Integrative oncology coordinates the delivery of evidence-based complementary therapies with conventional cancer care. Complementary therapies encompass a broad range of mind and body practices, natural products, and lifestyle modifications, and are commonly used by patients with breast cancer and survivors of breast cancer.

The American Society of Clinical Oncology (ASCO) has endorsed, with a few added discussion points, the Society for Integrative Oncology (SIO) evidence-based clinical practice guidelines on integrative therapies during and after breast cancer treatment. The ASCO endorsement was published in the Journal of Clinical Oncology.

The SIO guideline- originally published in 2017-was reviewed by ASCO for clinical accuracy and developmental rigor. The ASCO Expert Panel determined that the recommendations in the SIO guideline are clear, thorough, and based on the most relevant scientific evidence. In the SIO guideline, the researchers evaluated more than 80 different integrative therapies and developed grades of evidence based on the latest research.

The SIO guideline 2017 updated the original guidance document released in 2014 and addressed the use of integrative therapies for the management of symptoms and adverse effects, such as anxiety and stress, mood disorders, fatigue, quality of life, chemotherapy induced nausea and vomiting, lymphedema, chemotherapy-induced peripheral neuropathy, pain, and sleep disturbance. Interventions of interest included mind and body practices, natural products, and lifestyle modifications.

The target population include patients undergoing treatment of breast cancer and survivors of breast cancer. On the other hand, the target audience is oncologists, integrative medicine providers, supportive care specialists, nurses, pharmacists, primary care providers, and patients with breast cancer.

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Society of Integrative Oncology recommendations

• Music therapy, meditation, stress management, and yoga are recommended for anxiety/stress reduction
• Meditation, relaxation, yoga, massage, and music therapy are recommended for depression/mood disorders
• Meditation and yoga are recommended to improve quality of life
• Acupressure and acupuncture are recommended for reducing chemotherapy-induced nausea and vomiting
• Acetyl-L-carnitine is not recommended to prevent chemotherapy-induced peripheral neuropathy because of a possibility of harm
• No strong evidence supports the use of ingested dietary supplements to manage breast cancer treatment-related adverse effects

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ASCO discussion points and key recommendations

1. Acute Radiation Skin Reaction

• Aloe-vera and hyaluronic acid cream should not be recommended for improving acute radiation skin reaction (Grade D)

2. Anxiety and Stress Reduction

• Meditation is recommended for reducing anxiety (Grade A)
• Music therapy is recommended for reducing anxiety (Grade B)
• Stress management is recommended for reducing anxiety during treatment, but longer group programs are likely better than self-administered home programs or shorter programs (Grade B)
• Yoga is recommended for reducing anxiety (Grade B)
• Acupuncture, massage, and relaxation can be considered for reducing anxiety (Grade C)

3. Chemotherapy-Induced Nausea and Vomiting

• Acupressure can be considered as an addition to antiemetic drugs to control nausea and vomiting during chemotherapy (Grade B)
• Electroacupuncture can be considered as an addition to anti-emetic drugs to control vomiting during chemotherapy (Grade B)
• Ginger and relaxation can be considered as additions to antiemetic drugs to control nausea and vomiting during chemotherapy (Grade C)
• Glutamine should not be recommended for improving nausea and vomiting during chemotherapy (Grade D)

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ASCO Discussion Point: Acupressure and Electroacupuncture for chemotherapy-induced nausea and vomiting

The Grade B recommendations for acupressure and electroacupuncture differ from the 2017 ASCO antiemetic guideline, which states that evidence remains insufficient for a recommendation for or against complementary therapies for chemotherapy-induced nausea and vomiting. The ASCO Expert Panel feels that Grade C would be more appropriate given the limitations of the available evidence.

The ASCO Expert Panel noted that the two guidelines address different patient populations-the ASCO antiemetic guideline applies to all cancer types, whereas the SIO guideline focuses only on patients with breast cancer. Nevertheless, the ASCO Expert Panel favored a grade C recommendation for these therapies.

1. Depression and Mood Disturbance

• Meditation, particularly mindfulness-based stress reduction, is recommended for treating mood disturbance and depressive symptoms (Grade A)
• Relaxation is recommended for improving mood disturbance and depressive symptoms (Grade A)
• Yoga is recommended for improving mood disturbance and depressive symptoms (Grade B)
• Massage is recommended for improving mood disturbance (Grade B)
• Music therapy is recommended for improving mood disturbance (Grade B)
• Acupuncture, healing touch, and stress management can be considered for improving mood disturbance and depressive symptoms (Grade C)

2. Fatigue

• Hypnosis and ginseng can be considered for improving fatigue during treatment (Grade C)
• Acupuncture and yoga can be considered for improving post-treatment fatigue (Grade C)
• Acetyl-L-carnitine and guarana should not be recommended for improving fatigue during treatment (Grade D)

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ASCO Discussion Point: Ginseng for fatigue

This was a not a strong recommendation in the SIO guideline (grade C), but the ASCO Expert Panel wanted to highlight that the efficacy and safety of ginseng may vary by type of ginseng and extraction method and patients should seek guidance from a health care professional before using a dietary supplement. Some ginseng preparations may have estrogenic properties.

The ginseng studies cited by the SIO guideline used American ginseng (Panax quinquefolius) that was tested for quality and potency; the duration of treatment in these studies was short (8 weeks), and the safety and efficacy of ginseng over longer periods remains uncertain.

1. Lymphedema

• Low-level laser therapy, manual lymphatic drainage, and compression bandaging can be considered for improving lymphedema (Grade C)

2. Neuropathy

• Acetyl-L-carnitine is not recommended for the prevention of chemotherapy-induced peripheral neuropathy in patients with breast cancer due to potential harm (Grade H)

3. Pain

• Acupuncture, healing touch, hypnosis, and music therapy can be considered for the management of pain (Grade C)

4. Quality of Life

• Meditation is recommended for improving quality of life (Grade A)
• Yoga is recommended for improving quality of life (Grade B)
• Acupuncture, mistletoe, qigong, reflexology, and stress management can be considered for improving quality of life (Grade C)

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ASCO Discussion Point: Mistletoe and Quality of Life

The mistletoe trials cited by the SIO guideline evaluated subcutaneous delivery only. Subcutaneous mistletoe is not currently approved by the US Food and Drug Administration (USFDA).

Where subcutaneous mistletoe is available and provided and administered by a health care professional, it may be considered for improving quality of life in selected patients, as indicated by the SIO’s grade C recommendation. Ingestion of high doses of mistletoe berry or leaf is known to cause serious adverse reactions.

1. Sleep Disturbance

• Gentle yoga can be considered for improving sleep (Grade C)

2. Vasomotor/Hot Flashes

• Acupuncture can be considered for improving hot flashes (Grade C)
• Soy is not recommended for hot flashes in patients with breast cancer due to lack of effect (Grade D)

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In conclusion, awareness of the base of evidence for complementary and integrative therapies based on the recently published SIO guidelines and the emerging literature should be a core competence for the cancer care provider and should be applied in decision making for patients with breast cancer who require supportive care. Future studies need to include systematic assessments of treatment toxicities, including toxicities from both the integrative and the conventional therapies.