The Society for Integrative Oncology (SIO) and ASCO have partnered to develop a new guideline on integrative oncology care of symptoms of anxiety and depression in adults with cancer. The guideline reviews the evidence for a range of integrative approaches, including mindfulness-based interventions, yoga, relaxation therapy, music therapy, aromatherapy, acupuncture, tai chi/qigong, and reflexology.1
“Cancer survivors have a long history of using integrative (sometimes referred to as ‘complementary’) therapies to help them cope with illness and manage the side effects of cancer treatment,” said Guideline Co-Chair Julia H. Rowland, PhD, of the Smith Center for Healing and the Arts. Dr. Rowland noted there is now considerable evidence documenting the benefits of integrative interventions on quality of life, pain relief, stress reduction, and general mood/distress among cancer survivors, prompting the development of this new guideline to address interventions for symptoms of anxiety and depression.2-5
Julia H. Rowland, PhD
Linda E. Carlson, PhD
Guideline Co-Chair Linda E. Carlson, PhD, of the University of Calgary, Canada, emphasized the importance of having guidelines to outline the available evidence and provide concrete recommendations. “We want to be able to direct people with cancer, from among this wide [list] of different integrative therapies...where to best put their time, energy, and money,” she said.
Dr. Rowland added that anxiety and depression are associated with impaired quality of life and increased mortality, but they continue to be underrecognized and undertreated in cancer. “It is important that [oncology clinicians] be aware of what is most effective in helping their patients deal with anxiety and depression and which interventions may not yet have data informing their use,” she said.
The new guideline was designed to be complementary to, and synergistic with, the ASCO guideline for anxiety and depression in adults with cancer.6 The two guidelines differ in their focus, with one covering conventional psychosocial, behavioral, and pharmacologic interventions and the other covering use of integrative therapies. However, as integrative therapies are increasingly becoming more mainstream, there is overlap between the two guidelines. “Both sets of guidelines highlight the established value of mindfulness and meditative practices in managing anxiety and depression, as well as movement programs (ie, physical activity and yoga),” Dr. Rowland said.
The strongest recommendations in the guideline relate to the use of mindfulness-based interventions, in which there is high-quality evidence for a benefit to improve symptoms of anxiety and depression both during active treatment and after treatment.7 Interventions with a moderate strength of recommendation to treat anxiety and/or depression during treatment include yoga in people with breast cancer, hypnosis during cancer-related procedures, relaxation therapy, and music therapy or music-based interventions.
Other strategies to improve anxiety and/or depression during or after treatment are considered weak recommendations based on a lack of high-quality evidence. They include reflexology, lavender essential oil inhalation, acupuncture, tai chi and/or qigong, and relaxation therapies for depression.
The Guideline Co-Chairs hope the new guideline provides a needed resource for clinicians and patients seeking evidence-based information on the use of integrative therapies. By understanding the range of approaches and the evidence for their use, oncology clinicians can help guide patients to appropriate resources in the community.
“Even if not offered in their cancer center, it’s not hard for people with cancer to find meditation programs or yoga in the community,” Dr. Carlson explained, adding that the guideline “gives an impetus for oncology health-care providers to survey the community and create a database of qualified providers of these therapies. Better yet, health-care providers can advocate for including these therapies within their cancer care services. It is important that integrative therapy providers have training and experience specific to working with people who have had a cancer diagnosis.”
The Guideline Co-Chairs noted that additional work is needed to better understand the potential benefit of many interventions for which there was insufficient evidence to make clear recommendations in the current guideline. They include music therapy and music-based interventions, nutritional interventions, light therapy, psilocybin-assisted therapy, massage, natural products, melatonin, dance/movement therapy, laughter therapy, healing touch, and acupressure. We need to understand more about these interventions, including when not to use them, and their potential to cause any harm, they added. There could also be a benefit in establishing more specificity in how and when to use recommended interventions.
Advocacy is also an important component of the guideline. “We will need to develop both referral mechanisms and, importantly, therapy payment models to improve patient access to this care,” Dr. Rowland said. She added that more studies examining the cost-benefit of integrative therapies would be necessary, “if we are to pave the way forward to optimizing their appropriate and timely use.”
1. Carlson LE, Ismaila N, Addington EL, et al: Integrative oncology care of symptoms of anxiety and depression in adult patients with cancer: Society for Integrative Oncology–ASCO guideline. J Clin Oncol. August 15, 2023 (early release online).
2. Mao JJ, Farrar JT, Bruner D, et al: Electroacupuncture for fatigue, sleep, and psychological distress in breast cancer patients with aromatase inhibitor-related arthralgia: A randomized trial. Cancer 120:3744-3751, 2014.
3. Schell LK, Monsef I, Wöckel A, et al: Mindfulness-based stress reduction for women diagnosed with breast cancer. Cochrane Database Syst Rev 3:CD011518, 2019.
4. Deng C, Xie Y, Liu Y, et al: Aromatherapy plus music therapy improve pain intensity and anxiety scores in patients with breast cancer during perioperative periods: A randomized controlled trial. Clin Breast Cancer 22:115-120, 2022.
5. Oberoi S, Yang J, Woodgate RL, et al: Association of mindfulness-based interventions with anxiety severity in adults with cancer: A systematic review and meta-analysis. JAMA Netw Open 3:e2012598, 2020.
6. Andersen BL, Lacchetti C, Ashing K, et al: Management of anxiety and depression in adult survivors of cancer: ASCO guideline update. J Clin Oncol 41:3426-3453, 2023.
7. Trambert R, Kowalski MO, Wu B, et al: A randomized controlled trial provides evidence to support aromatherapy to minimize anxiety in women undergoing breast biopsy. Worldviews Evid Based Nurs 14:394-402, 2017.
Originally published in ASCO Daily News. © American Society of Clinical Oncology. ASCO Daily News, August 16, 2023. All rights reserved.