Jun J. Mao, MD, MSCE, on Updated Pain Management Guidelines for Cancer Care

Jun J. Mao, MD, MSCE, chief of the Integrative Medicine Service at Memorial Sloan Kettering Cancer Center in New York, New York, and past-president of SIO

A joint guidance from the Society for Integrative Oncology (SIO) and the American Society of Clinical Oncology (ASCO) was recently released regarding pain management for an integrative care approach to treating patients with cancer.¹ These updated guidelines were created for physicians to better guide their patients with cancer on the management of pain related to their disease.

The panel consisted of clinicians from multidisciplinary settings and reviewed literature pertaining to pain management in patients with cancer. A total of 227 relevant studies were used to form the basis of the guidelines. These new recommendations focus on pain intensity, symptom relief, and adverse effects.

CancerNetwork^® recently spoke with Jun J. Mao, MD, MSCE, chief of the Integrative Medicine Service at Memorial Sloan Kettering Cancer Center in New York, New York, and past-president of SIO, a strategic alliance partner of CancerNetwork^®. In the interview, Mao spoke about the updated guidelines, how to implement these into practice, and how clinicians can begin building relationships with others who specialize in these integrative approaches.

“Our guidelines for pain management are not meant [to suggest use of] acupuncture and massage to cure cancer. It’s more serving as an adjunctive role to help [patients with] cancer, and it will require all the disciplines to come together with a singular goal to serve the patient,” said Mao.

CancerNetwork^®: What were the updated recommendations?

Mao: This is a the joint clinical guideline from the Society for Integrative Oncology and the American Society of Clinical Oncology [discussing] integrated medicine for pain in patients with cancer. A major take-home point for breast cancer survivors experiencing aromatase inhibitor–related joint pain is that acupuncture should be recommended. This is based on several smaller studies and, most importantly, [the S1200 trial (NCT01535066)] involving 227 patients recruited from the SWOG Cancer Research Network showing that acupuncture produced statistically significant and also clinically meaningful benefits compared with sham acupuncture and usual care.² This type of joint pain is very common for women with breast cancer who are receiving aromatase inhibitors, which not only decrease the quality of life but can also cause many women to stop life-saving drugs that can potentially make their cancer come back. Having acupuncture as an additional tool is important for symptom control, quality of life, and well-being for breast cancer survivors. It’s also important because this month is Breast Cancer Awareness Month.

The second recommendation is that acupuncture can be recommended for general cancer pain [management]. This was based on several systematic review meta-analyses and also a large, randomized control trial conducted by my group [SIO] which involved 360 cancer survivors with chronic musculoskeletal pain.³ We demonstrated 2 types of acupuncture and showed electroacupuncture and auricular acupuncture both reduced pain, improved functions and quality of life, and reduced medications. Many of the improvements also persisted for months after the treatment finished, demonstrating acupuncture is not only effective but also the 2 main effects were durable.

The third recommendation is an important take-home point that includes massage which can be used for patients with advanced cancer [undergoing] palliative care in the hospice setting. There are numerous small studies, but the largest study involved over 300 patients and is published in the journal Annals of Internal Medicine.⁴ Relative to control, massage has improved pain control and poor quality of life. For patients living with advanced cancer, it is an incredibly challenging situation for both patients and caregivers. Acute massage can be a useful tool in the study.

Last but not least, many cancer diagnoses and procedures can be quite painful, such as a bone marrow biopsy. Hypnosis has demonstrated efficacy and may be recommended for biopsy or painful procedures to reduce acute pain. This set of clear recommendations is helpful to guide both physicians as well as patients to choose evidence-based interventions. However, we do not have clear evidence. Some of the evidence is inconclusive for mind-body treatments as well as for pain in children with cancer. Furthermore, many patients with cancer are interested in taking herbs, either orally or applied to their bodies, to help mitigate pain. Unfortunately, after an exhaustive search, we did not see a large, randomized control trial to support the use of herbs to treat pain in patients with cancer. Clearly, these are the gaps in research and require further rigorous research to build the evidence base.

When working on the updated guidelines, why was it important to have a multidisciplinary team involved?

What makes these guidelines very special is we have a team of 20 experts. I’m an integrative medicine specialist and my co-chair is Eduardo Bruera, MD, FAAHPM, who is chair of palliative care [at the University of Texas MD Anderson Cancer Center]. There’s a lot of synergy between integrative oncology and palliative care because we all partake in managing symptoms and support patients with cancer, regardless of their cancer journey. Also in our panel, we not only have integrative medicine physicians but also medical oncologists, radiation oncologists, surgical oncologists, a palliative care specialist, a psychosocial oncologist, and also a patient advocate. In addition, we also have international representatives because for these types of guidelines to have a balanced view and to ultimately be disseminated and hopefully implemented in diverse oncology settings, we need to have different perspectives to help us to weigh the benefit against the risks and appropriately assess the evidence base.

What populations will benefit from these updated guidelines on how to manage pain?

Some of the recommendations such as the use of acupuncture for general cancer pain and massage use in the advanced cancer setting are not limited to patients with breast cancer. This is our general recommendation for patients with solid or liquid tumors. There are potentially many applications for helping patients with cancer manage pain in the context of their conventional pain management.

How can clinicians begin to implement these guidelines into practice?

The first thing that is important for clinicians to know about are the basics of acupuncture. Acupuncture originated from traditional Chinese medicine and it has been around for about 2500 years. We use very thin, sterile, solid needles and put them in specific areas of the body to help to address symptoms and promote a sense of wellbeing. Often patients require a series of treatments, between 6 to 10, to see the initial benefit. However, the beneficial effects of acupuncture continue months after the course of treatment is finished. For clinicians to talk to patients about what the therapy is and what the evidence is [will be the most helpful in uptake]. Many people know what massage is, but oncology massage is not only manipulating the fascia, the muscle, the skin, and the tissue through touch, but also takes into consideration the patient’s cancer status.

In addition to massage techniques, there are some gentle techniques of the extremities, in the legs and hands, to help to induce a more general relaxation response in addition to localized pain management. It’s important for clinicians who see patients with pain to not just have a knee-jerk reaction and prescribe drugs. They need to consider what patients want and refer patients [to other specialties]. We did a study [on patients with breast cancer] that found when there is a choice between pain medications and acupuncture, about 27% of patients prefer exclusive acupuncture, 26% prefer exclusive drugs, and about 40% don’t have a clear preference.⁵ Clearly, understanding patient preferences and incorporating evidence is important for patient-centered care.

Another aspect is for clinicians to connect with acupuncturists or massage therapists within their health systems. These therapies are now much more available in places like comprehensive cancer centers and even in local hospitals. They often do have acupuncture massage services, but it does require the oncology physicians to build those networks for their own patient panel. For our community oncologists, often if they are practicing outpatient ambulatory care, there may not be a massage therapist in their office. They could consider building relationships with acupuncturists or massage therapists who are like-minded and want to support patients with cancer in a safe and effective way. This is an important [area to focus on and] to build that team for the patients. Acupuncturists and massage therapists need to take additional training to understand what typical and conventional cancer treatments are and what they can or cannot do. We want to make sure they’re evidence-based. Our guidelines for pain management are not meant to use acupuncture and massage to cure cancer. It’s more serving as an adjunct role to help [patients with] cancer, and it will require all the disciplines to come together with a singular goal to serve the patient.

Are any other guidelines currently under advisement?

SIO and ASCO have this collaboration to create more guidelines. Patients with cancer experience a lot of symptoms, physically and emotionally, and require careful guidance. One of the guidelines currently underway is for anxiety and psychological distress. Another guideline that is forthcoming is for cancer-related fatigue. Those are important guidelines to help to guide clinicians to recommend evidence-based integrative approaches, as well as identify where the research gap is, and to pave the way for more rigorous research to be conducted.

References

1. Mao JJ, Ismaila N, Bao T, et al. Integrative medicine for pain management in oncology: Society for Integrative Oncology–ASCO guideline. J Clin Oncol. Published online September 19, 2022. doi:10.1200/JCO.22.01357
2. Hershman DL, Unger JM, Greenlee H, et al. Randomized blinded sham- and waitlist-controlled trial of acupuncture for joint symptoms related to aromatase inhibitors in women with early stage breast cancer (S1200). Cancer Res. 2018;78(suppl 4):GS4-04. doi:10.1158/1538-7445.SABCS17-GS4-04
3. Mao JJ, Liou KT, Baser RE, et al. Effectiveness of electroacupuncture or auricular acupuncture vs usual care for chronic musculoskeletal pain among cancer survivors: The PEACE randomized clinical trial. JAMA Oncol. 2021;7(5):720-727. doi:10.1001/jamaoncol.2021.0310
4. Kutner JS, Smith MC, Corbin L, et al. Massage therapy versus simple touch to improve pain and mood in patients with advanced cancer. Ann Intern Med. 2008;149(6):369-379. doi:10.7326/0003-4819-149-6-200809160-00003
5. Bao T, Li SQ, Dearing JL, et al. Acupuncture versus medication for pain management: a cross-sectional study of breast cancer survivors. Acupunct Med. 2018;36(2):80-87. doi:10.1136/acupmed-2017-011435