2018 integrative-tx-slides

Integrative Therapies During and After Breast
Cancer Treatment: ASCO Endorsement of the
SIO Clinical Practice Guideline
Lyman, et al.
www.asco.org/supportive-care-guidelines ©American Society of
Clinical Oncology 2018. All rights reserved.

Introduction
 To summarize the available evidence for
clinicians and to provide evidence-based
guidance on the use of integrative therapies
during and after breast cancer treatment,
the Society for Integrative Oncology (SIO)
published an updated clinical practice
guideline in 2017.
 The purpose of this American Society of
Clinical Oncology (ASCO) guideline
endorsement is to critically evaluate the
SIO guideline.
 Upon detailed appraisal of the guideline and
supporting evidence, ASCO has decided to
endorse the SIO guideline on the use of

ASCO Endorsement Methodology
The ASCO Clinical Practice Guidelines
Committee endorsement review process
includes:
•a methodological review by ASCO
guidelines staff
•a content review by an Expert Panel
•final endorsement approval by ASCO CPGC.
The full ASCO Endorsement methodology
supplement can be found at:
www.asco.org/supportive-care-guidelines

Clinical Questions
 The SIO guideline addressed the use of
integrative therapies to manage
symptoms and side effects during or
after breast cancer treatment.
 The guideline excluded several lifestyle
and psychological interventions,
including those that are already well
summarized elsewhere (e.g., diet and
exercise in cancer survivors); those with
a strong evidence base that tend to be
viewed as mainstream (e.g., cognitive-
behavioral therapy and support groups);
those still in an early or pilot phase of
research (e.g., attention-restoration
therapy), or those that were not viewed
as an integrative oncology therapy for

Target Population and Audience
Target Population
Patients undergoing treatment for breast
cancer and breast cancer survivors
Target Audience
Oncologists, integrative medicine
providers, supportive care specialists,
nurses, pharmacists, primary care
providers, and patients with breast
cancer

Summary of Recommendations
Acute radiation skin reaction
Aloe vera and hyaluronic acid cream
should not be recommended for improving
acute radiation skin reaction. (Grade D)

Anxiety/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)

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 antiemetic 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)
ASCO Discussion Point: 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.1

Depression/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
and depressive symptoms. (Grade B)
Massage is recommended for improving
mood disturbance. (Grade B)
Music therapy is recommended for
improving mood. (Grade B)

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)
ASCO Discussion Point: The safety and efficacy of ginseng may vary
by type of ginseng, and patients should seek guidance from a
healthcare professional before using a dietary supplement. Some
ginseng preparations may have estrogenic properties. The ginseng

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 due to potential harm.
(Grade H)

Pain

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)
ASCO Discussion Point: The mistletoe trials cited by the SIO guideline
evaluated subcutaneous delivery only. Subcutaneous mistletoe is not
currently approved by the U.S. Food and Drug Administration. Orally
available mistletoe is available in the United States, but ingestion of
high doses of mistletoe berry or leaf is known to cause serious adverse
2

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
in patients with breast cancer due to
lack of effect. (Grade D)

Reprint Permission
This is an endorsement of Greenlee H,
DuPont-Reyes MJ, Balneaves LG, et al:
Clinical practice guidelines on the
evidence-based use of integrative
therapies during and after breast
cancer treatment. CA Cancer J Clin
67:194-232, 2017 by permission of John
Wiley and Sons on behalf of the
Society for Integrative Oncology.

Additional Resources
More information, including a Data
Supplement, a Methodology
Supplement, slide sets, and clinical
tools and resources, is available at
www.asco.org/supportive-care-
guidelines
Link to original guideline:
http://onlinelibrary.wiley.com/doi/10.3
322/caac.21397/epdf
Patient information is available at
www.cancer.net

ASCO Guideline Panel Members
Name
(and designation)
Affiliation/Institution
Gary H. Lyman, MD, MPH (co-chair) Fred Hutchinson Cancer Research Center and University of Washington, Seattle, WA
Lorenzo Cohen, PhD (co-chair) The University of Texas MD Anderson Cancer Center, Houston, TX
Ting Bao, MD, DABMA, MS Memorial Sloan Kettering Cancer Center, New York, NY
Angela M. DeMichele, MD, MSCE Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
Gary E. Deng, MD, PhD Memorial Sloan Kettering Cancer Center, New York, NY
Judith M. Fouladbakhsh, PhD, RN Oakland University, Rochester, MI
Brigitte Gil, PharmD, BCPS, BCOP Lahey Hospital & Medical Center-Burlington, MA
Heather Greenlee, ND, PhD, MPH Fred Hutchinson Cancer Research Center and University of Washington, Seattle, WA
Dawn L. Hershman, MD, MS Columbia University Medical Center, New York, NY
Sami Mansfield (PGIN representative) Cancer Wellness for Life, Shawnee, KS and Sarah Cannon Cancer Institute, Kansas City, MO
Dawn M. Mussallem, D.O. Mayo Clinic, Jacksonville, FL
Karen M. Mustian, PhD, MPH University of Rochester Medical Center, Rochester, NY
Erin Price, MSW, LGSW (patient representative) Smith Center for Healing and the Arts, Washington, DC
Susan Rafte (patient representative) Houston, TX
Kari Bohlke, ScD American Society of Clinical Oncology, Alexandria, VA

References
1. Hesketh PJ, Kris MG, Basch E, et al:
Antiemetics: American Society of Clinical
Oncology Clinical Practice Guideline
Update. J Clin Oncol 35:3240-3261, 2017
2. PDQ® Integrative Alternative and
Complementary Therapies Editorial Board:
PDQ Mistletoe Extracts. Bethesda, MD,
National Cancer Institute. Updated
11/06/2017. Available at:
https://www.cancer.gov/about-
cancer/treatment/cam/hp/mistletoe-pdq.
Accessed 01/30/18. [PMID: 26389489]

Disclaimer
The Clinical Practice Guidelines and other guidance
published herein are provided by the American Society
of Clinical Oncology, Inc. (ASCO) to assist providers in
clinical decision making. The information herein should
not be relied upon as being complete or accurate, nor
should it be considered as inclusive of all proper
treatments or methods of care or as a statement of
the standard of care. With the rapid development of
scientific knowledge, new evidence may emerge
between the time information is developed and when it
is published or read. The information is not
continually updated and may not reflect the most
recent evidence. The information addresses only the
topics specifically identified therein and is not
applicable to other interventions, diseases, or stages
of diseases. This information does not mandate any
particular course of medical care. Further, the
information is not intended to substitute for the
independent professional judgment of the treating
provider, as the information does not account for
individual variation among patients. Recommendations
reflect high, moderate, or low confidence that the
recommendation reflects the net effect of a given
course of action. The use of words like “must,” “must
not,” “should,” and “should not” indicates that a course

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2018 integrative-tx-slides