Integrative Approaches to Managing Pain in Patients With Cancer: SIO-ASCO Guideline

Get Permission

Jun J. Mao, MD, MSCE

Jun J. Mao, MD, MSCE

Eduardo Bruera, MD, FAAHPM

Eduardo Bruera, MD, FAAHPM

Pain is highly prevalent in people with cancer throughout the disease trajectory. Often persisting for years after initial diagnosis and undertreated, it is associated with poor functional, mental, and cancer-related outcomes.1 Consequently, the need for effective pain management strategies has never been greater.

Growing evidence supports the benefits of integrative medicine—an interdisciplinary approach that combines conventional approaches with complementary modalities such as acupuncture and massage—for managing cancer symptoms including pain.2,3 Patient interest in these therapies is also high, with surveys showing nearly 40% availing of them annually.4-6

New Guideline for Managing Cancer Pain

The recently published joint guideline from the Society for Integrative Oncology (SIO) and ASCO7 is based on the existing ASCO guideline “Management of Chronic Pain in Survivors of Adult Cancers.”8 Developed by an international group of experts, it provides evidence-informed recommendations on integrative strategies for managing pain in individuals impacted by cancer.

The evidence base consisted of randomized controlled trials, systematic reviews, meta-analyses (published between 1990 and 2021) that involved both adult and pediatric patients with cancer experiencing pain. Additionally, clinical experience and responses—from health-care professionals in medical oncology, integrative oncology, surgical oncology, family medicine, and nursing along with patient advocacy and social sciences representatives—were also used to arrive at the final recommendations. In addition, the panel identified important gaps in evidence and implementation of integrative therapies.

The Recommendations

Acupuncture should be offered to patients with breast cancer who have aromatase inhibitor–induced arthralgia. In a sham-controlled randomized controlled trial (n = 226), true acupuncture was more efficacious than sham acupuncture and waitlist control, affecting statistically significant reductions in joint pain at 6 weeks.9 Data showed that joint pain stemming from the use of aromatase inhibitors makes patients noncompliant to this treatment,10,11 which may result in greater recurrence and mortality.12

In addition, acupuncture may be recommended to patients experiencing general or musculoskeletal pain. In the largest randomized controlled trial (n = 360) to date of patients with cancer who have moderate-to--severe chronic musculoskeletal pain, 10 weeks of acupuncture treatment resulted in durable effects at 6 months after randomization, with few adverse effects.13

Massage may also be offered, especially to patients with pain during palliative or hospice care. In a randomized controlled trial of patients with advanced cancer (n = 380), massage therapy led to clinically significant benefits against moderate to severe pain.14 The long-term effects of massage, however, are not known.

Hypnosis may be offered to patients undergoing painful procedures. Randomized controlled trials involving those undergoing large core breast biopsies15 and tumor embolization or radiofrequency ablation16 found significant pain reduction in the hypnosis groups compared with the control arms.

The panel based these recommendations on intermediate-level evidence and, importantly, benefits outweighing risks. In addition, the panel emphasized the importance of timely education of oncology professionals about the latest evidence surrounding integrative medicine, so they can guide patients on its optimal use, and of addressing barriers to achieving health equity.

Finally, the available evidence to make recommendations for pediatric patients, other complementary approaches, and natural products was deemed insufficient at this time. More rigorous early-phase and large clinical trials are needed to increase the evidence base.

Closing Thoughts

As the treatment of cancer pain continues to be challenging for both patients and oncology care providers, this joint SIO-ASCO guideline provides the evidence base for integrating select complementary modalities into pain management. Dissemination and implementation of this guideline will significantly enhance pain control and, thereby, the quality of life and functional well-being for patients with cancer. By summarizing important studies, the guideline also highlights knowledge gaps to inform future research efforts. 

DISCLOSURE: Dr. Mao reported institutional research funding from Tibet Cheezheng Tibetan Medicine Co Ltd. Dr. Bruera reported institutional research funding from PharmaCann, Inc.


1. Paice JA: Managing pain in patients and survivors: Challenges within the United States opioid crisis. J Natl Compr Canc Netw 17:595-598, 2019.

2. Brauer JA, El Sehamy A, Metz JM, et al: Complementary and alternative medicine and supportive care at leading cancer centers: A systematic analysis of websites. J Altern Complement Med 16:183-186, 2010.

3. Yun H, Sun L, Mao JJ: Growth of integrative medicine at leading cancer centers between 2009 and 2016: A systematic analysis of NCI-designated comprehensive cancer center websites. J Natl Cancer Inst Monogr 2017:lgx004, 2017.

4. Mao JJ, Farrar JT, Xie SX, et al: Use of complementary and alternative medicine and prayer among a national sample of cancer survivors compared to other populations without cancer. Complement Ther Med 15:21-29, 2007.

5. Mao JJ, Palmer CS, Healy KE, et al: Complementary and alternative medicine use among cancer survivors: A population-based study. J Cancer Surviv 5:8-17, 2011.

6. John GM, Hershman DL, Falci L, et al: Complementary and alternative medicine use among US cancer survivors. J Cancer Surviv 10:850-864, 2016.

7. Mao JJ, Ismaila N, Bao T, et al: Integrative medicine for pain management in oncology: Society for Integrative Oncology–ASCO Guideline. J Clin Oncol. September 19, 2022 (early release online).

8. Paice JA, Portenoy R, Lacchetti C, et al: Management of chronic pain in survivors of adult cancers: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol 34:3325-3345, 2016.

9. Hershman DL, Unger JM, Greenlee H, et al: Effect of acupuncture vs sham acupuncture or waitlist control on joint pain related to aromatase inhibitors among women with early-stage breast cancer: A randomized clinical trial. JAMA 320:167-176, 2018.

10. Chim K, Xie SX, Stricker CT, et al: Joint pain severity predicts premature discontinuation of aromatase inhibitors in breast cancer survivors. BMC Cancer 13:401, 2013.

11. Brier MJ, Chambless DL, Gross R, et al: Perceived barriers to treatment predict adherence to aromatase inhibitors among breast cancer survivors. Cancer 123:169-176, 2017.

12. Hershman DL, Shao T, Kushi LH, et al: Early discontinuation and non-adherence to adjuvant hormonal therapy are associated with increased mortality in women with breast cancer. Breast Cancer Res Treat 126:529-537, 2011.

13. 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 7:720-727, 2021.

14. Kutner JS, Smith MC, Corbin L, et al: Massage therapy versus simple touch to improve pain and mood in patients with advanced cancer: A randomized trial. Ann Intern Med 149:369-379, 2008.

15. Lang EV, Berbaum KS, Faintuch S, et al: Adjunctive self-hypnotic relaxation for outpatient medical procedures: A prospective randomized trial with women undergoing large core breast biopsy. Pain 126:155-164, 2006.

16. Lang EV, Berbaum KS, Pauker SG, et al: Beneficial effects of hypnosis and adverse effects of empathic attention during percutaneous tumor treatment: When being nice does not suffice. J Vasc Interv Radiol 19:897-905, 2008.