Cancer Care Through Nonpharmacologic Symptom Management

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Lorenzo Cohen, PhD

Janet Kahn, PhD, LMT

Kathy Jo Gutgsell, RN, MT-BC

When it comes to these nonconventional modalities, if we don’t know the mechanism, even when we have the placebo-controlled randomized controlled trial, it’s hard for the skeptics to believe.

—Lorenzo Cohen, PhD
It is our belief that there is always some kind of touch that is safe and effective to offer a person with cancer.

—Janet Kahn, PhD, LMT
Music therapy reduces physical pain, brings joy to patients and teams, and helps to bring about the resolution of existential pain.

—Kathy Jo Gutgsell, RN, MT-BC

Nonpharmacologic approaches to managing pain have a fairly robust base of science and research supporting their use but are not as widely accepted and understood as drug therapy in the realm of cancer care. In a breakout session at the 2015 Palliative Care in Oncology Symposium in Boston, experts in acupuncture, massage therapy, and music therapy addressed the benefits of nonpharmacologic therapies in alleviating pain and other effects of cancer and its treatments.1


“At MD Anderson, we have a formal integrative medicine program with a focus on clinical care, research, and education,” said Lorenzo Cohen, PhD, Professor and Director of the Integrative Medicine Program at the University of Texas MD Anderson Cancer Center in Houston. “And it is clearly important to have these integrative medicine treatment modalities alongside conventional care.”

A component of traditional Chinese medicine, acupuncture has been used to treat 200 million people in at least 78 countries annually. According to Dr. Cohen, it is safe, cost-effective, minimally invasive, and can be used to treat individuals of all ages.

Acupuncture is integrated into patient care at MD Anderson, “because there is a good evidence base for chemotherapy-induced nausea and emerging data for many other cancer treatment–related symptoms.” But the mechanisms of action remain elusive,” explained Dr. Cohen, “and when it comes to these nonconventional modalities, if we don’t know the mechanism, even when we have the placebo-controlled randomized controlled trial evidence, it’s hard for the skeptics to believe.”

However, numerous studies have shown that acupuncture offers benefits for uncontrolled nausea and vomiting, hot flashes, noncancer- and cancer-related chronic pain, chemotherapy-induced peripheral neuropathy, and radiation-induced xerostomia.2-4

Dr. Cohen stated that acupuncture therapy is “worth trying” for uncontrolled nausea, vomiting, or pain. He also endorsed its utility when conventional treatment and palliative care have failed to improve symptoms and for dealing with side effects of treatment or medications.

Massage Therapy

“If somebody near you hurts, there’s an impulse to touch them,” said Janet Kahn, PhD, LMT, Research Assistant Professor at the University of Vermont’s College of Medicine in Burlington. “In fact, some form of massage has existed in virtually every kind of medicine that humans have ever developed.”

Massage has a robust literature base, indicating a wide range of benefits for people at all stages of life, and has been shown to relieve pain and stress and induce relaxation.

“Massage is a fairly popular form of care in the United States,” said Dr. Kahn. Data from the 2007 National Health Interview Survey revealed that in that year, Americans collectively made over 95 million visits to massage therapists and paid over $4 billion dollars for them. “Most of those 4 billion dollars were paid for out of pocket,” she added. “So you can imagine these numbers would be larger if this were covered care; we just don’t know by what magnitude.”

Dr. Kahn and her colleagues developed a program called Touch Caring and Cancer, “which is designed to teach family members and friends of people with cancer how to offer safe and effective touch and touch that can actually decrease nausea, pain, or anxiety,” she explained.

Designed to be low cost and easily accessible, the program is available as a 78-minute DVD and a 68-page (largely pictorial) manual.  In addition to teaching simple touch techniques for comfort and relaxation, it addresses communication in massage and each person’s responsibility for that communication, as well as safety precautions related to the side effects of cancer and its treatments.

A randomized controlled trial testing the efficacy of the program was conducted in 97 New England households.5 Patients were randomized to receive either massage or reading therapy for a study period of 4 weeks, and symptoms such as pain, fatigue, depression, and nausea were rated before and after the session.

“For each of these symptoms, the magnitude of change was greater among the massage group than it was among the reading group,” said Dr. Kahn. The reading group had anywhere from 12% to 28% improvement (reduction in troublesome symptoms), whereas the massage group had a 29% to 44% improvement. The investigators also noted significant improvement in the levels of caregiver comfort and confidence in delivering effective touch.

“One of the hardest things is feeling like you don’t know what to do for a loved one,” said Dr. Kahn. “But it is our belief that there is always some kind of touch that is safe and effective to offer a person with cancer.”

Music Therapy

“Music therapy reduces physical pain, brings joy to patients and teams, and helps to bring about the resolution of existential pain,” said Kathy Jo Gutgsell, RN, MT-BC, a music therapist at the University Hospitals Seidman Cancer Center in Cleveland.

Ms. Gutgsell was the principal investigator of a randomized controlled trial conducted at University Hospitals Case Medical Center.6 The study sought to determine the efficacy of a single music therapy session to reduce pain in palliative care patients.

A total of 200 inpatients were enrolled in the study from 2009–2011 and were randomly assigned to standard care with music therapy (live, music therapist–led autogenic relaxation followed by live ocean drum and harp music) or standard care alone.

Blinded clinical nurse specialists assessed pain before and after the intervention, evaluating the primary outcome of pain measured by the Numeric Rating Scale (NRS) and the secondary outcomes of Functional Pain Scale (FPS) and Face, Legs, Activity, Cry, Consolability (FLACC) scale measurements.

Significantly greater decreases in the NRS and FPS were observed in the music therapy group, although no significant difference in FLACC scores was found between the study groups. “We had wonderful results,” said Ms. Gutgsell. The trial demonstrated that music therapy does indeed lower pain.

“Music therapy helps to bring about a resolution of existential pain,” said Ms. Gutgsell. “And we all know that is the hardest part of pain— when we get into the existential issues. Interventions such as songwriting enable our patients to express their emotions and leave a legacy for loved ones.” n

Disclosure: Dr. Cohen, Dr. Kahn, and Ms. Gutgsell reported no potential conflicts of interest.


1. Cohen L, Kahn J, Gutgsell KJ: Nonpharmacologic symptom management. 2015 Palliative Care in Oncology Symposium. Breakout Session. Presented October 9, 2015.

2. Garcia MK, Graham-Getty L, Haddad R, et al: Systematic review of acupuncture to control hot flashes in cancer patients. Cancer 121:3948-3958, 2015.

3. Garcia M, McQuade J, Haddad R, et al: Systematic review of acupuncture in cancer care: A synthesis of the evidence. J Clin Oncol 31:952-960, 2013.

4. Garcia MK, McQuade J, Lee R, et al: Acupuncture for symptom management in cancer care: An update. Curr Oncol Rep 16:418, 2014.

5. Collinge W, Kahn J, Walton T, et al: Touch, caring, and cancer: Randomized controlled trial of a multimedia caregiver education program. Support Care Cancer 21:1405-1414, 2013.

6. Gutgsell KJ, Schluchter M, Margevicius S, et al: Music therapy reduces pain in palliative care patients: A randomized controlled trial. J Pain Symptom Manage 45:822-831, 2013.