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Complementary and alternative medicine in cancer pain management: A

systematic review

Article  in  Indian Journal of Palliative Care · February 2015

DOI: 10.4103/0973-1075.150202 · Source: PubMed

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Practitioner Section

Complementary and Alternative Medicine in Cancer Pain

Management: A Systematic Review
Priyanka Singh, Aditi Chaturvedi1
Departments of Pharmacology, Veer Chandra Singh Garhwali Government Institute of Medical Science and
Research, Srikot, 1Pharmacology, Subharti Medical College, Dehradun, Uttarakhand, India

Address for correspondence: Ms. Priyanka Singh; E‑mail: [email protected]

ABSTRACT

Quality of life (QoL) encompasses the physical, psychosocial, social and spiritual dimensions of life lived by
a person. Cancer pain is one of the physical component has tremendous impact on the QoL of the patient.
Cancer pain is multifaceted and complex to understand and managing cancer pain involves a tool box full of
pharmacological and non pharmacological interventions but still there are 50-70% of cancer patients who suffer
from uncontrolled pain and they fear pain more than death. Aggressive surgeries, radiotherapy and chemotherapy
focus more on prolonging the survival of the patient failing to realize that the QoL lived also matters equally. This
paper reviews complementary and alternative therapy approaches for cancer pain and its impact in improving
the QoL of cancer patients.

Key words: Cancer pain, Complementary and Alternative Medicine, Quality of life

INTRODUCTION Somerville explains pain as “many persons would rather

be dead than unloved, abandoned and, too often, left in
Health care benefit is judged broadly on parameters pain”.[2] “We must all die. But that I can save him from days of
of quantity and quality of life (QoL) lived by a person. torture, that is what I feel as my great and ever new privilege” says
While treating cancer by modern medicine we often focus Albert Schweitzer.[3] The International Association for
more on the quantity of life lived, however factors like the Study of Pain (IASP) defines pain as “an unpleasant
pain, stress, anxiety, fatigue, fear of death, depression are emotional situation which is originating from a certain
most of the time overlooked by the treating physicians. area, which is dependant or non‑dependant on tissue
Those health care professionals who sometimes bother damage and which is related to the past experience of
themselves with these aspects of patients’ life feel the person in question”.[4] About 50-70% of the cancer
unequipped with adequate knowledge to guide the patient patients suffer from uncontrolled pain associated with
into an unknown area of Complementary and Alternative anxiety, depression, suicidal tendency and fear pain more
Medicine (CAM). “Complementary Medicine” refers to than death.[5,6] Cancer pain has been described as moderate
treatments that are used in standard treatments. Clinicians to severe in approximately 40%-50% and as very severe in
and pain specialists have recognized that, even with endless 25%-30%.[7‑9] The mis‑belief of health professionals and
resources and huge advancements in the medical science, patients that pain is an in‑separable part of the human
every cancer patient’s pain can still not be eliminated.[1] suffering is widespread and that cancer pain is unavoidable
is very common.[10] Clinicians very gracefully label difficult
Access this article online to treat pain as psychological or malingerer’s pain unable
Quick Response Code: to recognize that the psychological component of pain
Website:
www.jpalliativecare.com
also needs treatment. Chronic pain in cancer patients
is dominated by the neuropathic, psychological, social
and spiritual components even when associated with
DOI:
10.4103/0973-1075.150202 nociceptive pain.[11] This has led to reduction in living
quality and functional situation of patients, increased

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Singh and Chaturvedi: CAM in cancer pain management

fatigue levels and impairment in daily activities and social with various allopathic interventions is the need of the
impairment.[12] These elements have directed patients and hour. Even though medical and surgical approaches are
caregivers to seek different approaches in pain management. considered the mainstay of cancer pain management, they
Hence, in addition to pharmacological treatment options have some limitations. Firstly, the patient may experience
for pain management non pharmacological options and severe side effects (constipation and nausea) thereby
complementary treatments are being attempted. [13,14] limiting their ability to take medication. Secondly, even on
Though evidence based CAM therapies are coming up still optimal pain medications, patients report uncontrolled
such practices are far from reality and beyond the scope pain. Thirdly, surgical techniques (implanted nerve pump
of a cancer patient especially in resource limited countries stimulators, morphine pump) are costly and not available
like India. This review is an endeavour to highlight the to large population. [17,18] The non pharmacological
importance of CAM therapies and its contribution in giving therapies aim to treat affective, cognitive, behavioral
the patient a pain free life and a feeling of well-being; a desire and socio‑cultural dimensions of cancer pain. These are
for which he lives and later dies also. Cancer institutes’ with generally classified as physical, cognitive, behavioural
well-developed palliative care facilities are collaborating and other complementary methods or as invasive or
with organisations that provide CAM therapies for a non‑invasive methods. Meditation, progressive relaxation,
holistic approach towards cancer. One such example is, dreaming, rhythmic respiration, biofeedback, therapeutic
in 2005 The University of Texas M. D. Anderson Cancer touching, transcutaneous electrical nerve stimulation
Institute announced collaboration with India’s yoga research (TENS), hypnosis, musical therapy, acupressure and
institution the Swami Vivekananda Yoga Anusadhana cold‑hot treatments are non‑invasive methods.[18,19]
Samsthana (Research Foundation) in Bangalore.
Lot of evidence supports use of CAM therapies in cancer
CAM encompasses a variety of discipline viz. acupuncture, patients and survivors and support an increase in QoL,
yoga, hypnosis, guided imagery, biofeedback, aromatherapy, sleep, mood, levels of stress, anxiety yet evidence of CAM
herbal remedies, massages and many others.[15] Today large in relieving pain of cancer patients seems insufficient. The
proportion of cancer pain patients use CAM possibly due present study aimed to conduct a review of evidence in
to dissatisfaction with conventional medication, desperation, support of CAM therapies in cancer pain.
compatibility between the philosophy of CAM and patient’s
own belief and wish for more control over one’s own Peripheral therapies
health.[16,17] The boundary between CAM and Conventional
This involves stimulating the patient’s skin in a harmless
Medicine is not absolute, and specific CAM practices may
manner. The skin stimulation techniques include
overtime be widely accepted. Various data sources viz.
hot‑ cold treatments, exercise, positioning, movement
Pubmed, Cochrane Library and Medline were searched
restriction‑resting, acupuncture, hydrotherapy, TENS,
with keywords like CAM and cancer pain, cancer pain and
massage and therapeutic touch. When used in an
yoga, acupuncture and cancer pain, Tai chi and cancer pain,
appropriate manner these methods are believed to be
Hypnotherapy and cancer pain, reflexology and cancer
effective on secondary pathologies such as inflammation,
pain, aromatherapy and cancer pain. Cognitive Behavioral
edema, progressive tissue damage, muscle spasm and
Therapy and cancer pain, music therapy and cancer pain,
function loss which takes part in acute pain.[19]
transcutaneous electrical nerve stimulation  (TENS) and
cancer pain, biofeedback and cancer pain. Emphasis was
Acupuncture
directed towards systematic reviews and meta‑analysis on
various topics pertaining to CAM and cancer pain. This is an important component of Traditional Chinese
Medicine (TCM) which has become a largely complementary
in the West together with the conventional medicine.
NON PHARMACOLOGICAL THERAPIES IN Acupuncture is accepted as a scientific treatment method
CANCER PAIN MANAGEMENT that provides the body to restore its balance by means of
stimulating some special points on the body with needles.
The medical, surgical and radiation oncologists while
It can be explained by Gate control theory, which states
treating cancer forget that there is a patient behind the
that sensory stimulant (lumbago), can be suppressed by
cancer whom they have to deal with. A comprehensive
another stimulant (pricking a needle) within the neural
cancer center, needs to address to the patients pain,
system.[19] Acupuncture has shown positive effects by
stress, anxiety, depression and fear of death and don’t
relieving nausea and vomiting during chemotherapy. It
just treat cancer and therefore a blend of CAM therapies
appears to be more effective in preventing vomiting than in
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Singh and Chaturvedi: CAM in cancer pain management

reducing. A randomized study found that true acupuncture claims that massage slows or reverses the growth or
was much more effective in relieving joint pain and spread of cancer. A growing number of health care
stiffness than sham (inactive) acupuncture in patients taking professionals recognize massage as a useful addition to
aromatase inhibitors.[20] Clinical trials have also been done conventional medical treatment.  Some evidence from
to show that acupuncture prevents xerostomia in cancer research studies with cancer patients supports the use
treated patients. Acupuncture has also shown to be effective of massage for short‑term symptom relief; additional
in treating hot flashes occurring in women with breast research is needed to find out if there are measurable,
cancer and men with prostate cancer caused by hormone long‑term physical or psychological benefits.
therapy.[21] The “Acu.Fatigue” trial is a big study that was
reported in 2012. It looked at whether acupuncture can help A systematic review has shown that out of 27 clinical trials
women with severe tiredness (fatigue) after chemotherapy testing massage interventions in cancer pain, 26 showed
treatment for breast cancer. The women in the trial had significant improvements in anxiety, emotional distress,
acupuncture carried out by a therapist for 20 minutes, once comfort, nausea and pain.[24]
a week, for 6 weeks. The results showed that it helped to
reduce fatigue and improve the women’s QoL. It is not A randomized control trial(RCT) involving 1290 cancer
clear from the study whether this benefit continues in the patients and 12 licensed massage therapist evaluating
longer term because the women were only followed up changes in symptoms scores for pain, fatigue, stress,
for 18 weeks. A review of acupuncture trials in 2013 also nausea and depression was conducted. Three variation of
found that there is not enough evidence that it can reduce massage were used‑ Swedish, light touch and foot massage.
tiredness and hence more research is needed.[22] The main outcome measures were data from symptom
cards collected from independent observers that were
A patient Ross who suffering from grade IV gliobastoma recorded before and after the first session of massage. The
states “acupunture that I used was so effective that it symptoms scores declined by 50%, however the effects of
enabled me to tolerate greater doses at closer intervals with massage were short‑ term.[25]
fewer side effects, so I never needed a blood transfusion.
Even with the stem cell rescue, I never needed a blood Another Cochrane review has concluded that massage
transfusion, never lost my hair, and never vomited” therapy confer short‑term benefits on psychological
(Cedars‑Sinai Medical Center, Los Angeles, California). benefits, with effects on anxiety supported by limited
evidence.[26]
There is also evidence to show that acupuncture has the
potential to produce rapid and effective analgesia when A special type of massage called manual lymph drainage
needles are inserted deeply enough and manipulated (MLD) is done as part of Complex Decongestive Therapy
sufficiently. For cancer break through pain this represents (CDT), which is used to treat lymphedema after certain
a possible adjunctive treatment and consideration should cancer surgeries. CDT also includes external compression
be given to administering acupuncture alongside ‘rescue’ garments, special exercises, and skin care. This treatment
doses of medication to ‘kick‑start’ the analgesic response is usually done by lymphedema specialists rather than
before the medication takes effect.[22] However, research is general‑practice massage therapists.[21]
needed to provide evidence that acupuncture is effective
for cancer pain, and the feasibility, practicality, safety of There is sufficient evidence to show that therapeutic
patients and reliability of acupuncturist administering massage is useful discipline in relieving various symptoms
acupuncture themselves must also be taken into account. of cancer. However, there is a dearth of randomised
controlled trials on massage therapy in cancer patients.
Massage It was difficult to interpret the results of reported trials
due to conflicting results, variation in methodology and
This involves manipulation of the body’s soft tissue use of non‑validated symptom scores. Further clinical
using various manual techniques and the application trials of better designs and mechanistic studies on
of pressure and traction. The peripheral receptors psychopyhsiologic effects of massage are required to
are stimulated which reaches the brain through spinal determine its significance in clinical practice.
cord. Massage seems to increase well‑being through
the reduction of stress and anxiety levels, and thus may Reflexology
contribute to pain control.[23] While massage appears
promising for symptom management and improving The use of manual pressure applied to specific areas, or
QoL, available scientific evidence does not support zones, of the feet (and sometimes the hands or ears) that
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Singh and Chaturvedi: CAM in cancer pain management

are believed to correspond to other body areas or organs. therapies like yoga can generate a feeling of well-being for
Pressure is applied to these reflex points by special hand the patient and promote the fighting capabilities.[29]
and finger techniques which relives stress and bring about
physiological changes and thereby reduction in pain Eshe et al., reported that yoga asanas stimulate not just
perception. It is stated in the literature that reflexology is muscles, but also increases blood flow, balances the glands
used especially for reducing end stage cancer pain and side and enhances the lymphatic flow in the body, all of which
effects of chemotherapy and to increase living quality.[27] enhances the body’s internal purification processes. The
A patient Lee‑Davis Conchie, who lives in South Shore, deep, relaxing breathing often emphasized in yoga in cancer
says “I was diagnosed with acute myeloid leukaemia 2 years therapy also increases the current of oxygen‑rich blood to
ago and have just had a transplant. I had reflexology on the cells, delivering vital nutrients to tired cells and further
my feet when I was being treated in the hospital and it clearing out toxins. For those recovering from surgery, such
benefitted me in many ways. as that for breast cancer, yoga can help restore motion and
flexibility in a gentle, balanced manner.[30]
“I found the treatment really wonderful. It gave me a feeling
of instant relaxation and was a welcome relief to get off Buffart et al., have conducted a systematic review and
the ward and be in a different environment. The room that meta‑analysis on physical and psychosocial benefits of yoga
is used has a real feeling of sacred space with music and in cancer patients and survivors. Out of the 1909 records
oils. I would definitely recommend it to other patients.” screened, 16 full text research papers on RCTs were included
in the review and only four such RCTs evaluated pain as
It can be argued that reflexology can be evaluated as holistic one of the physical outcomes and only one RCT reported
approaches that treat the whole person rather than the a decrease in cancer pain after yoga. The other three studies
symptoms.[28] The mechanistic link between manipulation reported no significant difference between yoga and control
of body tissue and corresponding relief from a broad range group. However two out of the four studies discussed in
of symptoms are not fully understood. None of the studies this extensive review of Buffart et al., did not have adequate
reported any adverse event associated with reflexology. Due effect size hence the results need to be interpreted with
to the lack of medical assessment data before or during caution on role of yoga in cancer pain. Buffart et al., also
implementation of reflexology, it is difficult to determine report that evidence for yoga to provide physical fitness
the safety of reflexology. Moreover, physicians must bear in and improve physical function are lacking and should be
mind that most patients use CAM to empower themselves assessed in further studies. However, several reviews and
in the management of their illness and thus may not be meta‑analysis suggest that yoga contribute to improvement
seeking evidence of safety.[28] in sleep, mood and QoL, depression, emotional function
and anxiety.[31‑33] Buffart et al., also report that literature
Yoga provides preliminary support for efficacy and feasibility of
yoga for cancer patients yet contribution of yoga in cancer
Yoga is an ancient healing system, inclusive of various pain needs assessment in future studies.
asanas or poses with breathing techniques and meditation
to assist in the movement and balancing of life force American Cancer Society (ACS) reports that evidence from
energy or prana. Though a lot of evidence supports use National Institutes of Health (NIH), suggests that yoga
of yoga as an adjunct treatment for cancer patients and may be helpful to relieve some of the symptoms linked
survivors yet studies on Yoga contributing in improvement to cancer. Recent studies of women cancer survivors of
of pain scores are scant. Individual experiences of patients breast cancer, suggest that yoga may help improve several
suffering from cancer have reported that Yoga helped aspects of QoL. However ACS does not comment about
them survive cancer better with strength, hope and vitality. effects of yoga on cancer pain.[34]
Michelle Parodi a patient with breast cancer who began
doing yoga asanas 2 months after surgery reports that “It Another meta‑analysis conducted by Lin et al., report the
helped me reconnect with my body and deal with all the beneficial effects of yoga on psychological and physical
achiness and joint pain that accompanied chemo”. Another health of cancer patients.[35] Ten RCTs were evaluated in
patient from Michigan also reports that «Yoga helped me this study and yoga was found to contribute positively
come into a nurturing energy, to befriend my body, listen towards psychological health for cancer patients and was
to it, and treat myself with gentleness and compassion”. beneficial in managing symptoms of fatigue, anxiety,
As chemotherapy and radiation therapy pose tremendous mood, stress and QoL of cancer patients. However
stress and emotional burden on the patient complementary interpretation of results on effects of yoga on physical

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Singh and Chaturvedi: CAM in cancer pain management

health demonstrates that there was no significant Yet another systematic review by Lee et al., assessed the use
difference between cancer patients in control group or of tai chi as an effective adjunct in cancer care reports that
yoga treated group. The author also agrees that because evidence is not conclusive to suggest Tai chi is an effective
of limited number of studies, effects of yoga on physical supportive treatment for cancer and needs well designed
health remains unclear. Therefore, at present a lot of research to answer the usefulness of this form of CAM.[38]
studies are providing preliminary support for the feasibility
and efficacy of yoga interventions and mindfulness based On search of various databases we could not find individual
stress reduction for cancer patients but evidence for studies, systematic reviews or meta‑analysis evaluating
contribution of yoga in relieving cancer pain remains scant. effects of tai chi specifically on cancer pain, hence at
Further studies, systematic reviews and meta‑analysis are present it is difficult to assess the role of Tai chi on cancer
required to comment on effects of yoga in cancer pain. pain though evidence supports its positive role in improving
QoL and psychological health of cancer patients.
Taichi
Hypnotherapy
Tai chi chuan is an ancient Chinese healing martial art form
consisting of a series of slow‑paced fluid‑like movements It is the induction of a trance‑like state to facilitate
and stretches that increase the flow of the “chi”—The life relaxation and enhance suggestibility for treating conditions
force energy—To prevent stagnation and blockages that and introduce behavioural changes. Many people have a
manifest as illness and disease. Tai chi also helps to balance misconception that hypnosis is a surrender of control and
the yin and yang principles, the feminine and masculine life you may start doing what you don’t want to do. Steven
force energies. Eshe reports that regular practice of tai chi Bloore, a Certified Hypnotherapist says “Hypnosis is not
promotes wellness of the mind, body and spirit, and can a surrender of control or a deep unconscious sleep. While
assist in decreasing the severity of side effects of cancer and hypnotized, you will never do what you would not normally
chemotherapy.[30] Mustian et al., from University of Rochester do in your regular conscious state”. Steven reports that eight
have reported that women who had completed treatment studies have been recently published in the International
of breast cancer were randomly categorized to receive Tai journal of Clinical and Experimental Hypnosis regarding
chi or psychological support therapy. Results demonstrated pain management using hypnosis and 75% of the people
that Tai chi significantly improved the functional capacity experienced pain relief, compared to the control group.
including the aerobic capacity, muscle strength and flexibility The expert also reports that “once cancer  is diagnosed
as well as QoL as compared to psychological support therapy the fear of the unknown begins to take over, both for the
which could only improve flexibility.[35] patient and the family which contributes to enormous levels
of anxiety and worry. It is not uncommon to see patients
Lee et al., have conducted various systematic reviews in
fearing a sense of helplessness and a loss of control over
2012, 2010, 2007 on various groups of cancer patients.
his or her own life due to cancer. Hypnosis helps patient
A systematic review by Lee et al., on effectiveness of tai chi
in various diseases concluded that though this therapy was cope more effectively with cancer. Liossi et al., conducted
effective in preventing falls and improving psychological a study with paediatric cancer patients in which it has been
health in elderly, its effect on preventing the symptoms of determined that hypnosis application has decreased pain and
cancer and hence cancer pain were insignificant.[36] anxiety level in patients. Research supports that hypnosis
can reduce anticipatory nausea and vomiting. Anticipatory
Another systematic review evaluating role of Tai chi on nausea and vomiting occur prior to chemotherapy when
breast cancer patients reports that evidence does not previous exposure to chemotherapy has already caused
support tai chi to be more effective CAM therapy than nausea and vomiting but hypnosis had less effects on
walking exercise, psychological support therapy or spiritual nausea and vomiting that happened after the chemotherapy
growth therapy (standard control procedures). Three dose is given. Hypnosis has also shown positive effects by
RCTs in this review compared tai chi with the standard improving cancer patients’ fatigue and hot flashes.[39]
control procedures in QoL and psychological health but
failed to demonstrate any significant difference between A prospective, randomized study of 39 advanced‑stage
the various procedures adopted. In contrast to the RCTs (Stage III or IV) cancer patients with malignant bone disease
the four non‑randomized controlled trials included in the who received weekly sessions of supportive attention or
extensive review did show some beneficial effects of Tai a hypnosis intervention. The hypnosis intervention group
chi for breast cancer patients but all the studies had high demonstrated an overall decrease in pain (P < 0.0001) for
risk of bias as assessed by the Cochrane criteria.[37] all sessions combined.
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Singh and Chaturvedi: CAM in cancer pain management

Nash et al., report that a yearlong intervention of hypnosis aromatherapy have beneficial short‑term effects on
was effective in reducing pain and suffering among women well‑being in cancer patients.[26] However, it has not been
with metastatic breast cancer as compared to control group.[40] convincingly demonstrated whether it is associated with
clinically relevant analgesic effects. Many people fear that
A systematic review of 27 papers comprising of RCTs, massage may spread the tumour to various other areas
observational studies, retrospective questionnaires as it shall increase the blood supply to which Horrigan
and 24 case studies for use of hypnotherapy to treat opines that surface massage will not make the cancer grow
symptoms of terminally ill adult cancer patients concludes due an increased blood supply,[48] nor make the cancer
that quality of research done is not adequate and further spread, nor interfere with chemotherapy or radiotherapy,
research is required to understand the role of hypnotherapy nor cure cancer by natural means.[49] In the normal low
in terminal cancer patients.[41] dosage usually adopted by trained aroma therapists there
should be no risk factor. However aroma therapists advise
A review concluded that four of five RCTs found hypnosis not to use unresearched oils or unfamiliar oils. There is
plus cognitive behavioural techniques reduced pain no evidence that either essential oils or aromatherapy has
intensity and severity compared with the control in patients caused cancer in humans.[50,51] Various oils that have been
with acute procedure related pain and oral mucositis pain found useful are Syzigium aromaticum (clove), Cupressus
related to bone marrow transplant.[42] sempervirens (cypress) and Pelargonium graveolens (geranium).
Lavender and citrus oils of a good quality are also useful
Various studies and reviews have reported that hypnotherapy
for relieving stress.
may be helpful to reduce procedure related pain viz. bone
marrow aspiration, lumbar puncture, venipuncture in Essential oils have been helpful when used during
various children and adults.[43‑45] Though results were radiotherapy to help reduce or prevent deep burning and
inconclusive for children between the age group of scarring.[49]
3-6  years as some studies report lack of effect in this
age-group yet children older than this age group showed There is no evidence of any interaction of any essential oils
consistent results of decrease in pain and anxiety related to with cytotoxic chemotherapeutic agents therefore cancer
these procedures. The review also cautions use of hypnosis patients may be given a trial of aromatherapy for nausea
by an expert only as this form of CAM may be associate and vomiting due to chemotherapy.
with short term (fatigue, anxiety, confusion, fainting) or
rarely serious reactions also (stupor, chronic psychological A systematic review of 18 clinical trials reveal that
problems, seizures) and therefore screening of vulnerable aromatherapy has short term benefits on depression,
individuals is recommended for this therapy.[46] anxiety and overall well-being, improved sleep and better
pain control. The neurotransmitters suggest inhibition of
A systematic review for effectiveness of hypnosis and glutamate binding and GABA augmentation. Linalool is the
procedure related pain and distress in pediatric cancer main component of lavender oil and it inhibits glutamate
patients reveals that though hypnosis has potential as binding in rats and augments gamma‑aminobutyric acid
a clinically valuable intervention in such patients yet (GABA) action.[51,52] It is proposed that the scent receptors
further research is required as various studies had lot of in the nose send chemical signals via olfactory nerve to the
methodological limitations.[47] limbic region and therefore affects a person’s emotional
responses, heart rate, blood pressure and breathing.
Therefore at present evidence supports use of hypnotherapy
Surveys carried out in the UK showed that 40.6% of
for various procedure related pain in pediatric and adult
cancer patients were using it.[53‑58] A US survey revealed
cancer patients but evidence for use of hypnotherapy for
that 11% of cancer patients may be using aromatherapy.
chronic cancer pain is inconclusive. [59,60]
The review concludes that use of diluted essential oils
Aromatherapy has minimal risks. Repeated exposure to lavender and tea
tree oils by topical administration was shown in one study
This is the controlled use of plant essences, applied to be associated with reversible prepubertal gynecomastia,
either to the skin through massage, added to baths or therefore patients with estrogen‑dependant tumors should
inhaled with steaming water. It has been shown that the exercise caution. Aromatherapy/essential oils may be
aromatic oils reached the lymph system by means of blood used by cancer patients for a short‑term benefit to reduce
circulation and provided recovery by means of intercellular anxiety, pain and depression and to increase sleep patterns
fluids. A  Cochrane systematic review concluded that and well-being.[60]

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Singh and Chaturvedi: CAM in cancer pain management

Music therapy always consult your health care provider before buying
and using one.[69]
Research reports that music therapy can help decrease the
nausea and vomiting in patients undergoing radiotherapy Blue Cross and Blue Shield Association Technology
and chemotherapy.[61,62] A meta‑analysis by Cepeda et al., Evaluation Center (TEC) have laid down some guidelines
shows that music therapy was best for short term pain for use of TENS in chronic pain patients. Though specific
after surgery and a new practice called music thenatology guidelines for cancer pain do not exist, TENS has been
is being tried as an end of life care measure in homes and tried in cancer patients for pain relief.[70‑74]
hospices to ease the last days of a person. Music therapy
can affect stress hormone levels and improve brain waves Important Guidelines for using TENS in chronic pain
and brain circulation.[63] patients
• TENS may be considered for 30  days to manage
Another review on quantitative literature on music based
refractory chronic pain (e.g. chronic musculoskeletal
interventions in palliative cancer care reports that available
evidence supports that music‑based interventions may have pain, or neuropathic pain that causes significant
a positive impact on cancer pain, anxiety, mood disturbance, disruption of function)
and QoL in cancer patients.[64] • The pain is unresponsive to at least 3  months of
conservative medical therapy
However a review published in Cochrane database on • The trial is monitored by a physician.
music therapy for end of‑life care suggests that limited
number of studies provide evidence on the benefit of Refractory chronic pain is defined as pain that causes
music therapy on the QoL of people in end‑of‑life care with significant disruption of function and has not responded
results suggesting that there is high risk of bias involved. to at least 3  months of conservative therapy, including
The review also reports that no evidence was found on the non‑steroidal anti‑inflammatory medications, ice, rest,
effect of music for pain or anxiety.[65] and/or physical therapy.

Therefore at present mixed results of use of music therapy

for cancer pain exists and high quality evidence for its use COGNITIVE‑BEHAVIOURAL THERAPY FOR PAIN
is awaited. MANAGEMENT

This is currently the most widely used psychological

TRANSCUTANEOUS ELECTRIC NERVE
treatment for persistent pain. This involves three steps. The
STIMULATION
first step is Pain education. Pain is described as a complex
sensory and emotional experience that is influenced by the
The TENS unit delivers low‑voltage electrical stimulation
patient’s thoughts, feelings, and behavior. By discussing
to leads which are placed over the skin on or near the
this topic, patients understand how their own responses to
painful sites. The efficacy of TENS in chronic cancer
patients has shown mixed results.[66] One study found pain influence their pain experience and start to recognize
positive results for patients with non‑malignant pain after the role that their own coping efforts can play a role in
1-3 months, with 25% reporting pain relief and use after pain control. The second step is training in one or more
4 years.[67] However, the recently published guidelines for coping skills for managing pain (e.g. relaxation or problem
cancer pain management state that cancer patients with solving). For each skill, a therapist provides an educational
mild pain may benefit from TENS.[68] rationale, basic instruction, and guided practice and
feedback. The third step in training is home practice with
Certain limitations of TENS therapy are that electrodes learned skills. Patients are initially encouraged to practice
should not be placed on certain parts of the body, such as in non‑demanding situations (e.g. reclining in a quiet room)
near eyes, on front of neck, open wounds or infections, near and then to apply their skills to more challenging tasks
tumors, in pregnant women, or on genitals. TENS is also (e.g. managing pain that may occur during walking or while
contraindicated for people with pacemakers, implantable transferring from one position to another). The final step
cardiac defibrillators, or other implanted devices, epilepsy in training involves helping patients develop a program for
and undiagnosed pain. maintaining their skills practice after training is completed
and for overcoming setbacks and relapses in their coping
According to FDA and the ACS, TENS is generally safe. efforts.[75] Several coping strategies have been studied in
Although TENS units are available “over the counter,” cancer pain, including diverting attention, reinterpretation
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Singh and Chaturvedi: CAM in cancer pain management

of painful sensations, active coping, passive coping, and throughout the treatment process. These guidelines
catastrophizing.[76] Beliefs about pain and cancer are targets advocate providing the patient and caregivers with written
of CBT. Spiritual beliefs and beliefs about the meaning of information about pain management, the types of pain
life are often overlooked in CBT, but can be critical when medications prescribed, and the type, cost, and efficacy of
cancer pain is persistent. pain treatment options.[68] In a study of 174 cancer patients
with pain due to bone metastases, pain education plus
A metanalysis of CBT on cancer survivors has shown that brief cognitive behavioural therapy produced significant
it is effective for short‑ term management (<8 months) reductions in average, worst, and least ratings of pain.[75]
of depression, anxiety and QoL of cancer survivors.[77]
Kangas et al. have reported CBT to be equally effective as In a recent review slightly over 50% of the studies testing pain
exercise interventions in treating cancer related fatigue.[78] education plus brief cognitive‑behavioral therapy showed
Two RCT have shown that CBT can be recommended for positive results. The studies that included more intensive
improving patients’ control or coping skills for short‑term skills training showed the best results.[86] Educational
and medium term benefits.[79,80] Tatrow et al. have supported interventions have directed at patients have resulted in
the use of CBT techniques when administered individually improved patient outcomes, however the mechanisms
to manage pain in breast cancer patients.[80] None of the by which these improvements occurs are still unclear.
trials have explored the long term effects of CBT.[81] Michael et al. suggest the use of educational intervention
with routine clinical practice alongside optimal oncological
Thus we can make no recommendations about the
and analgesic management.[87]
effectiveness of CBT in cancer pain management. We
suggest that future trials employ adequate sample size to A systematic review and metanalysis which aimed to
detect feasible and statistically significant improvements in
quantify the benefit of patient based education intervention
cancer pain management.
in management of cancer pain reported equivocal
evidence for the effect of education in self efficacy, but
IMAGERY AND HYPNOSIS BASED COGNITIVE no significant benefit on medication adherence or on
BEHAVIOURAL THERAPY reducing interference with daily activities.[88] Another
systematic review suggests that educational intervention
This has been the most promising psychosocial intervention can successfully improve cancer pain knowledge and
in the treatment of cancer pain. In this the patient is taught attitudes of healthcare professional but does not have
self guided imagery. The patient is made to focus on a much impact on patients’ pain level.
pleasant or distracting scene to attend to the sensation in
the scene like sights, sounds, smell etc. Once the patient There is no evidence showing that educational intervention
develops this skill, it will enable them to divert their can reduce cancer pain. The most promising avenue for
attention from pain. In hypnosis based CBT, the therapist improving cancer pain control in ambulatory settings
teach skills which helps the patient relax. This intervention may be brief nursing interventions targeting patients in
showed significant decrease in pain among children with combination with a daily pain diary. Allard et al. suggest
lumbar puncture and bone marrow biopsy.[82] This therapy the incorporation of systematic and valid method of
has found to be effective in reducing pain in women with documenting daily fluctuations in pain levels, and ensuring
metastatic breast cancer and adults undergoing bone that documented uncontrolled pain is followed rapidly by
marrow transplant.[83] A RCT has demonstrated that clinical reassessment and dose adjustment.[89]
imagery, relaxation and CBT can reduce the pain of certain
chemotherapy side effects.[84] It has also been found that self
hypnosis is one of the techniques that may provide relief COMPREHENSIVE COGNITIVE BEHAVIORAL
in cancer pain, and that relaxation and imagery could help THERAPY
with the pain of mouth sores caused by chemotherapy.[85]
This therapy emphasizes the importance of learning
different coping skills like relaxation, imagery, self calming
PAIN EDUCATION PLUS BRIEF COGNITIVE statements, problem solving. The patients systematically
BEHAVIOURAL THERAPY learn and master the skills of coping cancer pain. The
patients are encouraged to combine various coping
The guidelines for treatment of cancer pain involve skills to deal with daily challenges. In a study carried out
educating the patient and their family about cancer in advanced cancer patients, comprehensive cognitive
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Singh and Chaturvedi: CAM in cancer pain management

therapy showed an improvement in pain control. [90] dietary supplements, vitamins and minerals to choose
Further research is needed to on how best to implement for cancer patients (Web site: http://fnic.nal.usda.gov)
multicomponent interventions within clinical services • US FDA provide information and safe use of herbs
including the identification of which combinations are and dietary supplements. Here one can also report
most cost‑effective. the side effects with dietary supplements and herbs
(Web site: www.fda.gov/Food/DietarySupplements/
Caution with complementary and alternative therapies default.htm) dietary supplement to Medwatch at
1‑800‑FDA‑1088 (1‑800‑332‑1088) or visit www.fda.
The ACS provides detailed information on various CAM
gov/Safety/MedWatch)
therapies that can be helpful for the cancer patients. The
• United States Federal Trade Commission informs
Society also warns patients and families to avoid CAM
public about scams and unproven treatments and
therapies which make false claims for cancer.
also helps people log complaints that can detect such
Signs of treatments to avoid enlisted by ACS website. http:// patterns but does not resolve individual complaints by
www.cancer.org/treatment/treatmentsandsideeffects/ consumers (Web site: www.ftc.gov/curious
complementaryandalternativemedicine/complementary‑ • National Council Against Health Fraud which informs
and‑alternative‑methods‑for‑cancer‑management: public about health related fraud and quackery (Web
• Treatment promising cure for all cancers? site: www.ncahf.org)
• Advised not to use recommended or standard medical • Quack watch is a international network of people who
treatment? are concerned about the health related frauds, myths
• Treatment claims to offer benefits, but no side effects? and misconduct (Web site: www.quackwatch.org).
• The treatment or drug is offered by one person or
Limitations
clinic?
• The treatment requires you to travel to another country? This extensive review is an attempt by authors to help
• Do the proclaimers use terms like “scientific medical, surgical and radiation oncologists who wish to
breakthrough,” “miracle cure,” “secret ingredient,” or suggest CAM therapies to their patients and to help them
“ancient remedy”? evaluate the role of various CAM therapies and understand
• Personal miracle stories of amazing results, but no the existing evidence to guide the treatment. However this is
actual scientific evidence? not a systematic review and results must be interpreted with
• Do the promoters attack the medical or scientific caution. Also databases searched were limited to Pubmed,
community? Cochrane Library and Medline whereas other databases like
• The promotion is done by mass media (magazines, EMBASE, CINAHL, OVID etc., were beyond the scope
internet, TV, radio) and not by scientific journals? of the authors therefore the interpretations require a more
• What are the qualifications of the supporting team? extensive search and overview.
Are they recognised experts in complementary
medicines?
CONCLUSION
ACS also provides details of some of the websites that can
provide reliable information on CAM therapies: When battling cancer the worst part is not just the
• National Cancer Institute which provides information symptoms of the disease itself, but often the discomfort
on CAM therapies (www.cancer.gov/cancertopics/ and debilitating fatigue brought on from cancer treatments.
treatment/cam) Whether faced with severe pain in terminal cancer or ongoing
• National Center for Complementary and Alternative nausea and vomiting caused by chemotherapy/radiation,
Medicine (NCCAM) provides information on CAM surgery related pain; cancer patients endure a long road
therapies and related clinical trials (Web site: http:// of physical trials. To summarize, QoL of a cancer patient
nccam.nih.gov) can be effectively improved with the combination of
• Memorial Sloan Kettering Cancer Center provides pharmacological and non pharmacological therapies.
information on herbs and botanicals useful for There has been a rapid growth in CAM therapies for
cancer patients (Web site: www.mskcc.org/mskcc/ cancer patients in the recent past. However it needs to be
html/11570.cfm) steered by scientific enquiry, medical judgement, regulatory
• United States Department of Agriculture, Food and authority and collective decision making The modern
Nutrition Information Center provides details of medicine needs to accept its limitations and recognize the
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Singh and Chaturvedi: CAM in cancer pain management

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70. Bennett MI, Johnson MI. Transcutaneous electric nerve stimulation (TENS) Source of Support: Nil. Conflict of Interest: None declared.

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