COMPLEMENTARY THERAPIES FOR BREAST CANCER

Many cancer patients use alternative medicine, including supplements, massage therapy, yoga, and accupuncture, while undergoing conventional cancer care. Such therapies are usually acceptable, but patients must be discuss such therapies with their oncologist, because interactions may occur.

That appears to be the take-home message from the recent move by the American Society of Clinical Oncology (ASCO) to endorse new guidelines issued by the Society for Integrative Oncology (SIO).

The ASCO endorsement was published online June 11 in the Journal of Clinical Oncology.

The SIO had produced an evidence-based guideline on the use of integrative therapies during and after breast cancer treatment for the management of a variety of symptoms and adverse effects. An ASCO expert panel, cochaired by Gary H. Lyman, MD, MPH, codirector of the Hutchinson Institute for Cancer Outcomes Research at the Fred Hutchinson Cancer Research Center in Seattle, Washington, and Lorenzo Cohen, PhD, director of the Integrative Medicine Program at the University of Texas MD Anderson Cancer Center, Houston, reviewed the guidelines.

The panel determined that the recommendations in the 2017 SIO guideline "are clear, thorough, and based on the most relevant scientific evidence." ASCO endorsed them with a few added discussion points.

"We know that vast the majority of cancer patients, particularly breast cancer patients, are using some type of alternative medicines," Lyman said in an interview. "They may be taking supplements, doing yoga, getting massage therapy or acupuncture, but most doctors don't talk about it. They don't ask about it, and the patient doesn't offer the information."

Lyman estimates that 60% to 80% of breast cancer patients use some type of alternative therapy, but such therapies are not entered into the medical record. That generally is not too much a cause of concern, because most of these approaches are relatively safe, he noted. "But occasionally, there may be some interaction with a supplement and standard medicine," he said.

He told Medscape Medical News, "The biggest fear is that a patient is going to stop using a known effective conventional medicine and use one of the alternative approaches instead.

The biggest fear is that a patient is going to stop using a known effective conventional medicine and use one of the alternative approaches instead. Dr Gary Lyman

"That's why we want to make sure that the doctor and patient are discussing them, the doctor knows what the patient is doing and discusses the subject in a nonjudgmental way, and then encourages the patient to report any problems or side effects they might have," he explained.

It is also important that oncologists reassure patients that they can continue to receive their regular cancer treatment along with these alternative approaches.

Review of Recent Literature

The ASCO guidelines are an endorsement of a guideline from a much smaller organization, explained Lyman. "The SIO had approached ASCO about this, and they had done a really deep review of the available literature on these therapies," he said. "ASCO formed a panel, and we did our own search and added several studies that had come out since the other work had been completed."

ASCO used a modified version of the US Preventive Services Task Force grading system to assign a grade to each therapy, as applied to a specific clinical outcome. Grades A and B indicate that a therapy is recommended for a particular indication; grade C indicates that more evidence is needed or that the net benefit is small; grades D and H indicate that a therapy is not recommended for a particular indication; and grade I indicates that the evidence is inconclusive.

Lyman noted that the ASCO panel supported almost all of the recommendations in the SIO guidelines. "Some had sufficient evidence to recommend them, and for some, there wasn't much evidence, but they didn't incur any harm, and some approaches had no evidence," he said.

Key Recommendations

Some of their key recommendations are as follows:

• Acute radiation skin reaction — aloe vera and hyaluronic acid cream should not be recommended for improving acute radiation skin reaction (grade D).
• Anxiety and stress reduction — meditation (grade A), yoga (grade B), and music therapy (grade B) are recommended for reducing anxiety. Stress management is recommended for reducing anxiety during treatment; longer group programs are likely better than self-administered home programs or shorter programs (grade B). Acupuncture, massage, and relaxation can be considered for reducing anxiety (grade C).
• Chemotherapy-induced nausea and vomiting — acupressure (grade B), electroacupuncture (grade B), ginger (grade C), and relaxation (grade C) can be considered as an addition to antiemetic drugs to control nausea and vomiting during chemotherapy. Glutamine should not be recommended for improving nausea and vomiting during chemotherapy (grade D).
• Depression and mood disturbance — meditation, particularly mindfulness-based stress reduction (grade A), relaxation (grade A), and yoga (grade B) are recommended for treating mood disturbance and depressive symptoms. Massage (grade B) and music therapy (grade B) are recommended for improving mood disturbance.
• Fatigue — hypnosis and ginseng can be considered for improving fatigue during treatment (grade C). Acupuncture and yoga can be considered for improving posttreatment fatigue (grade C). Acetyl-L-carnitine and guarana should not be recommended for improving fatigue during treatment (grade D).
• Lymphedema — low-level laser therapy, manual lymphatic drainage, and compression bandaging can be considered for improving lymphedema (grade C).
• Neuropathy — acetyl-L-carnitine is not recommended for the prevention of chemotherapy-induced peripheral neuropathy in patients with breast cancer because of the potential for harm (grade H).
• Pain — acupuncture, healing touch, hypnosis, and music therapy can be considered for the management of pain (grade C).
• Quality of Life — meditation (grade A) and yoga (grade B) are recommended for improving quality of life. Acupuncture, mistletoe, qigong, reflexology, and stress management can be considered for improving quality of life (grade C).
• Sleep Disturbance — gentle yoga can be considered for improving sleep (grade C).
• Vasomotor/hot flashes — acupuncture can be considered for improving hot flashes (grade C). Soy is not recommended for hot flashes because of lack of effect (grade D).

"Our hope is that this will help disseminate this good information, break down barriers, and open up dialogs between patient and doctor," Lyman said. "Hopefully, patients will have improvements in their outcomes."

All funding was provided by ASCO. Dr Lyman has relationships with Generex Biotechnology, Halozyme, G1 Therapeutics, Coherus Biosciences, and Amgen (Inst); several coauthors have also disclosed relationships with industry, as noted in the original article.