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CME / ABIM MOC / CE

What Are the Newest Guidelines for Nonpharmacologic Management of Cancer Pain?

  • Authors: News Author: Sharon Worcester, MA; CME Author: Laurie Barclay, MD
  • CME / ABIM MOC / CE Released: 11/18/2022
  • Valid for credit through: 11/18/2023
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    Nurses - 0.25 ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology)

    Pharmacists - 0.25 Knowledge-based ACPE (0.025 CEUs)

    Physician Assistant - 0.25 AAPA hour(s) of Category I credit

    IPCE - 0.25 Interprofessional Continuing Education (IPCE) credit

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for hematologists/oncologists, internists, family medicine/primary care physicians, nurses, nurse practitioners, pharmacists, physician assistants, psychiatrists, hospice and palliative medicine physicians, and other members of the healthcare team for patients with cancer pain.

The goal of this activity is for learners to be better able to describe evidence-based recommendations for practicing cians on integrative approaches to managing pain in patients with cancer, according to a joint guideline from the Society for Integrative Oncology (SIO) and the American Society of Clinical Oncology (ASCO®).

Upon completion of this activity, participants will:

  • Describe recommendations regarding mind-body therapies and natural products for managing pain experienced by adult and pediatric patients diagnosed with cancer, according to a joint SIO-ASCO® guideline
  • Identify clinical implications of recommendations regarding mind-body therapies and natural products for managing pain experienced by adult and pediatric patients diagnosed with cancer, according to a joint SIO-ASCO® guideline
  • Outline implications for the healthcare team


Disclosures

Medscape, LLC requires every individual in a position to control educational content to disclose all financial relationships with ineligible companies that have occurred within the past 24 months. Ineligible companies are organizations whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

All relevant financial relationships for anyone with the ability to control the content of this educational activity are listed below and have been mitigated. Others involved in the planning of this activity have no relevant financial relationships.


News Author

  • Sharon Worcester, MA

    Freelance writer, Medscape

    Disclosures

    Sharon Worcester, MA, has no relevant financial relationships.

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer
    Medscape, LLC

    Disclosures

    Laurie Barclay, MD, has the following relevant financial relationships:
    Formerly owned stocks in: AbbVie Inc.

Editor/Compliance Reviewer

  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Amanda Jett, PharmD, BCACP, has no relevant financial relationships.

Nurse Planner

  • Stephanie Corder, ND, RN, CHCP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Stephanie Corder, ND, RN, CHCP, has no relevant financial relationships.

Peer Reviewer:

This activity has been peer reviewed and the reviewer has no relevant financial relationships.


Accreditation Statements



In support of improving patient care, Medscape, LLC is jointly accredited with commendation by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

This activity was planned by and for the healthcare team, and learners will receive 0.25 Interprofessional Continuing Education (IPCE) credit for learning and change.

    For Physicians

  • Medscape, LLC designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.

    Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.25 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

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    For Nurses

  • Awarded 0.25 contact hour(s) of nursing continuing professional development for RNs and APNs; 0.00 contact hours are in the area of pharmacology.

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    For Pharmacists

  • Medscape designates this continuing education activity for 0.25 contact hour(s) (0.025 CEUs) (Universal Activity Number: JA0007105-0000-22-373-H01-P).

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  • For Physician Assistants

    Medscape, LLC has been authorized by the American Academy of PAs (AAPA) to award AAPA Category 1 CME credit for activities planned in accordance with AAPA CME Criteria. This activity is designated for 0.25 AAPA Category 1 CME credits. Approval is valid until 11/18/2023. PAs should only claim credit commensurate with the extent of their participation.

For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For technical assistance, contact [email protected]


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There are no fees for participating in or receiving credit for this online educational activity. For information on applicability and acceptance of continuing education credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on the title page. To receive AMA PRA Category 1 Credit™, you must receive a minimum score of 75% on the post-test.

Follow these steps to earn CME/CE credit*:

  1. Read the target audience, learning objectives, and author disclosures.
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  3. Online, choose the best answer to each test question. To receive a certificate, you must receive a passing score as designated at the top of the test. We encourage you to complete the Activity Evaluation to provide feedback for future programming.

You may now view or print the certificate from your CME/CE Tracker. You may print the certificate but you cannot alter it. Credits will be tallied in your CME/CE Tracker and archived for 6 years; at any point within this time period you can print out the tally as well as the certificates from the CME/CE Tracker.

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CME / ABIM MOC / CE

What Are the Newest Guidelines for Nonpharmacologic Management of Cancer Pain?

Authors: News Author: Sharon Worcester, MA; CME Author: Laurie Barclay, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 11/18/2022

Valid for credit through: 11/18/2023

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Clinical Context

Pain is a leading, disabling symptom among patients with cancer, resulting from tumor burden or invasion of bones, muscles, or nerves. Many cancer treatments, including surgery, chemotherapy, radiotherapy, immunotherapy, or hormonal therapy can result in acute and chronic pain conditions, including aromatase inhibitor (AI)-induced joint pain or chemotherapy-induced peripheral neuropathy (CIPN) pain.

The Society for Integrative Oncology (SIO) and the American Society of Clinical Oncology (ASCO®) panel included experts in integrative, medical, radiation, surgical, and palliative oncology; social sciences; mind-body medicine; nursing; and patient advocacy. Literature search identified 227 relevant studies (systematic reviews, meta-analyses, and randomized controlled trials [RCTs] from 1990 to 2021 to inform consensus- and evidence-based recommendations.

Study Synopsis and Perspective

New guidelines highlight the role that integrative pain management techniques, such as massage, acupuncture, and music therapy, can play in relieving certain types of cancer pain in adults.

The recommendations,[1] published earlier this month in the Journal of Clinical Oncology, represent a joint effort between the American Society of Clinical Oncology (ASCO®) and the Society of Integrative Oncology (SIO) to guide cliniciansicians how to best weave various nonpharmacologic pain management strategies into cancer care.

"Pain is a clinical challenge for many oncology patients and clinicians, and there's a growing body of evidence showing that integrative therapies can be useful in pain management," Heather Greenlee, ND, PhD, explained in a press release.[2]

Still, clear clinical guidance as to when and when not to use these approaches is lacking, said Greenlee, co-chair of the SIO Clinical Practice Guideline Committee.

Previous guidelines from ASCO® on managing chronic cancer-related pain[3] largely focused on diagnosing pain and on pharmacologic interventions, and they only touched on evidence related to nonpharmacologic options.

The new guideline[1] "takes a deeper dive on the use of integrative therapies, which is important because clinicians and patients need to have access to the latest evidence-based information to make clinical decisions," Jun H. Mao, MD, SIO-ASCO® panel co-chair, noted.

In the guidance, the expert panel addresses 2 core questions: What mind-body therapies are recommended for managing pain experienced by adult and pediatric patients diagnosed with cancer, and what natural products are recommended for managing pain experienced by adult and pediatric patients diagnosed with cancer?

The panel conducted a literature search and identified 227 relevant studies. They included systematic reviews and randomized controlled trials published between 1990 and 2021 that evaluated outcomes related to pain intensity, symptom relief, and adverse events. After reaching a consensus, the expert panel made recommendations on the basis of the strength of the available evidence.

Regarding modalities for which there was stronger evidence, the panel highlighted several recommendations regarding acupuncture, reflexology, hypnosis, and massage.

The panel determined, for instance, that acupuncture should be offered for aromatase-related joint pain in patients with breast cancer and that it can be offered for general or musculoskeletal pain from cancer. It recommended reflexology or acupressure for pain experienced during systemic therapy for cancer.

Hypnosis is an option for patients experiencing procedural pain in cancer treatment or diagnostic workups, and massage is an option for pain experienced during palliative or hospice care or after breast cancer treatment.

These recommendations were considered moderate in strength and were based on intermediate levels of evidence that demonstrated that the benefits outweighed risks.

The panel added several recommendations it deemed to be weak in strength and that were based on low-quality evidence. These include Hatha yoga for patients experiencing pain after treatment for breast or head and neck cancers, and music therapy for patients experiencing pain from cancer surgery.

The experts also identified areas "potentially relevant to cancer care but needing more research," such as the safety and efficacy of natural products, including omega-3 fatty acids and glutamine, and determined that there is insufficient or inconclusive evidence to make recommendations for pediatric patients.

"With improved oncology treatments such as immunotherapy and targeted therapy, more patients diagnosed with cancer are living longer; therefore, pain and symptom management is critical for improving quality of life," Mao, chief of integrative medicine at Memorial Sloan Kettering Cancer Center, New York, New York, told Medscape Medical News. "The SIO-ASCO clinical guideline will provide very timely recommendations for physicians to incorporate nonpharmacological treatments such as acupuncture and massage to improve pain management for patients impacted by cancer."

Nonetheless, clinical uptake of such treatments "is always a concern," said panel co-chair Eduardo Bruera, MD, of The University of Texas MD Anderson Cancer Center, Houston, Texas. "We are hoping that by showing the growing evidence that is out there, healthcare systems will start hiring these kinds of practitioners and insurance systems will start covering these treatments, because more and more, these are being shown to be effective at managing pain for cancer populations," Bruera said.

The SIO-ASCO® panel’s work was supported by a grant from the Samueli Foundation to the Society for Integrative Oncology.

Study Highlights

  • Recommendations based on intermediate level of evidence, benefit outweighing risk, and with moderate strength of recommendation among adults include:
    • Acupuncture should be offered for AI-related joint pain in patients with breast cancer
    • Acupuncture, reflexology, or acupressure can be offered for general cancer pain or musculoskeletal pain
    • Reflexology or acupressure may be offered to patients experiencing pain during systemic cancer treatment
    • Hypnosis may be recommended to patients experiencing procedural pain
    • Massage may be recommended to patients during palliative or hospice care
  • Quality of evidence for other mind-body interventions for pain is either low or inconclusive: massage for patients with chronic pain after breast cancer treatment, hatha yoga for patients with pain after breast or head-and-neck cancer treatment, music therapy for patients with post-operative pain, and meditation-based interventions for procedural pain in patients with breast cancer.
  • Evidence is insufficient or inconclusive to make recommendations for pediatric patients.
  • Potentially relevant to cancer care, but needing more research and evidence, is natural product safety and efficacy (eg, omega-3 fatty acids and glutamine for CIPN from cancer treatment).
  • Evidence is insufficient to recommend for/against omega-3 fatty acids, Yi Shen Jian Gu granules, or topical pure emu oil for AI-related pain.
  • Despite tremendous patient interest, no herbs or natural supplements can currently be recommended for pain management; well-designed, placebo-controlled phase I to III trials are needed.
  • Pain in patients with cancer and survivors is complex, with varying etiologies (tumor burden, treatment-related, and non--cancer-related), presentations (neuropathic and musculoskeletal), and duration (acute and chronic).
  • Pain management therefore requires an interprofessional approach including pharmacologic and nonpharmacologic treatments, where appropriate.
  • Integrative medicine, or coordinated use of evidence-based complementary practices and conventional care treatments, includes interventions such as acupuncture, massage, meditation, and yoga, which are increasingly available in cancer centers and are recommended for symptom and pain management.
  • ~ 40% of patients with cancer use integrative medicine annually.
  • Integrative medicine aims to use these mind-body interventions together with conventional pain management approaches (medications, radiation, injections, and physical therapies) and not to replace them.
  • Patients may seek integrative medicine because they believe that conventional medical treatment insufficiently meets their needs; fear adverse effects from pharmacotherapies; prefer holistic approaches; or have received recommendations from their family or clinicians.
  • Clinicians and patients should be educated regarding the current evidence base of these therapies for pain management in cancer care, to guide a patient-centered and evidence-based approach to pain management incorporating integrative medicine interventions for appropriate indications.
  • Although effective communication between clinicians and patients is essential for patient-centered pain management, clinicians rarely inquire about use of integrative medicine, and patients often do not disclose it.
  • Lack of knowledge about integrative medicine is often the largest patient barrier, particularly among racial and ethnic minorities and persons with less education.
  • Patients with positive beliefs about natural health approaches, higher treatment expectancy, fewer barriers, and family endorsement are likely to prefer integrative medicine over pharmacology to manage pain.
  • Facilitating open communication and acknowledging patient values and preferences will enable shared decision making about the most appropriate pain management strategies.
  • Demographic factors, including race, ethnicity, age, socioeconomic status, sexual orientation and gender identity, geographic location of residence, immigrant status, insurance access, and other social determinants may result in knowledge gaps, limited availability to high-quality primary and specialty care, and transportation barriers.
  • Lack of insurance for integrative medical care, requiring out-of-pocket payment, limits access to lower-income populations.
  • More research is needed to better characterize the role of integrative medicine interventions in cancer care.
  • Increasing evidence from well-conducted RCTs suggests that acupuncture or massage can alleviate cancer-related pain, but for many other interventions, trials are small and have methodologic issues.
  • Studies should report the statistical significance and clinically meaningful change in pain severity (2-point reduction on a 0-10 scale) and should exclude or stratify patients based on comorbidities.
  • Despite tremendous patient interest, no herbs or natural supplements can currently be recommended for pain treatment; thus, well-designed, placebo-controlled phase 1 to 3 trials are needed to establish the safety and efficacy of high-quality natural products for pain.
  • SIO and ASCO® believe that cancer clinical trials are essential to inform clinical decisions and improve cancer care and that all patients should have the opportunity to participate.

Clinical Implications

  • Acupuncture, reflexology or acupressure can be offered for general cancer pain or musculoskeletal pain.
  • Lack of insurance for integrative medical care, requiring out-of-pocket payment, limits access to lower-income populations.
  • Implications for the Healthcare Team: Cancer pain management requires an interprofessional approach including pharmacologic and nonpharmacologic treatments, where appropriate.

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