Clinical Practice Guidelines

SIO is pleased to provide two new resources on integrative oncology. SIO developed new Clinical Practice Guidelines on the Use of Integrative Therapies as Supportive Care in Patients Treated for Breast Cancer, published in November 2014. The guidelines are a resource for clinicians and patients to inform evidence-based decisions on the use of integrative therapies during breast cancer treatment. Researchers at US and Canadian evaluated the efficacy and safety of more than 80 therapies.

The Journal of the National Cancer Institute Monograph has released a special issue co-sponsored by SIO, The Role of Integrative Oncology for Cancer Survivorship, highlighting original peer-reviewed research in the field of integrative oncology. The articles in the special Monograph were all peer-reviewed.



Mark your calendar: SIO's 12th International Conference will be held November 14-16, 2015, with a theme of "Integrative Innovation" preceded by a first-ever Joint Conference on November 14 presented by SIO, the Society for Acupuncture Research, and Fascia Research Society. All in Boston, Massachusetts. Watch for updates!


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! 

SIO Research Poster Session               

Cancer & Complementary/Alternative Therapies: Literature update (April 2015)

Our current literature update includes:


Lan SC; Lin YE; Chen SC; Lin YF; Wang YJ.
Effects of acupressure on fatigue and depression in hepatocellular carcinoma patients treated with transcatheter arterial chemoembolization: a quasi-experimental study.
Evidence-Based Complementary & Alternative Medicine: eCAM. 2015:496485, 2015.
This study was to examine the effects of acupressure on fatigue and depression in HCC patients undergoing TACE. A quasiexperimental study design was used. Patients were evaluated at five time points: before treatment (T1) and 2, 3, 4, and 5 days after treating TACE (T2, T3, T4, and T5). Fatigue and depression were assessed by a VAS fatigue scale and a VAS depression scale at each time point. TFRS and BDI were administered at T1 and T5. Patients' fatigue and depression were significantly higher at T5 than at T1 in two groups. Fatigue and depression increased in both the experimental and control groups' patients over the five days of hospitalization during which TACE and chemotherapy were administered. The experimental group had significantly less fatigue than the control group, with lower subscale scores on physical, psychosocial, daily, and overall fatigue. There were no differences between the groups on depression. At posttest, the experimental group experienced lower physical, psychosocial, daily, and overall fatigue than the control group. Acupressure can improve fatigue in HCC patients during treatment with TACE but did not alleviate depression. Discharge planning should include home care for management of fatigue and depression.
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Archer S; Phillips E; Montague J; Bali A; Sowter H.
"I'm 100% for it! I'm a convert!": women's experiences of a yoga programme during treatment for gynaecological cancer; an interpretative phenomenological analysis.
Complementary Therapies in Medicine. 23(1):55-62, 2015 Feb.
OBJECTIVES: To explore patients' experiences of taking part in a yoga intervention while undergoing treatment for gynaecological cancer.
DESIGN: Sixteen women (age range 31-79 years; mean age 60) participated in
focus groups based on a semi-structured question schedule. Resulting discussions were audio-recorded, transcribed verbatim and analysed using interpretative phenomenological analysis (IPA).
SETTING: Royal Derby Hospital, UK.
INTERVENTIONS: Patients took part in a 10-week course of Hatha yoga, where they participated in a one hour long class per week.
RESULTS: Three themes emerged from the data: applying breathing techniques, engaging in the physicality of yoga and finding a community. The first theme was particularly important to the patients as they noted the breadth and applicability of the techniques in their day-to-day lives.
The latter two themes reflect physical and social perspectives, which are established topics in the cancer and yoga literature and are contextualised here within the women's experiences of cancer treatment.
CONCLUSIONS: The women's perceptions of the programme were generally positive, providing a previously unseen view of the patient experience of participating in a yoga intervention. The difference between the women's prior expectations and lived experiences is discussed.
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Sprod LK; Fernandez ID; Janelsins MC; Peppone LJ; Atkins JN; Giguere J; Block R; Mustian KM.
Effects of yoga on cancer-related fatigue and global side-effect burden in older cancer survivors.
Journal of Geriatric Oncology. 6(1):8-14, 2015 Jan.
BACKGROUND: Sixty percent of cancer survivors are 65years of age or older. Cancer and its treatments lead to cancer-related fatigue and many other side effects, in turn, creating substantial global side-effect burden(total burden from all side effects) which, ultimately, compromises
functional independence and quality of life. Various modes of exercise, such as yoga, reduce cancer-related fatigue and global side-effect burden in younger cancer survivors, but no studies have specifically examined the effects of yoga on older cancer survivors.
OBJECTIVES: The purpose of this study was to assess the effects of a 4-week yoga intervention on overall cancer-related fatigue, and due to its multidimensional nature, the subdomains of cancer-related fatigue (general, physical, emotional,
and mental) and global side-effect burden in older cancer survivors.
MATERIALS AND METHODS: We conducted a secondary analysis on data from a multicenter phase III randomized controlled clinical trial with 2 arms(standard care and standard care plus a 4-week intervention).
The sample for this secondary analysis was 97 older cancer survivors(>60years of age), between 2months and 2years post-treatment, who participated in the original trial.
RESULTS: Participants in the intervention arm reported significantly lower cancer-related fatigue, physical fatigue, mental fatigue, and global side-effect burden than participants in the standard care arm following the 4-week intervention period (p<0.05).
CONCLUSIONS: YOCASis an effective standardized yoga intervention for reducing cancer-related fatigue, physical fatigue, mental fatigue, and global side-effect burden among older cancer survivors.
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Vardar Yagli N; Sener G; Arikan H; Saglam M; Inal Ince D; Savci S; Calik Kutukcu E; Altundag K; Kaya EB; Kutluk T; Ozisik Y.
Do yoga and aerobic exercise training have impact on functional capacity, fatigue, peripheral muscle strength, and quality of life in breast cancer survivors?
Integrative Cancer Therapies. 14(2):125-32, 2015 Mar.
AIM: The aim of the study was to compare the effects of aerobic exercise training and yoga on the functional capacity, peripheral muscle strength, quality of life (QOL), and fatigue in breast cancer survivors.
MATERIAL AND METHODS: A total of 52 patients with a diagnosis of breast cancer were included in the study. The patients were randomly assigned to 2 groups: aerobic exercise (n = 28) and yoga added to aerobic exercise (n= 24). Both groups participated in submaximal exercise 30 minutes/d, 3 d/wk for 6 weeks. The second group participated in a 1-hour yoga program in addition to aerobic exercise training. Functional capacity was assessed by the 6-Minute Walk Test (6MWT). Peripheral muscle strength was evaluated with a hand-held dynamometer. The fatigue severity level was assessed with the Fatigue Severity Scale (FSS). The QOL was determined by the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire.
RESULTS: There were statistically significant increases in peripheral muscle strength, the 6MWT distance, and the perception of QOL in both groups (P < .05). Additionally, the group with aerobic exercise and yoga showed marked improvement compared with the aerobic exercise group in fatigue perception (P < .05).
CONCLUSION: According to the data from this study, aerobic exercise training and yoga improved the functional capacity and QOL of breast cancer patients. Aerobic exercise programs can be supported by body mind techniques, such as yoga, in the rehabilitation of cancer patients for improving functional recovery and psychosocial wellness.
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Wang TJ; Wang HM; Yang TS; Jane SW; Huang TH; Wang CH; Lin YH.
The effect of abdominal massage in reducing malignant ascites symptoms.
Research in Nursing & Health. 38(1):51-9, 2015 Feb.
As many as 50% of end-stage cancer patients will develop ascites and associated symptoms, including pain, tiredness, nausea, depression, anxiety, drowsiness, loss of appetite, dyspnea, perceived abdominal bloating, and immobility. Abdominal massage may stimulate lymph return to the venous system and reduce ascites-related symptoms. The purpose of this study was to test the effect of abdominal massage in reducing these symptoms and reducing ascites itself as reflected in body weight. For a randomized controlled design using repeated measures, a sample of 80 patients with malignant ascites was recruited from gastroenterology and oncology units of a medical center in northern Taiwan and randomly assigned to the intervention or the control group. A 15-minute gentle
abdominal massage, using straight rubbing, point rubbing, and kneading, was administered twice daily for 3 days. The control group received a twice-daily 15-minute social interaction contact with the same nurse.
Symptoms and body weight were measured in the morning for 4 consecutive days from pre- to post-test. In generalized estimation equation modeling,a significant group-by-time interaction on depression, anxiety, poor wellbeing, and perceived abdominal bloating, indicated that abdominal massage improved these four symptoms, with the greatest effect on perceived bloating. The intervention had no effect on pain, tiredness, nausea, drowsiness, poor appetite, shortness of breath, mobility limitation, or body weight. Abdominal massage appears useful for managing selected symptoms of malignant ascites.
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Natural Health Products

Evid Based Complement Alternat Med. 2015;2015:601067. doi: 10.1155/2015/601067. Epub 2015 Mar 1.
Chinese herbal decoction based on syndrome differentiation as maintenance therapy in patients with extensive-stage small-cell lung cancer: an exploratory and small prospective cohort study.
Liu R1, He SL2, Zhao YC3, Zheng HG4, Li CH4, Bao YJ3, Qin YG4, Hou W4, Hua BJ4.

Objective. To investigate the treatment effect and treatment length of Chinese herbal decoction (CHD) as maintenance therapy on patients with extensive-stage small-cell lung cancer (ES-SCLC) and to reflect the real syndrome differentiation (Bian Zheng) practices of traditional Chinese medicine (TCM). Patients and Methods. Different CHDs were prescribed for each patient based on syndrome differentiation. The length of CHD treatment was divided into two phases for analyzing progression-free survival (PFS) and postprogression survival (PPS). Results. Three hundred and fifty-seven CHDs were prescribed based on syndrome differentiation during the study period. Median PFS was significantly longer in patients who received CHD >3 months than patients who received CHD ≤3 months in the first phase (8.7 months versus 4.5 months; hazard ratio (HR), 0.52; 95% confidence interval (CI), 0.41-0.99; P = 0.0009). Median PPS was significantly longer in patients who received CHD >7 months than patients who received CHD ≤7 months in the second phase (11.7 months versus 5.1 months; HR, 2.32; 95% CI, 1.90-2.74; P = 0.002). Conclusion. CHD could improve PFS and PPS, which are closely related to treatment time and deepness of response of first-line therapy. In addition, CHD could improve body function and keep patients in a relatively stable state.

Evid Based Complement Alternat Med. 2015;2015:385204. doi: 10.1155/2015/385204. Epub 2015 Mar 1.
The Prescription Pattern of Chinese Herbal Products Containing Ginseng among Tamoxifen-Treated Female Breast Cancer Survivors in Taiwan: A Population-Based Study.
Hsu WL1, Tsai YT2, Wu CT1, Lai JN3.

Background. The purpose of our study is to analyze the association between prescribed Chinese herbal products (CHPs) containing Ginseng and the risk of endometrial cancer among tamoxifen (TMX) users and to identify any possible interactive effects between Ginseng and TMX with respect to preventing the development of subsequent endometrial cancer in an estrogen-dependent breast cancer population in Taiwan. Methods. All patients newly diagnosed with invasive breast cancer receiving tamoxifen treatment from January 1, 1998, to December 31, 2008, were selected from the National Health Insurance Research Database. The usage, frequency of service, and CHP-Ginseng prescribed across the 30,556 TMX-treated breast cancer (BC) survivors were evaluated. Logistic regression was employed to estimate the odds ratios (ORs) for the utilization of CHP-Ginseng. Cox's proportional hazard regression was performed to calculate the hazard ratios (HRs) for endometrial cancer associated with Ginseng use among the TMX-treated BC cohort. Results. The HR for the development of endometrial cancer among breast cancer survivors who had ever taken Ginseng after TXM treatment was significantly decreased compared to those who never used CHP. Conclusion. A significant inhibitory relationship between Ginseng consumption and subsequent endometrial cancer less than 2 years after TMX treatment was detected among BC survivors.
PMID: 25815031 [PubMed] PMCID: PMC4359861

Commentary (by Ting Bao, MD, SIO Research Committee Co-Chair):
This is an observational study comparing the risk of endometrial cancer in breast cancer survivors taking tamoxifen in the group that took Ginseng containing herbal products vs those who did not take any herbal products. It showed that the group that took Ginseng had significantly lower risk of endometrial cancer compared to the group who did not take any herbal products. The authors concluded that their study suggested that Ginseng might have protective effect against the development of endometrial cancer in breast cancer survivors taking tamoxifen.

While we are impressed by the large sample size in this well-designed observational study and the intriguing results, we would argue: "not so fast." First, observational studies are not the gold standard study design to identify a causal relationship –randomized controlled trials (RCTs) best determine causality. We need additional RCTs to determine if Ginseng can actually prevent endometrial cancer. Second, the two groups were not balanced (or randomized, as previously mentioned); the group that was taking Ginseng had higher incomes than the group that was not taking any herbal products, and it is possible they could have differed in many other potentially important ways that were not measured in the study. Higher income is associated with higher socioeconomical status, which may also be associated with less stress, access to better medical care and healthier lifestyles. Those may be additional confounding factors that were not recorded or identified by the study. Lastly, there has been literature suggesting that ginseng may have estrogenic effects. As such, it is often recommended that Ginseng should not to be used in breast cancer survivors with estrogen receptor positive breast cancer in the U.S. because of the theoretical potential to contribute to cancer risk. This study occurs in Taiwan and the applicability in the U.S. or other Western countries is therefore unknown.

There continues to be a paucity of high quality research on natural products. We would like to urge other researchers to conduct more clinical trials on the use of natural product in cancer patients and survivors.