News

Article

Non-Pharmacologic Therapies for Pain Management in Patients With Cancer: Opportunities and Challenges

Janet Abrahm, MD, FACP, FAAHPM, reviews the standing of the role of integrative therapies in cancer care.

Janet Abrahm, MD, FACP, FAAHPM

Janet Abrahm, MD, FACP, FAAHPM

Patients with cancer and their families are very interested in Integrative Oncology and Complementary and Alternative Medicine (CAM) techniques. Oncologists need to know which have national consensus recommendations and which do not. This article will briefly review the available evidence of these often-valuable adjuncts in managing cancer patients’ pain.

Up to 40% of patients with cancer use integrative therapies.1 Unfortunately, a lack of insurance coverage, practitioner availability, acceptance in certain cultures, and interventions designed for people from those cultures limit their use among racially and culturally diverse groups.2

Clinicians may be unaware of their patients’ use of CAMs because only 14% tell their providers.3 Patients’ reasons for withholding this information include worries that their oncologists would disapprove, feelings that CAM use wasn’t relevant to their oncological care, or that their oncologist didn’t ask.4

Of the five domains of CAM defined by the National Center for Complementary and Alternative Medicine, ASCO made recommendations for the following: alternative medical systems, manipulative and body-based methods, and mind-body interventions.5

Although the 2022 Society for Integrative Oncology (SIO)-ASCO1 and the 2024 National Comprehensive Cancer Network (NCCN) guidelines6 differ in their recommendations, both agree there is insufficient or inconclusive evidence for the following: music therapy, guided imagery and Progressive Muscle Relaxation, meditation, reflexology, Virtual Reality (VR) therapy, natural products like honey, chamomile, propolis, glutamine, curcumin, omega-3 fatty acids, teas, and mouthwash, Vitamin D, Kampo, and aromatherapy.

Both guidelines recommend acupuncture, acupressure, hypnosis, and massage—at least for selected populations.1 NCCN guidelines are more permissive and include the physical modalities positioning, therapeutic and conditioning exercise, massage, heat and/or ice, transcutaneous electrical nerve stimulation (TENS), acupuncture, electro-acupuncture or acupressure, and the cognitive modalities, Cognitive Behavioral Training (CBT), mindfulness-based stress reduction, imagery, hypnosis, biofeedback, distraction training, and relaxation training.6 What follows is a discussion of the most important recommended therapies.

Alternative Medical Systems

Oncology Acupuncture is a specialty within acupuncture.7 Acupuncture practitioners use acupuncture meridian points, extra-meridian odd points, and new points to choose the appropriate areas of the skin to insert needles to stimulate peripheral nerves either mechanically or electrically and provide pain relief. Studies on acupuncture for cancer pain have had structural flaws, and results are mixed. The Cochrane Review in 2015 found data insufficient to recommend acupuncture for cancer-related pain.8 However, two other systematic reviews and the 2017 NCI conference on acupuncture recommended it for cancer pain.9-11

Manipulative and Body-Based Methods

Manipulative and body-based methods include various cutaneous interventions—such as cold and heat, massage and vibration, and transcutaneous nerve stimulation—positioning, and exercise.12

Cutaneous interventions are used for localized pain, apparent muscle tension or guarding, or when waiting for a diagnostic procedure, treatment, or pain medicine to take effect. They are effective for cancer pain caused by bony metastases or nerve involvement.13

Dry heat generated by topical capsaicin creams (0.025% to 0.075%) or 0.025% capsaicin adhesive patches helps muscle and joint discomfort by reducing Substance P, a pain transmitter in human nerves.

Cold (cold wraps, gel packs, ice bags, or menthol) helps skeletal muscle spasms induced by nerve injury and inflamed joints. Cold massage can be done by filling a small paper cup with water, freezing it, and massaging the painful area with ice that forms in the cup. The mechanism of pain relief is thought to be “hyperstimulation analgesia” or “counter-irritation”: A mildly painful stimulus paradoxically relieves severe pain by bombarding the spinal relay system with inconsequential messages that block the transmission of the more severe pain signal.

Massage slows heart and respiratory rates, lowers blood pressure, and lessens pain and anxiety. It is helpful for muscle spasms resulting from tension or nerve injury, anxiety, patients with limited ability to communicate, or those who can benefit from the closeness such touch can offer, such as patients with advanced cancer.14

TENS machines are especially beneficial for patients with dermatomal pain, such as that caused by post-herpetic neuralgia, fractured ribs, diabetic neuropathy, or radiculopathy due to disk disease or spinal cord compression. Maximal pain relief may take weeks and usually lasts no more than two or three months.13

Positioning. Cancer patients with pain may lose the spontaneous pain-relieving movements needed to minimize tissue ischemia. To relieve their pain and minimize complications such as frozen joints, decubitus ulcers, or contractures, patients need help to change their position. The goal is to achieve a “loose-packed” position that minimizes joint stress. The recommended joint flexion angles are 45° at the elbow and 30° at the hip. Abduct the hip at 20° or place it in whatever position provides comfort.12

Exercise does not worsen cancer pain and may be beneficial, as evidence indicates those patients who are physically active experience less pain than those who are less active.15

Mind-Body Interventions

Pain and psychological distress are ultimately cognitive experiences. World War II army surgeon Dr Henry Beecher found that extensively wounded soldiers who survived the assault on Anzio requested minimal or no analgesia for their wounds.16 Later, in his civilian practice, Beecher found that civilian patients with injuries comparable to those sustained by the soldiers required much more analgesia. For civilians, the injuries meant disruption of their usual lives and routines, loss of income, and impaired functioning. For the soldiers, the injury guaranteed a ticket home. The pain’s meaning altered the pain experience’s intensity and changed the analgesic requirements.17

A meta-analysis of studies investigating psychosocial interventions to decrease pain in patients with cancer confirmed their efficacy.18 Mind-body therapies, especially immersive VR, meditation, hypnosis, suggestion, and CBT, produce moderate improvements in pain in patients on opioid therapy.19

Pain-CBT, which trains patients to reframe their thoughts about and responses to pain, has proved effective for patients with non-malignant pain, but the data are mixed for patients with cancer.20,21

A systematic review of immersive VR in burn patients found decreased pain, anxiety, and stress associated with dressing changes, physical rehabilitation, and physiotherapy.22 VR is an effective method of distraction in procedural pain.23 Therefore, it can likely help patients with cancer undergoing similarly painful procedures, but the research has yet to be done.

In mindfulness meditation,24 patients pay attention only to what is going on “right here, right now,” even if that includes painful or frightening physical sensations or emotions. The patient “observes” these feelings and thoughts as they arise during the meditation and separates the sensations from their emotions. Such observation can often help the patient later reframe the meanings of the sensations so that they are less frightening or less able to provoke anxiety.

Under hypnosis, patients can use images or metaphors to change the intensity of their pain or other discomforting symptoms.13Patients can visualize a car speedometer with a 0-to-100 scale, move the indicator to the number that reflects the intensity of their distress, and then move it to a lower position. As the indicator moves, the pain intensity will decrease, and that decrease will persist when they come out of hypnosis. Hypnosis has efficacy in helping patients deal with anticipated pain or discomfort before surgery, radiation, or chemotherapy.

Summary

To enhance their patients’ comfort and quality of life, oncology clinicians employ supportive and palliative care therapies and consult palliative care specialists when they are available. Recommending approved non-pharmacologic therapies or referring patients to specialists in their use can be similarly effective.

References

  1. 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
  2. Liou KT, Ashare R, Worster B, et al. SIO-ASCO guideline on integrative medicine for cancer pain management: implications for racial and ethnic pain disparities. JNCI Cancer Spectr. 2023;7(4):pkad042. doi:10.1093/jncics/pkad042
  3. Latte-Naor S, Mao JJ. Putting integrative oncology into practice: concepts and approaches. J Oncol Pract. 2019;15(1):7-14. doi:10.1200/JOP.18.00554
  4. Davis EL, Oh B, Butow PN, Mullan BA, Clarke S. Cancer patient disclosure and patient-doctor communication of complementary and alternative medicine use: a systematic review. Oncologist. 2012;17(11):1475-1481. doi:10.1634/theoncologist.2012-0223
  5. Paice JA, Portenoy R, Lacchetti C, et al. Management of chronic pain in survivors of adult cancers: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol. 2016;34(27):3325-3345. doi:10.1200/JCO.2016.68.5206
  6. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines). Adult Cancer Pain. National Comprehensive Cancer Network. March 11, 2024. Accessed May 24, 2024. https://www.nccn.org/professionals/physician_gls/pdf/pain.pdf
  7. Lu W, Rosenthal DS. Oncology acupuncture for chronic pain in cancer survivors: a reflection on the American Society of Clinical Oncology Chronic Pain Guideline. Hematol Oncol Clin North Am. 2018;32(3):519-533. doi:10.1016/j.hoc.2018.01.009
  8. Paley CA, Johnson MI, Tashani OA, et al. Acupuncture for cancer pain in adults. Cochrane Database Syst Rev. 2015(10):CD007753. doi:10.1002/14651858.CD007753.pub3
  9. Choi TY, Lee MS, Kim TH, Zaslawski C, Ernst E. Acupuncture for the treatment of cancer pain: a systematic review of randomised clinical trials. Support Care Cancer. 2012;20(6):1147-1158. doi:10.1007/s00520-012-1432-9
  10. Garcia MK, McQuade J, Haddad R, et al. Systematic review of acupuncture in cancer care: a synthesis of the evidence. J Clin Oncol. 2013;31(7):952-960. doi:10.1200/JCO.2012.43.5818
  11. Zia FZ, Olaku O, Bao T, et al. The National Cancer Institute’s conference on acupuncture for symptom management in oncology: state of the science, evidence, and research gaps. J Natl Cancer Inst Monogr. 2017(52):Igx005. doi:10.1093/jncimonographs/lgx005
  12. Cheville AL, Smith SR, Basford JR. Rehabilitation medicine approaches to pain management. Hematol Oncol Clin North Am. 2018;32(3):469-482. doi:10.1016/j.hoc.2018.02.001
  13. Abrahm JL, with Collins M and Daubman BR. Comprehensive guide to supportive and palliative care for patients with cancer. Johns Hopkins University Press, 2022.
  14. Kutner JS, Smith MC, Corbin L, et al. Massage therapy versus simple touch to improve pain and mood in patients with advanced cancer: a randomized trial. Ann Intern Med. 2008;149(6):369-379. doi:10.7326/0003-4819-149-6-200809160-00003
  15. Plinsinga ML, Singh B, Rose GL, et al. The effect of exercise on pain in people with cancer: a systematic review with meta-analysis. Sports Med. 2023;53(9):1737-1752. doi:10.1007/s40279-023-01862-9
  16. Beecher HK. Pain in men wounded in battle. Ann Surg. 1946;123(1):96-105.
  17. Beecher HK. 1956. Relationship of significance of wound to the pain experienced. J Am Med Assoc. 1956;161(17):1609-1613. doi:10.1001/jama.1956.02970170005002
  18. Gorin SS, Krebs P, Badr H, et al. Meta-analysis of psychosocial interventions to reduce pain in patients with cancer. J Clin Oncol. 2012;30(5):539-547. doi:10.1200/JCO.2011.37.0437
  19. Garland EL, Brintz CE, Hanley AW, et al. Mind-body therapies for opioid-treated pain: a systematic review and meta-analysis. JAMA Intern Med. 2020;180(1):91-105. doi:10.1001/jamainternmed.2019.4917
  20. Syrjala KL, Jensen MP, Mendoza E, Yi JC, Fisher HM, Keefe FJ. Psychological and behavioral approaches to cancer pain management. J Clin Oncol. 2014;32(16):1703-1711. doi:10.1200/JCO.2013.54.4825
  21. Goodlev ER, Discala S, Darnall BD, Hanson M, Petok A, Silverman M. Managing cancer pain, monitoring for cancer recurrence, and mitigating risk of opioid-use disorders: a team-based, interdisciplinary approach to cancer survivorship. J Palliat Med. 2019;22(11):1308-1317. doi:10.1089/jpm.2019.0171
  22. Scapin S, Echevarria-Guanilo ME, Fuculo PRB Jr, Gonçalves N, Rocha PK, Coimbra R. Virtual reality in the treatment of burn patients: a systematic review. Burns. 2018;44(6):1403-1416. doi:10.1016/j.burns.2017.11.002
  23. Indovina P, Barone D, Gallo L, Chirico A, De Pietro G, Giordano A. Virtual reality as a distraction intervention to relieve pain and distress during medical procedures: a comprehensive literature review. Clin J Pain. 2018;34(9):858-877. doi:10.1097/AJP.0000000000000599
  24. Kabat-Zinn J. Mindfulness meditation for pain relief: practices to reclaim your body and your life. MacMillan 2009.
Related Videos
Alicia Morgans, MD, MPH, genitourinary medical oncologist, medical director, Survivorship Program, Dana-Farber Cancer Institute; associate professor, medicine, Harvard Medical School
Adrienne G. Waks, MD, Dana-Farber Cancer Institute
Bradley McGregor, MD, discusses findings from a phase 1b study of abemaciclib  in clear cell renal cell carcinoma.
Paolo Tarantino, MD
Adrienne G. Waks, MD,
Eric Winer, MD
Paolo Tarantino, MD
Joaquim Bellmunt, MD, PhD
Lakshmi Nayak, MD
Ana Christina Garrido-Castro, MD