IM for pain in oncology 2022

Inspired by Mao et al 2022.[1]

Photo by Yan Krukov on

IM – integrative medicine
SIO – Society for Integrative Oncology
ASCO – American Society of Clinical Oncology
MSKCC – Memorial Sloan Kettering Cancer Center
AI – aromatase inhibitor (eg letrozole – used to suppress endogenous oestrogen production in women with oestrogen sensitive cancers)
CIPN – chemotherapy induced peripheral neuropathy
RCT – randomised controlled trial
SR – systematic review
AMSTAR – A MeaSurement Tool to Assess systematic Reviews

key to acronyms

This guideline was published online in the Journal of Clinical Oncology (JCO) earlier this month. JCO is an ASCO journal with an impact factor of over 50, so this guideline will certainly draw significant attention.

The guideline was a joint venture of SIO and ASCO. SIO was established by Dr Barrie Cassileth in 2003 when she was the founding chief of the MSKCC Integrative Medicine Service. This was the same year that the BMAS launched its palliative care course under the guidance of Dr Jacqueline Filshie, who had been consistently using acupuncture in a cancer pain population at the Royal Marsden Hospital since the early 80’s.[2–6]

227 studies were identified as relevant to this guideline, and acupuncture had top billing with a ‘should be recommended’ for aromatase inhibitor (AI) related joint pain. I was interested to see that yoga received a ‘may be offered’ recommendation for the same indication.

Acupuncture also got top billing in general cancer pain or musculoskeletal pain, followed by reflexology or acupressure, massage, Hatha yoga, and guided imagery with progressive muscle relaxation. These were all ‘may be offered’ recommendations, so not as strong a recommendation as for acupuncture in AI related joint pain.

Acupuncture and reflexology or acupressure were given a weak recommendation in CIPN. I was a little surprised that this was not a stronger recommendation, but I guess the volume of evidence has not yet grown sufficiently for this indication. I have been watching the evidence for several years now and successfully treated a number of patients, so it seems to me that there is nothing to lose. I have devoted or mentioned CIPN research in 5 blogs over the last 4 years, and the most recent one reviewed research that demonstrated quite convincing objective improvements in nerve function.

Hypnosis was first to be mentioned for procedural pain followed by acupuncture or acupressure and then music therapy. As I consider this, I cannot help imagining that we should really be combining all three in routine practice as far as possible. Since attending a short course on medical hypnosis a few years ago I have become much more aware of the opportunities to use suggestion without any formal hypnotic induction procedure when treating patients in a clinical setting, and I invariably have music playing quietly in the background during my clinics.

The final recommendation is for the use of massage for pain during palliative care. This was a ‘may be offered’ recommendation of moderate strength supported by intermediate quality evidence.

The guideline also listed interventions with insufficient or inconclusive evidence. One example here is the use of honey for oral mucositis, for which there were already 19 RCTs.

The guideline includes a useful treatment algorithm summarising the positive recommendations and an extensive supplement to the paper includes details of all the 227 studies organised by intervention and indication.

An overview of SRs of acupuncture for cancer-related conditions has also been published this month.[7] It is published in the journal Phytomedicine, which we have discussed recently here. The last author is a well-known name in field of evidence-based medicine in China, so I guess it is a useful summary, but unfortunately, I do not have access to the full text.

They include 51 SRs, of which 16 were assessed as having a low risk of bias, but only one was rated as ‘high’ in terms of methodological quality using AMSTAR 2. The authors conclude:

Evidence from SRs showed that acupuncture is beneficial to cancer survivors with cancer-related pain, fatigue, insomnia, improved quality of life, nausea and vomiting, bone marrow suppression, menopausal symptoms, arthralgia, and dysphagia, and may also be potential for lymphoedema, gastrointestinal function, and xerostomia. For neuropathy, depression and anxiety, acupuncture should be used as an option based on individual conditions. Acupuncture is relatively safe without serious adverse events. More well-designed clinical trials of acupuncture are recommended on cancer-related depression and anxiety, arthralgia, xerostomia, gastrointestinal dysfunction and dysphagia.


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 2022;:JCO2201357. doi:10.1200/JCO.22.01357

2          Filshie J. Acupuncture for Malignant Pain. Acupunct Med 1984;2:12–4. doi:10.1136/aim.2.1.12

3          Filshie J, Redman D. Acupuncture and malignant pain problems. Eur J Surg Oncol 1985;11:389–94.

4          Filshie J. Acupuncture for Malignant Pain. Acupunct Med 1986;3:29–29. doi:10.1136/aim.3.1.29

5          Filshie J. The non-drug treatment of neuralgic and neuropathic pain of malignancy. Cancer Surv 1988;7:161–93.

6          Filshie J. Acupuncture for Malignant Pain. Acupunct Med 1990;8:38–9. doi:10.1136/aim.8.2.38

7          Zhang X-W, Hou W-B, Pu F-L, et al. Acupuncture for cancer-related conditions: An overview of systematic reviews. Phytomedicine 2022;106:154430. doi:10.1016/j.phymed.2022.154430

Declaration of interests MC