Complementary, Alternative, and Integrative Therapies in Oncology
M. Jennifer Cheng
Daniel L. Handel
Complementary and alternative medicine (CAM) includes a group of diverse medical and health care systems, practices, and products that are distinct from conventional medical modalities and used in conjunction with (complementary) or in lieu of (alternative) standard biomedical management (1,2). The use of CAM in the United States has substantially increased since the 1990s. The National Center for Health Statistics reported in 2008 that 38% of Americans use some form of CAM, reflecting CAM’s continued popularity through the past decade (3).
The use of CAM among people with cancer is particularly common, with up to 54% of patients initiating CAM after cancer diagnosis (4) and up to 80% of all cancer patients using some form of CAM during the course of their disease (5,6). A recent analysis by Mao et al. of the 2007 National Health Interview Survey shows that cancer survivors are more likely to use CAM than the general population. The researchers find that 65% of cancer survivors have used CAM in their lifetime; in contrast, only 53% of the non-cancer respondents used CAM in their lifetime (7).
While used in the same acronym, a distinction must be made between complementary and alternative therapies. Alternative therapies are used instead of mainstream treatments. There has not been convincing evidence to date of the effectiveness of alternative cancer treatments. On the other hand, complementary therapies complement mainstream oncologic treatments, and there is growing research supporting their safety and efficacy.
Patients are increasingly seeking holistic cancer care that is tailored to the unique needs of the individual. This trend has fueled the establishment of the field of Integrative Oncology in 2000, which interweaves conventional and evidence-based complementary therapies in oncology (5). Complementary therapies usually serve as adjuncts to mainstream cancer treatments to enhance well-being and selfempowerment (4,8), manage cancer and cancer treatment symptoms, and provide survivor care (9,10). There is limited evidence that CAM therapies might improve immune system function (11); however, there is not yet strong evidence for improved survival from this effect (12).
This chapter will review various modalities of complementary therapies in integrative oncology: mind-body interventions (hypnosis, relaxation therapies, meditation/mindfulness-based stress reduction (MBSR), biofeedback, yoga, and creative therapy), energy therapies (Reiki, healing/therapeutic touch), manipulative and body-based methods (chiropractic, massage therapy, exercise, Qigong, and Tai Chi Chuan), acupuncture, and biologically based therapies (herbs and vitamins). The biologically based therapies section also examines specific phytochemicals and vitamins that are under investigation for cancer prevention, cancer treatment, and symptom management.
MIND-BODY INTERVENTIONS
Mind-body interventions utilize the interactions among the brain, mind, body, and behavior and are defined by the National Institutes of Health Center for Complementary and Alternative Medicine as “a variety of techniques designed to enhance the mind’s capacity to affect bodily function and symptoms” (13,14). For the purposes of this chapter we will limit our discussions to select the better studied mind-body interventions, reviewing their characteristics and recommendations for use.
Hypnosis
In 1985, Kihlstrom (15) defined hypnosis as “a social interaction in which one person, designated the subject, responds to suggestions offered by another person, designated the hypnotist, for experiences involving alterations in perception, memory, and voluntary action”. Hypnosis allows for a highly relaxed state in which the patient’s conscious and unconscious mind is open to therapeutic suggestions (13).
Hypnosis has been well researched in randomized clinical studies as treatment interventions for outcomes in controlling chronic pain including alleviating cancer-related pain (16,17,18); improving acute and procedural pain in adults and children including procedures such as bone marrow aspiration, lumpectomy/breast cancer surgery, and vascular access procedures (19,20); alleviating stress, anxiety, and depression in breast cancer surgery patients and terminally ill cancer patients (21,22); improving anticipatory nausea and vomiting in children and adults receiving chemotherapy use (23,24,25); and reducing frequency and intensity of hot flashes among breast cancer survivors (26). Some studies support the use of self-hypnosis in the medical setting, where brief training sessions that build self-hypnosis skills result in improved clinical outcomes, coupled with increased sense of mastery and self-control (27,28).
Self-hypnosis has also been utilized in conjunction with other complementary therapies. In a 1989 prospective study by Spiegel et al. published in The Lancet, women with metastatic breast cancer are randomly assigned to the intervention
or control groups. Intervention includes 1 year of group therapy led by a psychiatrist or social worker with a therapist, and self-hypnosis training for pain control. At 10-year follow-up, there was significantly improved survival in the intervention group, with a mean survival of 36.6 months compared with 18.9 months in the control group, (29). However, subsequent multicenter randomized clinical trials (RCTs) did not replicate the survival benefit found by Spiegel et al. This may be due to the innovations in breast cancer treatment subsequent to Spiegel’s publication, including selective estrogen receptor modulators and earlier detection of breast cancer through routine cancer screening. However, all of these studies demonstrate improvements in quality of life and reductions in distress and pain among women utilizing self-hypnosis and group support strategies (30).
or control groups. Intervention includes 1 year of group therapy led by a psychiatrist or social worker with a therapist, and self-hypnosis training for pain control. At 10-year follow-up, there was significantly improved survival in the intervention group, with a mean survival of 36.6 months compared with 18.9 months in the control group, (29). However, subsequent multicenter randomized clinical trials (RCTs) did not replicate the survival benefit found by Spiegel et al. This may be due to the innovations in breast cancer treatment subsequent to Spiegel’s publication, including selective estrogen receptor modulators and earlier detection of breast cancer through routine cancer screening. However, all of these studies demonstrate improvements in quality of life and reductions in distress and pain among women utilizing self-hypnosis and group support strategies (30).
Relaxation Therapies
Beginning in the early 1900s with Jacobson’s progressive muscle relaxation technique (31), many relaxation techniques have evolved, such as jaw relaxation, focused breathing, and abdominal breathing, that aim to engender a state free of mental and/or physical tension (13).
A literature review by Kwekkeboom et al. found six studies where relaxation was implemented as the key intervention in treating two or more symptoms in the pain-fatigue-sleep disturbance cancer symptom cluster. Pain benefit was demonstrated in three of the four studies in which it was the key outcome. Other cancer-related symptoms mitigated by relaxation intervention include physical tension and sleep (32). Populations studied include hospitalized patients with cancer pain, outpatients with chronic cancer pain, and women with early-stage breast cancer. While symptoms generally improved compared with no treatment group, results have not been consistent (33).
Guided Imagery
Guided imagery engages the imagination in creating a sensory experience to achieve a specific clinical outcome (34). Imagery is often utilized with other mind-body techniques such as relaxation techniques and music therapy.
Guided imagery is one of the mind-body modalities recommended by the National Comprehensive Cancer Network for treatment of anticipatory nausea and vomiting. In one study, guided imagery with music therapy was found to improve the quality of life and mood disturbance in cancer survivors (35). Mood and quality of life improved significantly in the guided imagery group as well as the progressive muscle relaxation group compared with usual care in an RCT of 56 participants with advanced cancer receiving palliative care at home (36). While studies evaluating the use of guided imagery in participants receiving chemotherapy did not find significant improvements in nausea and vomiting prior to and hours to days after chemotherapy, there have generally been significant improvements in emotional response and anxiety during chemotherapy treatment associated with the use of guided imagery (37,38).
Only six RCTs compared imagery alone with a no treatment or another active intervention group. In general, imagery alone is more effective than no treatment in improving symptoms of depression, anxiety, pain, and quality of life. Its effects are generally comparable to other mind-body techniques such as hypnosis or relaxation (34,35). However, more stringently designed clinical trials are needed, as current studies lack explicit descriptions of the intervention procedures, duration, and outcome measures.
Meditation/Mindfulness-Based Stress Reduction
Meditation is a family of techniques with the goal of training the mind to focus on a single target perception to realize an ultimate benefit. While purported to have its origin from Eastern traditions, many religious and spiritual traditions have developed their own meditative practices. The most well-studied meditation technique is the MBSR, a secular meditation technique developed by Jon Kabat-Zinn and colleagues with its roots in Buddhist Vipassana and Zen practices (39). The primary goal of mindfulness meditation to complete engagement in the present moment experience with a nonjudgmental attitude of acceptance and patience— without ruminations about prior or future experience. Through this training, one develops a nonreactive awareness even during stressful situations (40).
MBSR is a well-defined patient-focused intervention typically offered in 7 to 10 weekly group sessions, each lasting for 1 to 1.5 hours. Breast and prostate cancer patients are the oncology populations most studied in MBSR intervention. Most interventions are one-group pretest-posttest design and generally demonstrate improvements in mood and stress (41), quality of life (42), cytokine production (42), sleep quality (43), coping styles, decreases in helplessness-hopelessness (44), and pain. Speca’s prospective, randomized, treatment controlled trial demonstrated significant decreases in overall symptoms of stress, depression, anxiety, anger, and confusion following a mindfulness meditationbased stress reduction program in cancer outpatients with various stages of disease. A study by Carlson et al. demonstrated improvements at 1 year following MBSR interventions in quality of life and stress symptoms. This study also found clinical and lab evidence consistent with reductions in the stress response, including hormonal, immunological, and vascular parameters (42,45).
Mindfulness-based cognitive therapy, a refinement of MBSR, focuses on the ruminative processes in major depression and recently has been evaluated in effectiveness for individuals with variety of cancer diagnoses. Preliminary evidence suggests improvement in depression and anxiety.
Overall, meta-analysis demonstrates that MBSR is effective in oncology populations for psychological stressors, with more modest effect sizes for physiological measurements and physical health measures. Larger RCTs are needed to fully determine the efficacy of mindfulness in oncology.
Yoga
The practice of yoga originates from Eastern traditions. The word yoga is derived from the Sanskrit root yuj, meaning to bind, join, and yoke. The goal of yoga is to strengthen the union between mind, body, and spirit through ethical disciplines, physical postures, and spiritual practices (13,46). Listed in Table 61.1 are various styles of yoga and corresponding clinical studies assessing its effectiveness in symptom management among cancer patients (13,46,56).
Overall, there has been preliminary positive evidence supporting the use of yoga through single-arm pilot trials and small-scale RCTs. Data suggest improved overall quality of life, emotional well-being, mood, hot flashes, spiritual well-being, and sleep (Table 61.1). Larger clinical trials are underway or have recently been completed. For example, the first nationwide, multisite, phase II/III RCT led by Mustain et al. has recently been completed with promising results. The National Cancer Institute is sponsoring a large phase III, three-arm clinical study comparing yoga, meditation, and simple stretching in radiation therapy patients with stage zero to III breast cancer.
Biofeedback
Biofeedback enables an individual to learn how to change physiologic functions by measuring these activities and providing real-time “feedback” to patients in order to facilitate changes in behavior, emotions, and cognition. Physiologic measures can include brainwaves, heart function, breathing, muscle activity, and skin temperature. The goal is for the physiologic changes to persist without the need for an instrument (57).
A small randomized control study in advanced cancer patients demonstrates reduction in cancer-related pain using electromyography biofeedback-assisted relaxation over a 4-week period. The mechanism of action is thought to be associated with attenuation of physiologic arousal (58).
The study of audio-visual feedback in respiratory-gated radiotherapy for lung cancer patients by George et al. assesses the effect of 5 weekly breath-training sessions with a goal of improved compliance during radiotherapy. Within each session the patients initially breathed without any instruction (free breathing), then with audio instructions, and finally with audio-visual biofeedback. Audio-visual biofeedback significantly reduces residual motion compared with free breathing and audio instruction (59). However, results in biofeedback have not been consistent. Bladder ultrasound biofeedback training did not produce a reproducible increase in bladder filling in prostate cancer patients during pelvic tumor irradiation (60).
Biofeedback is often used in conjunction with other integrative techniques. For example, a model for social work teaches cancer patients and their relatives ways of coping through a combination of cognitive behavioral intervention, relaxation methods with guided imagery, and biofeedback (61).
Creative Therapies
Creative therapies are a group of creative processes that aim to enhance individuals’ physical, mental, and emotional well-being. This category includes visual arts, music therapy, creative writing, and mixed-modality programs. Music therapy is one of the best studied creative therapies in the literature.
Music therapy in its strictest definition is provided by professional musicians trained at the university level whose training includes music theory, psychology, supervision, and personal psychotherapy (62). In recent years, the definition has broadened to include listening to pre-recorded music offered by medical staff.
In a descriptive review written by Gallagher from the Cleveland Clinic Arts and Medicine Institute, music therapy can be used throughout the spectrum of the cancer care process, including palliation, hospice, the active dying process, and bereavement. Common interventions include instrument playing, lyric analysis, musical entrainment, musicassisted relaxation, musical life review, music listening (live or recorded), participation (i.e., clapping, humming, and tapping foot), planning funeral music, singing, song-writing, and verbal processing (63).
A Cochrane review by Bradt et al. in 2011 examines the effects of music intervention on physical and psychological outcomes in cancer patients. The review includes all randomized controlled trials and quasi-randomized trials—30 trials with a total of 1,891 participants are included. The results suggest that music interventions may have beneficial effects in people with cancer, including quality of life and symptoms such as mood, anxiety, and pain. No strong evidence is found for improvements in fatigue, physical status, or depression. Authors conclude that the systematic review suggests beneficial effects of music therapy in aforementioned outcome, but caution that these trials are at high risk for bias (64).
Art therapy is another creative therapy modality commonly utilized by cancer patients; however, there is currently a dearth of controlled empirical studies evaluating this intervention. A literature review by Geue et al. in 2010 identifies 17 papers evaluating the effectiveness of using painting/drawing intervention for adult cancer patients. Nine out of the 17 papers are quantitative papers with two studies using randomization, the rest are qualitative studies. The sample sizes range from 7 and 70 participants with considerable variation in the structure and content of interventions. Results are generally positive, revealing decreases in anxiety and depression, increases in quality of life, and positive effects on personal growth, coping, and social interactions (65). More systematic evaluations are needed in this fertile field.
Acupuncture
Acupuncture is considered to be a part of mind-body medicine, but it is also considered a component of energy medicine, manipulative and body-based practices, and traditional Chinese medicine (66). Acupuncture involves the insertion
of fine needles into predefined meridian acupuncture points to relieve symptoms and improve disease processes. The World Health Organization reports 28 diseases, symptoms, and conditions for which evidence from controlled trials suggests benefit from acupuncture (67).
of fine needles into predefined meridian acupuncture points to relieve symptoms and improve disease processes. The World Health Organization reports 28 diseases, symptoms, and conditions for which evidence from controlled trials suggests benefit from acupuncture (67).
TABLE 61.1 Various styles of yoga with corresponding clinical studies in symptom management among cancer patients | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Capodice’s (68) review of the evidence supports the use of acupuncture in oncologic settings for pain, xerostomia, and fatigue (Table 61.2). Stone and Johnstone (80) further discuss the evidence behind acupuncture use in peripheral neuropathy, post-surgical pain and dysfunction, joint pain from aromatase inhibitors, cancer-related fatigue, and hyperemesis associated with chemotherapy.
The strength of the evidence supporting acupuncture use varies, with randomized controlled trials available for postoperative pain in head and neck cancer patients (81), fatigue (82,83), hyperemesis (84), xerostomia (85), and aromatase inhibitor-induced arthralgias (86).
Lu and Rosenthal (87) discuss safety considerations in acupuncture use and recommend against acupuncture use in the following conditions: absolute neutrophil count <500/µL; platelet count <25,000/µL; altered mental state; clinically significant cardiac arrhythmias; and other unstable medical conditions evaluated on a case-by-case basis.
ENERGY HEALING
Energy healing techniques include a group of therapies where the healer transfers and/or channels energy from an external source through their hands to the patient. Among the more commonly used energy healing are Reiki, therapeutic touch, and healing touch.
Reiki was developed in Japan by Mikao Usui in 1922 and brought to the West in 1938. It is widely practiced in the United States. Reiki is a Japanese word for “spirit-guided life energy” (88) and is administered through gentle touch with hands placed on or near the recipient’s body. Energy is thought to be channeled to the patient. The benefits from Reiki and other healing touch therapies are proposed to derive from improved flow of life energy (chi) that is associated with achieving and maintaining good health. According to a 2007 National Health Interview Survey, 1.2 million adults and 161,000 children in the United States received one or more sessions of energy healing such as Reiki during the year 2006 (89).
The 2010 scientific review of Reiki by Baldwin et al. reveals 26 peer-reviewed Reiki articles, including 7 qualitative and 19 quantitative trials. In total, 11 (42%) of the 26 studies are categorized as “weak” and 8 (30%) as “very good” to “excellent.” The eight studies classified as “very good” to “excellent” published between 2001 and 2009 suggest improved quality of research in Reiki with time. Most weaknesses relate to experimental design such as lack of blinding, small sample size, lack of controls, lack of standardization of Reiki treatments within study, and lack of information about participants (such as gender, age, and race). The articles classified as “very good” or “excellent” provide mixed results for using Reiki as a healing modality. Additional studies with robust study designs are encouraged to further elucidate the role and benefit of Reiki specifically for cancer patients (88).
A systematic review by Agdal et al. (90) of the use of energy healing in cancer patients in 2011 identifies a total of six quantitative and two qualitative studies in which practitioners explicitly intend to direct energy to the cancer patient for therapeutic purpose without the use of other technical devices, remedies, or massage. Studies utilizing prayer or ritual healing interventions are not included in this review, although there is acknowledged similarity between these modalities and energy healing.
Positive marginal to moderate effects of energy healing are found on pain, fatigue, well-being, and quality of life. There are mixed results concerning anxiety, physical indicators, and medication use for symptom management.
Methodological weaknesses such as lack of or inadequately described blinding process, modest sample size, self-selection, and sparse descriptions on the interaction between practitioner and patient limit the interpretation of many studies in energy healing. Lack of documented working mechanisms makes it a challenge to design sham treatments that do not activate the same working mechanism as the intervention. Thus far, the differences between intervention and sham treatments are small and patient expectation may be a large factor influencing outcome (91,92). It cannot be excluded that the so-called placebo effects may be an integral part of energy healing and other therapies. Psychosocial processes should be taken into account and explored, rather than dismissed. Additional validated spiritual healing outcome tools will hopefully improve the reliable measurement of efficacy in energy healing techniques (93).
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