

Hypnosis

Relaxation Techniques

Recommendations

Recommendation

Recommendations

Recommendation

Recommendation

Recommendation

Diet and Dietary Supplements Including Herbal Products

Recommendations

Recommendation

Research Priorities

Conclusion

Ann Oncol

Lancet Oncol

Psychoneuroendocrinology

J Psychosom Res

Pain

Pain

J Pain Symptom Manage

Trends Neurosci

Brain Res

Obstet Gynecol

J Pain Symptom Manage

Prog Neuropsychopharmacol Biol Psychiatry

Diabetes Res Clin Pract

Semin Oncol

Jpn J Pharmacol

J Affect Disord

Complementary therapies for cancer-related symptoms

J Support Oncol

Complementary and alternative therapies for cancer

Oncologist

Acupuncture treatment for chemotherapy-induced peripheral neuropathy: a case series

Acupunct Med

Complementary and alternative medicine use among adults: United States 2002

Adv Data

The profile of women who consult alternative health practitioners in Australia

Med J Aust

The use of complementary/alternative medicine by cancer patients in a New Zealand regional cancer treatment centre

N Z Med J

Trends in alternative medicine use in the United States, 1990–1997: results of a follow-up national survey

JAMA

Complementary and alternative medicine use among men with prostate cancer in 4 ethnic populations

Am J Public Health

Advising patients who seek complementary and alternative medical therapies for cancer

Ann Intern Med

The prevalence of complementary/alternative medicine in cancer: a systematic review

Cancer

Nationwide survey on complementary and alternative medicine in cancer patients in Japan

J Clin Oncol

Herbal composition PC-SPES for management of prostate cancer: identification of active principles

J Natl Cancer Inst

Herbal remedies in the United States: potential adverse interactions with anticancer agents

J Clin Oncol

Alpha-tocopherol and beta-carotene supplements and lung cancer incidence in the alpha-tocopherol, beta-carotene cancer prevention study: effects of base-line characteristics and study compliance

J Natl Cancer Inst

The effect of vitamin E and beta carotene on the incidence of lung cancer and other cancers in male smokers: the Alpha-Tocopherol, Beta Carotene Cancer Prevention Study Group

N Engl J Med

Use of mind-body medical therapies

J Gen Intern Med

The effects of psychoeducational care provided to adults with cancer: meta-analysis of 116 studies

Oncol Nurs Forum

Mind-body therapies for the management of pain

Clin J Pain

DIAGNOSIS AND MANAGEMENT OF LUNG CANCER: ACCP GUIDELINES (2ND EDITION)
Complementary Therapies and Integrative Oncology in Lung Cancer: ACCP Evidence-Based Clinical Practice Guidelines (2nd Edition)