One of the main goals of SIO’s research committee is to disseminate updated research to our members.  As such, we recently started a Research Update program.  We will provide bi-monthly updates of relevant literature by selecting a number of recent papers to be listed on the SIO website, based on search criteria that focus on original clinical research in human populations spanning a full range of complementary therapy modalities.  For chosen papers we will include the abstract and link to the journal cite for downloads.  We hope you enjoy this new feature and appreciate your comments and feedback! 

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August/September 2018

Adair M, Murphy B, Yarlagadda S, Deng J, Dietrich MS, Ridner SH. Feasibility and Preliminary Efficacy of Tailored Yoga in Survivors of Head and Neck Cancer: A Pilot Study. Integr Cancer Ther 2018 Sep;17(3):774-784 PMID 29355046

PURPOSE: Treatment for head and neck cancer (HNC) results in long-term toxicities and increased physical and psychosocial survivor burden. There are a limited number of treatments for these late effects. Yoga postures, breath work, relaxation, and meditation, may improve these late effects. The purpose of this study was to examine the feasibility of a tailored yoga program in HNC survivors and obtain preliminary efficacy data. METHODS: This was a randomized wait-list control study of yoga-naive HNC survivors who were >3 months post-cancer treatment. Baseline data were collected. Participants were randomized to either an 8-week hatha yoga intervention group or a wait-list group. Feasibility and efficacy data were collected. At 4 and 8 weeks, patients underwent a repeat assessment of health. Wait-list control group participants were offered the yoga program after data collection. Descriptive statistics evaluated feasibility. Mixed effects general linear models were used to generate estimates of the efficacy outcomes. RESULTS: Seventy-three individuals were screened and 40 were eligible. All eligible individuals consented and enrolled. Five of the intervention group discontinued early and none in the wait-list control group. Feasibility was affirmed as participants were recruited and retained in the study, there were no adverse events, fidelity to protocol was demonstrated, and satisfaction rates were high. Efficacy measures indicated potential benefit for shoulder range of motion ( d = 0.57-0.86, P < .05), pain ( d = 0.67-0.90, P </= .005), and anxiety ( d = 0.59, P = .015). CONCLUSION: A tailored hatha yoga program is feasible and potentially efficacious for HNC survivors. Preliminary data supports further investigation of yoga in this population is needed.

Andersen MR, Sweet E, Hager S, Gaul M, Dowd F, Standish LJ. Use of Integrative Oncology, Involvement in Decision-Making, and Breast Cancer Survivor Health-Related Quality of Life in the First 5 Years Postdiagnosis. Integr Cancer Ther 2018 Sep;17(3):636-645 PMID 29607686

OBJECTIVE: This study sought to describe changes in the health-related quality of life (HRQOL) of women who do and do not seek naturopathic oncology (NO) complementary and alternative medicine (CAM) care during and immediately after breast cancer treatment, and to explore the predictive role of NO CAM care, demographic characteristics, and involvement in decision-making on HRQOL in breast cancer survivors. METHODS: Matched cohorts of breast cancer survivors who did and did not choose to supplement their breast cancer treatment with NO care within 2 years of diagnosis participated. NO users were identified through naturopathic doctors' clinics and usual care (UC) controls with similar prognosis were identified through a cancer registry. The registry provided information about all participants' age, race, ethnicity, marital status, stage of cancer at time of diagnosis, date of diagnosis, and use of conventional medical treatments (surgery, chemotherapy, radiation, and endocrine therapy). Data of participants' self-reported involvement in decision-making and HRQOL were collected at study enrollment and at 6-month follow-up. RESULTS: At 6-month follow-up, the NO patients reported significantly more involvement in decision-making about care and better general health than did UC patients ( P < .05). Self-reported involvement in decision-making about cancer treatment was associated with better role-physical, role-emotional, and social-functional well-being ( P < .05). Race, age, marital status, and congruence of preferred and achieved levels of involvement also predicted aspects of HRQOL in breast cancer survivors ( P < .05). CONCLUSIONS: Both NO CAM care and involvement in decision-making about cancer treatment may be associated with better HRQOL in breast cancer survivors.

Anshasi HA, Ahmad M. An assessment of methodological quality of systematic reviews of acupuncture and related therapies for cancer-related pain. Complement Ther Clin Pract 2018 Aug;32:163-168 PMID 30057045

BACKGROUND AND PURPOSE: There currently exist many systematic reviews aimed at assessing acupuncture and related therapy effectiveness in cancer-related pain management. However, the methodological quality of existing systematic reviews remains unclear. The purpose of this review was to summarize and evaluate the methodological quality of these systematic reviews and meta-analyses papers. METHODS: A comprehensive search on multiple databases was performed using Assessing the Methodological Quality of Systematic Reviews (AMSTAR). RESULTS: Fourteen systematic reviews published between 2005 and 2017 were eligible for inclusion. The consensus across the included reviews was that acupuncture and related therapies alone did not have superior pain-relieving effects as compared with analgesic administration using various validated pain scales. However, as compared with analgesic administration alone, acupuncture and related therapies plus analgesics resulted in reduced cancer related-pain. CONCLUSION: The study findings emphasized that acupuncture and related therapies alone did not have clinically significant effects at cancer-related pain reduction as compared with analgesic administration alone. Clinicians may consider acupuncture and related therapies as adjunctive therapies for cancer-related pain management, in particular, when pain control is unsatisfactory under analgesics alone. Furthermore, the researchers should conduct the SRs and meta-analyses according to the AMSTAR and PRISMA.

Bao T, Li Q, DeRito JL, Seluzicki C, Im EO, Mao J. Barriers to Acupuncture Use Among Breast Cancer Survivors: A Cross-Sectional Analysis. Integr Cancer Ther 2018 Sep;17(3):854-859 PMID 29338443

INTRODUCTION: Increasing evidence suggests that acupuncture may be helpful to manage common symptoms and treatment side effects among breast cancer (BC) survivors. Acupuncture usage among BC survivors remains low with little known about the barriers to its utilization. We evaluated perceived barriers to acupuncture use among BC survivors and explored the sociodemographic variations of such barriers. METHODS: We conducted a cross-sectional analysis at an urban academic cancer center on 593 postmenopausal women with a history of stage I-III hormone receptor-positive BC who were taking or had taken an aromatase inhibitor. We used the modified Attitudes and Beliefs about Complementary and Alternative Medicine instrument to evaluate patients' perceived barriers to acupuncture. Multiple linear regression analysis was performed to determine sociodemographic factors associated with perceived barrier scores. RESULTS: The most common barriers were lack of knowledge about acupuncture (41.6%), concern for lack of insurance coverage (25.0%), cost (22.3%), and difficulty finding qualified acupuncturists (18.6%). Compared with whites, minority patients had higher perceived barriers to use acupuncture (beta coefficient = 1.63, 95% confidence interval = 0.3-2.9, P = .013). Patients with lower education had higher barriers to use acupuncture (beta coefficient = 4.23, 95% confidence interval = 3.0-5.4, P < .001) compared with patients with college education or above. CONCLUSION: Lack of knowledge and concerns for insurance coverage and cost are the common barriers to acupuncture use among BC survivors, especially among minority patients with lower education. Addressing these barriers may lead to more equitable access to acupuncture treatment for BC survivors from diverse backgrounds.

Bao T, Seidman AD, Piulson L, Vertosick E, Chen X, Vickers AJ, et al. A phase IIA trial of acupuncture to reduce chemotherapy-induced peripheral neuropathy severity during neoadjuvant or adjuvant weekly paclitaxel chemotherapy in breast cancer patients. Eur J Cancer 2018 Sep;101:12-19 PMID 30007894

PURPOSE: Chemotherapy-induced peripheral neuropathy (CIPN) is a common and potentially dose-limiting side-effect of neurotoxic chemotherapy for cancer patients. We evaluated the preliminary efficacy of acupuncture in preventing worsening CIPN in patients receiving paclitaxel. METHODS: In this phase IIA single-arm clinical trial, we screened stage I-III breast cancer patients receiving neoadjuvant/adjuvant weekly paclitaxel for development of CIPN. The primary objective was to assess acupuncture's efficacy in preventing the escalation of National Cancer Institute-Common Toxicity Criteria for Adverse Events (NCI-CTCAE), version 4.0, grade II CIPN to higher grades. Acupuncture was deemed worthy of further study if 23 or more of the 27 enrolled patients did not develop grade III CIPN. Outcome measures (NCI-CTCAE CIPN grade, Functional Assessment of Cancer Therapy/Gynecologic Oncology Group-Neurotoxicity [FACT/GOG-Ntx], Neuropathic Pain Scale [NPS]) were obtained weekly during the intervention. RESULTS: Of 104 patients screened, 37 developed grade II CIPN (36%), and 28 (27%) enrolled into the intervention phase; one was removed due to protocol violation. Of the 27 patients receiving acupuncture, 26 completed paclitaxel treatment without developing grade III CIPN, meeting our prespecified success criteria for declaring acupuncture worthy of further study. FACT/GOG-Ntx and NPS scores remained stable during the intervention while continuing weekly paclitaxel. Acupuncture treatment was well tolerated; 4 of 27 (15%) patients reported grade I bruising. CONCLUSIONS: Acupuncture was safe and showed preliminary evidence of effectiveness in reducing the incidence of high grade CIPN during chemotherapy. A follow-up randomised controlled trial is needed to establish definitive efficacy in CIPN prevention for patients at risk.

Ben-Arye E, Dahly H, Keshet Y, Dagash J, Samuels N. Providing integrative care in the pre-chemotherapy setting: a pragmatic controlled patient-centered trial with implications for supportive cancer care. J Cancer Res Clin Oncol 2018 Sep;144(9):1825-1833 PMID 29980837

CONTEXT AND OBJECTIVES: To examine the impact of a complementary/integrative medicine (CIM) program on quality of life (QoL)-related concerns among patients scheduled for chemotherapy for breast and gynecologic cancer. METHODS: Chemotherapy-naive patients were referred by their oncology healthcare professional to an integrative oncology program, where CIM is provided as part of palliative/supportive care. CIM treatments were tailored to patients' preferences and leading concerns, and for most included acupuncture and mind-body-spirit modalities, which were usually co-administered in the week preceding the first chemotherapy cycle. Patients attending the program were considered part of the treatment group; those who chose to receive only standard supportive care as controls. Assessment of quantitative outcomes was conducted during the week before chemotherapy; at 24 h before and after the treatment; and at 1 week post treatment. For this purpose, the Edmonton Symptom Assessment Scale (ESAS) and Measure Yourself Concerns and Well-being questionnaire (MYCAW) were used. Qualitative assessment was based on short narratives at the end of the follow-up MYCAW questionnaire, which were analyzed with ATLAS.Ti software for systematic coding. RESULTS: Of the 55 patients referred, 31 (56%) underwent CIM treatments, with 24 controls. Both groups had similar baseline demographic and cancer-related characteristics. QOL-related outcomes were significantly less impaired following CIM treatments for ESAS fatigue scores (P = 0.013), depression (P = 0.005), and feeling of well-being (P = 0.027); and MYCAW scores for well-being (P = 0.005) and emotional distress (P = 0.02). Qualitative analysis detected both specific and non-specific effects of the CIM treatment regimen, most describing a reduction in pre-chemotherapy anxiety. CONCLUSION: A patient-tailored CIM program, initiated within a week of the first chemotherapy cycle, may help reduce the severity of fatigue, depression, and impaired well-being among patients with breast and gynecological cancers.

Ben-Arye E, Doweck I, Schiff E, Samuels N. Exploring an Integrative Patient-Tailored Complementary Medicine Approach for Chemotherapy-Induced Taste Disorders. Explore (NY) 2018 Jul - Aug;14(4):289-294 PMID 29785939

CONTEXT: Chemotherapy-induced taste disorder (CITD) is a common adverse effect among patients with cancer, with no effective known treatment. OBJECTIVES: Exploring the impact of a patient-tailored complementary and integrative medicine (CIM) treatment program on CITD-related severity. DESIGN: Prospective study on patients' chart. SETTING: Integrative oncology program operating within the Clalit Healthcare Oncology Service in northern Israel. PATIENTS: Patients were referred by their oncology healthcare practitioner to a consultation with a CIM-trained integrative physician (IP). A patient-tailored CIM treatment program was designed, addressing quality of life (QOL)-related concerns which were evaluated using the Edmonton symptom assessment scale (ESAS) and the measure yourself concerns and well-being (MYCAW) questionnaires. RESULTS: A total of 626 patients were referred to the IP consultation, with CITD-related symptoms identified in 43, 34 of them returning for follow-up. The majority of patients treated with CIM reported a reduction in symptom severity (n = 29), with only three reporting no change, 2 an "unclear effect" and none a worsening of CITD-related symptoms. Acupuncture and herbal medicine (sage, carob, and wheatgrass juice, as mouthwash or applied to the oral mucosa) were the most frequently CIM modalities used. Assessment was considered optimal for 18 of the 29 patients who reported an improvement in ESAS scores for fatigue, drowsiness and depression. We conclude that a patient-tailored CIM program is a potentially effective and safe therapeutic option for CITD-related symptoms. Further research is needed in order to explore the impact of CIM treatments on taste and appetite-related concerns during chemotherapy.

Benson JR, Jatoi I. Tailoring breast cancer therapies to reduce mortality and improve quality of life: San Antonio Breast Cancer Symposium 2017 (part 2). Future Oncol 2018 Aug;14(19):1893-1896 PMID 30019940

The 40th annual San Antonio Breast Cancer Symposium was convened in San Antonio, TX, USA on 5-9 December 2017. More than 7500 clinicians and scientists from around the world participated in the symposium which featured a range of presentations and keynote talks pertaining to breast cancer screening, prevention, loco-regional and systemic therapies. This two-part report highlights a selection of important studies presented at this premier breast cancer event with part 1 focusing on dose-intense radiotherapy, perioperative endocrine therapy, duration of bisphosphonates, immunotherapy, ovarian function suppression and acupuncture. The second part of this report will discuss a range of topics related to de-escalation of loco-regional therapies, the significance of complete pathological response, older patients and CDK 4/6 inhibitors, circulating tumor cells and plasma DNA as a tumor marker.

Buckner CA, Lafrenie RM, Denommee JA, Caswell JM, Want DA. Complementary and alternative medicine use in patients before and after a cancer diagnosis. Curr Oncol 2018 Aug;25(4):e275-e281 PMID 30111972

Background: Cancer patients are increasingly seeking out complementary and alternative medicine (cam) and might be reluctant to disclose its use to their oncology treatment team. Often, cam agents are not well studied, and little is known about their potential interactions with chemotherapy, radiation therapy, or biologic therapies, and their correlations with outcomes. In the present study, we set out to determine the rate of cam use in patients receiving treatment at a Northern Ontario cancer centre. Methods: Patients reporting for treatment at the Northeast Cancer Centre (necc) in Sudbury, Ontario, were asked to complete an anonymous questionnaire to assess cam use. Changes in cam use before, compared with after, diagnosis were also assessed. Results: Patients in Northern Ontario reported significant cam use both before and after diagnosis. However, as a function of the cam type, cam use was greatly enhanced after cancer diagnosis. For example, the number of patients who reported use of biologic products increased to 51.8% after a cancer diagnosis from 15.6% before a cancer diagnosis. Patients reported much smaller changes in the use of alternative medical systems or spiritual therapy after diagnosis. Vitamin use was reported by 66% of respondents, and the number of different cams used correlated significantly with the reported number of vitamins used. Conclusions: Use of cam, particularly biologic products, increased significantly after a cancer diagnosis. Further studies are required to examine the effect of cam use on the efficacy and safety of cancer therapies.

Compen F, Bisseling E, Schellekens M, Donders R, Carlson L, van der Lee M, et al. Face-to-Face and Internet-Based Mindfulness-Based Cognitive Therapy Compared With Treatment as Usual in Reducing Psychological Distress in Patients With Cancer: A Multicenter Randomized Controlled Trial. J Clin Oncol 2018 Aug 10;36(23):2413-2421 PMID 29953304

Purpose Mindfulness-based cognitive therapy (MBCT) has been shown to alleviate psychological distress in patients with cancer. However, patients experience barriers to participating in face-to-face MBCT. Individual Internet-based MBCT (eMBCT) could be an alternative. The study aim was to compare MBCT and eMBCT with treatment as usual (TAU) for psychological distress in patients with cancer. Patients and Methods We obtained ethical and safety approval to include 245 patients with cancer with psychological distress (>/= 11 on the Hospital Anxiety and Depression Scale) in the study. They were randomly allocated to MBCT (n = 77), eMBCT (n = 90), or TAU (n = 78). Patients completed baseline (T0) and postintervention (T1) assessments. The primary outcome was psychological distress on the Hospital Anxiety and Depression Scale. Secondary outcomes were psychiatric diagnosis, fear of cancer recurrence, rumination, health-related quality of life, mindfulness skills, and positive mental health. Continuous outcomes were analyzed using linear mixed modeling on the intention-to-treat sample. Because both interventions were compared with TAU, the type I error rate was set at P < .025. Results Compared with TAU, patients reported significantly less psychological distress after both MBCT (Cohen's d, .45; P < .001) and eMBCT (Cohen's d, .71; P < .001) . In addition, post-treatment prevalence of psychiatric diagnosis was lower with both MBCT (33% improvement; P = .030) and eMBCT (29% improvement; P = .076) in comparison with TAU (16%), but these changes were not statistically significant. Both interventions reduced fear of cancer recurrence and rumination, and increased mental health-related quality of life, mindfulness skills, and positive mental health compared with TAU (all Ps < .025). Physical health-related quality of life did not improve ( P = .343). Conclusion Compared with TAU, MBCT and eMBCT were similarly effective in reducing psychological distress in a sample of distressed heterogeneous patients with cancer.

Eyigor S, Uslu R, Apaydin S, Caramat I, Yesil H. Can yoga have any effect on shoulder and arm pain and quality of life in patients with breast cancer? A randomized, controlled, single-blind trial. Complement Ther Clin Pract 2018 Aug;32:40-45 PMID 30057055

OBJECTIVE: To examine the effects of yoga on shoulder and arm pain, quality of life (QOL), depression, and physical performance in patients with breast cancer. METHODS: This prospective, randomized study included 42 patients. The patients in Group 1 underwent a 10-week Hatha yoga exercise program. The patients in Group 2 were included in a 10-week follow-up program. Our primary endpoint was arm and shoulder pain intensity. RESULTS: The group receiving yoga showed a significant improvement in their pain severity from baseline to post-treatment, and these benefits were maintained at 2.5 months post-treatment. When compared to the control group, there were no statistically significant differences between the 2 groups with respect to the parameters assessed at the end of week 10. CONCLUSION: Yoga was an effective and safe exercise for alleviating shoulder and arm pain, which is a complication with a high prevalence in patients with breast cancer.

Gonzalez-Hernandez E, Romero R, Campos D, Burychka D, Diego-Pedro R, Banos R, et al. Cognitively-Based Compassion Training (CBCT((R))) in Breast Cancer Survivors: A Randomized Clinical Trial Study. Integr Cancer Ther 2018 Sep;17(3):684-696 PMID 29681185

CONTEXT: Breast cancer (BC) requires a significant psychological adaptation once treatment is finished. There is growing evidence of how compassion training enhances psychological and physical well-being, however, there are very few studies analyzing the efficacy of compassion-based Interventions on BC survivors. OBJECTIVE: To study the efficacy of the Cognitively-Based Compassion Training (CBCT) protocol in a BC survivor sample on quality of life, psychological well-being, fear of cancer recurrence, self-compassion, and compassion domains and mindfulness facets. Furthermore, enrollment, adherence, and satisfaction with the intervention were also analyzed. METHODS: A randomized clinical trial was designed. Participants (n = 56) were randomly assigned to CBCT (n = 28) or a treatment-as-usual control group (TAU; n = 28). Pre-post intervention and 6-month follow-up measures took place to evaluate health-related quality of life, psychological well-being; psychological stress, coping strategies, and triggering cognitions; self-compassion and compassion; and mindfulness in both intervention and wait-list groups. RESULTS: Accrual of eligible participants was high (77%), and the drop-out rate was 16%. Attendance to CBCT sessions was high and practice off sessions exceeded expectations). CBCT was effective in diminishing stress caused by FCR, fostering self-kindness and common humanity, and increasing overall self-compassion scores, mindful observation, and acting with awareness skillsets. CONCLUSION: CBCT could be considered a promising and potentially useful intervention to diminish stress caused by FCR and enhance self-kindness, common humanity, overall self-compassion, mindful observation, and acting with awareness skillsets. Nevertheless, future randomized trials are needed and a process of deeper cultural adaptation required.

Hulbert-Williams NJ, Beatty L, Dhillon HM. Psychological support for patients with cancer: evidence review and suggestions for future directions. Curr Opin Support Palliat Care 2018 Sep;12(3):276-292 PMID 30074924

PURPOSE OF REVIEW: Psychological distress and mental health comorbidity are common in cancer. Various therapeutic frameworks have been used for interventions to improve psychological wellbeing and quality of life in cancer patients with mixed results. This article reviews contributions to that literature published since January 2017. RECENT FINDINGS: The majority of new psychological intervention research in cancer has used cognitive behavioural therapy (CBT) or mindfulness-based interventions. CBT has been considered a gold-standard intervention and recent evidence justifies continuation of this. Recent reviews call into question the validity of evidence for mindfulness-based interventions. A smaller number of trials using acceptance and commitment therapy, meta-cognitive therapy, dignity therapy and coaching have emerged, and whereas findings are promising, additional fully powered trials are required. Weaker evidence exists for counselling, support-based and narrative therapy interventions. SUMMARY: Efficacious, timely and acceptable psychological interventions are a necessary component of comprehensive cancer care. There is some way to go before the evidence conclusively points towards which interventions work for which cancer groups and for which specific outcomes. Methodological limitations must be addressed in future trials; at the forefront remains the need for fully powered, head-to-head comparison trials.

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  1. 17. Massingill J, Jorgensen C, Dolata J, Sehgal AR. Myofascial Massage for Chronic Pain and Decreased Upper Extremity Mobility After Breast Cancer Surgery. Int J Ther Massage Bodywork 2018 Aug 5;11(3):4-9 PMID 30108667

    Background: Chronic localized pain and decreased upper extremity mobility commonly occur following breast cancer surgery and may persist despite use of pain medication and physical therapy. Purpose: We sought to determine the value of myofascial massage to address these pain and mobility limitations. Setting: The study took place at a clinical massage spa in the U.S. Midwest. The research was overseen by MetroHealth Medical Center's Institutional Review Board and Case Center for Reducing Health Disparities research staff. Participants: 21 women with persistent pain and mobility limitations 3-18 months following breast surgery. Research Design: We conducted a pilot randomized controlled trial where intervention patients received myofascial massages and control patients received relaxation massages. Intervention: Intervention participants received 16 myofascial massage sessions over eight weeks that focused on the affected breast, chest, and shoulder areas. Control participants received 16 relaxation massage sessions over eight weeks that avoided the affected breast, chest, and shoulder areas. Participants completed a validated questionnaire at the beginning and end of the study that asked about pain, mobility, and quality of life. Main Outcome Measures: Outcome measures include change in self-reported pain, self-reported mobility, and three quality-of-life questions. Results: At baseline, intervention and control participants were similar in demographic and medical characteristics, pain and mobility ratings, and quality of life. Compared to control participants, intervention participants had more favorable changes in pain (-10.7 vs. +0.4, p < .001), mobility (-14.5 vs. -0.8, p < .001), and general health (+29.5 vs. -2.5, p = .002) after eight weeks. All intervention and control participants reported that receiving massage treatments was a positive experience. Conclusions: Myofascial massage is a promising treatment to address chronic pain and mobility limitations following breast cancer surgery. Further work in several areas is needed to confirm and expand on our study findings.

    Matthews EE, Janssen DW, Djalilova DM, Berger AM. Effects of Exercise on Sleep in Women with Breast Cancer: A Systematic Review. Sleep Med Clin 2018 Sep;13(3):395-417 PMID 30098755

    Sleep deficiency is common and distressing for women with breast cancer throughout the care continuum. This article describes the scope and quality of evidence related to exercise interventions to improve sleep in women with breast cancer. Fifteen studies met the criteria and 12 were judged to be excellent quality. The most frequent intervention was walking, primarily during the time of chemotherapy. Eleven studies reported postintervention improvement in sleep deficiency. Most yoga, qigong, and dance intervention studies reported no differences between groups. Emerging evidence exists for the effectiveness of aerobic exercise to improve various sleep outcomes in women with breast cancer.

Meghani SH, Peterson C, Kaiser DH, Rhodes J, Rao H, Chittams J, et al. A Pilot Study of a Mindfulness-Based Art Therapy Intervention in Outpatients With Cancer. Am J Hosp Palliat Care 2018 Sep;35(9):1195-1200 PMID 29514486

BACKGROUND: Patients with cancer frequently experience physical and psychological distress that can worsen their quality of life. OBJECTIVES: We assessed the outcomes of an 8-week mindfulness-based art therapy (MBAT) intervention, Walkabout: Looking In, Looking Out, on symptoms, sleep quality, health-related quality of life, sense of coherence (SOC), and spirituality in outpatients with cancer. METHODS: A 1-group, pre-post intervention design with repeated measures at baseline, week 4, and week 8. RESULTS: Despite a small pilot sample (n = 18), we found large effect sizes and statistically significant improvements from week 1 to week 8 in depression, the comprehensibility subscale of the SOC, and each subscale of spirituality, that is, peace, meaning, and faith. There were no significant changes in physical functioning, pain, sleep, tiredness, drowsiness, nausea, and appetite. CONCLUSIONS: The MBAT intervention, Walkabout, seems to meet key palliative care goals including improvement in emotional well-being, comprehensibility, and meaning making among outpatients with cancer.

Pan Y, Yang K, Shi X, Liang H, Shen X, Wang R, et al. Clinical Benefits of Acupuncture for the Reduction of Hormone Therapy-Related Side Effects in Breast Cancer Patients: A Systematic Review. Integr Cancer Ther 2018 Sep;17(3):602-618 PMID 30117343

IMPORTANCE: Acupuncture can help reduce unpleasant side effects associated with endocrine therapy for breast cancer. Nevertheless, comprehensive evaluation of current evidence from randomized controlled trials(RCTs) is lacking. OBJECTIVE: To estimate the efficacy of acupuncture for the reduction of hormone therapy-related side effects in breast cancer patients. EVIDENCE REVIEW: RCTs of acupuncture in breast cancer patients that examined reductions in hormone therapy-related side effects were retrieved from PubMed, EMBASE, Web of Science, Ovid MEDLINE, and Cochrane Library databases through April 2016. The quality of the included studies was evaluated according to the 5.2 Cochrane Handbook standards, and CONSORT and STRICTA (Revised Standards for Reporting Interventions in Clinical Trials of Acupuncture) statements. INTERVENTION: Interventions included conventional acupuncture treatment compared with no treatment, placebo, or conventional pharmaceutical medication. Major outcome measures were the alleviation of frequency and symptoms and the presence of hormone therapy-related side effects. Findings/Results. A total of 17 RCTs, including a total of 810 breast cancer patients were examined. The methodological quality of the trials was relatively rigorous in terms of randomization, blinding, and sources of bias. Compared with control therapies, the pooled results suggested that acupuncture had moderate effects in improving stiffness. No significant differences were observed in hot flashes, fatigue, pain, gastrointestinal symptoms, Kupperman index, general well-being, physical well-being, tumor necrosis factor (TNF), and interleukin (IL). CONCLUSIONS: Acupuncture therapy appears to be potentially useful in relieving functional stiffness. However, further large-sample trials with evidence-based design are still needed to confirm these findings.

Park H, Oh S, Noh Y, Kim JY, Kim JH. Heart Rate Variability as a Marker of Distress and Recovery: The Effect of Brief Supportive Expressive Group Therapy With Mindfulness in Cancer Patients. Integr Cancer Ther 2018 Sep;17(3):825-831 PMID 29417836

OBJECTIVES: We aimed to investigate the effects of brief supportive expressive group therapy with mindfulness for cancer patients and to assess the utility of heart rate variability (HRV) as a biomarker of distress and treatment effect. METHODS: A total of 28 female patients with nonmetastatic cancer at a university hospital in South Korea received a 4-week modified group therapy for distress reduction. The BESTMIND (Brief Expression and Support Therapy with Mindfulness) program consisted of supportive-expressive group therapy and mindfulness-based stress reduction. The subjective outcomes of distress, anger, sleep quality, and sense of well-being and the physiological outcome of HRV were assessed before and after the program. RESULTS: After the program, patients showed significantly reduced distress, perceived stress, anger, and sleep disturbance and increased quality of life. No significant change was observed in the degree of mindfulness. A significantly increased SD in the normal beat-to-beat intervals and normalized high-frequency (HF 0.15-0.4 Hz) power from spectral analysis were observed after treatment. According to the correlation analyses, HF power correlated with depression scores, and normalized HF power was associated with depression, anxiety, perceived stress, and anger at baseline. The pretreatment and posttreatment comparison indicated that an increase in HF power was associated with a decrease in anger. CONCLUSIONS: These results suggest the effectiveness of this modified group-based program for distress reduction and also provide preliminary evidence for the use of HRV as a biomarker of distress and recovery. HF power from HRV variables may serve as a quantitative biomarker of the treatment response of distress management, including anger.

Qureshi M, Zelinski E, Carlson LE. Cancer and Complementary Therapies: Current Trends in Survivors' Interest and Use. Integr Cancer Ther 2018 Sep;17(3):844-853 PMID 29629606

BACKGROUND: Cancer survivors use complementary therapies (CTs) for a variety of reasons; however, with interest and use reportedly on the rise and a widening range of products and practices available, there is a need to establish trends in and drivers of interest. We aimed to determine (1) frequencies of use, level of interest, and barriers for 30 specific CTs and (2) whether physical symptoms, perceived stress (PS), or spiritual well-being were related to interest levels. METHOD: A total of 212 cancer outpatients were surveyed at the Tom Baker Cancer Centre in Calgary, Canada. RESULTS: Overall, up to 75% of survivors already used some form of CTs since their diagnosis. The most highly used were the following: vitamins B12 and D, multivitamins, calcium, and breathing and relaxation exercises. Those who had not used CTs indicated highest interest in massage, vitamin B12, breathing and relaxation, mindfulness-based stress reduction, and antioxidants. The most frequently reported barriers for all CTs were not knowing enough about what a therapy was and not having enough evidence on whether it worked. High PS predicted higher interest for all CTs, but spirituality was not significantly related to any. Physical symptoms, anxiety, and depression were significant predictors of interest for some CTs. CONCLUSION: These findings provide a blueprint for future clinical efficacy trials and highlight the need for clinical practice guidelines.

Seely D, Ennis JK, McDonell E, Zhao L. Naturopathic Oncology Care for Thoracic Cancers: A Practice Survey. Integr Cancer Ther 2018 Sep;17(3):793-805 PMID 29558830

BACKGROUND AND OBJECTIVES: There is a lack of information on therapies recommended by naturopathic doctors (NDs) for lung and gastroesophageal cancer care. Study objectives were to: (1) identify the most common interventions considered for use by NDs; (2) identify interventions NDs recommend to support key therapeutic goals; and (3) identify potential contraindications between integrative and conventional therapies. METHODS: Oncology Association of Naturopathic Physicians (OncANP) members (n = 351) were invited to complete an electronic survey. Respondents provided information on interventions considered for thoracic cancer pre- and postoperatively across 4 therapeutic domains (supplemental natural health products, physical, mental/emotional, and nutritional), therapeutic goals, and contraindications. This survey was part of the development of the Thoracic Perioperative Integrative Surgical Evaluation trial. RESULTS: Forty-four NDs completed the survey (12.5% response rate), all of whom were trained at accredited colleges in North America and the majority of whom were Fellows of the American Board of Naturopathic Oncology (FABNO) (56.8%). NDs identified significantly more interventions in the postoperative compared to preoperative setting. The most frequently identified interventions included modified citrus pectin, arnica, omega-3 fatty acids, vitamin D, probiotics, exercise, acupuncture, meditation, stress reduction, low glycemic index diet, and Mediterranean diet. Potential contraindications with conventional treatment (surgery, chemotherapy, radiotherapy) differed across natural health products. CONCLUSIONS: These findings highlight naturopathic interventions with a high level of use in thoracic cancer care, describe and characterize therapeutic goals and the interventions used to achieve these goals, and provide insight on how practice changes relative to conventional cancer treatment phase.

Serce S, Ovayolu O, Pirbudak L, Ovayolu N. The Effect of Acupressure on Pain in Cancer Patients With Bone Metastasis: A Nonrandomized Controlled Trial. Integr Cancer Ther 2018 Sep;17(3):728-736 PMID 29649905

BACKGROUND: Pain is a serious and common problem in bone metastases. For this purpose, complementary and supportive practices are also applied along with medical treatment. This study was conducted for the purpose of evaluating the effect of acupressure on pain in cancer patients with bone metastasis. METHODS: The study was conducted in a nonrandomized controlled trial with patients who applied to the radiotherapy unit of an oncology hospital. The data of the study were collected by using a questionnaire and the Visual Analog Scale. A total of 8 acupressure sessions, which lasted for approximately 10 minutes each (with warming and acupressure periods), was applied to the intervention group. The data were analyzed by using chi(2) test, paired t test, and Pearson's correlation coefficient. RESULTS: It was determined that the pain mean score of the intervention group was 7.6 +/- 1.9 before the acupressure and decreased to 6.8 +/- 1.9 after the acupressure and this result was statistically significant. On the other hand, no significant difference was determined in the pain mean score of the control group. CONCLUSIONS: Acupressure is applicable for cancer patients with bone metastasis by nursing staff after receiving brief training and may make a difference in relieving pain of the patients. Further well-designed trials should be conducted.

Sodergren SC, Husson O, Rohde GE, Tomasewska IM, Vivat B, Yarom N, et al. A Life Put on Pause: An Exploration of the Health-Related Quality of Life Issues Relevant to Adolescents and Young Adults with Cancer. J Adolesc Young Adult Oncol 2018 Aug;7(4):453-464 PMID 29565709

PURPOSE: In recent years, the assessment of health-related quality of life (HRQoL) has been recognized as particularly informative to healthcare providers. For adolescents and young adults (AYAs), the impact of a cancer diagnosis and subsequent treatment is likely to be distinct from other age groups given the unique and complex physical and psychosocial challenges of this developmental phase. The objective of this study was to capture the HRQoL issues described by AYAs with cancer using thematic analysis. METHODS: Semi-structured interviews were carried out with 45 AYAs aged 14-25 years from six countries. RESULTS: The most prevalent cancers presented were leukemia (n = 12) and lymphoma (n = 8). AYAs' descriptive accounts were analyzed and 12 categories identified: Symptoms (i.e., pain, nausea, vomiting) (84% AYAs); activity limitations (education, leisure time activities) (87%); disrupted life plans (29%); social (loss of friends, family life) (91%); emotional (depression, anxiety) (64%); body image (conscious of changed appearance) (36%); self-appraisals (greater maturity, braver) (47%); outlook on life (altered priorities, increased motivation to achieve) (33%); lifestyle (restricted diet, avoidance of infections) (18%), treatment-related (absence of age-appropriate information, treatment burden) (31%); fertility (24%); and financial concerns (13%). CONCLUSIONS: A wide spectrum of both negative and positive issues were described. Several of these issues, such as disrupted life plans and difficulty establishing romantic relationships, are likely to be more common to AYAs with cancer and might not be captured by existing HRQoL measures. Recognition of these issues and finding ways of addressing them should be seen as an essential component of AYA-tailored cancer care.

Sun L, Mao JJ, Vertosick E, Seluzicki C, Yang Y. Evaluating Cancer Patients' Expectations and Barriers Toward Traditional Chinese Medicine Utilization in China: A Patient-Support Group-Based Cross-Sectional Survey. Integr Cancer Ther 2018 Sep;17(3):885-893 PMID 29888609

BACKGROUND: Traditional Chinese medicine (TCM) is widely used among Chinese cancer patients. However, little is known about Chinese patients' expectations and barriers toward using TCM for cancer. METHODS: We conducted a cross-sectional survey within a patient-support group, the Beijing Anti-Cancer Association. We measured the outcome, Chinese cancer survivors' expectations and barriers toward TCM utilization, using a modified version of ABCAM (Attitudes and Beliefs towards Complementary and Alternative Medicine), the ABTCM (Attitudes and Beliefs towards Traditional Chinese Medicine). We used multivariate models to evaluate the impact of socioeconomic status and clinical factors on their expectations and barriers (including treatment concerns and logistical challenges domain) toward TCM. RESULTS: Among 590 participants, most patients expected TCM to boost their immune system (96%), improve their physical health (96%), and reduce symptoms (94%). Many had logistical challenges (difficulty decocting herbs (58%) and finding a good TCM physician (55%)). A few were concerned that TCM might interfere with conventional treatments (7.6%), and that many TCM treatments are not based on scientific research (9.1%). In the multivariable regression model, age </=60 years was independently associated with higher expectation score ( P = .031). Age </=60 years (coefficient 5.0, P = .003) and localized disease (coefficient 9.5, P = .001) were both associated with higher treatment concerns. Active employment status (coefficient 9.0, P = .008) and localized disease (coefficient 7.5, P = .030) were related to more logistical challenges. CONCLUSION: Age and cancer stage were related to Chinese cancer patients' perceived expectations and barriers toward TCM use. Understanding these attitudes is important for reshaping the role that TCM plays in China's patient-centered comprehensive cancer care model.

Tolia M, Tsoukalas N, Nikolaou M, Mosa E, Nazos I, Poultsidi A, et al. Utilizing Yoga in Oncologic Patients Treated with Radiotherapy: Review. Indian J Palliat Care 2018 Jul-Sep;24(3):355-358 PMID 30111951

Purpose: Several trials on noncancer population indicate that yoga is associated with meaningful clinical effects. This study evaluated the physical and psychosocial outcomes of yoga in oncologic patients treated with radiotherapy. Methods: We focused on a research through Cochrane Register of Controlled Trials (CENTRAL), BioMed Central, and MEDLINE studies up to May 2017. Results: Yoga was found to have a substantial benefit in cancer patients' distress, anxiety, and depression. It also demonstrated a moderate impact on fatigue and emotional function and a small and insignificant effect on functional well-being and sleep disturbances. As far as the effects on psychological outcomes are concerned, there was insufficient evidence. Conclusions: This systematic review of randomized controlled trials showed that yoga has strong beneficial effects on oncologic patients' quality of life. Results of the current review must be interpreted with caution due to the relative small sample sizes of most of the included studies, while a prospective randomized study stands in need for the confirmation of our results.

Vergo MT, Pinkson BM, Broglio K, Li Z, Tosteson TD. Immediate Symptom Relief After a First Session of Massage Therapy or Reiki in Hospitalized Patients: A 5-Year Clinical Experience from a Rural Academic Medical Center. J Altern Complement Med 2018 Aug;24(8):801-808 PMID 29620922

OBJECTIVES: There is an increasing demand for and use of alternative and complementary therapies, such as reiki and massage therapy, in hospital-based settings. Most controlled studies and practice-based reports include oncology and surgical patient populations; thus the effect in a more heterogeneous hospitalized patient population is hard to estimate. We examined the immediate symptom relief from a single reiki or massage session in a hospitalized population at a rural academic medical center. DESIGN: Retrospective analysis of prospectively collected data on demographic, clinical, process, and quality of life for hospitalized patients receiving massage therapy or reiki. SETTINGS/LOCATION: A 396-bed rural academic and tertiary medical center in the United States. SUBJECTS: Hospitalized patients requesting or referred to the healing arts team who received either a massage or reiki session and completed both a pre- and post-therapy symptom questionnaire. INTERVENTIONS: First session of routine reiki or massage therapy during a hospital stay. OUTCOME MEASURES: Differences between pre- and postsession patient-reported scores in pain, nausea, fatigue, anxiety, depression, and overall well-being using an 11-point Likert scale. RESULTS: Patients reported symptom relief with both reiki and massage therapy. Analysis of the reported data showed reiki improved fatigue (-2.06 vs. -1.55 p < 0.0001) and anxiety (-2.21 vs. -1.84 p < 0.001) statistically more than massage. Pain, nausea, depression, and well being changes were not statistically different between reiki and massage encounters. Immediate symptom relief was similar for cancer and noncancer patients for both reiki and massage therapy and did not vary based on age, gender, length of session, and baseline symptoms. CONCLUSIONS: Reiki and massage clinically provide similar improvements in pain, nausea, fatigue, anxiety, depression, and overall well-being while reiki improved fatigue and anxiety more than massage therapy in a heterogeneous hospitalized patient population. Controlled trials should be considered to validate the data.

Yong JSJ, Park JFJ, Kim J, Kim PFJ, Seo IS, Lee H. The Effects of Holy Name Meditation on Spiritual Well-being, Depression, and Anxiety of Patients With Cancer. J Hosp Palliat Nurs 2018 Aug;20(4):368-376 PMID 30063630

This study was conducted to evaluate the effects of the Holy Name Meditation on cancer patients' spiritual well-being, anxiety, depression, and pain. Twenty-eight patients were enrolled in the control group, and 18 patients were selected for the experimental group. Only the patients in the experimental group completed 5 weeks of the Holy Name Meditation Program. All participants were surveyed to assess spiritual well-being (Spiritual Well-Being Scale), anxiety and depression (Symptom Checklist 90-R), and pain (numeric pain rating scale). There were no significant differences between the two groups' general characteristics, but the baseline survey revealed that anxiety and depression levels were higher in the experimental group. Analyzing the results after controlling the baseline scores of anxiety and depression showed that spiritual well-being was increased (F = 4.80, P = .034), whereas anxiety (F = 4.98, P = .031) and depression (F = 7.28, P = .010) were decreased after the intervention. No difference in pain was found between the two groups. The Holy Name Meditation Program was thus effective in enhancing cancer patients' spiritual well-being and decreasing their anxiety and depression. Therefore, it is recommended that Holy Name Meditation be provided in clinical settings to reduce the psychosocial and spiritual suffering of cancer patients.

Zeng Y, Cheng ASK, Song T, Sheng X, Wang S, Xie J, et al. Effects of Acupuncture on Cancer-Related Cognitive Impairment in Chinese Gynecological Cancer Patients: A Pilot Cohort Study. Integr Cancer Ther 2018 Sep;17(3):737-746 PMID 29806502

BACKGROUND: Among women in China, gynecological cancers are the second most common cancers after breast cancer. Cancer-related cognitive impairment (CRCI) has emerged as a significant problem affecting gynecological cancer survivors. While acupuncture has been used in different aspects of cancer care, the possible positive effects of acupuncture on cognitive impairment have received little attention. This study hypothesized that patients would demonstrate lower neurocognitive performance and lower structural connectivity compared to healthy controls. This pilot study also hypothesized that acupuncture may potentially be effective in treating CRCI of cancer patients by increasing brain structural connectivity and integrity. METHODS: This prospective cohort study consisted of 3 stages: the first stage included a group of gynecological cancer patients and a group of age-matched healthy controls. This baseline stage used a core set of neurocognitive tests to screen patients with cognitive impairment and used a multimodal approach of brain magnetic resonance imaging (MRI) to explore the possible neurobiological mechanism of cognitive impairment in cancer patients, comparing the results with a group of noncancer controls. The second stage involved assigning CRCI patients into the acupuncture intervention group, while patients without CRCI were assigned into the cancer control group. The third stage was a postintervention assessment of neurocognitive function by the same set of neurocognitive tests at baseline. To explore the possible neurobiological basis of acupuncture for treating CRCI, this study also used a multimodal MRI approach to assess changes in brain structural connectivity, and neurochemical properties in patients at pre- and postacupuncture intervention. RESULTS: This study found that the prevalence of cognitive impairment in Chinese gynecological cancer patients at diagnosis was 26.67%. When investigating the microstructural white matter in the brain, diffusion tensor imaging data in this study indicated that premorbid cognitive functioning (before clinical manifestations become evident) has already existed, as the global and local connectome properties in the entire patient group were lower than in the healthy control group. Using magnetic resonance spectroscopy, this study indicated there was a significant reduction of relative concentration of NAA ( N-acetyl aspartate) in the left hippocampus, comparing these results with healthy controls. Regarding the effects of acupuncture on reducing CRCI, patients in the acupuncture group reported better neurocognitive test performance after matching for age, menopausal status, cancer stage, and chemotherapy regimen dosage. On a microstructural level, acupuncture's ability to reduce CRCI may be attributed to a reduction in demyelination and an enhancement of the neuronal viability of white matter in the hippocampus. CONCLUSION: This pilot study indicates that acupuncture is a promising intervention in treating CRCI in gynecological cancer patients undergoing chemotherapy; however, it requires evaluation in larger randomized controlled studies to definitively assess its benefit. By using a multimodal imaging approach, this pilot study also provides novel insights into the neurobiological basis of cognitive impairment on the human brain that has been induced by cancer and/or its treatment.

Zhang F, Shen A, Jin Y, Qiang W. The management strategies of cancer-associated anorexia: a critical appraisal of systematic reviews. BMC Complement Altern Med 2018 Aug 9;18(1):236-018-2304-8 PMID 30092794

BACKGROUND: Cancer-related anorexia remains one of the most prevalent and troublesome clinical problems experienced by patients with cancer during and after therapy. To ensure high-quality care, systematic reviews (SRs) are seen as the best guide. Considering the methodology quality of SRs varies, we undertook a comprehensive overview, and critical appraisal of pertinent SRs. METHODS: Eight databases (between the inception of each database and September 1, 2017) were searched for SRs on the management of cancer-related anorexia. Two researchers evaluated the methodological quality of each SR by using the Revised Assessment of Multiple Systematic Reviews (R-AMSTAR) checklist. Characteristics of the "high quality" SRs were abstracted, included information on relevant studies numbers, study design, population, intervention, control, outcome and result. RESULTS: Eighteen SRs met the inclusion criteria. The R-AMSTAR scores of methodological quality ranged from 18 to 41 out of 44, with an average score of 30. Totally eight SRs scored >/=31 points, which showed high methodological quality, and would be used for data extraction to make summaries. Anamorelin had some positive effects to relieve cancer anorexia-cachexia syndrome (CACS) and improve the quality of life (QoL). Megestrol Acetate (MA) could improve appetite, and was associated with slight weight gain for CACS. Oral nutritional interventions were effective in increasing nutritional intake and improving some aspects of QoL in patients with cancer who were malnourished or at nutritional risk. The use of thalidomide, Eicosapentaenoic Acid, and minerals, vitamins, proteins, or other supplements for the treatment of cachexia in cancer were uncertain, and there was inadequate evidence to recommend it to clinical practices, the same situation in Chinese Herb Medicine and acupuncture (acupuncture and related therapies were effective in improving QoL) for treating anorexia in cancer patients, warranting further RCTs in these areas. CONCLUSIONS: Anamorelin, MA, oral nutrition interventions, and acupuncture could be considered to be applied in patients with cancer-related anorexia. Future RCTs and SRs with high quality on the pharmaceutical or non-pharmaceutical interventions of anorexia in cancer patients are warranted.

Zorba P, Ozdemir L. The Preliminary Effects of Massage and Inhalation Aromatherapy on Chemotherapy-Induced Acute Nausea and Vomiting: A Quasi-Randomized Controlled Pilot Trial. Cancer Nurs 2018 Sep/Oct;41(5):359-366 PMID 28426542

BACKGROUND: Despite pharmacological treatment, chemotherapy-induced nausea and vomiting (CINV) are observed in patients. OBJECTIVE: This quasi-randomized controlled pilot study evaluated the feasibility and preliminary effects of massage and inhalation aromatherapies on chemotherapy-induced acute nausea/vomiting. METHODS: Seventy-five patients with breast cancer were randomly grouped into 1 of 3 groups: massage (n = 25), inhalation (n = 25), and control (n = 25). The patients in the massage group received 20-minute aromatherapy foot massage, whereas those in the inhalation group received 3-minute inhalation aromatherapy before their second, third, and fourth chemotherapy cycles. The control group underwent only the routine treatment. A nausea, vomiting, and retching patient follow-up form was used to evaluate nausea severity by visual analog scale and frequency of vomiting and retching. RESULTS: The incidence of nausea and retching was significantly higher in the control group than in the other groups in the third and fourth chemotherapy cycles (P < .001). Furthermore, in these 2 cycles, the incidence of nausea and retching was significantly lower in the massage group than in the inhalation group (P < .001). Nausea severity was significantly lower among patients in the massage and inhalation groups than in the control group in all 3 cycles (P < .001). CONCLUSION: Nausea severity was significantly lower in the massage and inhalation aromatherapy groups than in the control group. Nausea and retching incidence was reduced in the aromatherapy groups compared with that in the control group. IMPLICATIONS FOR PRACTICE: Nonpharmacological approaches are recommended for managing CINV. Massage and inhalation aromatherapy seems promising regarding the management of CINV.


July 2018

Al Daken LI, Ahmad MM.

The implementation of mindfulness-based interventions and educational interventions to support family caregivers of patients with cancer: A systematic review.

Perspect Psychiatr Care 2018 Jul;54(3):441-452 PMID 29745417

This review aims to determine the effectiveness of mindfulness-based interventions (MBIs) and educational interventions (EIs) as supportive care for family caregivers (FCs) of patients with cancer.

DESIGN AND METHODS: Review was conducted following PRISMA guidelines. The search protocol was performed using EBSCO, Google Scholar, and Science Direct for the studies published between 2007 and 2017. FINDINGS: Little evidence is available on the usefulness of MBIs among FCs of patients with cancer. However, the available evidence supports that MBIs have the potential to enhance overall well-being and reduce the burden for FCs. EIs have shown positive outcomes on some aspects of well-being and reducing the burden.

PRACTICE IMPLICATIONS: The findings provide preliminary support for effectiveness of MBIs and EIs as a supportive care for FCs.



Bao T, Iris Zhi W, Vertosick EA, Li QS, DeRito J, Vickers A, et al.

Acupuncture for breast cancer-related lymphedema: a randomized controlled trial.

Breast Cancer Res Treat 2018 Jul;170(1):77-87 PMID 29520533

Approximately 20% of breast cancer survivors develop breast cancer-related lymphedema (BCRL), and current therapies are limited. We compared acupuncture (AC) to usual care wait-list control (WL) for treatment of persistent BCRL.

METHODS: Women with moderate BCRL lasting greater than six months were randomized to AC or WL. AC included twice weekly manual acupuncture over six weeks. We evaluated the difference in circumference and bioimpedance between affected and unaffected arms. Responders were defined as having a decrease in arm circumference difference greater than 30% from baseline. We used analysis of covariance for circumference and bioimpedance measurements and Fisher's exact to determine the proportion of responders.

RESULTS: Among 82 patients, 73 (89%) were evaluable for the primary endpoint (36 in AC, 37 in WL). 79 (96%) patients received lymphedema treatment before enrolling in our study; 67 (82%) underwent ongoing treatment during the trial. We found no significant difference between groups for arm circumference difference (0.38 cm greater reduction in AC vs. WL, 95% CI - 0.12 to 0.89, p = 0.14) or bioimpedance difference (1.06 greater reduction in AC vs. WL, 95% CI - 5.72 to 7.85, p = 0.8). There was also no difference in the proportion of responders: 17% AC versus 11% WL (6% difference, 95% CI - 10 to 22%, p = 0.5). No severe adverse events were reported. CONCLUSIONS: Our acupuncture protocol appeared to be safe and well tolerated. However, it did not significantly reduce BCRL in pretreated patients receiving concurrent lymphedema treatment. This regimen does not improve upon conventional lymphedema treatment for breast cancer survivors with persistent BCRL.



Baumann FT, Reike A, Reimer V, Schumann M, Hallek M, Taaffe DR, et al.

Effects of physical exercise on breast cancer-related secondary lymphedema: a systematic review.

Breast Cancer Res Treat 2018 Jul;170(1):1-13 PMID 29470804

The aim of this systematic review is to assess the effect of different types of exercise on breast cancer-related lymphedema (BCRL) in order to elucidate the role of exercise in this patient group.

METHODS: A systematic data search was performed using PubMed (December 2016). The review is focused on the rehabilitative aspect of BCRL and undertaken according to the PRISMA statement with Levels of Evidence (LoE) assessed.

RESULTS: 11 randomized controlled trials (9 with LoE 1a and 2 with LoE 1b) that included 458 women with breast cancer in aftercare were included. The different types of exercise consisted of aqua lymph training, swimming, resistance exercise, yoga, aerobic, and gravity-resistive exercise. Four of the studies measured a significant reduction in BCRL status based on arm volume and seven studies reported significant subjective improvements. No study showed adverse effects of exercise on BCRL.

CONCLUSION: The evidence indicates that exercise can improve subjective and objective parameters in BCRL patients, with dynamic, moderate, and high-frequency exercise appearing to provide the most positive effects.



Beseme S, Bengston W, Radin D, Turner M, McMichael J.

Understanding rationales for acupuncture treated individuals' beliefs in acupuncture effects, to be able to maximize therapeutic results: A qualitative analysis.

Complement Ther Med 2018 Aug;39:101-108 PMID 30012380

OBJECTIVE: To investigate how individuals expressed rationales for their beliefs regarding efficacy of acupuncture.

METHODS: Qualitative data from participants of two different randomized sham-controlled trials, of relaxing (non-cancer volunteers of the general population) or antiemetic (patients with cancer undergoing radiotherapy) effects of acupuncture was analyzed. Participants (n=441) received genuine (n=120 and n=100) or sham (n=121 and n=100) (telescopic blunt sham-needle) relaxing or antiemetic acupuncture. The participants (n=428; 97% response rate) expressed their belief regarding the efficacy of acupuncture, and n=264 delivered qualitative rationales for their belief, analyzed using qualitative content analysis.

RESULTS: Of the 428 participants, 35 (8%) believed entirely that the acupuncture was effective, 209 (49%) believed much, 136 (32%) believed moderately, 39 (9%) believed a little, and 9 (2%) did not believe that the acupuncture was effective. Five categories and seven subcategories represented the meaning units of the central message of the rationales for the treatment belief. Participants with positive beliefs (believed entirely/much, n=244) presented rationales related to: "Experienced positive effects", "Knowledge regarding effect-mechanisms of acupuncture", and "General trustworthiness of acupuncture". Participants with more negative beliefs (believed a little or not, n=48) presented rationales related to: "Lack of feasibility of the acupuncture", "Varying effects", and "The effect is individual, not available for everybody".

CONCLUSION: In order to strengthen acupuncture treated patients' beliefs in the efficacy of acupuncture during clinical practice or research, acupuncture therapists may consider emphasizing these aspects in the therapeutic situation.


Hershman DL, Unger JM, Greenlee H, Capodice JL, Lew DL, Darke AK, 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 2018 Jul 10;320(2):167-176 PMID 29998338

Importance: Musculoskeletal symptoms are the most common adverse effects of aromatase inhibitors and often result in therapy discontinuation. Small studies suggest that acupuncture may decrease aromatase inhibitor-related joint symptoms.

Objective: To determine the effect of acupuncture in reducing aromatase inhibitor-related joint pain.

Design, Setting, and Patients: Randomized clinical trial conducted at 11 academic centers and clinical sites in the United States from March 2012 to February 2017 (final date of follow-up, September 5, 2017). Eligible patients were postmenopausal women with early-stage breast cancer who were taking an aromatase inhibitor and scored at least 3 on the Brief Pain Inventory Worst Pain (BPI-WP) item (score range, 0-10; higher scores indicate greater pain).

Interventions: Patients were randomized 2:1:1 to the true acupuncture (n = 110), sham acupuncture (n = 59), or waitlist control (n = 57) group. True acupuncture and sham acupuncture protocols consisted of 12 acupuncture sessions over 6 weeks (2 sessions per week), followed by 1 session per week for 6 weeks. The waitlist control group did not receive any intervention. All participants were offered 10 acupuncture sessions to be used between weeks 24 and 52.

Main Outcomes and Measures: The primary end point was the 6-week BPI-WP score. Mean 6-week BPI-WP scores were compared by study group using linear regression, adjusted for baseline pain and stratification factors (clinically meaningful difference specified as 2 points).

Results: Among 226 randomized patients (mean [SD] age, 60.7 [8.6] years; 88% white; mean [SD] baseline BPI-WP score, 6.6 [1.5]), 206 (91.1%) completed the trial. From baseline to 6 weeks, the mean observed BPI-WP score decreased by 2.05 points (reduced pain) in the true acupuncture group, by 1.07 points in the sham acupuncture group, and by 0.99 points in the waitlist control group. The adjusted difference for true acupuncture vs sham acupuncture was 0.92 points (95% CI, 0.20-1.65; P = .01) and for true acupuncture vs waitlist control was 0.96 points (95% CI, 0.24-1.67; P = .01). Patients in the true acupuncture group experienced more grade 1 bruising compared with patients in the sham acupuncture group (47% vs 25%; P = .01).

Conclusions and Relevance: Among postmenopausal women with early-stage breast cancer and aromatase inhibitor-related arthralgias, true acupuncture compared with sham acupuncture or with waitlist control resulted in a statistically significant reduction in joint pain at 6 weeks, although the observed improvement was of uncertain clinical importance. Trial Registration: Identifier: NCT01535066.


Ling CQ, Fan J, Lin HS, Shen F, Xu ZY, Lin LZ, et al.

Clinical practice guidelines for the treatment of primary liver cancer with integrative traditional Chinese and Western medicine.

J Integr Med 2018 Jul;16(4):236-248 PMID 29891180

Traditional Chinese medicine (TCM) is an important part of the treatment of primary liver cancer (PLC) in China; however, the current instructions for the integrative use of traditional Chinese and Western medicine for PLC are mostly based on expert opinion. There is no evidence-based guideline for clinical practice in this field. Therefore, the Shanghai Association of Chinese Integrative Medicine has established a multidisciplinary working group to develop this guideline, which focuses on the most important questions about the use of TCM during PLC treatment. This guideline was developed following the methodological process recommended by the World Health Organization Handbook for Guideline Development. Two rounds of questionnaire survey were performed to identify clinical questions; published evidence was searched; the Grading of Recommendations Assessment, Development and Evaluation approach was used to evaluate the body of evidence; and recommendations were formulated by combining the quality of evidence, patient preferences and values, and other risk factors. The guideline was written based on the Reporting Items for Practice Guidelines in Healthcare tool. This guideline contains 10 recommendations related to 8 questions, including recommendations for early treatment by TCM after surgery, TCM combined with transcatheter arterial chemoembolization for advanced PLC, TCM drugs for external use, and acupuncture and moxibustion therapy.



Myers JS, Erickson KI, Sereika SM, Bender CM.

Exercise as an Intervention to Mitigate Decreased Cognitive Function From Cancer and Cancer Treatment: An Integrative Review.

Cancer Nurs 2018 Jul/Aug;41(4):327-343 PMID 29194066

BACKGROUND: Decreased cognitive function associated with non-central nervous system cancers and cancer treatment significantly affects cancer survivors' quality of life. Exercise may be an effective intervention to mitigate decreased cognitive function.

OBJECTIVE: The aim of this article is to conduct an integrative review to summarize and critique the available evidence related to the use of exercise as a potential intervention for decreased cognitive function from cancer and cancer treatment.

METHODS: We conducted an integrative review through January 2016 utilizing PubMed, CINAHL, and PsycINFO. Broad inclusion criteria included any quantitative study in which cognitive outcomes were reported in relationship to any type of exercise for adult cancer survivors. Effect sizes were calculated when possible based on available data.

RESULTS: Twenty-six studies were included for review. The majority of studies (including aerobic or resistance exercise as well as mindfulness-based exercise) were associated with some improved cognitive outcomes. However, studies varied significantly in levels of evidence, cognitive domains assessed, and types of cognitive measures. Less than half of the studies included objective measures of cognitive function.

CONCLUSIONS: The evidence shows promising trends for the use of exercise as a potential intervention for improving cognitive function following cancer and cancer treatment, but questions remain concerning exercise type, timing of initiation, intensity, frequency, and duration.

IMPLICATIONS FOR PRACTICE: Additional research is warranted to understand how various types of exercise influence cognitive function in the cancer survivor population and to better understand the mechanisms driving these effects. Trial designs that include both objective and subjective measures of cognitive function are needed.



Pehlivan S, Suner A, Yildirim Y, Fadiloglu C.

Investigation into Complementary and Integrative Health Approaches for Turkish Patients with Gastrointestinal Cancer.

J Relig Health 2018 Aug;57(4):1497-1508 PMID 29299785

The study was conducted to determine the levels of usage of complementary and integrative health (CIH) approaches and the symptoms experienced by Turkish patients with gastrointestinal cancer. A descriptive study was conducted on 81 patients with gastrointestinal cancer attending the medical oncology department of an oncology hospital. In the data collection stage, the patient description form that prepared by the researchers and the "Edmonton Symptom Assessment Scale" were used. Data were evaluated via Chi-square and student t test. It was determined that 55.6% of the patients with gastrointestinal cancer applied at least one CIH approaches, and these CIH approaches were praying (80.0%), herbal medicine (57.7%), a special diet (40.0%), therapeutic touch (15.6%), exercise (13.3%) and psychotherapy (4.4%). 68.8% of patients who used the CIH approach stated that they applied the CIH approaches in order to supplement the medical treatment, and 91.1% stated that they did not inform health employees about that they using the CIH approach. It was also found that the use of CIH approaches was not related to socio-demographic characteristics, disease characteristics and experienced symptoms. It is very important that patients with gastrointestinal cancer be questioned in terms of CIH approaches used.


Van Gessel LD, Abrahams HJG, Prinsen H, Bleijenberg G, Heins M, Twisk J, et al.

Are the effects of cognitive behavior therapy for severe fatigue in cancer survivors sustained up to 14 years after therapy?

J Cancer Surviv 2018 Aug;12(4):519-527 PMID 29651784

PURPOSE: Cognitive behavior therapy (CBT) reduces cancer-related fatigue (CRF) in cancer survivors in the short term. We examined fatigue levels up to 14 years after CBT.

METHODS: Eligible participants of two randomized controlled trials who had completed CBT for CRF and a post-treatment assessment were contacted (n = 81). Fatigue was assessed with the subscale "fatigue severity" of the Checklist Individual Strength (CIS-fatigue). The course of fatigue over time was examined with linear mixed model analyses. Fatigue levels of participants were compared to matched population controls at long-term follow-up. We tested with multiple regression analysis if fatigue at follow-up was predicted by the patients' fatigue level and fatigue-perpetuating factors directly after CBT (post-CBT).

RESULTS: Seventy-eight persons completed a follow-up assessment (response rate = 96%, mean time after CBT = 10 years). The mean level of fatigue increased from 23.7 (SD = 11.1) at post-CBT to 34.4 (SD = 12.4) at follow-up (p < 0.001). Population controls (M = 23,9, SD = 11.4) reported lower fatigue levels than participants. Half of the patients (52%) who were recovered from severe fatigue at post-CBT (CIS-fatigue < 35) were still recovered at long-term follow-up. Patients with lower fatigue levels at post-CBT were less likely to show relapse.

CONCLUSION: Despite initial improvement after CBT, levels of fatigue deteriorated over time. Half of the patients who were recovered from severe fatigue after CBT still scored within normal ranges of fatigue at long-term follow-up.

IMPLICATIONS FOR CANCER SURVIVORS: It should be explored how to help patients with a relapse of severe fatigue following an initially successful CBT. They may profit from CBT again, or another evidence-based intervention for fatigue (like mindfulness or exercise therapy). Future research to gain insight into reasons for relapse is warranted.