New ASCO guideline recommends integrative interventions to manage cancer pain

Pain is a clinical challenge for many oncology patients and clinicians, and there is a growing body of evidence showing that integrative therapies can be helpful 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 manage pain in patients treated for cancer.1

The guideline, published in the Journal of Clinical Oncology, gives moderate strength of recommendation to the use of acupuncture for joint pain related to aromatase inhibitors, and may recommend it, along with reflexology or acupressure, for general cancer pain or musculoskeletal pain. skeletal. Additionally, hypnosis may be recommended for patients experiencing procedural pain, and massage is recommended for patients experiencing pain while in palliative care or hospice.

According to the joint committee, the recommendations were based on an intermediate level of evidence, but the benefits of these practices outweighed the risks to 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, was not sufficient to recommend or not these interventions. Additionally, they did not have sufficient evidence to recommend pain interventions in pediatric cancer patients.

“Pain is a clinical challenge for many oncology patients and clinicians, and there is a growing body of evidence showing that integrative therapies can be helpful in pain management. But to date, there have been no clear clinical guidelines on when and when not to use these approaches,” said Heather Greenlee, ND, PhD, co-chair of the SIO Clinical Practice Guideline Committee, in a statement. SIO press release.2

To develop this guideline, an international multidisciplinary expert committee was formed between the two groups, which included a patient representative and a health research methodologist. Recommendations were then developed using a systematic review of 1,346 articles from PubMed (1990-2021) and the Cochrane Library (1990-2021) to determine whether the study population included adults and pediatric patients with pain at any stage of their cancer care. path; integrative interventions including acupuncture, acupressure, mind-body therapies and natural products; no within-trial comparison; 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 formed the basis of the guideline recommendations. Although the committee 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 relevant primary studies. Other flaws included lack of blinding in the study design, unmatched control arms, small sample sizes and/or high attrition rates, and limited statistical power, which reduced confidence in the results of some of the interventions.

Acupuncture was the most identified intervention in 51 articles versus massage in 14 articles. In patients with general cancer pain or musculoskeletal pain, a study of 360 patients randomized 2:1:1 to receive either electroacupuncture, auricular acupuncture, or usual care. Electroacupuncture reduced pain by 1.9 points on a numeric pain rating scale of 0 to 10, 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 are using treatments based on quality evidence from scientific studies that have shown the treatment to be effective and safe,” said Scott T. Tagawa. , MD, MS, in the press release. “The guidelines focus on important concerns in patient care that have a significant impact on quality of life and will help equip the oncology community with the essential knowledge needed to manage integrative treatment approaches.”

Integrative oncology is a patient-centered, evidence-based area of ​​cancer care that uses pain interventions such as mind-body practices, natural products, and lifestyle modifications. life of various traditions alongside conventional treatments. With such a broad field, the committee feels the need to provide evidence-based recommended guidelines that allow oncology professionals to make informed choices.

In the guidelines, they also note that the guidelines exist within a health care setting that has disparities between patient groups and note that many patients may have limited access to medical care. For example, race and ethnicity, age, socioeconomic status, sexual orientation and gender identity, geographic location of residence, immigration status, and access to insurance have an impact on the amount that integrative patients can receive. Therefore, the committee recommends working through these interventions for patient care and removing 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,” added Linda E. Carlson, PhD, President of SIO in the Press release. “The goal of this important collaboration is to educate as many clinicians and patients as possible about the evidence for integrative therapies to support the best possible clinical outcomes 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. 2022 Sep 19. doi:10.1200/JCO.22.01357

2. Release of new SIO/ASCO pain guidelines. Hanna Hayden. September 19, 2022. Accessed: September 22, 2022.

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