Growing Evidence Supports Integrative Care in Breast Cancer

Heather Greenlee, ND, PhD, MPH, associate professor of the Cancer Prevention Program in the Public Health Sciences Division at Fred Hutchinson Cancer Research Center

Integrative approaches to management of patients with breast cancer may help mitigate adverse effects from treatments and promote survivorship. This is best achieved through dissemination of education to clinicians who then pass on the recommendations to their patients.

Heather Greenlee, ND, PhD, MPH, associate professor of the Cancer Prevention Program in the Public Health Sciences Division at Fred Hutchinson Cancer Research Center, spoke to CancerNetwork® regarding clinical practice guidelines for integrative care in the treatment of breast cancer that she helped develop with other thought leaders and The Society of Integrative Oncology (SIO).

“The upshot of the guidelines is that there is a growing evidence base on the use of mind-body therapies. [This includes] meditation, yoga, acupuncture, acupressure, [and other similar therapies] and there continues to be a growing evidence base on the use of those therapies to mitigate [adverse] effects of treatment,” said Greenlee.

During the interview, Greenlee spoke about the current guidelines, how clinicians can begin to use these in their everyday practices, and where she would like the research to focus next.

CancerNetwork®: Can you discuss why it’s important to be aware of integrative therapies for breast cancer treatment?

Greenlee: [Patients with] breast cancer, while they’re going through treatment, often experienced [adverse] effects, which can result in decreased quality of life, increased symptom burden during treatment, and some women and men not adhering to their treatment. We know that many integrative therapies can be supportive at mitigating the [adverse] effects of treatment and enhancing the ability for people to adhere to their treatment long term, which will result in better clinical outcomes for this patient population.

Looking at the practice guidelines, how were they determined? Have there been any updates in recent years?

We first published the guidelines in 2014, and then we published an expanded version of those in CA: A Cancer Journal for Clinicians in 2017. We updated the guidelines with new findings and we also provided a much more comprehensive description of the different kinds of integrative therapies. We added a lot of discussion about who implements these different therapies and the differences in licensure and credentialing across different states and provinces. We wanted to make it a more robust set of guidelines [for] dissemination and implementation of these practices, some of which have been shown to be effective.

We haven’t updated the guidelines since then, it is on cue for us to do within SIO. We do not have a growing evidence base suggesting that dietary supplements are effective at mitigating [adverse] effects of treatment. We feel like that’s really important information to get out to patients, but also to providers when they’re thinking about what to offer and what to discuss with patients going forward in treatment.

How can clinicians begin to implement these updated guidelines into their practice?

Provide very simple and basic information to patients about what evidence base [there] is regarding these different therapies. Our institution, for example, has created a series of handouts for new patient education to show how to implement acupressure, how to use some mind-body therapies, or to help with sleep or anxiety. We’re hoping that that’s a way to disseminate some of this information to clinicians in clinical settings that are looking for patient education materials. Some of it is very basic applications that patients can do on their own, and that can be based at home.

Some of the applications like acupuncture or massage require credentialed and licensed providers. Those require institutions either identifying qualified and credentialed people to practice within their institution, or to identify ways to refer patients out to qualified and credentialed practitioners in the community. At our institution, we do both. We have an in-house acupuncture program where we see patients and conduct acupuncture research. We’ve also developed a referral list to practitioners in the community who we’ve spoken with and have similar practice goals in mind working with [patients with cancer]. Specifically, we make sure that they’re aware of the safety requirements.

Has acupuncture and acupressure become something that is more common in the practice of cancer treatment?

There’s a growing body of literature showing that acupuncture can help mitigate some of the [adverse] effects of treatment. Acupuncture has a growing [evidence] base showing that it can be useful in pain management. Currently at our institution, we have 3 acupuncture trials that are open focused on different pain syndromes and helping patients adhere to different types of oncology treatments. The results of those trials remain to be seen, but we do think it can be useful. One of the wonderful things about acupuncture is that it’s nonpharmacologic, so we don’t have to worry about any interactions with conventional treatment. Some patients find it very relaxing; it can also help with other things that might not be treatment related, specifically like anxiety, sleep, and fatigue, and that can be helpful.

What are the next steps for researching integrative practices for patients with breast cancer?

The sky is the limit at this point, and there are multiple acupuncture trials underway right now. There’s so much work focused on these mind-body and nonpharmacologic interventions that can be effective in supporting patients during their treatment and into survivorship.

There’s also a lot of interest in diet and nutrition, physical activity, and weight management. That continues to be a growing area of research. Our guidelines did not focus on those areas, specifically because there are other excellent guidelines already in place for cancer survivors. The American Institute for Cancer Research, the American Cancer Society, and the American College of Sports Medicine have all put together excellent guidelines on the use of nutrition and physical activity for cancer survivorship. We felt that that wasn’t important to include in our guidelines, because that was redundant and we didn’t need to redo their excellent work.

Is there anything else you want to discuss?

[My background is from a] shared decision making perspective in that many patients have interests in a holistic approach to their health care. We feel it’s important for patients and providers to have the evidence in hand so that they can understand where the evidence does and does not support the use of these different therapies so that patients can decide what’s best for them. At SIO, we feel like one of our obligations is to get this information out into the hands of people who need it.

Reference

Greenlee H, DuPont-Reyes MJ, Balneaves LG, et al. Clinical practice guidelines on the evidence-based use of integrative therapies during and after breast cancer treatment. CA Cancer J Clin. 2017;67(3):194-232. doi:10.3322/caac.21397