ASCO/SIO Panel Recommends Acupuncture For Adults With Aromatase Inhibitor–Related Joint Pain

Acupuncture should be recommended for aromatase inhibiter (AI)-related joint pain, according to a panel of experts across the Society of Integrative Oncology (SIO) and the American Society of Clinical Oncology (ASCO).¹ Moreover, acupuncture, reflexology, or acupressure may all be recommended for general cancer pain or musculoskeletal pain, and hypnosis may be recommended for those who experience procedural pain. Massage may also be recommended to those experiencing pain during palliative or hospice care.

These recommendations, which were published as part of a guideline update in the Journal of Clinical Oncology, note that the quality of evidence is low for mind-body interventions or natural products, and that the body of evidence is insufficient to make integrative medicine recommendations for pediatric patients. Authors also stated that more research is needed to better define the role of integrative medicine interventions throughout the cancer continuum.

“Pain is one of the most common, disabling, and feared symptoms experienced by patients diagnosed with cancer,” the panel wrote in the update. “Integrative medicine, defined as the coordinated use of evidence-based complementary practices and conventional care treatments, includes interventions such as acupuncture, massage, meditation, and yoga, which are increasingly available in cancer centers and are recommended for symptom and pain management.”

According to researchers, an estimated 40% of patients with cancer use integrative medicine on an annual basis. They stressed that these therapies should be used in conjunction with conventional pain management and are not intended to replace these therapies.

A number of well-conducted randomized controlled trials (RCTs) have shown that acupuncture and massage can alleviate pain in patients and survivors, the authors wrote. However, for other interventions, the trials have been small and have lacked methodologic rigor. The panel noted that studies should not only report the statistical significance of their findings, but also the clinically meaningful change in pain severity (a 2-point reduction on a 0 to 10 scale).

The panel consisted of experts in integrative oncology, medical oncology, radiation oncology, surgical oncology, palliative oncology, social sciences, mind-body medicine, nursing, and patient advocacy representatives. They conducted a literature search which included systematic reviews, meta-analyses, and randomized controlled trials published from 1990 through 2021, with an emphasis on pain intensity, symptom relief, and adverse events. A total of 227 relevant studies were used to inform this guideline update.

“Since AI-related joint pain affects up to 50% of women on this class of drug and negatively affects quality of life and adherence to hormonal treatment, we recommend that acupuncture should be used for management of this painful condition,” the panel wrote.

AI-related joint pain

Recommendation 1.1 Acupuncture should be offered to patients experiencing AI-related joint pain in breast cancer. (Type: Evidence based, benefits outweigh harms; Evidence quality: Intermediate; Strength of recommendation: Moderate).

The panel assessed 4 systematic reviews and 5 RCTs in acupuncture and AI-related joint and muscle pain. They determined that the most definitive evidence is from a phase 3 sham-controlled RCT which included 226 patients experiencing moderate to serve AI-related join pain. In 6 weeks, the intervention significantly reduced pain compared with sham acupuncture and standard of care, on a 0 to 10 point numerical rating scale (NRS). More patients receiving acupuncture experience a 2-point pain reduction than those in the sham or waitlist groups (58%, 33%, and 31%, respectively).

Recommendation 1.2 Yoga may be offered to patients experiencing AI-related joint pain in breast cancer. (Type: Evidence based, benefits outweigh harms; Evidence quality: Low; Strength of recommendation: Weak).

The yoga recommendation comes from a RCT which assessed a 4-week yoga intervention in 142 breast cancer survivors receiving hormone therapy. Compared with women in the wait-list control, yoga significant reduced body aches (88.0% vs 56.7% with control; P = .02), and pain (57.1% vs 37.1%; P = .09). However, in this trial, pain represented the secondary outcome, as the parent trial was designed around insomnia.

General cancer pain or musculoskeletal pain

Recommendation 1.3. Acupuncture may be offered to patients experiencing general pain or musculoskeletal pain from cancer. (Type: Evidence based, benefits outweigh harms; Evidence quality: Intermediate; Strength of recommendations: Moderate).

Eight RCTs were used to inform this recommendation. Only one of these had a large sample size (n = 360), where patients were allocated 1:1:1 to receive either electroacupuncture (EA), auricular acupuncture (AA), and wait-list control using usual care prescribed by their physicians. This RCT showed that EA reduced pain by 1.9 points on a 0 to 10 NRS, and AA reduced pain by 1.6 points compared with usual care at the end of treatment. These treatment effects were maintained 6 months post-assignment and were associated with minimal toxicities. Although there was no blinded sham control, the committee determined that acupuncture may be considered for chronic musculoskeletal pain.

Recommendation 1.4. Reflexology or acupressure may be offered to patients experiencing pain during systemic therapy for cancer treatmen.t (Type: Evidence based, benefits outweigh harms; Evidence quality: Intermediate; Strength of recommendation: Moderate).

Seven RCTs evaluated the efficacy of reflexology, 6 of which showed significantly less pain with the intervention than with controls. Four trials included less than 50 patients per arm, but 3 included more than 90 patients per arm. Controls varied across the trial, and 2 trials blinded patients to group assignments.

Recommendation 1.5. Massage may be offered to patients experiencing chronic pain following breast cancer treatment. (Type: Evidence based, benefits outweigh harms; Evidence quality: Low; Strength of recommendation: Moderate).

Massage was assessed in 5 randomized trials with a total of 127 patients experiencing chronic musloskeletal pain after breast cancer treatment assessed. Three of these were of high methodologic quality, and 1 was a blind intervention. Controls in the trials included an educational session, physical therapy, or sham control. Massage was shown to have a small to moderate effect in pain reduction, and therefore, massage may be offered to decrease pain intensity in this setting.

Recommendation 1.6. Hatha yoga may be offered to patients experiencing pain after treatment for breast or head and neck cancers. (Type: Evidence based, benefits outweigh harms; Evidence quality: Low; Strength of recommendation: Weak).

Hatha yoga for musculoskeletal pain was evaluated in 2 RCTs, 1 with patients with head and neck cancer (n = 40) and 1 with patients with breast cancer (n = 42). Both trials had small sample size and follow up was completed at similar intervals. Both trials showed a significant difference in pain severity with the intervention, and pain reduction was maintained at 2.5 months post treatment; however, the small sample and lack of attention controls result in a body of evidence that is considered low.

Recommendation 1.7. Guided imagery with progressive muscle relaxation may be offered to patients experiencing general pain from cancer treatment. (Type: Evidence based, benefits and harms not assessable; Evidence quality: Low; Strength of recommendation: Weak).

Four RCTs supported this recommendation. These studies spanned across multiple types of cancer, and 2 included intervention arms that only included 20 participants. The blinding of participants, health professionals, data collectors and data analysts were inconsistent, and there were little safety data.

Chemotherapy-induced peripheral neuropathy

Recommendation 1.8. Acupuncture may be offered to patients experiencing chemotherapy-induced peripheral neuropathy from cancer treatment. (Type: Evidence based-informal consensus, benefits outweigh harms; Evidence quality: Low; Strength of recommendation: Weak).

This recommendation was informed by 2 systematic reviews and 7 RCTs with small sample sizes. No major toxicities were reported and most demonstrated a benefit of acupuncture for pain reduction in this setting. One phase 2 trial showed a significant reduction in chemotherapy-induced peripheral neuropathy with acupuncture over sham acupuncture. However, the small sample sizes and high or unclear risk of biases limit the evidence.

Recommendation 1.9. Reflexology or acupressure may be offered to patients experiencing chemotherapy-induced peripheral neuropathy from cancer treatment. (Type: Evidence based, benefits outweigh harms; Evidence quality: Low; Strength of recommendation: Weak).

Two small RCTS with approximately 30 patients per arm have been conducted to assess reflexology for chemotherapy-induced peripheral neuropathy symptoms, including pain. The first found improvement ins sensory functions, but not pain, while the latter showed lower levels of symptoms, and higher peripheral skin temperature level. Adverse effects were not reported in either study; however, the potential benefits likely outweigh the potential arms, the panel concluded.

Procedural or Surgical Pain

Recommendation 1.10. Hypnosis may be offered to patients experiencing procedural pain in cancer treatment or diagnostic workups. (Type: Evidence based, benefits outweigh harms; Evidence quality: Intermediate; Strength of recommendation: Moderate).

Five studies have evaluated the efficacy of hypnosis in procedures 3 of which demonstrated methodologic weakness and 2 of which were well designed with an attention control as well as at standard of care arm. The 2 most rigorous trials, which included more than 200 randomly assigned participants, demonstrated significantly lower pain ratings compared with control rms with a median reduction of at least 2 points on the 0 to 10 pain point scale. Based on these trials, hypnosis may be recommended to help manage pain. Of note, in these studies, hypnosis was provided throughout the procedure, not just for a short time before the procedure.

Recommendation 1.11. Acupuncture or acupressure may be offered to patients undergoing cancer surgery or other cancer-related procedures such as bone marrow biopsy. (Type: Evidence based-informal consensus, benefits outweigh harms; Evidence quality of: Low; Strength of recommendation: Weak).

Investigators assessed 12 RCTS which looked at the effect of acupuncture or acupressure in reducing surgery or procedure-related pain; however, all were limited by small sample size and an unclear or high risk of bias.

Recommendation 1.12. Music therapy may be offered to patients experiencing surgical pain from cancer surgery. (Type: Evidence based, benefits outweigh harms; Evidence quality of: Low; Strength of recommendation: Weak).

The investigators looked at 3 studies which showed significant benefit with pain scores with music therapy; however, 2 of the studies were determined to have a high risk of bias, and 1 included a small study sample.

Pain During Palliative Care

Recommendation 1.13. Massage may be offered to patients experiencing pain during palliative and hospice care. (Type: Evidence based; benefits outweigh harms; Evidence quality: Intermediate; Strength of recommendation: Moderate).

Fourteen “low-quality” trials from 2009 showed that there is encouraging evidence that massage can be useful in alleviating pain in this setting. However, a 2020 systematic review showed that 3 RCTs also showed favorable results for massage, including 1 high-quality large multicenter trial with 380 adults with various types of advanced cancer. In this trial, treatment with massage showed an immediate beneficial effect on pain reduction (mean difference, 0.90; P < .001) and no adverse events were reported.

Reference

Mao JJ, Ismaila N, Bao T, et al. Integrative medicine for pain management in oncology: Society for Integrative Oncology-ASCO guideline. J Clin Oncol. 2022;40(34):3998-4024. doi:10.1200/JCO.22.01357