Complementary Psychological and/or Physical Approaches for Cancer Symptoms and Treatment Side Effects: What the Science Says

Acupuncture

Available data suggest that acupuncture may help reduce cancer pain, manage treatment-related nausea and vomiting in people with cancer, and relieve cancer-related fatigue. Research on the effects of acupuncture on cancer-related hot flashes is limited.

What Does the Research Show?

Several clinical practice guidelines from the Society for Integrative Oncology and the American Society for Clinical Oncology based on systematic reviews of many randomized controlled trials, as well as guidelines from the American College of Chest Physicians, report there is some demonstrated efficacy for acupuncture for relief of some cancer-related symptoms and treatment side effects.

• In 2022, the Society for Integrative Oncology and the American Society for Clinical Oncology issued a joint guideline on integrative medicine for pain management in oncology. The guideline makes the following recommendations regarding acupuncture:
  • Acupuncture should be offered to patients experiencing aromatase inhibitor-related joint pain in breast cancer (Type: Evidence based, benefits outweigh harms; Evidence quality: Intermediate; Strength of recommendation: Moderate).
  • 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).
  • 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).
  • 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: Low; Strength of recommendation: Weak).
• In 2023, the Society for Integrative Oncology and the American Society for Clinical Oncology issued a joint guideline on integrative oncology care of symptoms of anxiety and depression in adults with cancer. The guideline recommends that acupuncture may be offered to women with breast cancer to improve anxiety symptoms post treatment (Type: Evidence based; Quality of evidence: Intermediate; benefits outweigh harms; Strength of recommendation: Weak).
• Clinical practice guidelines issued in 2009 by the Society for Integrative Oncology recommend acupuncture as a complementary therapy when pain is poorly controlled, when side effects associated with other treatments are significant, when nausea and vomiting associated with chemotherapy or surgical anesthesia are poorly controlled, or when reducing the amount of pain medicine becomes a clinical goal. The benefits of acupuncture for other symptoms, including fatigue or hot flashes, have not been established.
• In 2017, the Society for Integrative Oncology issued guidelines on the evidence-based use of integrative therapies during and after breast cancer treatment, recommending the use of acupressure and acupuncture for reducing chemotherapy-induced nausea and vomiting.
• In a 2017 monograph in the Journal of the National Cancer Institute, the authors state that although there is general consensus that acupuncture is useful for chemotherapy-induced nausea and vomiting, this is primarily based on studies that predate current antiemetic guidelines. Whether acupuncture has benefits above current standard treatments is unknown. However, a 2015 reported randomized trial of 70 participants found comparable efficacy between acupuncture and ondansetron in the prevention of delayed chemotherapy-induced nausea and vomiting. Participants in the acupuncture group appeared to have fewer adverse events and improved quality of life.
• Guidelines on complementary therapies and integrative medicine for lung cancer patients issued in 2013 by the American College of Chest Physicians suggest acupuncture as an adjunct treatment option for nausea or vomiting from either chemotherapy or radiation therapy. The guidelines also suggest acupuncture as an adjunct option in patients with cancer-related pain and peripheral neuropathy with inadequate control of these symptoms.
• A 2020 systematic review and meta-analysis (17 randomized controlled trials involving 1,111 participants were included in the systematic review, and data from 14 randomized controlled trials involving 920 participants were used in the meta-analysis) found that acupuncture and/or acupressure was significantly associated with reduced cancer pain and decreased use of analgesics; however, the evidence level was moderate. The reviewers noted that more rigorous trials are needed to identify the association of acupuncture and acupressure with specific types of cancer pain and to integrate such evidence into clinical care to reduce opioid use.
• A 2018 meta-analysis of 10 studies involving 1,327 participants showed that acupuncture may be more helpful than sham acupuncture or usual care in relieving cancer-related fatigue.
• A 2017 systematic review and meta-analysis of 13 randomized controlled trials involving 844 breast cancer patients found that acupuncture significantly alleviated menopause symptoms but had no effect on hot flashes.

Safety

• Complications from acupuncture are rare, as long as the acupuncturist uses sterile needles and proper procedures. Chemotherapy and radiation therapy weaken the immune system, so it’s especially important for acupuncturists to follow strict clean-needle procedures to reduce the risk of infection when treating people with cancer.

Hypnosis and Relaxation Techniques

Hypnosis may be helpful for pain caused by cancer itself or by procedures used in cancer care, for nausea and vomiting in people with breast cancer, and for anxiety and distress around surgical and medical procedures. It also may be helpful for hot flashes in women with breast cancer.

There is some moderate-quality evidence that relaxation techniques may improve anxiety symptoms in people with cancer who are undergoing treatment. In addition, there is some low-quality evidence that guided imagery with progressive muscle relaxation may help patients experiencing general pain from cancer treatment.

What Does the Research Show?

• According to the 2022 Society for Integrative Oncology/American Society for Clinical Oncology joint guideline on integrative medicine for pain management in oncology, 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). The guideline also recommends that 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).
• In the 2023 joint guideline issued by the Society for Integrative Oncology/American Society for Clinical Oncology on integrative oncology care of symptoms of anxiety and depression in adults with cancer, relaxation therapies may be offered to people with cancer to improve anxiety symptoms during active treatment (Type: Evidence based; Quality of evidence: Intermediate; benefits outweigh harms; Strength of recommendation: Moderate). The guideline recommends that hypnosis may be offered to people with cancer to improve anxiety symptoms during cancer-related diagnostic and treatment procedures (Type: Evidence based; Quality of evidence: Intermediate; benefits outweigh harms; Strength of recommendation: Moderate).
• A 2018 review found that hypnosis may help treat symptoms of nausea and vomiting in people with breast cancer, manage pain in a variety of contexts, and also reduce levels of anxiety and overall distress around surgical and medical procedures.
• In 2017 the Society for Integrative Oncology issued guidelines on the evidence-based use of integrative therapies during and after breast cancer treatment and suggested that hypnosis (based on two trials from a single research group) can be considered for use for fatigue during treatment (Grade C). These guidelines also indicate that hypnosis can be recommended as a therapy for pain (Grade C).
• A 2022 randomized controlled trial involving 109 adult cancer survivors with chronic pain found that recorded hypnosis and relaxation interventions are similarly effective in reducing pain and the pain-related sequelae of pain interference and anxiety. In addition, the study found that the hypnosis intervention also reduced fatigue and sleep disturbance.

Safety

• Hypnosis is a safe technique when practiced by a trained, experienced, licensed health care provider.

• Relaxation techniques are generally considered safe for healthy people. In most research studies, there have been no reported negative side effects. However, occasionally, people report negative experiences such as increased anxiety, intrusive thoughts, or fear of losing control. There have been rare reports that certain relaxation techniques might cause or worsen symptoms in people with epilepsy or certain psychiatric conditions, or with a history of abuse or trauma.

Massage Therapy and Reflexology

Massage therapy, with or without aromatherapy (the use of essential oils), has been used to attempt to relieve pain, anxiety, and other symptoms in people with cancer. However, there is only limited evidence on whether it is beneficial.

There is some limited evidence suggesting that reflexology may be helpful for people experiencing pain during systemic therapy or chemotherapy-induced peripheral neuropathy from cancer treatment.

What Does the Research Show?

• In 2022, the Society for Integrative Oncology and the American Society for Clinical Oncology issued a joint guideline on integrative medicine for pain management in oncology. 
  • The guideline recommends that 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). The guideline also recommends that 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). 
  • The guideline recommends that reflexology or acupressure may be offered to patients experiencing pain during systemic therapy for cancer treatment (Type: Evidence based, benefits outweigh harms; Evidence quality: Intermediate; Strength of recommendation: Moderate). The guideline also recommends that 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).
• According to the 2023 joint guideline issued by the Society for Integrative Oncology/American Society for Clinical Oncology on integrative oncology care of symptoms of anxiety and depression in adults with cancer, reflexology may be offered to people with cancer to improve anxiety symptoms during active treatment (Type: Evidence based; Quality of evidence: Low; benefits outweigh harms; Strength of recommendation: Weak).
• A 2021 systematic review and meta-analysis of 13 studies involving 1,100 participants of various manual therapies, including but not limited to massage therapy, provided evidence for benefits on pain, physical function, and global well-being but not fatigue, nausea, anxiety, or depression. These results should be interpreted cautiously because a variety of different manual therapies and measurement techniques were included and because some studies included small numbers of participants or were of low quality.
• A 2016 Cochrane review of 19 studies involving more than 1,200 participants found that there was a lack of evidence on the clinical effectiveness of massage for symptom relief in people with cancer. Most studies were too small to be reliable and key outcomes were not reported.
• Clinical practice guidelines issued in 2009 by the Society for Integrative Oncology recommend considering massage therapy delivered by an oncology-trained massage therapist as part of a multimodality treatment approach in patients experiencing anxiety or pain.
• In 2017 the Society for Integrative Oncology issued guidelines on the evidence-based use of integrative therapies during and after breast cancer treatment, recommending the use of massage therapy to improve mood disturbance in breast cancer survivors after active treatment (grade B). This recommendation is based on results from six trials.
• In clinical practice guidelines issued by the American College of Chest Physicians in 2013, massage therapy is suggested as part of a multimodality supportive care program for lung cancer patients whose anxiety or pain is not adequately controlled by usual care.

Safety

• Massage therapists may need to modify their usual techniques when working with people with cancer; for example, they may have to use less pressure than usual in areas that are sensitive because of cancer or cancer treatments.

Mindfulness-Based Stress Reduction

There is evidence that mindfulness-based stress reduction, a type of meditation training, can help cancer patients cope with stress, anxiety, and depression and can help reduce fatigue and improve quality of life.

What Does the Research Show?

• According to the 2023 joint guideline issued by the Society for Integrative Oncology/American Society for Clinical Oncology on integrative oncology care of symptoms of anxiety and depression in adults with cancer, mindfulness-based interventions should be offered to people with cancer to improve anxiety symptoms during active treatment (Type: Evidence based; Quality of evidence: High; benefits outweigh harms; Strength of recommendation: Strong).
• A 2020 systematic review and meta-analysis of 26 studies involving 3,476 participants with various types of cancer showed that those who participated in mindfulness-based interventions had less anxiety, depression, fatigue, and stress and a better quality of life than those who did not participate in mindfulness-based interventions.
• Findings from a 2022 randomized controlled trial of 60 participants with breast cancer suggest that MBSR training may reduce subjective (but not objective) memory-related impairments in people who receive treatment with chemotherapy. 
• 2009 reported clinical practice guidelines from the Society for Integrative Oncology recommend mind and body modalities, including mindfulness-based stress reduction, as part of a multidisciplinary approach to reduce anxiety, mood disturbance, and chronic pain and improve quality of life.
• Clinical practice guidelines issued in 2017 by the Society for Integrative Oncology on the evidence-based use of integrative therapies during and after breast cancer treatment recommend meditation for anxiety/stress reduction (Grade A), depression/mood disorders (Grade A), and to improve quality of life (Grade A).

Safety

• Mindfulness and other forms of meditation are generally considered to be safe for healthy people. However, they may need to be modified to make them safe and comfortable for people with some health conditions.

Tai Chi and Qigong

There is some limited evidence that tai chi may improve fatigue in people with cancer when used as an addition to conventional care but not when used as an alternative to conventional care. Tai chi or qigong may also help improve sleep quality in people with cancer.

What Does the Research Show?

• According to the 2023 joint guideline issued by the Society for Integrative Oncology/American Society for Clinical Oncology on integrative oncology care of symptoms of anxiety and depression in adults with cancer, tai chi and/or qigong may be offered to women with breast cancer to improve anxiety symptoms post treatment (Type: Evidence based; Quality of evidence: Intermediate; benefits outweigh harms; Strength of recommendation: Weak).
• A 2020 systematic review and meta-analysis analyzed 16 studies (1,268 participants) of tai chi in women with breast cancer. Some of the studies evaluated tai chi as an alternative to conventional supportive care interventions such as aerobic exercise and cognitive behavioral therapy, and others evaluated it as an addition to conventional care. Tai chi improved fatigue when used as an addition to conventional care (two studies) but not when used as an alternative to conventional care (two studies). Tai chi improved overall quality of life when used either as an addition to conventional care (four studies) or as an alternative to conventional care (two studies).
• A 2019 systematic review and meta-analysis of 12 recent studies (915 participants) of qigong or tai chi for patients with various types of cancer found favorable effects on symptoms of fatigue and sleep quality that were large enough to be meaningful to patients.

Safety

• Tai chi and qigong are generally considered to be safe practices.

Yoga

Studies in women with breast cancer show that yoga may provide a modest improvement in fatigue and sleep disturbances, depression and anxiety, and quality of life. Most yoga studies have focused on women with breast cancer; much less is known about yoga for people with other types of cancer.

What Does the Research Show?

• According to the 2022 Society for Integrative Oncology/American Society for Clinical Oncology joint guideline on integrative medicine for pain management in oncology, yoga may be offered to patients experiencing aromatase inhibitor-related joint pain in breast cancer (Type: Evidence based, benefits outweigh harms; Evidence quality: Low; Strength of recommendation: Weak). In addition, the guideline recommends that 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).
• According to the 2023 joint guideline issued by the Society for Integrative Oncology/American Society for Clinical Oncology on integrative oncology care of symptoms of anxiety and depression in adults with cancer, yoga may be offered to people with breast cancer to improve anxiety symptoms during active treatment (Type: Evidence based; Quality of evidence: Intermediate; benefits outweigh harms; Strength of recommendation: Moderate) and post treatment (Type: Evidence based; Quality of evidence: Intermediate; benefits outweigh harms; Strength of recommendation: Moderate).
• A 2020 systematic review and meta-analysis of 24 studies of yoga for women with breast cancer, involving a total of more than 1,600 participants, concluded that yoga provides small-to-moderate improvements in cancer-related fatigue and quality of life compared to interventions not involving physical activity. Therefore, it could be a supportive intervention for women with breast cancer, as an addition to standard treatment.
• A 2021 systematic review and meta-analysis of 26 studies of yoga-based interventions for depressive symptoms (1,486 participants) and 16 studies of yoga-based interventions for anxiety symptoms (977 participants) in people with various types of cancer found evidence that the interventions were helpful for both types of symptoms. The majority of the studies involved women with breast cancer.
• In 2013 guidelines from the American College of Chest Physicians, yoga is suggested as part of a multidisciplinary approach to reduce fatigue and sleep disturbance while improving mood and quality of life in patients with lung cancer.
• 2009 clinical practice guidelines from the Society for Integrative Oncology recommend mind and body modalities, including yoga, as part of a multidisciplinary approach to reduce anxiety, mood disturbance, and chronic pain and improve quality of life.
• In 2017 the Society for Integrative Oncology issued guidelines on the evidence-based use of integrative therapies during and after breast cancer treatment, recommending the use of yoga for reducing anxiety in breast cancer patients (Grade B), for improving mood disturbances and depressive symptoms in women with breast cancer (Grade B), and for improving the quality of life in breast cancer patients (Grade B).
• A 2017 Cochrane review of 24 studies involving 2,166 women with breast cancer concluded that moderate-quality evidence supports the recommendation of yoga as a supportive intervention for improving health-related quality of life and reducing fatigue and sleep disturbances when compared with no therapy, as well as for reducing depression, anxiety, and fatigue, when compared with psychosocial/educational interventions.

Safety

• Yoga is generally considered a safe form of physical activity for healthy people when performed properly under the guidance of a qualified instructor. However, as with other forms of physical activity, injuries can occur. The most common injuries are sprains and strains. Serious injuries are rare. In studies of yoga in people with cancer, adverse events have mostly been minor. However, having an ongoing health problem such as cancer may increase the risks of doing yoga.

Music-Based Interventions

There is some low-quality evidence that music-based interventions may improve anxiety symptoms in people with cancer during active treatment. Additionally, there is some low-quality evidence that music therapy may reduce surgical pain from cancer surgery.

What Does the Research Show?

• In the 2023 joint guideline issued by the Society for Integrative Oncology/American Society for Clinical Oncology on integrative oncology care of symptoms of anxiety and depression in adults with cancer, music therapy or music-based interventions may be offered to people with cancer to improve anxiety symptoms during active treatment (Type: Evidence based; Quality of evidence: Low; benefits outweigh harms; Strength of recommendation: Moderate).
• According to the 2022 Society for Integrative Oncology/American Society for Clinical Oncology joint guideline on integrative medicine for pain management in oncology, music therapy may be offered to patients experiencing surgical pain from cancer surgery (Type: Evidence based, benefits outweigh harms; Evidence quality: Low; Strength of recommendation: Weak).
• A 2021 Cochrane review of 81 studies with a total of 5,576 participants found that music-based interventions compared to standard care may have beneficial effects on anxiety, depression, hope, pain, and fatigue in adults with cancer. Two trials included in the review suggest that music-based interventions may have a beneficial effect on anxiety in children with cancer; however, there weren’t enough studies with pediatric participants to draw conclusions about the treatment benefits of music for other outcomes. The reviewers noted that most trials were at high risk of bias and low or very low certainty of evidence; therefore, these results need to be interpreted with caution.
• A 2022 systematic review of 25 randomized controlled trials found that music therapy (both as a standalone treatment and when used as adjunct therapy with other pharmacologic and nonpharmacologic modalities) has a generally beneficial effect across several physiologic and psychosocial aspects of cancer.

Safety

• In general, research studies of music-based interventions do not show any negative effects. However, listening to music at too high a volume can contribute to noise-induced hearing loss. 
• Because music can be associated with strong memories or emotional reactions, some people may be distressed by exposure to specific pieces or types of music. 
• Music-based interventions that involve exercise or other types of movement could lead to injury if appropriate safety precautions are not taken.

References