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Overview of complementary, alternative, and integrative medicine practices in oncology care, and potential risks and harm

Overview of complementary, alternative, and integrative medicine practices in oncology care, and potential risks and harm
Literature review current through: Jan 2024.
This topic last updated: Mar 23, 2023.

INTRODUCTION — Complementary, alternative, and integrative medical (CAIM) therapies are used by an estimated 60 to 80 percent of patients with a history of a cancer diagnosis and are used throughout the cancer continuum following a diagnosis [1,2]. CAIM therapies may be used to promote overall health and wellness, mitigate cancer-related symptoms, as supportive care during cancer treatment to mitigate side effects, during survivorship care to address late effects of cancer treatment, and to improve overall quality of life during the continuum of cancer care, including end-of-life care. Given the high frequency of use, and the various reasons for CAIM use in cancer patients, it is important for clinicians to ascertain what CAIM therapies are being used and for what purpose.

This topic will provide an overview of CAIM therapies and practices in patients with cancer, including definitions, how to discuss CAIM use with patients, the potential risks and harms of CAIM use by patients with cancer, a description of those complementary and integrative medicine practices that require specific training (including licensing and credentialing) and those that do not, and a general overview of the role of these practices in oncology care.

Further details on rehabilitative and integrative strategies for pain in patients with cancer are discussed elsewhere:

(See "Rehabilitative and integrative therapies for pain in patients with cancer".)

DEFINITIONS — It is important to understand the different definitions of complementary medicine, alternative medicine, and integrative medicine:

As defined by the National Institutes of Health's National Center for Complementary and Integrative Health, and the National Cancer Institute, "complementary medicine" is used along with standard care; in the setting of oncology, this is often considered supportive care.

By contrast, "alternative medicine" is the use of nonstandard treatments in lieu of standard medical care; in the oncology setting, these are often nonevidence-based cancer treatments. "Integrative medicine" refers to an approach that combines evidence-based complementary therapies with standard medical care.

Integrative oncology, as defined by the Society for Integrative Oncology, is a patient-centered, evidence-informed field of cancer care that utilizes mind and body practices, natural products, and/or lifestyle modifications from different traditions alongside conventional cancer treatments [3]. Integrative oncology aims to optimize health, quality of life, and clinical outcomes across the cancer care continuum and to empower people to prevent cancer and become active participants before, during, and beyond cancer treatment.

EPIDEMIOLOGY — The use of CAIM in cancer patients is common. Multiple studies have found that over the course of one year, up to 90 percent of patients with cancer used a CAIM approach for at least a part of their therapy [2,4-11]. Some patients limit use to common dietary supplements, such as calcium and vitamin D, whereas others use a broad range of supplements, mind-body medicine practices, and body-based practices [12]. In 2012, the estimated national cost in the United States of CAIM use by patients with active cancer and survivors was $6.7 billion [13]. CAIM usage patterns differ by patient population, demographics, and geography:

Among cancer populations, individuals with breast cancer represent the highest users of CAIM [13,14].

Globally, the reasons for CAIM use may differ based on cultural preferences, as well as access to conventional medical care.

In the United States, vitamins and minerals are the most commonly used form of CAIM, and use is higher among cancer survivors compared with cancer-free adults (75 versus 68 percent), followed by herbal supplements (24 versus 19 percent, respectively) [13].

Patterns of CAIM use also differ by geographic region in the United States, with use of non-vitamin, non-mineral dietary supplements being significantly higher than the national average of 18 percent in the Pacific (23 percent), Mountain (29 percent), and West North Central (23 percent) regions compared with the rest of the country [15]. In addition, the use of mind and body practices, such as yoga and meditation also differ across geographic regions in the United States, with use being significantly higher than the national average of 8.4 percent in the Pacific (12 percent), Mountain (11.5 percent), and New England (11 percent) regions.

Users of CAIM are generally not dissatisfied with conventional medicine but find CAIM therapies to be more congruent with their own values, beliefs, and philosophical orientations toward health and life [16]. Factors reported to be associated with CAIM use in cancer patients include:

Increased psychosocial stress (eg, anxiety, depression) [17]

Being given a less hopeful prognosis [18]

Having the feeling of "nothing to lose" [19]

Attending support groups [20]

Age (younger versus older) and sex (female more than male) [10]

DISCUSSING CAIM WITH PATIENTS

Importance — It is important to ask all patients with cancer about CAIM use throughout the course of their treatment/survivorship, and to ascertain what they are using, who is directing the therapy (eg, self or practitioner/provider), and their reasons for use of specific forms of CAIM. Clinicians will then be able to assess the patient's goals of therapy, whether the approach/modality is known to be effective or risky, whether the specific approach is helpful, whether there are adverse effects, and if there are other known therapies that might be equally or more effective. The risk-to-benefit ratio of each CAIM approach should be addressed.

The following data pertain to cancer patients:

Despite the high prevalence of CAIM use among oncology populations, patient-provider communication about CAIM use is generally lacking [21,22]. In a survey of 752 newly diagnosed adult cancer patients in the United States receiving chemotherapy or radiation therapy, 91 percent were using one or more forms of CAIM, yet only 51 percent discussed at least one form of CAIM with their oncologist, and 24 percent discussed between two and four modalities; 49 percent did not discuss any CAIM therapy [21]. Among the reasons for patient nondisclosure to providers of CAIM therapies are: not being asked by the provider; perceived time constraints; and patients feeling providers are uninterested, unreceptive, or unknowledgeable about supplements [23,24].

Cancer patients may not reveal the use of CAIM unless specifically asked. In one study, disclosure increased from 7 to 43 percent when directed questions were added to standard history taking [25]. Unfortunately, communication between oncologists and patients about CAIM is poor, infrequent, and mostly initiated by patients or their kin [26].

Despite the current popularity of CAIM, most mainstream oncologists have little understanding of these therapies [27], and in one study, fewer than one-half initiated discussions about their use with patients [28].

Communication strategies — Oncology healthcare providers can use published clinical practice guidelines to inform their approach to discussing and documenting CAIM therapies with their patients [29].

Communicate respectfully and nonjudgmentally with patients and caregivers about CAIM.

Assess all patients for CAIM use, including details of therapies, dose, frequency, and goals for use.

Determine patient's information needs around CAIM and assist with knowledge acquisition.

Provide patients with coaching and support for making evidence-informed CAIM decisions.

Document patient's CAIM use, discussions about use, potential interactions, and monitoring plans in the electronic medical record.

Monitor and follow up with patients about their CAIM use.

Report suspected serious adverse events to appropriate regulatory bodies; adverse events related to dietary and herbal supplements should be reported to the US Food and Drug Administration (800-FDA-1088).

Engaging in a meaningful discussion with a patient about a topic for which there is limited formal education and is potentially controversial is a daunting task. Although training programs have been established [30], the best way to educate patients and clinicians about the appropriate and effective use of CAIM in the oncology setting is not established, and there is no consensus on the most successful method(s) [31].

POTENTIAL RISKS AND HARMS OF CAIM USE — While many forms of CAIM being used by cancer patients are associated with minimal or no risk, this is not true for all such therapies; there are three distinct issues related to potential risks and harms of CAIM use:

Direct toxicity or injury resulting from the CAIM therapy.

Potential interactions with conventional treatment.

Possible delay in receipt of effective conventional therapy or treatment due to use/pursuit of CAIM therapy, or due to conflicting belief system.

Direct toxicity of CAIM medications and procedures — A variety of natural products may produce serious side effects. These are reviewed separately. (See "Overview of herbal medicine and dietary supplements" and "Hepatotoxicity due to herbal medications and dietary supplements" and "Nephropathy induced by aristolochic acid (AA) containing herbs".)

Specific procedures are discussed below:

Acupuncture – Acupuncture is generally safe in oncology patients [32]. There are complications that are seen with any type of needle use, including transmission of infectious diseases, retained needle fragments, nerve damage, and very rarely, pneumothorax, pneumoperitoneum, organ puncture, cardiac tamponade, and osteomyelitis. Local complications may include bleeding, contact dermatitis, infection, pain, and paresthesias. Major adverse events are exceedingly rare and are usually associated with poorly trained, unlicensed acupuncturists. (See "Overview of the clinical uses of acupuncture", section on 'Adverse events'.)

Deep massage – Therapeutic deep massage can result in hematoma, particularly in anticoagulated or thrombocytopenic patients, and other serious complications have been reported [33-35].

Yoga – Like other forms of exercise, yoga may be associated with adverse events such as musculoskeletal injury (eg, soreness, sprains, and strains). More serious adverse events reported in rare case reports and case series include cerebrovascular dissection or occlusion; femoral or vertebral compression fracture; and injuries of the sciatic, median, ulnar, and common peroneal nerves. In addition, poses that involve extreme flexion or extension may be associated with an increased risk of a compression fracture in patients with osteoporosis, osteopenia, or bone metastases [36]. Guidelines are available from an expert consensus group on safety of exercise interventions in cancer patients with bone metastases, but they do not cover yoga [37]. (See "Overview of yoga", section on 'Risks associated with yoga'.)

Interactions of CAIM with conventional treatment — Many herbal medicines and supplements are pharmacologically active, raising concerns about potential interactions with conventional anticancer therapy, both cytotoxic agents and other medical therapies [38-47].

Frequency — In one study of 67 patients with breast or prostate cancer who recently completed chemotherapy and were surveyed by phone about their use of herbs and dietary supplements before, during, and after chemotherapy, 84 percent reported using herbs and/or dietary supplements [45]. Interaction software programs were used to screen for potential medication interactions (PMIs), which were identified in 1747 cases and were related to prescription medications (70 percent), herbs and supplements (56 percent), and with anticancer therapies (22 percent). More than one-half of identified PMIs were of moderate severity (54 percent), but 38 percent were considered major severity (which included "contraindicated" and "high-risk" PMIs), with herb and supplement users at significantly higher risk for a major interaction (92 versus 70 percent).

Specific interactions — Dietary supplement use among cancer patients can present risks at all stages of treatment including during surgery, systemic therapy, and radiation therapy. As examples:

In the perioperative period, dietary supplements such as botanicals can increase the risk of bleeding (eg, garlic, ginkgo, and ginseng) and increase sedation with anesthesia (eg, kava and valerian) [48]. (See "Perioperative medication management", section on 'Herbal medications'.)

While patients are receiving systemic anticancer therapy, concurrent use of dietary supplements such as botanicals can increase the risk of drug-botanical interactions related to drug metabolism (eg, cytochrome P450 enzymes [CYP]) and drug transport (eg, P-glycoprotein [Pgp]). As examples:

St. John's wort affects both drug metabolism (CYP3A4), and drug transport (Pgp), and significantly reduces circulating plasma concentrations of docetaxel and increases clearance [49,50].

Concern has also been raised about the potential for supplemental antioxidants to counteract or decrease the efficacy of "pro-oxidative" treatments like some forms of chemotherapy (eg, anthracyclines) and with radiation therapy [51].

Given these concerns, all patients should be screened for dietary supplement use several weeks before surgery to allow time for a "washout period" before an operation. Patients should also be screened prior to initiation of systemic therapy and radiation therapy, allowing time for a clinical pharmacist to review the patient's dietary supplements to screen for potential interactions, followed by communication between the patient and care team regarding risks and benefits of dietary supplement use during treatment. Further discussion about interactions of dietary supplements with conventional medications is presented separately. (See "Overview of herbal medicine and dietary supplements", section on 'Herb-drug interactions'.)

For additional information about potential herbal interactions with chemotherapy, the following resources are available:

Cancer Therapy Interactions With Foods and Dietary Supplements (PDQ)–Health Professional Version

Specific interactions of herbs and herbal mixtures with medications, including chemotherapy drugs, may be determined using the Lexicomp drug interactions tool (Lexi-Interact) included in UpToDate.

National Cancer Institute Office of Cancer Complementary and Alternative Medicine Therapies: A-Z

Society for Integrative Oncology

Natural Medicines, Therapeutic Research

Memorial Sloan Kettering Cancer Center - About Herbs

Delay or avoidance of conventional therapy of known benefit — Although not a direct "toxic" effect, the use of "alternative medicine" may result in a significant delay in instituting conventional treatment that is of documented benefit for a specific condition, particularly among patients (and caregivers) who may have unrealistic expectations such as those for cure or life prolongation [52-56]. In one survey, 40 percent of the United States population believed that cancer can be cured by alternative treatments [57].

Although limited, the best available data on patients refusing/delaying standard treatments in favor of alternative/complementary therapies are as follows [58-61]:

In one study (the Breast Cancer Quality of Care [BQUAL] study) in which 685 females with newly diagnosed breast cancer from three separate health systems were queried about their baseline CAIM use, 87 percent reported current CAIM use and 38 percent reported use of ≥3 modalities [61]. Among patients for whom chemotherapy was clinically indicated, 89 percent initiated chemotherapy, but 11 percent did not. Users of dietary supplements were less likely to initiate clinically indicated chemotherapy (odds ratio [OR] 0.16, 95% CI 0.03-0.51). Patients with high CAIM index scores (defined as the number of CAIM modalities used by the individual) were also significantly less likely to initiate clinically indicated chemotherapy (OR per unit CAIM index 0.64, 95% CI 0.46-0.87). In this study, mind-body practices were not associated with refusal of chemotherapy initiation (OR 1.45, 95% CI 0.57-3.59).

The impact of treatment delay or refusal on cancer outcomes was addressed in a second report, in which 258 patients diagnosed with nonmetastatic breast, prostate, lung, or colorectal cancer who underwent alternative medicine treatment as the sole therapy were compared with a matched cohort of 1032 patients who received conventional cancer therapy [59]. Patients who chose alternative therapy had higher refusal rates for surgery (70 versus 0.1 percent), radiation therapy (53 versus 22 percent), chemotherapy (34 versus 3 percent), and hormone therapy (34 versus 3 percent). Alternative medicine use was associated with worse five-year overall survival (82 versus 87 percent). While use of alternative treatment was independently associated with a greater risk of death (hazard ratio [HR] 2.08), there was no significant association between use of alternative treatment and survival once treatment delay or refusal was included in the model. These data suggest that the mortality risk associated with use of alternative treatments was mediated by the refusal of conventional cancer therapy.

Important limitations of this study are its observational nature and the reliance on medical diagnosis coding at a single facility.

SELF-CARE VERSUS PRACTITIONER-BASED CARE — The following sections will focus on complementary and integrative medicine (CIM) approaches and not alternative medicine approaches.

The term "complementary and integrative medicine" (CIM) encompasses a wide variety of practices and therapies. Some practices involve "self-care," that is, what a patient does on their own (eg, online yoga class, purchasing herbal tea at the grocery store, or buying a dietary supplement online). Other practices involve the care of a specifically trained, and often licensed health care provider or practitioner, for example an acupuncturist, massage therapist, or yoga instructor.

Examples of CIM approaches that fall within the broad categories of psychologic, physical, and nutritional interventions, are outlined in the figure (figure 1).

In the United States, the scope of practice, licensing, and credentialing requirements for CIM providers varies from state to state. It is important for patients and referring providers to understand the training, scope of practice, and licensing/credentialing requirements for CIM providers to understand the appropriateness of referrals and what can and cannot be managed by those providers. Issues related to training, licensing, and credentialing for various CIM practices are discussed below. (See 'CIM practices that require specialized training' below.)

CIM PRACTICES THAT REQUIRE SPECIALIZED TRAINING — The following practices require specialized training. Certain practices, such as acupuncture or massage (in the United States), also require licensing. Certification may be obtained for certain practices (eg, yoga).

Acupuncture, acupressure, and reflexology

Description of practice — Acupuncture involves inserting thin, solid, metal needles to stimulate specific anatomical points (ie, acupoints). A form of acupuncture, called electroacupuncture, includes electrical stimulation to certain acupuncture needles to provide a different stimulus than acupuncture alone with specific effects demonstrated in functional magnetic resonance imaging [62,63]. Acupuncture is considered a part of traditional Chinese medicine and has been practiced for thousands of years. Traditionally it is thought to stimulate the flow of a form of energy called qi (chee) throughout the body via a meridian system. Traditional Chinese acupuncture, which is commonly used in North America, utilizes needle manipulation to produce a de qi sensation (a soreness, fullness, heaviness, or local area distension) [63], along with a period of needle retention or rest with the needles inserted. The mechanisms for acupuncture's effects are not well understood but are thought to function in part through modulation of specific neuronal/cortical pathways [64].

Acupressure draws on the same knowledge and acupoint system as acupuncture. A trained practitioner, the patient or caregiver uses his/her fingers or a device to apply pressure to specific points on the body (acupoints), without insertion of needles [65].

Reflexology is another body work technique which involve applying pressure to specific points on the body; in contrast to acupressure, which involves the whole body, reflexology involves the feet, hands, ears, and face [66].

Training, licensing, and credentialing — The practice of acupuncture in North America is regulated by most states in the United States and some Canadian provinces and territories. Licensed acupuncturists, like Chinese herbal practitioners, have attended formal schools of East Asian medicine (EAM), have passed national certification examinations, and have been licensed by individual states or provinces. Additional examinations may be required for licensing depending on the state or province. This is discussed in more detail elsewhere. (See "Overview of the clinical uses of acupuncture", section on 'Credentialing'.)

Useful sites regarding training include the following:

The Accreditation Commission for Acupuncture and Herbal Medicine (ACAHM)

The National Certification Commission for Acupuncture and Oriental Medicine

The Canadian Alliance of Regulatory Bodies of Traditional Chinese Medicine Practitioners and Acupuncturists

Role in cancer care — Acupuncture is often used in the oncology setting and may be beneficial for pain management, and alleviation of chemotherapy‐induced nausea/vomiting (CINV), chronic musculoskeletal complaints, treatment- and premature menopause-associated hot flashes, fatigue, stress, anxiety, chemotherapy-induced peripheral neuropathy (CIPN), radiation-induced xerostomia, dyspnea, leukopenia, and sleep disorders. Acupressure may be used for CINV, pain, stress management, sleep disorders, and fatigue.

Acupuncture research is evolving, and some studies are subject to bias [64]. A particular problem is that different forms of control groups have been used in acupuncture trials, including sham acupuncture that involves a non-penetrating needle device, sham acupuncture that targets non-acupoints with shallow rather than deep needling, attention controls, and waitlist controls. In addition, some trials use standardized protocols and some use individualized protocols.

In 2017, the Society for Integrative Oncology (SIO) published clinical practice guidelines that include the use of acupuncture to manage symptoms during and after breast cancer treatment [66]. The guidelines were based on a systematic review of the literature and were endorsed by the American Society of Clinical Oncology (ASCO) [67]. The specific recommendations for acupuncture and acupressure are as follows:

Acupuncture can be considered for reducing anxiety, for improving mood disturbance and depressive symptoms, for improving posttreatment fatigue, for improving hot flashes, and improving quality of life (QOL) in general.

Acupressure or electroacupuncture can be considered as an addition to antiemetic drugs to control nausea and vomiting during chemotherapy.

Acupuncture can be considered for the management of pain.

The data to support these recommendations are presented in detail elsewhere. (See "Management of poorly controlled or breakthrough chemotherapy-induced nausea and vomiting in adults", section on 'Acupuncture and related therapies' and "Rehabilitative and integrative therapies for pain in patients with cancer", section on 'Acupuncture, acupressure, and reflexology'.)  

In 2022, SIO and ASCO published a joint guideline on the use of integrative therapies in cancer pain, and issued the following recommendations on the use of acupuncture and acupressure [68]:

Acupuncture should be offered to patients experiencing joint pain associated with aromatase inhibitor use in breast cancer. Use of acupuncture in patients with breast cancer on aromatase inhibitors is discussed elsewhere. (See "Managing the side effects of tamoxifen and aromatase inhibitors", section on 'Musculoskeletal pains and stiffness'.)

Acupuncture may be offered to patients experiencing general pain or musculoskeletal pain from cancer. (See "Rehabilitative and integrative therapies for pain in patients with cancer", section on 'Chronic pain related to cancer'.)

Acupuncture or acupressure may be offered to patients experiencing CIPN from cancer treatment. (See "Rehabilitative and integrative therapies for pain in patients with cancer", section on 'Pain during systemic anticancer therapy'.)

Acupuncture or acupressure may be offered to patients undergoing cancer surgery or other cancer-related procedures, such as bone marrow biopsy. (See "Rehabilitative and integrative therapies for pain in patients with cancer", section on 'Surgical or procedural pain'.)

Meditation and mindfulness-based stress reduction — The term "meditation" is an umbrella term that covers a large number of traditions and practices with specific evidence on their effectiveness for improved symptom management and ability to improve the stress response. They all require an active participant in the meditation, and specific training in the ability to "let go," of thoughts, feeling sensations, external distractions, and consistent daily or regular practice. Some examples include mindfulness meditation, transcendental meditation, and Zen meditation.

These self-regulation practices focus on training attention and awareness to bring mental processes under greater voluntary control [69]. In patients with cancer, these practices are intended to foster general mental well-being, calmness, clarity, and concentration.

Most meditation practices have four elements in common: a quiet location with few distractions; a specific, comfortable posture achieved by sitting or lying down; a focus of attention; and an open attitude of letting thoughts come and go naturally without judgment [70]. The focus of attention may be on a specific target, such as the breath or a repeated sound or mantra (known as concentration meditation); on all experiences that enter the field of awareness (called open awareness or mindfulness meditation); or a combination of both.

Mindfulness-based stress reduction (MBSR) is a well-defined and systematic patient-centered educational approach which uses relatively intensive training in mindfulness meditation as the core of a program to teach people how to take better care of themselves and live healthier and more adaptive lives [71].

Description of practice — MBSR is typically delivered in an eight-week, structured group program consisting of a range of meditation practices, including a sensate focus body scan, sitting meditation, walking meditation, loving-kindness practice, and gentle Hatha yoga postures. All formal practices are designed to cultivate increasing levels of mindfulness in day-to-day life. Participants engage in home practice daily throughout the program, and each session involves teaching relevant concepts, discussions of progress and barriers to practice, and introduction and practice of new meditation modalities.

Training and credentialing — There are no regulatory bodies that certify practitioners of MBSR. Completing mindfulness teacher training courses at one of the recognized training programs (some of which are outlined below), in addition to professional certification by an organization such as the International Mindfulness Teachers Association, would be the optimal level of training for providing these interventions. In both the United States and Canada, there is no registration or licensure currently available.

The following are examples of formal training programs:

The International Mindfulness Teachers Association

The Center for Mindfulness in Massachusetts provides MBSR training

The Mindfulness Center at Brown University provides teacher education, development, and certification

Role in cancer care — Multiple reviews and meta-analyses have explored the evidence to support a benefit for MBSR in the oncology setting, several of which are specific to breast cancer. Most suggest modest benefits for a broad range of symptoms, including fear of recurrence, anxiety, fatigue, depression, and vasomotor symptoms. As an example, a year 2019 Cochrane review of 10 randomized trials of MBSR for females diagnosed with breast cancer [72] concluded that:

MBSR may improve QOL slightly at the end of the intervention but may result in little to no difference at later time points.

MBSR probably slightly reduces anxiety and depression, and slightly improves quality of sleep at both the end of the intervention and up to six months later.

A beneficial effect on fatigue was apparent at the end of the intervention but not up to six months later.

Up to two years after the intervention, MBSR probably results in little to no difference in anxiety and depression; there were no data available for fatigue or quality of sleep.

Notably, almost all of the data are from trials utilizing a single training session for MBSR in the intervention group. Ongoing practice of these techniques, rather than one-time participation in a training program may be key to promoting long-lasting benefits.

The 2017 SIO guideline on integrative care in breast cancer treatment, endorsed by ASCO concluded that meditation, particularly MBSR, is recommended for the treatment of mood disturbance and depressive symptoms, for treating anxiety, and for improving QOL [66,67].

This is discussed in greater detail elsewhere. (See "Cancer-related fatigue: Treatment", section on 'Meditation and mindfulness-based approaches'.)

Massage therapy — Massage therapy has been used as a form of medical therapy since ancient times. Some of the earliest references are found in ancient Chinese medical texts. The Yellow Emperor's Classic of Internal Medicine, written more than 2500 years ago and believed to be the first book on Chinese medicine, includes information on Tuina, an ancient form of massage, and acupressure (applied finger pressure to points that are putatively sensitized by organ impairment) [73].

Description of practice — Massage is defined as the systematic manipulation of the soft tissues of the body to enhance health and healing [74]. It includes a group of manual techniques that include applying fixed or movable pressure. The primary characteristics are the application of touch and movement. A different form of touch therapy, therapeutic touch, is described below. (See 'Reiki' below.)

There are many different forms of this type of manual therapy, which involves a therapist stroking, kneading, applying friction, and stretching specific muscles and other connective tissues with various levels of pressure [75] usually at a regular tempo. There are multiple forms of massage, including, but not limited to Swedish, Shiatsu, and deep‐tissue massage.

Training, licensing, credentialing — The practice of massage therapy in North America is regulated by some states in the United States and some Canadian provinces and territories. Associated Bodywork and Massage Professionals [76] members at the certified or professional levels must possess a valid massage license from a regulated state/province/territory, must have completed 500 approved educational hours or be certified through the National Certification Board for Therapeutic Massage and Bodywork [77]. Licensed nurses and physical therapists may qualify for membership at either the certified or professional level with a minimum of 50 hours of additional massage therapy training.

Role in cancer care — In patients with cancer, the goal of massage therapy is to promote relaxation and address muscle stiffness and pain. Some studies conducted with adult and pediatric patients with both limited and advanced cancer have suggested that massage can yield at least temporary benefits for pain, other symptoms such as nausea and fatigue, and mood [78-85]; however, others have not [86-88], and the quality of the evidence is low, limiting the ability to draw definitive conclusions. A 2016 Cochrane review that evaluated the effects of massage with or without the addition of aromatherapy on pain and other symptoms (eg, anxiety and depression) in patients with cancer concluded that there is a lack of evidence due to low reliability of studies and poor methodologic quality [89].

Nevertheless, collective experience [79], combined with demonstrable effects on massaged tissues that suggest the potential for a specific mode of action, provide a rationale for the wide acceptance of this technique in symptom management, especially for pain.

Massage therapists should take precautions with all patients who have cancer and avoid massaging specific vulnerable areas of the body that have open wounds, bruises, skin breakdown, a blood clot in a vein, active tumor, areas near a medical device (eg, drains), or sensitive skin following radiation therapy [90]. At least in theory, patients with multiple bone metastases may be at risk for a fracture during deep massage; however, judiciously applied massage may improve bone pain in these patients [91]. Adaptations in oncology massage, which is available at many cancer centers, may include changes to applied pressure, site avoidance or restrictions, and precautions related to recent treatments, surgery, or metastases.

Patients interested in massage should be advised to seek a massage therapist who has received training in oncology massage and who has substantial clinical experience working with patients with cancer. Massage therapists can pursue certification in lymphedema management. (See 'Manual lymphatic drainage and compression bandaging' below.)

The 2017 SIO Clinical Practice Guideline for integrative therapy during and after breast cancer treatment [66], which was endorsed by ASCO, included the following recommendations [67]:

Massage is recommended for improving mood disturbance.

Massage can be considered for reducing anxiety.

The 2022 SIO and ASCO joint guideline on the use of integrative therapies in cancer pain issued the following recommendations on the use of massage [68]:

Massage may be offered to patients experiencing chronic pain following breast cancer treatment.

Massage may be offered to patients experiencing pain during palliative and hospice care.

The data to support these recommendations are presented separately. (See "Rehabilitative and integrative therapies for pain in patients with cancer", section on 'Massage therapy'.)

Manual lymphatic drainage and compression bandaging — Lymphedema is defined as accumulation of fluid and fibroadipose tissues due to disruption of lymphatic flow, which can be primary or, more commonly, secondary. Among cancer patients, the main underlying causes of secondary lymphedema include interruption of lymphatics by surgery and/or radiation therapy, and/or malignant obstruction of the lymphatics. Most cases arise in the upper extremities following breast cancer treatment, but secondary lymphedema can also develop in the lower extremities [92]. (See "Breast cancer-associated lymphedema" and "Lower extremity lymphedema".)

Description of practice — Manual lymphatic drainage (MLD) and compression bandaging are used individually and in combination for the treatment of secondary lymphedema. MLD can decrease lymphedema when utilized early, before symptoms advance [92,93]. Compression bandages or garments, including sleeves, stockings, bras, compression shorts, gloves, bandages, or neck compression wraps can be worn during the day or night, depending on the garment and the individual. Conservative, multimodal therapy for lymphedema consists of general measures for monitoring and self-care, which are applicable to all stages of lymphedema, along with varying levels of compression therapy and physiotherapy, with the choice of specific management dependent upon the clinical stage of disease (mild, moderate, severe). (See "Clinical staging and conservative management of peripheral lymphedema", section on 'Overview of management' and "Breast cancer-associated lymphedema", section on 'Lymphedema management'.)

Training, licensing, credentialing — MLD is a massage-like technique that is typically performed by specially trained physical therapists. However, courses to certify in MLD-type massage are widely available for anyone, including other health professionals. There is no licensure or credentialing for such individuals.

Role in cancer care — Manual techniques such as MLD are typically included as a component of complete decongestive therapy for acquired lymphedema in cancer patients despite the low quality of the evidence supporting benefit. (See "Clinical staging and conservative management of peripheral lymphedema", section on 'Techniques' and "Breast cancer-associated lymphedema", section on 'Effectiveness of conservative treatments'.)

The 2017 SIO Clinical Practice Guideline for integrative therapy during and after breast cancer treatment, endorsed by ASCO, concluded that MLD and compression bandaging can be considered for improving lymphedema [66,67].

There are some concerns that MLD may dislodge and promote the spread of tumor cells among those with secondary lymphedema related to cancer. These concerns and other contraindications to MLD are described elsewhere. (See "Clinical staging and conservative management of peripheral lymphedema", section on 'Contraindications'.)

Hypnotherapy — Clinical hypnosis is similar to guided imagery and is facilitated by a specially trained therapist or can be practiced on one's own (self‐hypnosis).

Definition of practice — Hypnosis involves an induction phase, the visualization/treatment itself, and then guidance out of the trance state of mind. The trance‐like state of hypnosis allows a patient to be more aware, focused, and open to suggestion. A person in a hypnotic state can concentrate more clearly on specific feelings, thoughts, images, sensations, or behaviors without distraction. The hypnotic state is obtained by first relaxing the body and then shifting attention toward a narrow range of objects or ideas given by the hypnotist or hypnotherapist. A person under hypnosis may feel calmer and more relaxed. In patients with cancer, hypnosis is often used to help relieve stress, anxiety, and pain.

Hypnosis can be defined as an induced state of attentive, focused concentration with suspension of some peripheral awareness. Major components of the hypnotic state include absorption (capacity to contemplate deeply a selected theme or focal point), controlled alteration of one's attention, dissociation (the capacity to compartmentalize different aspects of an individual experience), and suggestibility (the capacity for heightened responsiveness to instructions) [94-96]. Hypnosis has been increasingly utilized for chronic and acute pain conditions and is increasingly accepted for both acute and procedure-related pain [97].

The mechanisms responsible for hypnotic phenomena are not entirely clear. Research in breast cancer surgical patients suggests that the benefits are mediated by altered response expectancies (ie, specific expectations for nonvolitional events such as the occurrence of pain and fatigue after an operation) and diminished emotional distress when stressful surgical procedures are undertaken [98,99]. Hypnosis may also provide therapeutic benefit by decreasing the unpleasantness of the sensation, or reducing the attention paid to the painful sensation and refocusing attention elsewhere [100-103].

Patients vary widely in their ability to achieve a hypnotic state. Typically, individuals have been classified as "high hypnotizables" or "low hypnotizables," as assessed by validated instruments such as the Penn State Scale of Hypnotizability [104] or the Stanford Hypnotic Clinical Scale [105]. These scales of hypnotic susceptibility provide a relatively stable measurement of individual differences [106]. Cooperation and suggestibility are important foundations for hypnotizability. The trait of suggestibility alone, however, does not determine the potential for hypnotic induction and does not imply that any particular outcomes will be achieved. To allay concerns, some patients need reassurance that hypnosis cannot induce behaviors that would not be desired or are contrary to the patient's values. While individuals who are "high hypnotizables" are more responsive to hypnotic suggestions of analgesia, there is evidence that distraction, relaxation, and hypnotic suggestions of analgesia typical of a hypnotic session can modulate the pain experience even in patients with a medium or low level of hypnotizability [107]. This can result in an improved ability to achieve cognitive control of pain and, therefore, to experience symptom improvement.

Training and credentialing — Mental health and medical professionals typically practice hypnosis as a specialty or subspecialty. Certified hypnotherapists, in general, hold a graduate‐level or bachelor's‐level degree in a broad range of specialties, including MD, registered nurse, dentist, social worker, licensed counselor or psychologist, pastoral counselor, ordained minister, and chiropractor, among many others, prior to obtaining training in hypnosis. Currently, there are no accredited schools offering standard college or university degrees in hypnosis; therefore, training in one of the above professions is typically required before acceptance into one of many training or certification programs. These programs have a wide range of training requirements but in general require anywhere from 50 to 200 hours of classroom and clinical training before certification.

There are a number of certification programs with a range of requirements, including:

The International Society of Hypnosis

The Hypnosis Alliance Network

The Association of Registered Hypnotherapists

Role in cancer care — The evidence in favor of the positive effects of hypnosis is variable. Several randomized controlled studies have shown hypnosis to be effective in reducing pain and anxiety related to procedures performed in early cancer diagnosis and treatment, and possibly hot flashes (vasomotor symptoms) and cancer-related fatigue. (See "Cancer-related fatigue: Treatment", section on 'Hypnosis'.)

However, the evidence for benefit in any of these settings is mixed and it is clear that hypnosis research would benefit from more rigorous methodology, including standardization of interventions [108]. The 2017 SIO clinical practice guidelines for integrative therapy during and after breast cancer treatment [66], which were endorsed by ASCO, included the following recommendations for hypnosis [67]:

Hypnosis can be considered for the management of pain;

Hypnosis can be considered for improving fatigue during treatment.

There is insufficient evidence to form a clinical recommendation about hypnosis to treat hot flashes/vasomotor symptoms.

The 2022 SIO and ASCO joint guideline on the use of integrative therapies for cancer pain concluded that the evidence base to support a benefit for hypnosis was adequate for procedural pain experienced during cancer therapy or during diagnostic workup, but not for pain during palliative care or during radiation therapy [68].

The data to support these recommendations are discussed in detail elsewhere. (See "Rehabilitative and integrative therapies for pain in patients with cancer", section on 'Clinical hypnosis' and "Menopausal hot flashes", section on 'Promising therapies: Need further study' and "Cancer-related fatigue: Treatment", section on 'Hypnosis'.)

Yoga — Yoga is a collection of mind-body practice with origins in ancient South Asian philosophy and practice [109]. It includes physical postures ("asanas"), breathing and relaxation techniques, as well as diet and meditation. The term yoga is derived from the Sanskrit word "yug," meaning "yoke" or "union" [110]. According to traditional yoga philosophy, the ultimate intent of a yoga practice is to unite the individual with the totality of the universe.

Description of practice — The techniques of yoga include ethical daily living ("yamas" and "niyamas"), physical postures ("asanas"), breathing techniques ("pranayama"), and meditation training ("dhyana"). There are a wide range of yoga forms and styles, and it can be individualized for a specific symptom or medical issue. The most commonly practiced form of yoga in the United States and Canada is Hatha yoga, which emphasizes postures ("asanas") and often breathing exercises ("pranayama"). (See "Overview of yoga", section on 'The practice of yoga'.)

Training and credentialing — There are very stringent criteria to be a yoga instructor, and most jurisdictions have their own requirements. (See "Overview of yoga", section on 'Yoga teacher training and certification'.)

Yoga therapy is a special application of yogic principles, methods, and techniques to specific human ailments for restorative, palliative, or curative purposes after diseases or injury. Yoga therapists often work one-on-one with individual patients. A more advanced set of educational standards and competencies have been established for the training of yoga therapists [111]. The minimum requirement for certification as a yoga therapist is 800 hours. A process for accrediting therapists, programs, and facilities that meet these standards has been developed by the (IAYT) [112].

In the United States, standards for use of the designations 'yoga teacher' or 'yoga therapist' have not existed [113]. Even with the updated Yoga Alliance policy statements and the IAYT standards, anyone can use the words 'yoga therapy' or 'yoga therapist' as a title or in marketing materials. No local, state, or federal regulatory restrictions on the use of these designations exist, leaving any oversight on the use of such terms to the IAYT and YA. However, at the national level, there are "registered yoga therapist" (RYT) 200 and RYT 500 certifications.

Role in cancer care — The evidence base for benefits of yoga in the general population for fitness, strength, flexibility, balance and mobility, stress and anxiety, and QOL are reviewed elsewhere. (See "Overview of yoga" and "Overview of yoga", section on 'The practice of yoga'.)

In patients with cancer, yoga has been used for a variety of conditions, including stress, anxiety, depression, and fatigue, and as a method to increase physical activity. Several randomized trials, many conducted in breast cancer patients, have demonstrated modest benefits in a variety of symptoms, including anxiety, mood disturbance, stress reduction, posttreatment fatigue, and improving sleep and QOL. As an example, the 2017 Cochrane review of 23 studies totaling 2166 patients on the benefits of yoga as a supportive intervention for patients with cancer came to the following conclusions [114]:

Moderate-quality evidence supports the recommendation of yoga as a supportive intervention for improving health-related QOL 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.

Very low-quality evidence suggests that yoga might be as effective as other exercise interventions and might be used as an alternative to other exercise programs.

The 2017 SIO Clinical Practice Guidelines on the use of integrative therapies during and after breast cancer treatment [66], which were endorsed by ASCO, included the following recommendations [67]:

Yoga is recommended for reducing anxiety and improving mood disturbance and depressive symptoms

Yoga is recommended for improving QOL

Yoga can be considered for improving posttreatment fatigue

Gentle yoga can be considered for improving sleep

The 2022 SIO and ASCO joint guideline on integrative medicine in cancer pain concluded that yoga may be offered to patients experiencing joint pain related to aromatase inhibitor use in breast cancer, or pain after treatment for breast or head and neck cancer [68].

The data to support these recommendations are discussed in detail elsewhere:

(See "Cancer-related fatigue: Treatment", section on 'Yoga'.)

(See "Rehabilitative and integrative therapies for pain in patients with cancer", section on 'Yoga'.)

(See "Managing the side effects of tamoxifen and aromatase inhibitors", section on 'Musculoskeletal pains and stiffness'.)

Music therapy

Description of practice — Music therapy is the clinical use of music to accomplish individualized goals. Qualified music therapists assess a patient's strengths and needs and provide indicated treatment, such as creating, singing, moving to, and listening to music [115]. Music therapy interventions can be described as either passive (eg, listening to music before a medical intervention with the intent to produce a calming effect on the patient) or active (eg, a therapist engaging the patient in the creation of live music through singing, playing an instrument, or writing lyrics), depending on the level of engagement required [116].

Although the exact mechanisms by which music therapy works are not well understood, the most commonly accepted theories are through neurologic, psychologic, behavioral, and physiologic pathways [117,118].

Training and credentialing — A professional music therapist holds a bachelor's degree or higher in music therapy from one of over 70 American Music Therapy Association-approved college and university programs. Music therapists who currently hold professional designation are listed on the National Music Therapy Registry and are qualified to practice music therapy.

There are a few certification groups, including Certification Board for Music Therapists and the Canadian Association for Music Therapy.

The practice of music therapy in North America is regulated by some states in the United States (state‐by‐state licensure information is available [119]). Currently no Canadian provinces/territories license or regulate music therapists.

Role in cancer care — In cancer care, music therapy can be used to improve pain; decrease muscle tension; promote relaxation; and improve anxiety, depression, fatigue, and QOL, although the effects may be transient.

A 2021 Cochrane review of music interventions (defined as music therapy offered by trained music therapists) for improving psychologic and physical outcomes in people with cancer included 81 trials with a total of 5576 participants; 74 trials involved adults, and seven trials included children [120]. Music interventions had a large effect on anxiety and depression, a moderate positive effect on pain and QOL, and a small impact on fatigue.

The 2017 SIO guideline on integrative therapies during breast cancer treatment, endorsed by ASCO, included the following [66,67]:

Music therapy is recommended for reducing anxiety/stress reduction

Music therapy is recommended for improving mood disturbance

Music therapy can be considered for the management of pain

The 2022 SIO and ASCO joint guideline for integrative approaches to cancer pain concluded that, music therapy may be offered to patients experiencing surgical pain from cancer surgery, but not in other settings for pain [68].

The data to support these recommendations are presented in detail separately:

(See "Acute procedural anxiety and specific phobia of clinical procedures in adults: Treatment overview".)

(See "Rehabilitative and integrative therapies for pain in patients with cancer", section on 'Creative arts therapy'.)

Reiki

Description of practice — The National Center for Complementary and Integrative Health classifies Reiki as a complementary noninvasive form of energy healing in which practitioners place their hands lightly on or just above a person, with the goal of directing energy to help facilitate the person's own healing response. Reiki has Japanese origins and is based on an Eastern belief in an energy that supports the body's innate or natural healing abilities. The intention is to create deep relaxation, to help speed healing, reduce pain, ease tension and stress, decrease other symptoms, and help support the body to facilitate an environment for healing. However, there is no scientific evidence supporting the existence of the energy field thought to play a role in Reiki, and this is a controversial practice.

Proponents of Reiki suggest that it can reduce stress and induce a relaxation response, which may be therapeutic in a manner similar to mind-body interventions. While Reiki has been studied for a variety of conditions, including pain, anxiety, and depression, there is no clear evidence that Reiki is an effective treatment for any health condition. Reiki has not been shown to have any harmful effects, however [121].

Training and credentialing — Reiki training programs range from two days to a few weeks to years, depending on the level of training and certification. There is no regulation of Reiki practitioners in most areas.

Role in cancer care — Reiki has received increasing interest in clinical and research settings, including hospice and palliative care, but the limited data on effectiveness and the lack of large and well-controlled studies prevent drawing firm conclusions as to the benefit of this therapy [122,123].

Several clinical trials have tested the effectiveness of Reiki to reduce anxiety [124], and improve wellbeing or QOL in cancer patients [125-127]. Although some of these studies have yielded positive results it is unclear whether the observed effects were due to a specific therapeutic benefit of reiki or nonspecific (placebo) effects [128].

Traditional and whole medical systems

Traditional East Asian medicine

Description of practice — Herbs play a significant role in traditional EAM. Traditional East Asian herbal medicine formulas are used to treat acute and chronic conditions. Traditional East Asian herbal medicine almost exclusively uses herbal combinations. Traditional East Asian herbal medicine practitioners utilize thousands of herbs, minerals, and other extracts from traditional herbal materia medica or medicinal materials. Practitioners are trained in individual herbs and formulas including the symptoms that they treat, the proper dosing and preparation, as well as toxicologic information on the foundation substances [129-131].

Training, licensing, credentialing — Licensed EAM practitioners with specific training in herbal medicine, like acupuncturists, have attended formal schools of EAM and have passed national certification examinations in order to sit for national, state, or provincial licensing examinations. The ACAHM accredits schools of EAM in the United States. On a national level, in the United States, ACAHM also offers board certification in combined acupuncture, Chinese herbology, and Oriental medicine, which requires an examination. Credentialing and licensure are described in more detail above. (See 'Acupuncture, acupressure, and reflexology' above.)

Role in oncologic care — East Asian herbal medicines are widely used in many areas of Asia, most often in conjunction with conventional anticancer therapy. Although the body of evidence is growing, there is not enough research on the effects of combining East Asian herbal medicine with conventional cancer treatment to understand whether and how cancer outcomes are impacted [132]. East Asian herbal therapy may also be a valuable additional therapy following cancer treatment to aid the body's recovery from the after-effects of chemotherapy and/or radiation, depending on the individual patient and treatment. However, rigorously conducted clinical trials are needed to address the impact of traditional EAM on cancer outcomes [133].

Chiropractic care

Description of practice — Chiropractic treatment is a nonsurgical, nonpharmacologic method of manual therapy, often including spinal manipulation. Other forms of treatment, such as exercise, may be used. Chiropractors often treat problems related to the musculoskeletal system. Chiropractors often do tests, which may include radiographs. The treatment methods used by chiropractors range from stretching and sustained pressure to specific joint manipulations, which usually involve a quick and gentle thrust delivered by hand or specifically designed devices. The goal of manipulations is to improve joint motion and function. Manipulations are most commonly administered to the spine, but other parts of the body may also be manipulated [134]. (See "Spinal manipulation in the treatment of musculoskeletal pain".)

Training, licensing, credentialing — Chiropractors have typically completed a four-year Doctor of Chiropractic program accredited by the Council on Chiropractic Education in the United States. Chiropractic education includes classes in basic sciences, such as anatomy and physiology, and supervised clinical experience [135]. The scope of services for chiropractors' practice varies by state. Chiropractors must hold a Doctor of Chiropractic (DC) degree, pass the National Board of Chiropractic Examiners exam, and have a state license. Some states also require chiropractors pass state exams. All 50 states, the District of Columbia, Puerto Rico, and the US Virgin Islands officially recognize chiropractic as a health care profession and officially recognize chiropractic as a primary health care profession distinct from medicine [136]. Many other countries also recognize and regulate chiropractic, including Canada, Mexico, Great Britain, Australia, Japan, and Switzerland. While there is still considerable variation among countries, licensure procedures are standardized within many countries, including the United States, Canada, England, Australia, and New Zealand. By law, licensed chiropractors may use the titles "Doctor of Chiropractic," "DC," or "Chiropractic Physician" [137].

Role in cancer care — Patients with cancer seek the care of chiropractors for a variety of reasons, commonly musculoskeletal complaints. The literature regarding benefits and potential harms is not extensive [138], and even among chiropractors, there is no consensus on which, if any, patients should be excluded from spinal manipulation, particularly in the setting of bone metastases [139]. An additional concern is that neuromusculoskeletal complaints may not be recognized as being potentially due to an underlying neoplasm.

Naturopathic medicine

Description of practice — Naturopathic medicine is a distinct method of holistic health care. Naturopathic practice can include clinical and laboratory diagnostic testing, nutritional medicine, botanical medicine, naturopathic physical medicine including naturopathic manipulative therapy, public health measures, hygiene, counseling, minor surgery, homeopathy, prescription medication, intravenous and injection therapy, and naturopathic obstetrics (natural childbirth) [140]. Practitioners are called naturopathic doctors (ND), naturopathic physicians, or naturopaths.

NDs practicing integrative cancer care use evidence-informed natural and supportive therapies to help reduce side effects, optimize conventional care, prevent recurrence, and provide education for a healthy lifestyle.

Training, licensing, credentialing — Education and licensing differ for the three types of naturopathic practitioners:

NDs generally complete a four-year, graduate-level program at a naturopathic medical school accredited by the Council on Naturopathic Medical Education in the United States and Canada.

Traditional naturopaths, also known simply as "naturopaths," may receive training in a variety of ways. Training programs vary in length and content and are not accredited by organizations recognized for accreditation purposes by the United States Department of Education. Traditional naturopaths are often not eligible for licensing.

Other health care providers (such as clinicians, osteopathic physicians, chiropractors, dentists, and nurses) sometimes offer naturopathic treatments, functional medicine, and other holistic therapies, having pursued additional training in these areas. Training programs vary.

Role in cancer care — NDs working in oncology address foundational determinants of health with patients undergoing cancer treatment, and those in posttreatment survivorship, including harmful exposures (eg, tobacco, alcohol, environmental and occupational carcinogen exposure); physical activity and exercise; nutrition; sleep and circadian rhythm; stress; and psychologic, emotional, and spiritual health. NDs are guided by the principles of naturopathic medicine and the Oncology Association of Naturopathic Physicians Principles of Care Guidelines, published in 2019 [141]. NDs create integrative treatment plans for patients that include recommendations on diet and lifestyle, mind and body practices, and natural product counseling and/or recommendations, and coordinate referrals with additional integrative therapies and supportive care services (eg, acupuncture, massage, yoga, meditation, physical therapy, pain management, psychology and counseling, palliative care, spiritual care, etc).

NDs can provide support for side effects patients experience during cancer treatment including fatigue, pain, mucositis, nausea and vomiting, diarrhea or constipation, dermatitis, and peripheral neuropathy. NDs also treat common chronic conditions such as allergies, anxiety, autoimmune conditions, depression, diabetes, fatigue, hypertension, hyperlipidemia, insomnia, osteoarthritis, peri-postmenopausal symptoms, and reflux esophagitis.

Homeopathy

Description of practice — Homeopathy, also known as homeopathic medicine, is a medical system that was developed in Germany more than 200 years ago. It is based on two theories: "Like cures like" and "law of minimum dose." "Like cures like" or The Law of Similars is the concept that symptoms can be cured by a substance that produces similar symptoms in healthy people. For example, large quantities of coffee can make people sleepless and agitated, whereas a homeopathic preparation of coffee could be used to treat people with insomnia and agitation. "Law of minimum dose" is the concept that the smallest dose necessary to elicit a healing response in a patient should be used. Homeopathic products are made by a process of dilution and succussion; with each dilution of the original substance (eg, plant, mineral, herb) the remedy or medicine is vigorously shaken or succussed. As the number of dilutions and succussions increases the medicine is thought to be more potent, even though less of the original substance remain. [142,143].

Homeopathic products come from plants, minerals, or animals. Homeopathic products are often made as sugar pellets to be placed sublingually under the tongue, they may also be in other forms such as ointments, gels, drops, creams, and tablets. Homeopathic medicines, called remedies, may be used in chronic conditions and acute illnesses and injuries. Treatments are individualized to each person and it's common for different people with the same condition to receive different treatments. Additionally, the same single medicine may be useful for several different conditions. (See "Homeopathy", section on 'Foundations of homeopathy'.)

Although there have been studies on homeopathic products for a variety of conditions, there is little evidence proving efficacy for any component of homeopathic medicine [144,145]. (See "Homeopathy", section on 'Limited evidence supporting the use of homeopathy'.)

Training, licensing, credentialing — No specific license to practice homeopathy exists in the United States or Canada [146]. Individual state laws and licensing boards regulate the practice of homeopathy and each state's laws and requirements for practice may be different [142]. (See "Homeopathy", section on 'Certification of homeopathic practitioners'.)

Role in cancer care — There are very few data on the benefits of homeopathy in any situation, including patients with cancer, and benefits remain uncertain:

One Viennese randomized, placebo-controlled trial evaluating the benefit of adding a variety of homeopathic treatments to standard chemotherapy in 106 patients with advanced non-small cell lung cancer concluded that individuals receiving homeopathic treatment had better QOL and estimated mean survival times [147]. However, patients in the control group were not randomized because of patient preference, the numbers of patients who received early palliative intervention (which improves survival) were not reported, and the study was stopped early before the planned 300 patients were enrolled because of slow accrual.

Benefit for homeopathic medicine in reducing vasomotor symptoms induced by adjuvant endocrine therapy could not be shown in a randomized, placebo-controlled trial conducted in 299 females with localized breast cancer [148].

In 2015 a comprehensive assessment of evidence by the Australian government's National Health and Medical Research Council concluded that there is no reliable evidence that homeopathy is effective for any health condition, cancer or otherwise [149]. This is due to the many research challenges such as small sample sizes and "individualized" treatments.

OTHER PRACTICES

Relaxation therapy and stress management — Acute stress is a normal physical and emotional reaction that people experience as they encounter changes in life [150], including after a cancer diagnosis, during cancer treatment, and throughout cancer survivorship. Long‐term chronic stress may contribute to or worsen a range of health problems, including digestive disorders, headaches, sleep disorders, depression, anxiety, and other mental health problems [150]. To address stress and induce the relaxation response, stress‐management programs teach techniques like progressive muscle relaxation (PMR), guided imagery, and breathing exercises.

Stress management also typically incorporates elements of cognitive‐behavioral therapy, such as understanding the effects of appraisal and perception on the experience of subjective stress [151]. Participants are taught coping skills and practice various techniques for cognitive reappraisal. One common structured group stress-reduction program studied in oncology is called cognitive‐behavioral stress management [152,153]. There are overlaps in some techniques used in stress management, relaxation, and meditation therapies. For example, meditation, guided imagery, and yoga may be practiced as techniques in isolation or combined. In this review, we distinguish between stress‐management, relaxation, and meditation interventions. Stress‐management interventions include psychoeducation on stress and coping and emphasize cognitive‐behavioral therapy and coping skills training, relaxation interventions typically consist of PMR and guided imagery, and meditation interventions use some form of meditation practice as the focal point of the training.

Techniques – Various techniques can be used to promote relaxation in patients with cancer. The National Center for Complementary and Integrative Health defines relaxation techniques as including PMR, guided imagery, autogenic training, biofeedback, self-hypnosis, and deep breathing exercises [154]:

PMR focuses on the tightening and relaxation of specific, successive muscle groups. This technique can be done actively or passively and involves bringing awareness to each part of the body in a progressive fashion. The relaxation portion of this practice is typically coordinated with therapeutic breathing.

Guided imagery can be self- or practitioner-guided and can assist in the production of relaxing thoughts and emotions through the use of physical relaxation and visualizations.

Guided imagery utilizes recall of pleasant sights, smells, sounds, tastes, or somatic sensations (touch, movements, or positions) to create a positive cognitive and emotional state that can prevent or ameliorate pain or other sources of distress. Guided imagery practitioners use words to create states of focused attention that are thought to alter the experience of pain. Other coping techniques, such as distraction, mental dissociation, muscle relaxation, and controlled abdominal breathing, are also practiced as part of guided imagery.

Two of the most common clinical imagery techniques are mental rehearsal imagery and end-state imagery.

-Mental rehearsal imagery is a technique that is often used to prepare patients for painful treatments or surgical procedures (eg, biopsies). It is primarily used to relieve anxiety, pain, and side effects that are exacerbated by a heightened emotional reaction. Typically, a relaxation strategy is taught to the patients, who are then led through a "guided imagery trip" from the treatment through the recovery period.

During mental rehearsal imagery, it is important to be factual, to avoid emotionally-charged or fear-provoking words, and to reframe the medical procedure in realistic yet positive terms.

-End-state imagery is a technique intended to produce a specific physiologic or biologic change in the body. Its clearest objective is to reduce sympathetic nervous system arousal. End-state imagery has been successfully used to alleviate chemotherapy-induced nausea and to assist in the control of cancer pain.

End-state imagery for the treatment of pain is called analgesic imagery; it is either pain-transforming or pain-incompatible. Pain-transforming imagery concentrates on changing specific aspects of the pain experience, such as the contextual aspect of the painful experience (eg, imagining that the moment the chemotherapy needle touches the skin and before it is inserted, it releases a massive amount of powerful analgesic medication that completely numbs the arm). Pain incompatible-imagery can be used to evoke positive emotions and feelings of relaxation, excitement, or peace that are not compatible with the image of pain.

Autogenic training involves concentrating on physical sensations of warmth, heaviness, and relaxation in different parts of the body.

Biofeedback-assisted relaxation uses electronic devices to monitor and teach control of certain bodily functions, such as breathing or heart rate, to facilitate relaxation.

Self‐hypnosis refers to training patients to induce a hypnotic state, which is a natural state of aroused, attentive, focal concentration along with a relative suspension of peripheral awareness, either on their own or when prompted by a phrase or a cue.

Therapeutic breathing is foundational to relaxation therapies. Initially this is taught by bringing awareness to normal breathing and then developed by practicing abdominal breathing and other breathing techniques such as four-seven-eight breathing. Deep breathing exercises involve the use of slow, deep, and even breaths, sometimes called diaphragmatic or belly breathing.

Training

Relaxation and stress management are usually provided by trained mental health professionals, such as registered/chartered/counseling psychologists, psychiatrists, marital and family counselors, clinical social workers, and nurses. Any of these professions could have specific training in these two modalities.

Typically, the aforementioned professionals would take courses in relaxation training or stress management as part of their training.

Role in cancer care

The 2017 Society for Integrative Oncology (SIO) guideline on integrative therapy in breast cancer, endorsed by American Society of Clinical Oncology (ASCO), came to the following conclusions about the role of relaxation and stress management [66,67]:

-Relaxation is recommended for improving mood disturbance and depressive symptoms.

-Stress management (especially longer group programs) is recommended for reducing anxiety during treatment.

-Relaxation can be considered for reducing anxiety, and as an addition to antiemetic drugs to control nausea and vomiting during chemotherapy.

-Stress management can be considered for improving mood disturbance and depressive symptoms, and for improving quality of life (QOL).

The 2022 joint SIO and ASCO guideline on integrative therapies for cancer pain concluded that guided imagery with PMR may be offered to patients experiencing general pain from cancer treatment [68].

This is discussed in detail elsewhere. (See "Rehabilitative and integrative therapies for pain in patients with cancer", section on 'Relaxation training'.)

Physical activity and nutrition — Physical activity and nutrition are both fundamental to a holistic and integrative approach to supportive cancer care. Both areas have been addressed in guidelines put forward by the American College of Sports Medicine [155], the American Institute for Cancer Research [156], and the American Cancer Society [157].

If consistent with the goals of care, individuals with cancer, including survivors and those with bone metastases, should be supported and encouraged to engage in regular physical activity. Exercise prescription for patients with cancer should follow the standard recommendations as outlined by the International Exercise Guidelines for Cancer Survivors from the American College of Sports Medicine [158].

Specific recommendations for exercise as supportive intervention in cancer care are provided separately:

(See "Cancer-related fatigue: Treatment", section on 'Exercise'.)

(See "Prevention and treatment of chemotherapy-induced peripheral neuropathy".)

(See "Overview of therapeutic approaches for adult patients with bone metastasis from solid tumors", section on 'Exercise'.)

(See "Side effects of androgen deprivation therapy", section on 'Role of structured exercise'.)

(See "The roles of diet, physical activity, and body weight in cancer survivors".)

Tai chi/qigong — Tai chi (also known as taiji or tai chi chuan) is a form of mind-body exercise that originated in China and involves martial arts, meditation, and dance-like movements that focus on the mind and body connection (movie 1). (See "Exercise for adults: Terminology, patient assessment, and medical clearance", section on 'Common types of exercise'.)

Tai chi is a subset of qigong, which is a form of ancient and traditional Chinese medicine that integrates movement (physical postures), meditation (focused attention), and controlled breathing [159]. The word qigong consists of two Chinese words: qi (chee), meaning life force or vital energy that flows through all things in the universe, and gong (gung), meaning accomplishment or skill that is cultivated through steady practice [160]. Qigong practices are used to increase, circulate, and store qi, which is used to cleanse and heal the body. Practices range in intensity from the gentle movements of tai chi to the more vigorous practice of kung fu [160].

Training, licensing, credentialing – Various tai chi and qigong organizations offer training and certification programs with differing criteria and levels of certification for instructors. There is no formal licensing for tai chi or qigong instructors and the practice is not regulated nationally or by individual states, provinces, or territories. There is no national standard for certification, although efforts to develop accreditation standards are ongoing [161].

Role in cancer care

Tai chi – Several trials in non-cancer patients suggest benefit for tai chi in reducing depression and anxiety, improving QOL, reducing pain and disability in individuals with low back pain and fibromyalgia, and decreasing the risk of falls in older adults. (See "Complementary and alternative treatments for anxiety symptoms and disorders: Physical, cognitive, and spiritual interventions", section on 'Tai chi' and "Complementary and alternative therapies for rheumatic disorders", section on 'Others' and "Falls: Prevention in community-dwelling older persons", section on 'Exercise'.)

Among patients with cancer and cancer survivors, multiple systematic reviews and meta-analyses have been conducted on the benefits of tai chi for reducing symptom burden, many of which focus on patients with breast cancer. Most (but not all [162,163]) suggest benefit for a variety of symptoms, including fatigue and insomnia, as well as improvements in QOL [164-171]. However, the quality of these analyses, as well as the included trials, has been called into question [165]. Furthermore, others have noted that the benefits of mind-body therapies such as tai chi may not be evident in trials that used an active control arm as a comparator [172].

Tai chi is generally safe [173], but may be associated with minor musculoskeletal aches and pains.

Qigong Multiple systematic reviews and meta-analyses of qigong in cancer patients have been performed, most of which conclude that there is a modest benefit in reducing anxiety, fatigue, sleep disturbance-related symptom clusters, and pain; and improving physical and emotional balance [164,166,169-171,174-180]. As an example, in one systematic review of 22 studies (1283 participants with various cancers), a 3- to 12-week qigong intervention was associated with significant improvements in cancer-related fatigue, sleep difficulty, depression, and overall QOL [164].

However, as with tai chi, concerns have been raised as to what control group is appropriate for randomized trials examining the benefits of qigong [181]. The benefits of mind-body therapies such as qigong may be more difficult to demonstrate in trials that used an active control arm as a comparator [172].

Comparator studies with other CIM modalities There is a general lack of comparator trials of tai chi/qigong versus other "mind and body" complementary and integrative medicine (CIM) practices such as yoga or mindfulness-based stress reduction (MBSR). (See 'Yoga' above and 'Meditation and mindfulness-based stress reduction' above.)

Information is expected from the multisite, rigorously performed Canadian randomized MATCH (Mindfulness And Tai chi for Cancer Health) trial [182,183], in which cancer survivors with a preference for either MBSR or tai Chi/qigong will get their preferred intervention; while those without a preference will be randomized into either of the two interventions.

SUMMARY

Definitions

As defined by the , and the National Cancer Institute, "complementary medicine" is used along with standard care; in the setting of oncology, this is often considered supportive care. By contrast, "alternative medicine" is the use of nonstandard treatments in lieu of standard medical care; in the oncology setting, these are often nonevidence-based cancer treatments. "Integrative medicine" refers to an approach that combines evidence-based complementary therapies with standard medical care. (See 'Definitions' above.)

"Integrative oncology" is a patient-centered, evidence-informed field of cancer care that utilizes mind and body practices, natural products, and/or lifestyle modifications from different traditions alongside conventional cancer treatments. Integrative oncology aims to optimize health, quality of life (QOL), and clinical outcomes across the cancer care continuum and to empower people to prevent cancer and become active participants before, during, and beyond cancer treatment.

Frequency and reasons for use

The use of complementary, alternative, and integrative medical (CAIM) therapies by patients with a history of a cancer diagnosis is common.

CAIM therapies may be used to promote overall health and wellness, mitigate cancer-related symptoms, as supportive care during cancer treatment to mitigate side effects, during survivorship care to address late effects of cancer treatment, and to improve overall QOL during the continuum of cancer care, including end-of-life care. (See 'Epidemiology' above.)

Discussing CAIM with patients

All patients with cancer should be asked about CAIM use throughout the course of their treatment/survivorship to ascertain what they are using, who is directing the therapy (eg, self or practitioner/provider), and their reasons for use of specific forms of CAIM. Clinicians will then be able to assess the patient's goals of therapy, whether the approach/modality is known to be effective or risky, whether the specific approach is helpful, whether there are adverse effects, and if there are other known therapies that might be equally or more effective. The risk to benefit ratio of each CAIM approach should be addressed. (See 'Discussing CAIM with patients' above.)

Oncology healthcare providers can use published clinical practice guidelines to inform their approach to discussing and documenting CAIM therapies with their patients.

Potential risks/harms – There are three distinct issues related to potential risks and harms of CAIM use (see 'Potential risks and harms of caim use' above):

Direct toxicity or injury resulting from the CAIM therapy.

Potential interactions with conventional treatment.

Possible delay in receipt of effective conventional therapy or treatment due to use/pursuit of "alternative" therapy, or due to conflicting belief systems.

Specific complementary/integrative medicine (CIM) practices

CIM practices encompass a wide variety of practices and therapies, some of which involve "self-care," (eg, purchasing herbal tea at the grocery store, or buying a dietary supplement online), and others involve the care of a specifically trained and often licensed health care provider or practitioner.

-The above sections outline specific mind and body practices (eg, acupuncture, meditation/mindfulness-based stress reduction, massage therapy, manual lymphatic drainage, hypnosis, yoga, music therapy, reiki), as well as traditional and whole medical systems (ie, traditional East Asian medicine, chiropractic, naturopathic medicine, homeopathy) used for CIM that require specific training for the practitioner. (See 'CIM practices that require specialized training' above.)

-Other mind-body CIM practices include relaxation and stress management, physical exercise, and tai chi/qigong. (See 'Other practices' above.)

ACKNOWLEDGMENT — The editorial staff at UpToDate would like to acknowledge Kathleen Sanders, ARNP-BC, MPH, who contributed to the development of this topic review.

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Topic 2831 Version 64.0

References

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