Integrative Oncology Approaches to Managing Gastrointestinal Cancer

Options like acupuncture or cannabis use may be viable to help manage symptoms related to gastrointestinal cancer treatment.

Among the treatment landscape for gastrointestinal cancer, the use of integrative oncology to improve quality of life and alleviate toxicity is one that needs to be considered. Acupuncture, cannabis, and supplements were the key topics of a recent presentation at the 2025 ASCO Gastrointestinal Cancer Symposium, discussing evidenced-based approaches in the aforementioned patient population.¹

Richard T. Lee, MD, FASCO, a clinical professor and Cheng Family Director’s Chair for the Center for Integrative Oncology at City of Hope National Medical Center, explained the science behind these integrative methods. He focused on the research that has been conducted in each of these spaces and why clinicians should begin to recommend these in conjunction with traditional treatment.

“Acupuncture may be considered for pain and nausea/vomiting symptoms. Cannabis has some evidence for benefit, although limited. [Additional] supplements can be useful for specific symptoms,” Lee noted during the presentation.

Acupuncture

Acupuncture targets nerves that stimulate A-delta fibers that which transmit to the dorsal horn of the spinal cord while inhibiting C-fiber pain impulses. It also targets endorphins like enkephalin and dynorphin, while naloxone blocks analgesia in a dose-dependent manner. Of note, it also works on CNS modulation.^2-4

Lee highlighted a study by Bao et al. that assessed the effect of acupuncture compared with Sham procedure for patients with chemotherapy-induced peripheral neuropathy symptoms.⁵ The study looked at acupuncture from baseline to 8 weeks. A reduction in pain of –1.75 occurred with acupuncture, –0.91 with Sham acupuncture, and –0.19 with usual care. Tingling was reduced by –1.83 with acupuncture, –1.22 with Sham acupuncture, and –0.14 with usual care. Numbness was reduced by –1.54, –1.52 for Sham acupuncture, and 0.57 with usual care.

Another study looked at emesis and graded patients based on no nausea, mild, moderate, or severe. Patients , and were given either verum acupuncture, sham acupuncture, or standard of care.⁶ For verum acupuncture, 82.4% had no nausea, 5.9% had mild nausea, 11.8% had moderate nausea, and 0.0% had severe nausea. For Sham acupuncture, 60.0% had no nausea, 30.0% had mild nausea, 10.0% had moderate nausea, and 0.0% had severe nausea. For standard care, 54.5% of patients had no nausea, 27.3% had mild nausea, 9.1% had moderate nausea, and 9.1% had severe nausea.

Finally, guideline recommendations on the use of acupuncture were reviewed. The Society for Integrative Oncology and the American Society for Clinical Oncology (ASCO) guidelines suggest acupuncture use for pain, nausea/vomiting, anxiety, and fatigue.⁷ The NCCN recommends acupuncture for pain, nausea/vomiting, and fatigue, but not for anxiety.⁸ The Multinational Associate of Supportive Care in Cancer (MASCC) determined acupuncture could be used for nausea/vomiting but not for pain, anxiety, or fatigue.⁹

Cannabis Use

The mechanism of action of cannabis targets the endocannabinoid system. There, the anandamide and 2-arachidonoylglycerol, are the main endogenous agonists of cannabis receptors.¹⁰ In the nervous system, there are CB1 receptors and CB2 receptors in the immune cells. It was noted that tetrahydrocannabinol (THC) has a high affinity to cannabinoid receptors, but there were associations of negative adverse effects (AEs).

In the US, cannabis has been around for centuries:

• 1600s: Hemp was used for fiber
• 1800s: Cannabis was used as a medicine
• 1930s: Cannabis was outlawed in 29 states¹¹
• 1971: The Drug Enforcement Administration classified it as a Schedule I drug¹²
• 1985: Ddronabinol (Marinol) and nabilone (Cesamet) were approved by the FDA for chemotherapy-induced nausea/vomiting (CINV)¹³
• 1996: California legalized medical cannabis¹⁴
• 2018: Tthe Farm Bill was passed and legalized hemp and CBD for seizures¹⁵

A study by Ellison et al. looked at cannabis use in patients with cancer across 12 National Cancer Institute-designated cannabis centers which included 13,180 patients.¹⁶ The study found that 62% of patients had used cannabis with 26% before cancer, 26% before and since their cancer diagnosis, 6% since their cancer diagnosis, and 20% were active users. The most common modes of cannabis use were edibles, smoking, pills/tinctures, vaping, or topical cream.

The reasons for cannabis use included difficulty sleeping (~ 50%), pain (~ 45%), mood changes, stress, anxiety or depression (~ 45%), recreationally for enjoyment (~ 30%), lack of appetite (~ 25%), digestive problems (~ 25%), neuropathy (~ 15%), and lack of energy or fatigue (~15%).

Lee highlighted some approved options for cannabis including dronabinol and nabilone in the US for CINV and anorexia. Cannabidiol (Epidiolex; CBD) is approved for a rare seizure disorder. In Europe and Canada, nabiximols (Sativex) is approved for multiple sclerosis spasticity, neuropathic pain, and cancer pain.

Grimison et al. focused on the use of oral cannabis to help prevent CINV. THC plus CBD was given at 2.5 mg each compared with placebo.¹⁷ Of the 147 enrolled, 24% had a complete response in the combination arm vs 8% in the placebo arm. The Functional Living Index found that emesis was improved as well as pain.

The ASCO guidelines for cannabis use in patients with cancer included prescribing for nausea/vomiting but not for pain, anxiety, sleep, or anorexia.¹⁸ The NCCN recommends it for nausea/vomiting and sleep but not for pain, anxiety, or anorexia⁹ Finally, the MASCC does not recommend cannabis use for any of the aforementioned categories.¹⁹

To summarize, Lee reviewed the current FDA-approved cannabis options, how medical cannabis can be used and the guidelines provided for it, and to remember to “start low and slow” when prescribing dosages. He noted to avoid inhaling products or smoking.

Other Supplements to Consider

Lee highlighted a few natural supplements to consider to that help with AEs related to cancer treatment. These included:

1. Ginger for nausea
2. Ginseng for fatigue
3. Glutamine for mucositis related to chemoradiation

Currently, more data are needed on the uses of vitamin C, vitamin D, and probiotics. Lee told patients and clinicians to check the quality of the supplements before taking them and to consider potential medication interactions.

References

1. Lee RT. Acupuncture and supplements: practical approaches to incorporating evidence-based integrative therapies for patients with gastrointestinal cancers. Presented at the 2025 ASCO Gastrointestinal Cancer Symposium. San Francisco, CA; January 23-25, 2025.
2. Liu X, Zhu B, Zhang S. Relationship between electroacupuncture analgesia and descending pain inhibitory mechanism of nucleus raphe magnus. Pain. 1986;24(3):383-396. doi:10.1016/0304-3959(86)90124-7
3. Han JS. Acupuncture and endorphins. Neurosci Lett. 2004;361(1-3):258-261. doi:10.1016/j.neulet.2003.12.019
4. Zhang RX, Lao L, Wang L, et al. Involvement of opioid receptors in electroacupuncture-produced anti-hyperalgesia in rats with peripheral inflammation. Brain Res. 2004;1020(1-2):12-17. doi:10.1016/j.brainres.2004.05.067
5. Bao T, Patil S, Chen C, et al. Effect of Acupuncture vs sham procedure on chemotherapy-induced peripheral neuropathy symptoms: a randomized clinical trial. JAMA Netw Open. 2020;3(3):e200681. Published 2020 Mar 2. doi:10.1001/jamanetworkopen.2020.0681
6. Widgren Y, Enblom A. Emesis in patients receiving acupuncture, sham acupuncture or standard care during chemo-radiation: a randomized controlled study. Complement Ther Med. 2017 Oct;34:16-25. doi:10.1016/j.ctim.2017.07.003.
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. 2022;40(34):3998-4024. doi:10.1200/JCO.22.01357
8. NCCN Clinical Practice Guidelines in Oncology. Survivorship v2.2024. Updated December 9, 2024. Accessed January 28, 2025. https://shorturl.at/OqPl2
9. Molassiotis A, Affronti ML, Fleury M, Olver I, Giusti R, Scotte F. 2023 MASCC/ESMO consensus antiemetic guidelines related to integrative and non-pharmacological therapies. Support Care Cancer. 2023;32(1):30. Published 2023 Dec 16. doi:10.1007/s00520-023-08225-0
10. Maccarrone M, Finazzi-Agró A. The endocannabinoid system, anandamide and the regulation of mammalian cell apoptosis. Cell Death Differ. 2003;10(9):946-955. doi:10.1038/sj.cdd.4401284
11. Marijuana law in the United States: history ofr marijuana regulation in the United States. Alexander Campbell King Law Library University of Georgia. Accessed January 28, 2025. https://shorturl.at/00tjc
12. Drug scheduling. United States Drug Enforcement Administration. Accessed January 28, 2025. https://shorturl.at/0qiYO
13. Todaro B. Cannabinoids in the treatment of chemotherapy-induced nausea and vomiting. J Natl Compr Canc Netw. 2012;10(4):487-492. doi:10.6004/jnccn.2012.0048
14. California’s cannabis laws. Department of Cannabis Control, California./ Accessed January 28, 2025. https://shorturl.at/R2APF
15. Farm bill. U.S. Department of Agriculture. Accessed January 28, 2025. https://shorturl.at/glaPf
16. Ellison GL, Helzlsouer KJ, Rosenfield SM, et al. Perceptions, prevalence, and patterns of cannabis use among cancer patients treated at 12 NCI-Designated Cancer Centers. J Natl Cancer Inst Monogr. 2024;2024(66):202-217. doi:10.1093/jncimonographs/lgae029
17. Grimison P, Mersiades A, Kirby A, et al. Oral cannabis extract for secondary prevention of chemotherapy-induced nausea and vomiting: final results of a randomized, placebo-controlled, phase II/III trial. J Clin Oncol. 2024;42(34):4040-4050. doi:10.1200/JCO.23.01836
18. Braun IM, Bohlke K, Abrams DI, et al. Cannabis and cannabinoids in adults with cancer: ASCO guideline. J Clin Oncol. 2024;42(13):1575-1593. doi:10.1200/JCO.23.02596
19. MASCC guideline: cannabis for cancer-related pain and risk of harms and adverse effects. Multinational Association of Supportive Care in Cancer. Accessed January 28, 2025. https://shorturl.at/GotiG