Complementary and alternative medicine in cancer pain management: a systematic review.

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.

INTRODUCTION

Health care benefit is judged broadly on parameters of quantity and quality of life (QoL) lived by a person. While treating cancer by modern medicine we often focus more on the quantity of life lived, however factors like pain, stress, anxiety, fatigue, fear of death, depression are most of the time overlooked by the treating physicians. Those health care professionals who sometimes bother themselves with these aspects of patients’ life feel unequipped with adequate knowledge to guide the patient into an unknown area of Complementary and Alternative Medicine (CAM). “Complementary Medicine” refers to treatments that are used in standard treatments. Clinicians and pain specialists have recognized that, even with endless resources and huge advancements in the medical science, every cancer patient's pain can still not be eliminated.[1] Somerville explains pain as “many persons would rather be dead than unloved, abandoned and, too often, left in pain”.[2] “We must all die. But that I can save him from days of torture, that is what I feel as my great and ever new privilege” says Albert Schweitzer.[3] The International Association for the Study of Pain (IASP) defines pain as “an unpleasant emotional situation which is originating from a certain area, which is dependant or non-dependant on tissue damage and which is related to the past experience of the person in question”.[4] About 50-70% of the cancer patients suffer from uncontrolled pain associated with anxiety, depression, suicidal tendency and fear pain more than death.[56] Cancer pain has been described as moderate to severe in approximately 40%-50% and as very severe in 25%-30%.[789] The mis-belief of health professionals and patients that pain is an in-separable part of the human suffering is widespread and that cancer pain is unavoidable is very common.[10] Clinicians very gracefully label difficult to treat pain as psychological or malingerer's pain unable to recognize that the psychological component of pain also needs treatment. Chronic pain in cancer patients is dominated by the neuropathic, psychological, social and spiritual components even when associated with nociceptive pain.[11] This has led to reduction in living quality and functional situation of patients, increased fatigue levels and impairment in daily activities and social impairment.[12] These elements have directed patients and caregivers to seek different approaches in pain management. Hence, in addition to pharmacological treatment options for pain management non pharmacological options and complementary treatments are being attempted.[1314] Though evidence based CAM therapies are coming up still such practices are far from reality and beyond the scope of a cancer patient especially in resource limited countries like India. This review is an endeavour to highlight the importance of CAM therapies and its contribution in giving the patient a pain free life and a feeling of well-being; a desire for which he lives and later dies also. Cancer institutes’ with well-developed palliative care facilities are collaborating with organisations that provide CAM therapies for a holistic approach towards cancer. One such example is, in 2005 The University of Texas M. D. Anderson Cancer Institute announced collaboration with India's yoga research institution the Swami Vivekananda Yoga Anusadhana Samsthana (Research Foundation) in Bangalore.

CAM encompasses a variety of discipline viz. acupuncture, yoga, hypnosis, guided imagery, biofeedback, aromatherapy, herbal remedies, massages and many others.[15] Today large proportion of cancer pain patients use CAM possibly due to dissatisfaction with conventional medication, desperation, compatibility between the philosophy of CAM and patient's own belief and wish for more control over one's own health.[1617] The boundary between CAM and Conventional Medicine is not absolute, and specific CAM practices may overtime be widely accepted. Various data sources viz. Pubmed, Cochrane Library and Medline were searched with keywords like CAM and cancer pain, cancer pain and yoga, acupuncture and cancer pain, Tai chi and cancer pain, Hypnotherapy and cancer pain, reflexology and cancer pain, aromatherapy and cancer pain. Cognitive Behavioral Therapy and cancer pain, music therapy and cancer pain, transcutaneous electrical nerve stimulation (TENS) and cancer pain, biofeedback and cancer pain. Emphasis was directed towards systematic reviews and meta-analysis on various topics pertaining to CAM and cancer pain.

NON PHARMACOLOGICAL THERAPIES IN CANCER PAIN MANAGEMENT

The medical, surgical and radiation oncologists while treating cancer forget that there is a patient behind the cancer whom they have to deal with. A comprehensive cancer center, needs to address to the patients pain, stress, anxiety, depression and fear of death and don’t just treat cancer and therefore a blend of CAM therapies with various allopathic interventions is the need of the hour. Even though medical and surgical approaches are considered the mainstay of cancer pain management, they have some limitations. Firstly, the patient may experience severe side effects (constipation and nausea) thereby limiting their ability to take medication. Secondly, even on optimal pain medications, patients report uncontrolled pain. Thirdly, surgical techniques (implanted nerve pump stimulators, morphine pump) are costly and not available to large population.[1718] The non pharmacological therapies aim to treat affective, cognitive, behavioral and socio-cultural dimensions of cancer pain. These are generally classified as physical, cognitive, behavioural and other complementary methods or as invasive or non-invasive methods. Meditation, progressive relaxation, dreaming, rhythmic respiration, biofeedback, therapeutic touching, transcutaneous electrical nerve stimulation (TENS), hypnosis, musical therapy, acupressure and cold-hot treatments are non-invasive methods.[1819]

Lot of evidence supports use of CAM therapies in cancer patients and survivors and support an increase in QoL, sleep, mood, levels of stress, anxiety yet evidence of CAM in relieving pain of cancer patients seems insufficient. The present study aimed to conduct a review of evidence in support of CAM therapies in cancer pain.

Peripheral therapies

This involves stimulating the patient's skin in a harmless manner. The skin stimulation techniques include hot- cold treatments, exercise, positioning, movement restriction-resting, acupuncture, hydrotherapy, TENS, massage and therapeutic touch. When used in an appropriate manner these methods are believed to be effective on secondary pathologies such as inflammation, edema, progressive tissue damage, muscle spasm and function loss which takes part in acute pain.[19]

Acupuncture

This is an important component of Traditional Chinese Medicine (TCM) which has become a largely complementary in the West together with the conventional medicine. Acupuncture is accepted as a scientific treatment method that provides the body to restore its balance by means of stimulating some special points on the body with needles. It can be explained by Gate control theory, which states that sensory stimulant (lumbago), can be suppressed by another stimulant (pricking a needle) within the neural system.[19] Acupuncture has shown positive effects by relieving nausea and vomiting during chemotherapy. It appears to be more effective in preventing vomiting than in reducing. A randomized study found that true acupuncture was much more effective in relieving joint pain and stiffness than sham (inactive) acupuncture in patients taking aromatase inhibitors.[20] Clinical trials have also been done to show that acupuncture prevents xerostomia in cancer treated patients. Acupuncture has also shown to be effective in treating hot flashes occurring in women with breast cancer and men with prostate cancer caused by hormone therapy.[21] The “Acu.Fatigue” trial is a big study that was reported in 2012. It looked at whether acupuncture can help women with severe tiredness (fatigue) after chemotherapy treatment for breast cancer. The women in the trial had acupuncture carried out by a therapist for 20 minutes, once a week, for 6 weeks. The results showed that it helped to reduce fatigue and improve the women's QoL. It is not clear from the study whether this benefit continues in the longer term because the women were only followed up for 18 weeks. A review of acupuncture trials in 2013 also found that there is not enough evidence that it can reduce tiredness and hence more research is needed.[22]

A patient Ross who suffering from grade IV gliobastoma states “acupunture that I used was so effective that it enabled me to tolerate greater doses at closer intervals with fewer side effects, so I never needed a blood transfusion. Even with the stem cell rescue, I never needed a blood transfusion, never lost my hair, and never vomited” (Cedars-Sinai Medical Center, Los Angeles, California).

There is also evidence to show that acupuncture has the potential to produce rapid and effective analgesia when needles are inserted deeply enough and manipulated sufficiently. For cancer break through pain this represents a possible adjunctive treatment and consideration should be given to administering acupuncture alongside ‘rescue’ doses of medication to ‘kick-start’ the analgesic response before the medication takes effect.[22] However, research is needed to provide evidence that acupuncture is effective for cancer pain, and the feasibility, practicality, safety of patients and reliability of acupuncturist administering acupuncture themselves must also be taken into account.

Massage

This involves manipulation of the body's soft tissue using various manual techniques and the application of pressure and traction. The peripheral receptors are stimulated which reaches the brain through spinal cord. Massage seems to increase well-being through the reduction of stress and anxiety levels, and thus may contribute to pain control.[23] While massage appears promising for symptom management and improving QoL, available scientific evidence does not support claims that massage slows or reverses the growth or spread of cancer. A growing number of health care professionals recognize massage as a useful addition to conventional medical treatment. Some evidence from research studies with cancer patients supports the use of massage for short-term symptom relief; additional research is needed to find out if there are measurable, long-term physical or psychological benefits.

A systematic review has shown that out of 27 clinical trials testing massage interventions in cancer pain, 26 showed significant improvements in anxiety, emotional distress, comfort, nausea and pain.[24]

A randomized control trial(RCT) involving 1290 cancer patients and 12 licensed massage therapist evaluating changes in symptoms scores for pain, fatigue, stress, nausea and depression was conducted. Three variation of massage were used- Swedish, light touch and foot massage. The main outcome measures were data from symptom cards collected from independent observers that were recorded before and after the first session of massage. The symptoms scores declined by 50%, however the effects of massage were short- term.[25]

Another Cochrane review has concluded that massage therapy confer short-term benefits on psychological benefits, with effects on anxiety supported by limited evidence.[26]

A special type of massage called manual lymph drainage (MLD) is done as part of Complex Decongestive Therapy (CDT), which is used to treat lymphedema after certain cancer surgeries. CDT also includes external compression garments, special exercises, and skin care. This treatment is usually done by lymphedema specialists rather than general-practice massage therapists.[21]

There is sufficient evidence to show that therapeutic massage is useful discipline in relieving various symptoms of cancer. However, there is a dearth of randomised controlled trials on massage therapy in cancer patients. It was difficult to interpret the results of reported trials due to conflicting results, variation in methodology and use of non-validated symptom scores. Further clinical trials of better designs and mechanistic studies on psychopyhsiologic effects of massage are required to determine its significance in clinical practice.

Reflexology

The use of manual pressure applied to specific areas, or zones, of the feet (and sometimes the hands or ears) that are believed to correspond to other body areas or organs. Pressure is applied to these reflex points by special hand and finger techniques which relives stress and bring about physiological changes and thereby reduction in pain perception. It is stated in the literature that reflexology is used especially for reducing end stage cancer pain and side effects of chemotherapy and to increase living quality.[27] A patient Lee-Davis Conchie, who lives in South Shore, says “I was diagnosed with acute myeloid leukaemia 2 years ago and have just had a transplant. I had reflexology on my feet when I was being treated in the hospital and it benefitted me in many ways.

“I found the treatment really wonderful. It gave me a feeling of instant relaxation and was a welcome relief to get off the ward and be in a different environment. The room that is used has a real feeling of sacred space with music and oils. I would definitely recommend it to other patients.”

It can be argued that reflexology can be evaluated as holistic approaches that treat the whole person rather than the symptoms.[28] The mechanistic link between manipulation of body tissue and corresponding relief from a broad range of symptoms are not fully understood. None of the studies reported any adverse event associated with reflexology. Due to the lack of medical assessment data before or during implementation of reflexology, it is difficult to determine the safety of reflexology. Moreover, physicians must bear in mind that most patients use CAM to empower themselves in the management of their illness and thus may not be seeking evidence of safety.[28]

Yoga

Yoga is an ancient healing system, inclusive of various asanas or poses with breathing techniques and meditation to assist in the movement and balancing of life force energy or prana. Though a lot of evidence supports use of yoga as an adjunct treatment for cancer patients and survivors yet studies on Yoga contributing in improvement of pain scores are scant. Individual experiences of patients suffering from cancer have reported that Yoga helped them survive cancer better with strength, hope and vitality. Michelle Parodi a patient with breast cancer who began doing yoga asanas 2 months after surgery reports that “It helped me reconnect with my body and deal with all the achiness and joint pain that accompanied chemo”. Another patient from Michigan also reports that “Yoga helped me come into a nurturing energy, to befriend my body, listen to it, and treat myself with gentleness and compassion”. As chemotherapy and radiation therapy pose tremendous stress and emotional burden on the patient complementary therapies like yoga can generate a feeling of well-being for the patient and promote the fighting capabilities.[29]

Eshe et al., reported that yoga asanas stimulate not just muscles, but also increases blood flow, balances the glands and enhances the lymphatic flow in the body, all of which enhances the body's internal purification processes. The deep, relaxing breathing often emphasized in yoga in cancer therapy also increases the current of oxygen-rich blood to the cells, delivering vital nutrients to tired cells and further clearing out toxins. For those recovering from surgery, such as that for breast cancer, yoga can help restore motion and flexibility in a gentle, balanced manner.[30]

Buffart et al., have conducted a systematic review and meta-analysis on physical and psychosocial benefits of yoga in cancer patients and survivors. Out of the 1909 records screened, 16 full text research papers on RCTs were included in the review and only four such RCTs evaluated pain as one of the physical outcomes and only one RCT reported a decrease in cancer pain after yoga. The other three studies reported no significant difference between yoga and control group. However two out of the four studies discussed in this extensive review of Buffart et al., did not have adequate effect size hence the results need to be interpreted with caution on role of yoga in cancer pain. Buffart et al., also report that evidence for yoga to provide physical fitness and improve physical function are lacking and should be assessed in further studies. However, several reviews and meta-analysis suggest that yoga contribute to improvement in sleep, mood and QoL, depression, emotional function and anxiety.[313233] Buffart et al., also report that literature provides preliminary support for efficacy and feasibility of yoga for cancer patients yet contribution of yoga in cancer pain needs assessment in future studies.

American Cancer Society (ACS) reports that evidence from National Institutes of Health (NIH), suggests that yoga may be helpful to relieve some of the symptoms linked to cancer. Recent studies of women cancer survivors of breast cancer, suggest that yoga may help improve several aspects of QoL. However ACS does not comment about effects of yoga on cancer pain.[34]

Another meta-analysis conducted by Lin et al., report the beneficial effects of yoga on psychological and physical health of cancer patients.[35] Ten RCTs were evaluated in this study and yoga was found to contribute positively towards psychological health for cancer patients and was beneficial in managing symptoms of fatigue, anxiety, mood, stress and QoL of cancer patients. However interpretation of results on effects of yoga on physical health demonstrates that there was no significant difference between cancer patients in control group or yoga treated group. The author also agrees that because of limited number of studies, effects of yoga on physical health remains unclear. Therefore, at present a lot of studies are providing preliminary support for the feasibility and efficacy of yoga interventions and mindfulness based stress reduction for cancer patients but evidence for contribution of yoga in relieving cancer pain remains scant. Further studies, systematic reviews and meta-analysis are required to comment on effects of yoga in cancer pain.

Taichi

Tai chi chuan is an ancient Chinese healing martial art form consisting of a series of slow-paced fluid-like movements and stretches that increase the flow of the “chi”—The life force energy—To prevent stagnation and blockages that manifest as illness and disease. Tai chi also helps to balance the yin and yang principles, the feminine and masculine life force energies. Eshe reports that regular practice of tai chi promotes wellness of the mind, body and spirit, and can assist in decreasing the severity of side effects of cancer and chemotherapy.[30] Mustian et al., from University of Rochester have reported that women who had completed treatment of breast cancer were randomly categorized to receive Tai chi or psychological support therapy. Results demonstrated that Tai chi significantly improved the functional capacity including the aerobic capacity, muscle strength and flexibility as well as QoL as compared to psychological support therapy which could only improve flexibility.[35]

Lee et al., have conducted various systematic reviews in 2012, 2010, 2007 on various groups of cancer patients. A systematic review by Lee et al., on effectiveness of tai chi in various diseases concluded that though this therapy was effective in preventing falls and improving psychological health in elderly, its effect on preventing the symptoms of cancer and hence cancer pain were insignificant.[36]

Another systematic review evaluating role of Tai chi on breast cancer patients reports that evidence does not support tai chi to be more effective CAM therapy than walking exercise, psychological support therapy or spiritual growth therapy (standard control procedures). Three RCTs in this review compared tai chi with the standard control procedures in QoL and psychological health but failed to demonstrate any significant difference between the various procedures adopted. In contrast to the RCTs the four non-randomized controlled trials included in the extensive review did show some beneficial effects of Tai chi for breast cancer patients but all the studies had high risk of bias as assessed by the Cochrane criteria.[37]

Yet another systematic review by Lee et al., assessed the use of tai chi as an effective adjunct in cancer care reports that evidence is not conclusive to suggest Tai chi is an effective supportive treatment for cancer and needs well designed research to answer the usefulness of this form of CAM.[38]

On search of various databases we could not find individual studies, systematic reviews or meta-analysis evaluating effects of tai chi specifically on cancer pain, hence at present it is difficult to assess the role of Tai chi on cancer pain though evidence supports its positive role in improving QoL and psychological health of cancer patients.

Hypnotherapy

It is the induction of a trance-like state to facilitate relaxation and enhance suggestibility for treating conditions and introduce behavioural changes. Many people have a misconception that hypnosis is a surrender of control and you may start doing what you don’t want to do. Steven Bloore, a Certified Hypnotherapist says “Hypnosis is not a surrender of control or a deep unconscious sleep. While hypnotized, you will never do what you would not normally do in your regular conscious state”. Steven reports that eight studies have been recently published in the International journal of Clinical and Experimental Hypnosis regarding pain management using hypnosis and 75% of the people experienced pain relief, compared to the control group. The expert also reports that “once cancer is diagnosed the fear of the unknown begins to take over, both for the patient and the family which contributes to enormous levels of anxiety and worry. It is not uncommon to see patients fearing a sense of helplessness and a loss of control over his or her own life due to cancer. Hypnosis helps patient cope more effectively with cancer. Liossi et al., conducted a study with paediatric cancer patients in which it has been determined that hypnosis application has decreased pain and anxiety level in patients. Research supports that hypnosis can reduce anticipatory nausea and vomiting. Anticipatory nausea and vomiting occur prior to chemotherapy when previous exposure to chemotherapy has already caused nausea and vomiting but hypnosis had less effects on nausea and vomiting that happened after the chemotherapy dose is given. Hypnosis has also shown positive effects by improving cancer patients’ fatigue and hot flashes.[39]

A prospective, randomized study of 39 advanced-stage (Stage III or IV) cancer patients with malignant bone disease who received weekly sessions of supportive attention or a hypnosis intervention. The hypnosis intervention group demonstrated an overall decrease in pain (P < 0.0001) for all sessions combined.

Nash et al., report that a yearlong intervention of hypnosis was effective in reducing pain and suffering among women with metastatic breast cancer as compared to control group.[40]

A systematic review of 27 papers comprising of RCTs, observational studies, retrospective questionnaires and 24 case studies for use of hypnotherapy to treat symptoms of terminally ill adult cancer patients concludes that quality of research done is not adequate and further research is required to understand the role of hypnotherapy in terminal cancer patients.[41]

A review concluded that four of five RCTs found hypnosis plus cognitive behavioural techniques reduced pain intensity and severity compared with the control in patients with acute procedure related pain and oral mucositis pain related to bone marrow transplant.[42]

Various studies and reviews have reported that hypnotherapy may be helpful to reduce procedure related pain viz. bone marrow aspiration, lumbar puncture, venipuncture in various children and adults.[434445] Though results were inconclusive for children between the age group of 3-6 years as some studies report lack of effect in this age-group yet children older than this age group showed consistent results of decrease in pain and anxiety related to these procedures. The review also cautions use of hypnosis by an expert only as this form of CAM may be associate with short term (fatigue, anxiety, confusion, fainting) or rarely serious reactions also (stupor, chronic psychological problems, seizures) and therefore screening of vulnerable individuals is recommended for this therapy.[46]

A systematic review for effectiveness of hypnosis and procedure related pain and distress in pediatric cancer patients reveals that though hypnosis has potential as a clinically valuable intervention in such patients yet further research is required as various studies had lot of methodological limitations.[47]

Therefore at present evidence supports use of hypnotherapy for various procedure related pain in pediatric and adult cancer patients but evidence for use of hypnotherapy for chronic cancer pain is inconclusive.

Aromatherapy

This is the controlled use of plant essences, applied either to the skin through massage, added to baths or inhaled with steaming water. It has been shown that the aromatic oils reached the lymph system by means of blood circulation and provided recovery by means of intercellular fluids. A Cochrane systematic review concluded that aromatherapy have beneficial short-term effects on well-being in cancer patients.[26] However, it has not been convincingly demonstrated whether it is associated with clinically relevant analgesic effects. Many people fear that massage may spread the tumour to various other areas as it shall increase the blood supply to which Horrigan opines that surface massage will not make the cancer grow due an increased blood supply,[48] nor make the cancer spread, nor interfere with chemotherapy or radiotherapy, nor cure cancer by natural means.[49] In the normal low dosage usually adopted by trained aroma therapists there should be no risk factor. However aroma therapists advise not to use unresearched oils or unfamiliar oils. There is no evidence that either essential oils or aromatherapy has caused cancer in humans.[5051] Various oils that have been found useful are Syzigium aromaticum (clove), Cupressus sempervirens (cypress) and Pelargonium graveolens (geranium). Lavender and citrus oils of a good quality are also useful for relieving stress.

Essential oils have been helpful when used during radiotherapy to help reduce or prevent deep burning and scarring.[49]

There is no evidence of any interaction of any essential oils with cytotoxic chemotherapeutic agents therefore cancer patients may be given a trial of aromatherapy for nausea and vomiting due to chemotherapy.

A systematic review of 18 clinical trials reveal that aromatherapy has short term benefits on depression, anxiety and overall well-being, improved sleep and better pain control. The neurotransmitters suggest inhibition of glutamate binding and GABA augmentation. Linalool is the main component of lavender oil and it inhibits glutamate binding in rats and augments gamma-aminobutyric acid (GABA) action.[5152] It is proposed that the scent receptors in the nose send chemical signals via olfactory nerve to the limbic region and therefore affects a person's emotional responses, heart rate, blood pressure and breathing. Surveys carried out in the UK showed that 40.6% of cancer patients were using it.[535455565758] A US survey revealed that 11% of cancer patients may be using aromatherapy.[5960] The review concludes that use of diluted essential oils has minimal risks. Repeated exposure to lavender and tea tree oils by topical administration was shown in one study to be associated with reversible prepubertal gynecomastia, therefore patients with estrogen-dependant tumors should exercise caution. Aromatherapy/essential oils may be used by cancer patients for a short-term benefit to reduce anxiety, pain and depression and to increase sleep patterns and well-being.[60]

Music therapy

Research reports that music therapy can help decrease the nausea and vomiting in patients undergoing radiotherapy and chemotherapy.[6162] A meta-analysis by Cepeda et al., shows that music therapy was best for short term pain after surgery and a new practice called music thenatology is being tried as an end of life care measure in homes and hospices to ease the last days of a person. Music therapy can affect stress hormone levels and improve brain waves and brain circulation.[63]

Another review on quantitative literature on music based interventions in palliative cancer care reports that available evidence supports that music-based interventions may have a positive impact on cancer pain, anxiety, mood disturbance, and QoL in cancer patients.[64]

However a review published in Cochrane database on music therapy for end of-life care suggests that limited number of studies provide evidence on the benefit of music therapy on the QoL of people in end-of-life care with results suggesting that there is high risk of bias involved. The review also reports that no evidence was found on the effect of music for pain or anxiety.[65]

Therefore at present mixed results of use of music therapy for cancer pain exists and high quality evidence for its use is awaited.

TRANSCUTANEOUS ELECTRIC NERVE STIMULATION

The TENS unit delivers low-voltage electrical stimulation to leads which are placed over the skin on or near the painful sites. The efficacy of TENS in chronic cancer patients has shown mixed results.[66] One study found positive results for patients with non-malignant pain after 1-3 months, with 25% reporting pain relief and use after 4 years.[67] However, the recently published guidelines for cancer pain management state that cancer patients with mild pain may benefit from TENS.[68]

Certain limitations of TENS therapy are that electrodes should not be placed on certain parts of the body, such as near eyes, on front of neck, open wounds or infections, near tumors, in pregnant women, or on genitals. TENS is also contraindicated for people with pacemakers, implantable cardiac defibrillators, or other implanted devices, epilepsy and undiagnosed pain.

According to FDA and the ACS, TENS is generally safe. Although TENS units are available “over the counter,” always consult your health care provider before buying and using one.[69]

Blue Cross and Blue Shield Association Technology Evaluation Center (TEC) have laid down some guidelines for use of TENS in chronic pain patients. Though specific guidelines for cancer pain do not exist, TENS has been tried in cancer patients for pain relief.[7071727374]

Important Guidelines for using TENS in chronic pain patients

TENS may be considered for 30 days to manage refractory chronic pain (e.g. chronic musculoskeletal pain, or neuropathic pain that causes significant disruption of function)

The pain is unresponsive to at least 3 months of conservative medical therapy

The trial is monitored by a physician.

Refractory chronic pain is defined as pain that causes significant disruption of function and has not responded to at least 3 months of conservative therapy, including non-steroidal anti-inflammatory medications, ice, rest, and/or physical therapy.

COGNITIVE-BEHAVIOURAL THERAPY FOR PAIN MANAGEMENT

This is currently the most widely used psychological treatment for persistent pain. This involves three steps. The first step is Pain education. Pain is described as a complex sensory and emotional experience that is influenced by the patient's thoughts, feelings, and behavior. By discussing this topic, patients understand how their own responses to pain influence their pain experience and start to recognize the role that their own coping efforts can play a role in pain control. The second step is training in one or more coping skills for managing pain (e.g. relaxation or problem solving). For each skill, a therapist provides an educational rationale, basic instruction, and guided practice and feedback. The third step in training is home practice with learned skills. Patients are initially encouraged to practice in non-demanding situations (e.g. reclining in a quiet room) and then to apply their skills to more challenging tasks (e.g. managing pain that may occur during walking or while transferring from one position to another). The final step in training involves helping patients develop a program for maintaining their skills practice after training is completed and for overcoming setbacks and relapses in their coping efforts.[75] Several coping strategies have been studied in cancer pain, including diverting attention, reinterpretation of painful sensations, active coping, passive coping, and catastrophizing.[76] Beliefs about pain and cancer are targets of CBT. Spiritual beliefs and beliefs about the meaning of life are often overlooked in CBT, but can be critical when cancer pain is persistent.

A metanalysis of CBT on cancer survivors has shown that it is effective for short- term management (<8 months) of depression, anxiety and QoL of cancer survivors.[77] Kangas et al. have reported CBT to be equally effective as exercise interventions in treating cancer related fatigue.[78] Two RCT have shown that CBT can be recommended for improving patients’ control or coping skills for short-term and medium term benefits.[7980] Tatrow et al. have supported the use of CBT techniques when administered individually to manage pain in breast cancer patients.[80] None of the trials have explored the long term effects of CBT.[81]

Thus we can make no recommendations about the effectiveness of CBT in cancer pain management. We suggest that future trials employ adequate sample size to detect feasible and statistically significant improvements in cancer pain management.

IMAGERY AND HYPNOSIS BASED COGNITIVE BEHAVIOURAL THERAPY

This has been the most promising psychosocial intervention in the treatment of cancer pain. In this the patient is taught self guided imagery. The patient is made to focus on a pleasant or distracting scene to attend to the sensation in the scene like sights, sounds, smell etc. Once the patient develops this skill, it will enable them to divert their attention from pain. In hypnosis based CBT, the therapist teach skills which helps the patient relax. This intervention showed significant decrease in pain among children with lumbar puncture and bone marrow biopsy.[82] This therapy has found to be effective in reducing pain in women with metastatic breast cancer and adults undergoing bone marrow transplant.[83] A RCT has demonstrated that 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 in cancer pain, and that relaxation and imagery could help with the pain of mouth sores caused by chemotherapy.[85]

PAIN EDUCATION PLUS BRIEF COGNITIVE BEHAVIOURAL THERAPY

The guidelines for treatment of cancer pain involve educating the patient and their family about cancer throughout the treatment process. These guidelines advocate providing the patient and caregivers with written information about pain management, the types of pain medications prescribed, and the type, cost, and efficacy of pain treatment options.[68] In a study of 174 cancer patients with pain due to bone metastases, pain education plus brief cognitive behavioural therapy produced significant reductions in average, worst, and least ratings of pain.[75]

In a recent review slightly over 50% of the studies testing pain education plus brief cognitive-behavioral therapy showed positive results. The studies that included more intensive skills training showed the best results.[86] Educational interventions have directed at patients have resulted in improved patient outcomes, however the mechanisms by which these improvements occurs are still unclear. Michael et al. suggest the use of educational intervention with routine clinical practice alongside optimal oncological and analgesic management.[87]

A systematic review and metanalysis which aimed to quantify the benefit of patient based education intervention in management of cancer pain reported equivocal evidence for the effect of education in self efficacy, but no significant benefit on medication adherence or on reducing interference with daily activities.[88] Another systematic review suggests that educational intervention can successfully improve cancer pain knowledge and attitudes of healthcare professional but does not have much impact on patients’ pain level.

There is no evidence showing that educational intervention can reduce cancer pain. The most promising avenue for improving cancer pain control in ambulatory settings may be brief nursing interventions targeting patients in combination with a daily pain diary. Allard et al. suggest the incorporation of systematic and valid method of documenting daily fluctuations in pain levels, and ensuring that documented uncontrolled pain is followed rapidly by clinical reassessment and dose adjustment.[89]

COMPREHENSIVE COGNITIVE BEHAVIORAL THERAPY

This therapy emphasizes the importance of learning different coping skills like relaxation, imagery, self calming statements, problem solving. The patients systematically learn and master the skills of coping cancer pain. The patients are encouraged to combine various coping skills to deal with daily challenges. In a study carried out in advanced cancer patients, comprehensive cognitive therapy showed an improvement in pain control.[90] Further research is needed to on how best to implement multicomponent interventions within clinical services including the identification of which combinations are most cost-effective.

Caution with complementary and alternative therapies

The ACS provides detailed information on various CAM therapies that can be helpful for the cancer patients. The Society also warns patients and families to avoid CAM therapies which make false claims for cancer.

Signs of treatments to avoid enlisted by ACS website. http://www.cancer.org/treatment/treatmentsandsideeffects/complementaryandalternativemedicine/complementary- and-alternative-methods-for-cancer-management:

Treatment promising cure for all cancers?

Advised not to use recommended or standard medical treatment?

Treatment claims to offer benefits, but no side effects?

The treatment or drug is offered by one person or clinic?

The treatment requires you to travel to another country?

Do the proclaimers use terms like “scientific breakthrough,” “miracle cure,” “secret ingredient,” or “ancient remedy”?

Personal miracle stories of amazing results, but no actual scientific evidence?

Do the promoters attack the medical or scientific community?

The promotion is done by mass media (magazines, internet, TV, radio) and not by scientific journals?

What are the qualifications of the supporting team? Are they recognised experts in complementary medicines?

ACS also provides details of some of the websites that can provide reliable information on CAM therapies:

National Cancer Institute which provides information on CAM therapies (www.cancer.gov/cancertopics/treatment/cam)

National Center for Complementary and Alternative Medicine (NCCAM) provides information on CAM therapies and related clinical trials (Web site: http://nccam.nih.gov)

Memorial Sloan Kettering Cancer Center provides information on herbs and botanicals useful for cancer patients (Web site: www.mskcc.org/mskcc/html/11570.cfm)

United States Department of Agriculture, Food and Nutrition Information Center provides details of dietary supplements, vitamins and minerals to choose for cancer patients (Web site: http://fnic.nal.usda.gov)

US FDA provide information and safe use of herbs and dietary supplements. Here one can also report the side effects with dietary supplements and herbs (Web site: www.fda.gov/Food/DietarySupplements/default.htm) dietary supplement to Medwatch at 1-800-FDA-1088 (1-800-332-1088) or visit www.fda.gov/Safety/MedWatch)

United States Federal Trade Commission informs public about scams and unproven treatments and also helps people log complaints that can detect such patterns but does not resolve individual complaints by consumers (Web site: www.ftc.gov/curious

National Council Against Health Fraud which informs public about health related fraud and quackery (Web site: www.ncahf.org)

Quack watch is a international network of people who are concerned about the health related frauds, myths and misconduct (Web site: www.quackwatch.org).

Limitations

This extensive review is an attempt by authors to help medical, surgical and radiation oncologists who wish to suggest CAM therapies to their patients and to help them evaluate the role of various CAM therapies and understand the existing evidence to guide the treatment. However this is not a systematic review and results must be interpreted with caution. Also databases searched were limited to Pubmed, Cochrane Library and Medline whereas other databases like EMBASE, CINAHL, OVID etc., were beyond the scope of the authors therefore the interpretations require a more extensive search and overview.

CONCLUSION

When battling cancer the worst part is not just the symptoms of the disease itself, but often the discomfort and debilitating fatigue brought on from cancer treatments. Whether faced with severe pain in terminal cancer or ongoing nausea and vomiting caused by chemotherapy/radiation, surgery related pain; cancer patients endure a long road of physical trials. To summarize, QoL of a cancer patient can be effectively improved with the combination of pharmacological and non pharmacological therapies. There has been a rapid growth in CAM therapies for cancer patients in the recent past. However it needs to be steered by scientific enquiry, medical judgement, regulatory authority and collective decision making The modern medicine needs to accept its limitations and recognize the calling of cancer patients for inadequate symptom control and needs to stretch out its hand to accept the holistic approaches for cancer treatment to actually provide health benefit to its consumers by improving both the quality and quantity of life lived by the patient as together every one achieves more.