Skip to main content

Integrative Oncology Care of Symptoms of Anxiety and Depression in Adults With Cancer: Society for Integrative Oncology–ASCO Guideline

Publication: Journal of Clinical Oncology

Abstract

Purpose

To provide evidence-based recommendations to health care providers on integrative approaches to managing anxiety and depression symptoms in adults living with cancer.

Methods

The Society for Integrative Oncology and ASCO convened an expert panel of integrative oncology, medical oncology, radiation oncology, surgical oncology, palliative oncology, social sciences, mind-body medicine, nursing, methodology, and patient advocacy representatives. The literature search included systematic reviews, meta-analyses, and randomized controlled trials published from 1990 through 2023. Outcomes of interest included anxiety or depression symptoms as measured by validated psychometric tools, and adverse events. Expert panel members used this evidence and informal consensus with the Guidelines into Decision Support methodology to develop evidence-based guideline recommendations.

Results

The literature search identified 110 relevant studies (30 systematic reviews and 80 randomized controlled trials) to inform the evidence base for this guideline.

Recommendations

Recommendations were made for mindfulness-based interventions (MBIs), yoga, relaxation, music therapy, reflexology, and aromatherapy (using inhalation) for treating symptoms of anxiety during active treatment; and MBIs, yoga, acupuncture, tai chi and/or qigong, and reflexology for treating anxiety symptoms after cancer treatment. For depression symptoms, MBIs, yoga, music therapy, relaxation, and reflexology were recommended during treatment, and MBIs, yoga, and tai chi and/or qigong were recommended post-treatment.

Discussion

Issues of patient-health care provider communication, health disparities, comorbid medical conditions, cost implications, guideline implementation, provider training and credentialing, and quality assurance of natural health products are discussed. While several approaches such as MBIs and yoga appear effective, limitations of the evidence base including assessment of risk of bias, nonstandardization of therapies, lack of diversity in study samples, and lack of active control conditions as well as future research directions are discussed.
Additional information is available at www.asco.org/survivorship-guidelines.

Introduction

Worldwide rates of cancer occurrence continue to rise, along with overall improvements in survival, such that by 2040, the 5-year prevalence of all cancers is estimated to become 50.5 million people across the globe,1 with approximately 26 million living with and beyond cancer in the United States alone.2,3 Among this expanding cohort of cancer survivors (referred to throughout this guideline as people with cancer to include those living with any stage of cancer), mental health concerns have become more prominent. Indeed, the 12-month prevalence rates for mental disorders are higher in people with cancer compared with the general population (odds ratio, 1.28 [95% CI, 1.14 to 1.45]).4 A systematic review (SR) of 210 studies reported the mean prevalence of clinical depression as 21.2%, across all types of cancers.5 Rates of depressive disorder diagnoses were reported at 24.6% across 24 studies of people diagnosed with advanced cancers in palliative care settings.6 Similarly, a meta-analysis of 40 studies across 15 low- and middle-income countries reported a pooled prevalence of 21% for major depression among people with cancer.7 Rates of anxiety symptoms are similar, with a meta-analysis of 44 studies in over 50,000 longer-term cancer survivors reporting a 17.9% prevalence of self-reported elevated anxiety symptoms,8 consistent with other SRs, one of which reported rates ranging from 3.4% to 43% in longer-term survivors (pooled prevalence: 21%).9 Rates of anxiety and distress tend to be even higher around the time of diagnosis, as patients are experiencing the initial shock and implications of their diagnosis, decreasing somewhat as they move into active treatment.10 Importantly, research shows that people with mental health conditions who have a concurrent general medical condition (including cancer), have increased risk of death and shorter life expectancy than the general population.11
Despite their ubiquity, psychologic symptoms among people with cancer often remain undertreated.10 With the added burden of the COVID-19 pandemic, many people with cancer have had decreased access to mental health support at a time when there is even more uncertainty, fear, and anxiety than prior to the pandemic.12,13 This has culminated in a mental health crisis, not only among people with cancer but more broadly in society since the onset of the pandemic in 2020.14,15
A recently published ASCO guideline addressed the question “What are the recommended psychosocial, behavioral, and psychopharmacologic treatment approaches in the management of anxiety and/or depression in survivors of adult cancer?”16 This represented an update of the earlier 2014 ASCO guideline on the optimum screening, assessment, and care of anxiety and depressive symptoms in adults with cancer.17 This current Society for Integrative Oncology (SIO)–ASCO guideline addresses the question of which integrative therapies are also recommended for treating these symptoms. Taken together, these guidelines provide a comprehensive set of recommendations for assessing and treating anxiety and depression in adults with cancer.
Integrative oncology is defined by SIO as “a patient-centered, evidence-informed field of cancer care that uses mind and body practices, natural products, and/or lifestyle modifications from different traditions alongside conventional cancer treatments. Integrative oncology aims to optimize health, quality of life, and clinical outcomes across the cancer care continuum and to empower people to prevent cancer and become active participants before, during, and beyond cancer treatment.”18(p7) Grouped together, these therapies are sometimes called complementary therapies; however, they are referred to as integrative therapies throughout this guideline to emphasize the point that for optimal patient-centered care, they are intended to be fully integrated into routine oncology practice.
Integrative therapies such as those mentioned in the definition are commonly used by people with cancer, with worldwide usage in approximately half of all people with cancer in both developed19,20 and low- and middle-income regions.21 A review of studies from 18 countries with over 65,000 people with cancer found the highest usage rates in the United States and the lowest in Italy and the Netherlands. Globally, integrative therapy use rose from an estimated 25% in the 1970s and 1980s to more than 32% in the 1990s and to 49% after 2000.22 Another 2019 SR of 61 research articles from around the world included people with all types of cancers and reported an average complementary therapy usage rate of 51%.23
Given the high usage of integrative therapies by people diagnosed with cancer, and the growing evidence base to support their use in this context, development of this guideline was jointly convened by SIO and ASCO to critically review the current evidence and produce recommendations on the use of integrative therapies for treating anxiety and depression symptoms in people with cancer across the disease trajectory. Specific objectives are described in the Bottom Line Box.

The Bottom Line

Integrative Oncology Care of Symptoms of Anxiety and Depression in Adults With Cancer: Society for Integrative Oncology–ASCO Guideline

Guideline Questions

1.
What integrative therapies are recommended for managing symptoms of anxiety experienced after diagnosis or during active treatment in adults with cancer?
2.
What integrative therapies are recommended in managing symptoms of anxiety experienced post treatment in adults with cancer?
3.
What integrative therapies are recommended for managing symptoms of depression experienced after diagnosis or during active treatment in adults with cancer?
4.
What integrative therapies are recommended in managing symptoms of depression experienced post treatment in adults with cancer?
Target Population
Adults with cancer experiencing symptoms of anxiety and/or depression.
Target Audience
Clinicians who provide care to people with cancer, people with cancer, their family members, and other informal caregivers.
Methods
An Expert Panel was convened to develop clinical practice guideline recommendations based on a systematic review of the clinical oncology literature.
Recommendations
Anxiety
Active treatment.
Recommendation 1.1.
Mindfulness-based interventions (MBIs) should be offered to people with cancer to improve anxiety symptoms during active treatment (Type: Evidence based; Quality of evidence: High; benefits outweigh harms; Strength of recommendation: Strong).
Recommendation 1.2.
Yoga may be offered to people with breast cancer to improve anxiety symptoms during active treatment (Type: Evidence based; Quality of evidence: Intermediate; benefits outweigh harms; Strength of recommendation: Moderate).
Qualifying statement: For people with cancer types other than breast, the quality of evidence is low, and the strength of recommendation is weak.
Recommendation 1.3.
Hypnosis may be offered to people with cancer to improve anxiety symptoms during cancer-related diagnostic and treatment procedures (Type: Evidence based; Quality of evidence: Intermediate; benefits outweigh harms; Strength of recommendation: Moderate).
Recommendation 1.4.
Relaxation therapies may be offered to people with cancer to improve anxiety symptoms during active treatment (Type: Evidence based; Quality of evidence: Intermediate; benefits outweigh harms; Strength of recommendation: Moderate).
Recommendation 1.5.
Music therapy or music-based interventions may be offered to people with cancer to improve anxiety symptoms during active treatment (Type: Evidence based; Quality of evidence: Low; benefits outweigh harms; Strength of recommendation: Moderate).
Recommendation 1.6.
Reflexology may be offered to people with cancer to improve anxiety symptoms during active treatment (Type: Evidence based; Quality of evidence: Low; benefits outweigh harms; Strength of recommendation: Weak).
Recommendation 1.7.
Lavender essential oil inhalation may be offered to people with cancer to improve anxiety symptoms during cancer-related diagnostic and treatment procedures (Type: Evidence based; Quality of evidence: Low; benefits outweigh harms; Strength of recommendation: Weak).
Post treatment.
Recommendation 2.1.
MBIs should be offered to people with cancer to improve anxiety symptoms post treatment (Type: Evidence based; Quality of evidence: High; benefits outweigh harms; Strength of recommendation: Strong).
Recommendation 2.2.
Yoga may be offered to people with breast cancer to improve anxiety symptoms post treatment (Type: Evidence based; Quality of evidence: Intermediate; benefits outweigh harms; Strength of recommendation: Moderate).
Qualifying statement: For people with cancers types other than breast the quality of evidence is low, and the strength of recommendation is weak.
Recommendation 2.3.
Acupuncture may be offered to women with breast cancer to improve anxiety symptoms post treatment (Type: Evidence based; Quality of evidence: Intermediate; benefits outweigh harms; Strength of recommendation: Weak).
Recommendation 2.4.
Tai chi and/or qigong may be offered to women with breast cancer to improve anxiety symptoms post treatment (Type: Evidence based; Quality of evidence: Intermediate; benefits outweigh harms; Strength of recommendation: Weak).
Recommendation 2.5.
Reflexology may be offered to people with cancer to improve anxiety symptoms post treatment (Type: Evidence based; Quality of evidence: Low; benefits outweigh harms; Strength of recommendation: Weak).
Inconclusive.
There is inconclusive evidence to make recommendations for or against music therapy and music-based interventions to improve anxiety symptoms in people with cancer who are post treatment. There is also inconclusive evidence for nutritional interventions, light therapy, psilocybin, massage, dance/movement therapy, laughter therapy, healing touch, expressive writing, acupressure, biofeedback, autogenic training, energy healing, melatonin, or other natural products and supplements to improve anxiety symptoms in people with cancer, regardless of when in the course of care the intervention is provided.
Depression
Active treatment.
Recommendation 3.1.
MBIs should be offered to people with cancer to improve depression symptoms during active treatment (Type: Evidence based; Quality of evidence: High; benefits outweigh harms; Strength of recommendation: Strong).
Recommendation 3.2.
Yoga may be offered to people with breast cancer to improve depression symptoms during active treatment (Type: Evidence based; Quality of evidence: Intermediate; benefits outweigh harms; Strength of recommendation: Moderate).
Qualifying statement: For people with other cancers the quality of evidence is low, and the strength of recommendation is weak.
Recommendation 3.3.
Music therapy or music-based interventions may be offered to people with cancer to improve depression symptoms during active treatment (Type: Evidence based; Quality of evidence: Low; benefits outweigh harms; Strength of recommendation: Moderate).
Recommendation 3.4.
Relaxation therapies may be offered to people with cancer to improve depression symptoms during active treatment (Type: Evidence based; Quality of evidence: Low; benefits outweigh harms; Strength of recommendation: Weak).
Recommendation 3.5.
Reflexology may be offered to people with cancer to improve depression symptoms during active treatment (Type: Evidence based; Quality of evidence: Low; benefits outweigh harms; Strength of recommendation: Weak).
Post treatment.
Recommendation 4.1.
MBIs should be offered to people with cancer to improve depression symptoms post treatment (Type: Evidence based; Quality of evidence: High; benefits outweigh harms; Strength of recommendation: Strong).
Recommendation 4.2.
Yoga may be offered to people with breast cancer to improve depression symptoms post treatment (Type: Evidence based; Quality of evidence: Intermediate; benefits outweigh harms; Strength of recommendation: Moderate).
Qualifying statement: For people with other cancers the quality of evidence is low, and the strength of recommendation is weak.
Recommendation 4.3.
Tai chi and/or qigong may be offered to people with breast cancer to improve depression symptoms post treatment (Type: Evidence based; Quality of evidence: Intermediate; benefits outweigh harms; Strength of recommendation: Weak).
Recommendation 4.4.
Expressive writing should not be offered to people with cancer to improve depression symptoms at any point in the course of care (Type: Evidence based; Quality of evidence: Intermediate; no net benefit; Strength of recommendation: Moderate).
Inconclusive.
There is inconclusive evidence to make recommendations for or against reflexology to improve depression symptoms in people with cancer who are post treatment. There is also inconclusive evidence for nutritional interventions, light therapy, psilocybin, massage therapy, biofeedback, autogenic training, energy healing, melatonin, and other natural products and supplements to improve depression symptoms in people with cancer, regardless of when in the course of care these therapies are provided.
Please refer to the treatment algorithm in Figures 1 and 2 for the visual representation of these recommendations.
Fig 1. Integrative therapies algorithm for anxiety symptoms.
Fig 2. Integrative therapies algorithm for depression symptoms.
Additional Resources
Definitions for the quality of the evidence and strength of recommendation ratings are available in Appendix Table A1, online only. More information, including a supplement with additional evidence tables, slide sets, and clinical tools and resources, is available at https://integrativeonc.org/practice-guidelines/guidelines and www.asco.org/survivorship-guidelines. The Society for Integrative Oncology (SIO) Guidelines Methodology Manual (available at https://integrativeonc.org/practice-guidelines/sio-guidelines-guidelines-methodology) and the ASCO Methodology Manual (available at www.asco.org/guideline-methodology) provide additional information about the methods used to develop this guideline. Patient information is available at https://integrativeonc.org/knowledge-center/patients and www.cancer.net.
SIO and ASCO believe that randomized clinical trials are vital to inform clinical decisions and improve cancer care, and that all patients should have the opportunity to participate.

Guideline Questions

This clinical practice guideline addresses four overarching clinical questions: (1) What integrative therapies are recommended for managing symptoms of anxiety experienced after diagnosis or during active treatment in adults with cancer? (2) What integrative therapies are recommended in managing symptoms of anxiety experienced post treatment in adults with cancer? (3) What integrative therapies are recommended for managing symptoms of depression experienced after diagnosis or during active treatment in adults with cancer? and (4) What integrative therapies are recommended in managing symptoms of depression experienced post treatment in adults with cancer?

Methods

Guideline Development Process

This SR-based guideline was developed by an international multidisciplinary Expert Panel, which included a patient representative and a health research methodologist (Appendix Table A2). The Expert Panel met via webinar and corresponded through e-mail. Based on the evidence, the authors were asked to contribute to the development of the guideline, provide critical review, and finalize the guideline recommendations. The guideline recommendations were available for an open comment period of 2 weeks, allowing the public to review and comment on the recommendations after submitting a confidentiality agreement. These comments were taken into consideration while finalizing the recommendations. Members of the Expert Panel were responsible for reviewing and approving the penultimate version of the guideline, which was then circulated for external review by the SIO Clinical Practice Guidelines Committee and the ASCO Evidence Based Medicine Committee. Upon their approval, it was submitted to the Journal of Clinical Oncology for editorial review and consideration for publication. All funding for the administration of the project was provided by SIO.
The recommendations were developed through a SR of the evidence identified via online searches of PubMed (1990-November 2021) and Cochrane Library (1990-November 2021) of phase III randomized clinical trials (RCTs), SRs, and meta-analysis. An updated search of PubMed was done from November 2021 to January 2023. Articles were selected for inclusion in the SR based on the following criteria:
Population: Adults with cancer experiencing symptoms of anxiety and/or depression during any stage of their cancer trajectory
Interventions: Integrative interventions for anxiety and depression management (see details in the Data Supplement, online only)
Comparisons: No intervention, waitlist, usual care or standard care, guideline-based care, active control, attention control, placebo, or sham interventions
Outcomes: Changes in symptoms of anxiety and depression measured by valid tools reported as primary or secondary outcome
Sample size: Minimum total sample size of 50
Articles were excluded from the SR if they were (1) meeting abstracts not subsequently published in peer-reviewed journals; (2) editorials, commentaries, letters, news articles, case reports, and narrative reviews; or (3) published in a non-English language. Ultimately, the Expert Panel used effect sizes computed in the SRs to inform the recommendations and in cases where the SRs did not pool data based on outcomes of interest, the primary studies were evaluated individually.
The guideline recommendations were crafted, in part, using the Guidelines into Decision Support methodology and accompanying BRIDGE-Wiz software (Yale University, New Haven, CT).24 Ratings for type and strength of the recommendation and evidence quality are provided with each recommendation. The project methodologist in collaboration with the Expert Panel co-chairs and the full Expert Panel evaluated the quality of the evidence for each trial using the Cochrane risk-of-bias tool,25 and SRs and meta-analyses were assessed for quality using the assessment of multiple SRs (AMSTAR-2) tool.26
The SIO and ASCO Expert Panel and guidelines staff will work with co-chairs to keep abreast of any substantive updates to the guideline. Based on formal review of the emerging literature, SIO will determine the need to update the guideline in the future. The SIO Guidelines Methodology Manual (available at https://integrativeonc.org/practice-guidelines/sio-guidelines-guidelines-methodology) provides additional information about the guideline update process.

Open Comment Review

The draft recommendations were released to the public for open comment from October 25 through November 8, 2022, with invitations distributed to 34 organizations. There were 17 respondents in total, representing integrative oncology (seven), medical oncology (two), clinical psychology (two), guideline methodology (two), nursing (two), family medicine (one), and patient advocacy (one). Response categories of “Agree as written,” “Agree with suggested modifications,” and “Disagree. See comments” were captured for every proposed recommendation, with 79 written comments received. A total of 88% of the responses either agreed or agreed with slight modifications to the recommendations and 12% of the responses disagreed. Expert Panel members reviewed comments from all sources and determined whether to maintain original draft recommendations, revise with minor language changes, or consider major recommendation revisions. All changes were incorporated prior to SIO and ASCO review and approval.

Guideline Disclaimer

The Clinical Practice Guidelines and other guidance published herein are provided by the SIO and ASCO to assist health care providers in clinical decision making alongside the people diagnosed with cancer that they serve. The information herein should not be relied upon as being complete or accurate, nor should it be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care. With the rapid development of scientific knowledge, new evidence may emerge between the time information is developed and when it is published or read. The information is not continually updated and may not reflect the most recent evidence. The information addresses only the topics specifically identified therein and is not applicable to other interventions, diseases, or stages of diseases. This information does not mandate any particular course of medical care. Further, the information is not intended to substitute for the independent professional judgment of the treating provider, as the information does not account for individual variation among patients. Recommendations specify the level of confidence that the recommendation reflects the net effect of a given course of action. The use of words like “must,” “must not,” “should,” and “should not” indicates that a course of action is recommended or not recommended for either most or many patients, but there is latitude for the treating clinician to select other courses of action in individual cases. In all cases, the selected course of action should be considered by the treating provider in the context of treating the individual patient. Use of the information is voluntary. SIO and ASCO do not endorse third party drugs, devices, services, therapies, apps, or programs used to diagnose, treat, monitor, manage, or alleviate health conditions. SIO and ASCO provide this information on an “as is” basis and make no warranty, express or implied, regarding the information. SIO and ASCO specifically disclaim any warranties of merchantability or fitness for a particular use or purpose. SIO and ASCO assume no responsibility for any injury or damage to persons or property arising out of or related to any use of this information, or for any errors or omissions.

Guideline and Conflicts of Interest

The Expert Panel was assembled in accordance with SIO's and ASCO's Conflict of Interest Policy Implementation for Clinical Practice Guidelines (“Policy,” found at https://integrativeonc.org/practice-guidelines/sio-guidelines-guidelines-methodology and https://www.asco.org/guideline-methodology). All members of the Expert Panel completed SIO's disclosure form, which requires disclosure of financial and other interests, including relationships with commercial entities that are reasonably likely to experience direct regulatory or commercial impact because of promulgation of the guideline. Categories for disclosure include employment; leadership; stock or other ownership; honoraria, consulting, or advisory role; speaker's bureau; research funding; patents, royalties, other intellectual property; expert testimony; travel, accommodations, expenses; and other relationships. In accordance with the Policy, the majority of the members of the Expert Panel disclosed no relationships that would constitute conflict under the Policy.

Results

Characteristics of Studies Identified in the Literature Search

A total of 5,144 publications were identified in the literature search. After applying the eligibility criteria, 30 SRs and meta-analyses and 80 RCTs remained, forming the evidentiary basis for the guideline recommendations. Table 127-102 and Table 2103-136 include a breakdown of the included studies by integrative therapies and anxiety or depression symptoms outcome. Studies were also classified as including participants in active treatment, post treatment (those who had completed their definitive therapy but who, in the case of breast cancer survivors, might remain on adjuvant hormonal therapy), or in the palliative care setting (stage IV cancer or hospice). The SRs included a mix of populations, while a small number of the RCTs were mixed as well (Appendix Tables A3 and A4).
Table 1. Studies on Interventions With Sufficient Evidence to Inform Recommendations
Table 2. Studies on Interventions With Inconclusive Evidence to Inform Recommendations
The identified studies were published between 1990 and 2023. The RCTs compared various integrative therapies to standard of care, placebos, sham interventions, other interventions, or active controls. The primary outcome for most of the studies included change in anxiety and depression symptoms, which were measured with some commonly used standardized tools (Appendix Table A5). Characteristics of the included studies and the PRISMA flow diagram for the SR are provided in the Data Supplement.

Study Quality Assessment

Study design aspects related to individual study quality and risk of bias were assessed. Thirty SRs and meta-analyses were assessed for quality using the AMSTAR-2 tool.26 The rating for the overall confidence in the results of the review was critically low in 73% (22/30); low in 10% (3/30); moderate in 7% (2/30); and high in 10% (3/30). The AMSTAR-2 critical domains that contributed to the critically low rating for most studies included a priori protocol, list of excluded studies with reason, potential impact of risk of bias, and heterogeneity or publication bias. Design elements, such as masking, allocation concealment, sufficient sample size, intention-to-treat, and funding sources, were assessed for each RCT using the Cochrane risk-of-bias tool.25 The assessment result ranged from low risk of bias for randomization in 78% (62/80) of trials to high risk of bias for blinding of participants and personnel in 79% (63/80) of the trials. In addition, 53% of the studies reported allocation concealment, while 29% reported masking of outcome assessors. The included studies were also heterogeneous with respect to patient populations, sample size, methodologic quality, treatment duration, and outcome measures. Refer to the Data Supplement for quality rating scores and the Methodology Manual for more information and for definitions of ratings for overall potential risk of bias.

Recommendations

Anxiety

Clinical Question 1

What integrative therapies are recommended for managing symptoms of anxiety experienced after diagnosis or during active treatment in adults with cancer?
Recommendation 1.1.
Mindfulness-based interventions (MBIs) should be offered to people with cancer to improve anxiety symptoms during active treatment (Type: Evidence based; Quality of evidence: High; benefits outweigh harms; Strength of recommendation: Strong).
Literature review and clinical interpretation.
This recommendation is based on seven SR papers published since 2017,48-54 which reviewed 7-29 individual RCTs including 1,094-3,476 individual participants. However, some of these do not apply to people with cancer during treatment, as many of the studies included individuals post treatment. For example, in the largest SR by Oberoi et al,48 10 of 29 studies enrolled participants both during and after treatment, but only two included participants solely during active treatment, who had thyroid cancer (n = 120)137 and leukemia (n = 65).138 These studies had particularly large standardized mean differences (SMDs) favoring the MBI of 0.94137 and 2.4138 compared with control groups. Additionally, in the studies that included mixed groups of participants both during and after treatment SMDs were in the medium sized range of about 0.2-0.5, with some higher outliers (eg, Lorca et al,139 SMD, 1.33).
Recommendation 1.2.
Yoga may be offered to people with breast cancer to improve anxiety symptoms during active treatment (Type: Evidence based; Quality of evidence: Intermediate; benefits outweigh harms; Strength of recommendation: Moderate).
Qualifying statement: For people with cancer types other than breast, the quality of evidence is low, and the strength of recommendation is weak.
Literature review and clinical interpretation.
Six SRs have evaluated the effect of yoga on anxiety in people with cancer.96-101 Most SRs and multiple RCTs included a mix of participants on active treatment and post-treatment survivors. Few studies included active control conditions (exceptions include Banerjee et al and Porter et al).140,141 In one SR, subgroup analyses revealed medium effects of yoga on anxiety in studies conducted during treatment (N = 7, g = –0.508) and in those using active controls (N = 3, g = –0.441).96 The evidence base includes a preponderance of studies of women with breast cancer. One SR99 focused on yoga for women undergoing chemotherapy for breast cancer only and reported moderate effects, without heterogeneity, on anxiety (five RCTs, n = 412). Only minor adverse events have been reported.96 Thus, despite weak evidence overall and intermediate evidence in women with breast cancer, the potential benefits outweigh risk of harm, such that yoga may be offered to patients to reduce anxiety during cancer treatment.
SRs have reported benefits of yoga interventions immediately or up to approximately 6 months post-intervention. Few studies have included people with metastatic cancer (eg, Porter et al).141 Thus, the benefits of yoga for people with metastatic cancer and intervention duration in people with localized or regionally advanced cancer requires further study.
Recommendation 1.3.
Hypnosis may be offered to people with cancer to improve anxiety symptoms during cancer-related diagnostic and treatment procedures (Type: Evidence based; Quality of evidence: Intermediate; benefits outweigh harms; Strength of recommendation: Moderate).
Literature review and clinical interpretation.
This recommendation is based on nine RCTs published between 2005 and 2021.39-47 Notably, the moderate strength of this recommendation is based on sample sizes that range from 50 to 201 participants per study. Overall, studies that applied hypnosis to address anxiety in the context of a diagnostic or treatment procedure, such as central venous port implantation, showed the greatest effectiveness. For instance, a recent RCT conducted by Etienne et al45 investigated the effects of hypnotherapy on anxiety during placement of a capsaicin patch, compared with music or usual care in a sample of 69 patients with cancer (n = 23 per group) experiencing post-treatment neuropathic pain. While hypnotherapy and music were both found to reduce procedural anxiety, hypnotherapy was superior in alleviating anxiety post-procedure. Evidence also supports the use of digital tools for the application of hypnosis in alleviating anxiety. Specifically, research by Sánchez-Jáuregui et al46 used pre-recorded hypnotherapy provided in MP3 format, which suggests the use of such technology can improve accessibility of this modality. Cumulatively, the evidence regarding the use of hypnosis for anxiety in people undergoing procedures in the context of cancer care indicates benefit with minimal risk of adverse effects.
Recommendation 1.4.
Relaxation therapies may be offered to people with cancer to improve anxiety symptoms during active treatment (Type: Evidence based; Quality of evidence: Intermediate; benefits outweigh harms; Strength of recommendation: Moderate).
Literature review and clinical interpretation.
The strongest data supporting this recommendation comes from studies during active treatment, often postsurgically or during chemotherapy or radiation therapy. Of the relaxation therapies, most evidence supports progressive muscle relaxation (PMR) and a combination of guided imagery, relaxation, and breathing interventions. A 2022 SR of 12 RCTs of PMR included nine studies in a meta-analysis.78 All of the studies were conducted during chemotherapy, radiation, or recovery from surgery, and included patients with lung, breast, colorectal, and mixed cancer types. Six of the RCTs (n = 742) measured anxiety and found a large overall SMD of –1.32 comparing PMR to various controls, including usual care, education, and exercise. Among these was a large study from China where 400 women with breast cancer received either PMR once daily for 30 minutes over 5 weeks, or usual care.142 A SMD in anxiety of –1.18 was reported for PMR compared with usual care control.
An earlier 2018 SR of seven different RCTs (conducted only with individuals with breast cancer) of PMR and visualization therapies during chemotherapy similarly reported improvements in three of four studies that measured anxiety.79 One of the largest studies in this group included PMR with guided imagery and visualization over 3 weeks during chemotherapy for 236 people with breast or prostate cancer, and found significantly greater improvements in anxiety in the relaxation group with a large effect (d = 0.83).143 Finally, a third SR of PMR for people undergoing chemotherapy included five different RCTs than the previous SR, and reported significantly greater reductions in anxiety across all four studies that included anxiety as an outcome (but meta-analysis was not conducted).80
Another SR and meta-analysis included 15 RCTs assessing breathing exercises for people undergoing treatment for lung cancer; of these, five studies (total n = 189) measured anxiety as secondary outcomes.81 Three of the five found significantly greater improvements in anxiety in the breathing intervention groups compared with control, with large effect sizes. However, the overall meta-analysis was not statistically significant due to large variability among studies (SMD, –1.18 [95% CI, –2.65 to 0.28]). These studies were also rated with a high risk of bias.
Five other RCTs not included in any of the SRs assessed relaxation in 53 women with gynecologic cancers postsurgically82; 51 women after breast cancer surgery83; 52 people in Iran with mixed cancer diagnoses undergoing active treatment84; 81 people undergoing chemotherapy assigned to either biofeedback or relaxation therapy85; and 66 women with gynecologic or breast cancer receiving brachytherapy.86
Recommendation 1.5.
Music therapy or music-based interventions may be offered to people with cancer to improve anxiety symptoms during active treatment (Type: Evidence based; Quality of evidence: Low; benefits outweigh harms; Strength of recommendation: Moderate).
Literature review and clinical interpretation.
There were three recent SRs62-64 and three RCTs66-68 investigating the effect of music therapy and music-based interventions on anxiety in people with cancer during active treatment. A SR from 202162 examined the effects of music interventions on psychologic and physical outcomes in people with cancer and included a total of 81 trials. The SR included two meta-analyses related to anxiety, one for 17 trials (N = 1,381) that used the Spielberger State-Trait Anxiety Inventory–State version (STAI-S) and one for nine trials (N = 882) that used other standardized measures of anxiety. Trial interventions included music therapy sessions offered by a trained music therapist and listening to pre-recorded or live music. Both meta-analyses suggested large effect sizes for music therapy and music-based interventions compared with standard care controls (mean difference [MD], −7.71 for trials that used STAI-S and SMD, −0.76 for non-STAI-S trials). A subgroup analysis comparing music therapy with listening to pre-recorded music suggested that music therapy interventions offered by a trained music therapist may lead to more consistent results.
Another SR64 reported a large treatment effect (SMD, –1.51) of music therapy and music-based interventions on anxiety (seven trials, N = 447). A third SR63 summarized the effects of eight trials (N = 630) that examined if a traditional five-element Chinese music intervention can help reduce anxiety. No evidence of an effect was found for this traditional Chinese music intervention. In these three SRs, most trials were rated as having low methodologic quality. However, it is important to note that for music interventions, as in most other integrative therapies, participants cannot be masked to the intervention, and since anxiety is measured using self-report, outcome assessment cannot be masked either. As a result, integrative therapy intervention trials typically receive low-quality ratings for methodology, even if common criteria used to determine methodologic quality (eg, masking of participants and outcome assessors) cannot be met.
One RCT,68 examining the effects of a music therapy protocol delivered by a trained music therapist compared with standard care on anxiety in 108 participants with cancer during chemotherapy, resulted in a large effect size for music therapy (SMD, –1.87). A three-arm RCT67 with 137 Muslim patients with cancer compared listening to pre-recorded music with listening to the Quran and a standard care control group during chemotherapy. The results suggested large treatment effects for music listening and listening to the Quran compared to the control group. Finally, one RCT66 examined the effects of listening to patient-selected pre-recorded music versus standard care on anxiety in 125 women with cancer during the first session of radiotherapy. No significant difference was found between the two treatment arms.
Based on the large effect sizes reported in the two SRs,62,64 music therapy and music-based interventions may be recommended to help manage anxiety in people with cancer.
Recommendation 1.6.
Reflexology may be offered to people with cancer to improve anxiety symptoms during active treatment (Type: Evidence based; Quality of evidence: Low; benefits outweigh harms; Strength of recommendation: Weak).
Literature review and clinical interpretation.
There were six RCTs evaluating the effectiveness of reflexology to reduce anxiety during active treatment.69,70,73-76 Two trials evaluated patients with breast cancer (N = 286, 183),73,74 two trials evaluated patients with gynecologic cancers (N = 66, 62),75,76 and one trial included patients with multiple cancers (N = 60),70 all undergoing chemotherapy; one trial evaluated postoperative patients with gastrointestinal cancers (N = 61).69 Reflexology interventions varied regarding the number and length of sessions, as well as the qualifications of reflexology providers. Control procedures also varied across studies (eg, lay foot massage,73 reading,70 usual care,69,73,74,76 and delayed intervention69). Reduction in anxiety was reported in postoperative patients with gastrointestinal cancers, although the 1.1-point difference on the Hospital Anxiety and Depression Scale (HADS) score may not be clinically meaningful. For people with gynecologic cancers undergoing chemotherapy, small and medium effect sizes were reported on the HADS (2.46-point difference) and Beck Anxiety Inventory (BAI) (11.03-point difference), respectively, although both trials had several important limitations including masking, allocation concealment, and analysis plans. Two well-conducted trials in people with breast cancer did not show benefit. In participants with multiple cancer types, one trial reported a 2.3-point improvement in anxiety measured on an 11-point visual analog scale (VAS). However, study groups at baseline may have been imbalanced and there was no reporting of masking.70,76
Overall, four studies demonstrated at least small benefits of foot reflexology with short-term interventions. No study reported significant adverse events. Although the net benefit may be small, without evidence of important harms, reflexology may be beneficial for anxiety in some patients.
Recommendation 1.7.
Lavender essential oil inhalation may be offered to people with cancer to improve anxiety symptoms during cancer-related diagnostic and treatment procedures (Type: Evidence based; Quality of evidence: Low; benefits outweigh harms; Strength of recommendation: Weak).
Literature review and clinical interpretation.
There were six RCTs with sample sizes ranging from 70 to 313, examining the effectiveness of lavender essential oil aromatherapy inhalation to reduce anxiety.30-35 Four of the six trials evaluated people during clinical procedures such as biopsy,31-34 and the other two trials evaluated people with cancer during active treatment, such as receiving chemotherapy or radiotherapy.30,35 Three trials evaluated people with multiple cancers (unspecified),30,32,35 and three trials evaluated people with breast cancer.31,33,34 Control procedures also varied across studies (eg, health education, wound care, scar massage, no aromatherapy, and placebo tablets). Some aromatherapy treatments were also paired with other interventions such as music listening and other essential oil aromatherapy.33 Reduction in anxiety was reported in five trials, with only three recording statistically significant differences between the aromatherapy inhalation versus the control.31,32,34

Clinical Question 2

What integrative therapies are recommended in managing symptoms of anxiety experienced post treatment in adults with cancer?
Recommendation 2.1.
MBIs should be offered to people with cancer to improve anxiety symptoms post treatment (Type: Evidence based; Quality of evidence: High; benefits outweigh harms; Strength of recommendation: Strong).
Literature review and clinical interpretation.
This is the strongest recommendation in the guideline, supported by seven meta-analytic reviews published since 201748-54 that summarize a range of 7-29 individual RCTs including 1,094-3,476 participants, all of which were included in a meta-analysis for anxiety. Overall SMDs for anxiety reduction in the short term ranged from 0.2853 to 0.54,52 with a high of 0.92.54 Most values fell into the medium-sized range of effect. A subset of RCTs in the SRs reported medium-term (up to 6 months postintervention) or long-term (>6 months) anxiety, but those that did reported SMDs of 0.28 (seven trials)51 to 0.43 (nine trials)48 for the medium term, which was slightly smaller than immediately postintervention. Not enough studies reported on long-term anxiety to conclude efficacy beyond the medium term.
Most studies compared an MBI to either usual care or waitlist control groups, limiting conclusions largely to the effect of MBIs versus no other active intervention. Exceptions to this are five well-designed studies that compared an MBI to supportive-expressive group therapy,144,145 psychoeducation,146 or cognitive behavioral therapy.60 Effect sizes favoring the MBI in these studies are typically smaller than those with a usual care or waitlist control (in the 0.3 range), but still show significantly greater improvements in anxiety in the MBI groups over active control.
Of the individual studies included within these SRs, the largest was by Würtzen et al147 in Denmark, which included 336 women with nonmetastatic breast cancer both on and off treatment, compared with a usual care control. Similarly, Lengacher et al148 in the United States included 322 women with nonmetastatic breast cancer who had completed treatment, compared with usual care. Würtzen et al147 found a significant within-group effect size of 0.36 over the entire 12-month follow-up period in the MBI group, with greater benefit for those with higher baseline anxiety. Lengacher et al similarly reported a between-groups effect size of 0.27 over a 12-week period pre-post intervention, with those experiencing more anxiety at baseline improving the most. Carlson et al144,145 randomly assigned a sample of 271 distressed women with breast cancer post-treatment to either an MBI or supportive-expressive group therapy. While both active interventions improved anxiety significantly pre- to post-intervention, the MBI group improved more, with a between-group effect on anxiety of 0.39 favoring the mindfulness group. These greater benefits of the MBI were maintained over 12 months of follow-up.
A majority of the studies included in these SRs enrolled participants after treatment, with a minority also including samples receiving MBIs both during and after treatment. Hence, the strength of the evidence and the recommendation during the post-treatment phase is strongest. Similarly, most participants in these studies were women, and the majority were diagnosed with breast cancer. Hence, the recommendations are stronger for women with breast cancer, but there are enough male participants and people with other types of cancers to include all people with cancer broadly within the recommendation.
Most of the interventions were offered in-person, with a few notable exceptions such as Compen et al149 who separately compared in-person and online mindfulness-based cognitive therapy (MBCT) to usual care in a post-treatment sample of 245 people with a variety of cancer types, showing superiority of each modality to usual care alone (combined Hedges' g = 0.56), but the two modalities were not directly compared with one another. Zernicke et al150 also found online videoconferencing Mindfulness-Based Cancer Recovery superior to usual care in a sample of rural and remote people with cancer both on and off treatment (n = 63; between groups Hedges' g = 0.45). By contrast, however, Chambers et al151 delivered MBCT via teleconference for men with prostate cancer compared with enhanced usual care (N = 189) to no effect. Currently, the Expert Panel cannot strongly recommend digital health MBIs for treating anxiety in people with cancer, but this question should be answered more conclusively in coming years with the increase in remotely delivered mindfulness applications necessitated by the COVID-19 pandemic.
Recommendation 2.2.
Yoga may be offered to people with breast cancer to improve anxiety symptoms post treatment (Type: Evidence based; Quality of evidence: Intermediate; benefits outweigh harms; Strength of recommendation: Moderate).
Qualifying statement: For people with cancer types other than breast, the quality of evidence is low, and the strength of recommendation is weak.
Literature review and clinical interpretation.
Two SRs focusing specifically on yoga in women with breast cancer reported significant effects for anxiety (k = 8, n = 505, SMD, –1.35; k = 10, SMD, –0.98)98,101 as did the SR of yoga or mindfulness-based stress reduction (MBSR) for women with breast cancer.97 Only minor adverse events were reported.98 Therefore, the Expert Panel made a moderate recommendation for use of yoga to decrease post-treatment anxiety in women with breast cancer. A SR of yoga for people with any type of cancer at any phase in the cancer trajectory included 16 studies that measured anxiety. While the overall meta-analysis showed a significant medium effect on anxiety (N = 977, g = –0.347), subgroup analysis found no significant effect of yoga for anxiety in post-treatment survivors (n = 4, g = –0.164, P = .157) or in studies that included both active cancer treatment and post-treatment participants (n = 4, g = –0.234, P = .141).96
Recommendation 2.3.
Acupuncture may be offered to women with breast cancer to improve anxiety symptoms post treatment (Type: Evidence based; Quality of evidence: Intermediate; benefits outweigh harms; Strength of recommendation: Weak).
Literature review and clinical interpretation.
Three RCTs evaluated the effectiveness of acupuncture for relieving anxiety symptoms in patients with stage I-III breast cancer following treatment.27-29 All three studies, including 52-302 participants, reported a statistically significant improvement in anxiety as measured by the HADS with small-to-moderate effect sizes, corresponding to improvements on HADSs for anxiety (HADS-A) of approximately two points. However, interventions were heterogeneous regarding controls and methods used (standard, electroacupuncture, and auricular28 acupuncture over 8 weeks).28 Further adequately powered studies with appropriate sham controls are needed, as well as the inclusion of other eligible populations of people with cancer post treatment.
Recommendation 2.4.
Tai chi and/or qigong may be offered to women with breast cancer to improve anxiety symptoms post treatment (Type: Evidence based; Quality of evidence: Intermediate; benefits outweigh harms; Strength of recommendation: Weak).
Literature review and clinical interpretation.
A 2021 SR89 specific to individuals with breast cancer reviewed five RCTs with 439 patients and concluded there was a significant benefit of qigong on anxiety measures (SMD, –0.71 [95% CI, –1.32 to –0.10]; P = .02). An additional RCT of 86 breast cancer survivors not included in the SR because of heterogeneity of instrument used found no difference in anxiety after 6 months of medical qigong intervention compared with usual physical activity.93 On the other hand, a mixed cancer RCT involving 162 people with a variety of cancer types (30% breast cancer) showed significant improvement in Profile of Mood State (POMS) scores in the tension/anxiety subscale at 10 weeks postintervention when comparing treatment and control groups.95
Recommendation 2.5.
Reflexology may be offered to people with cancer to improve anxiety symptoms post treatment (Type: Evidence based; Quality of evidence: Low; benefits outweigh harms; Strength of recommendation: Weak).
Literature review and clinical interpretation.
Three RCTs of reflexology demonstrated reduction of anxiety in participants with a variety of different cancer types who had metastatic cancer or were in a palliative care program.71,72,77 None of these studies reported whether participants were receiving active cancer treatments or were post-treatment. All three trials (N = 80-86) reported decreased anxiety in their study populations, but effect sizes were small (1.8-point difference on 11-point VAS, 4.5-point difference on STAI, and 0.8-point difference on HADS-A) and may have been below clinically meaningful differences in two of three trials. All three trials had elements at high risk of bias, including unclear randomization, lack of masking, and unclear intervention protocol.
Given the late-stage cancers represented in these trials and the low likelihood of harm due to reflexology, there is indirect evidence of the potential of a small net benefit of reflexology for anxiety symptoms in the post-treatment phase.
Inconclusive.
There is inconclusive evidence to make recommendations for or against music therapy and music-based interventions to improve anxiety symptoms in people with cancer who are post treatment. There is also inconclusive evidence for nutritional interventions, light therapy, psilocybin-assisted therapy, massage, dance/movement therapy, laughter therapy, healing touch, expressive writing, acupressure, biofeedback, autogenic training, energy healing, melatonin, or other natural products and supplements to improve anxiety symptoms in people with cancer, regardless of when in the course of care the intervention is provided.
Literature review and clinical interpretation. Music therapy, music-based interventions.
Many RCTs included in two SRs62,64 that examined the effects of music therapy and music-based interventions on anxiety in people with cancer included people along the cancer care continuum, including those who were post treatment. However, the literature search did not identify any RCTs that met our inclusion criteria that only included people with cancer who were post treatment.
Nutritional interventions.
Three eligible trials of nutritional interventions, including a residential nutritional rehabilitation program for people with head and neck cancer, hospital-based nutritional education sessions for people with nonmetastatic breast cancer, and mixed motivational interviewing or pamphlet or newsletter intervention in people with colorectal cancer, that examined effects on anxiety symptoms were analyzed,131-133 two of which incorporated both dietary and physical activity interventions.132,133 Two of three eligible trials did not show a significant effect on anxiety outcomes but due to significant heterogeneity of methodology, including the nature and duration of nutritional interventions given in the trials, as well as variability in the patient groups who received the intervention, it is not possible to draw robust conclusions. Further research should focus on specific and well-defined dietary interventions studied in adequately powered trials that monitor for nutritional compliance, as well as measuring both anxiety and depression outcomes during and after the intervention.
Light therapy.
There is insufficient evidence to recommend for or against the use of light therapy for treating anxiety symptoms in people with cancer. Light therapy has largely been investigated in this population for the treatment of fatigue; hence anxiety, when measured, has been a secondary outcome. For example, Johnson et al114 compared 4 weeks of daily bright white light to dim red light in 84 fatigued people living with cancer post-treatment and found both groups improved significantly on fatigue and mood with generally large effect sizes, but there was no usual care comparison group.
Psilocybin-assisted therapy.
This is a promising modality for the treatment of existential anxiety and depression in cancer care. Currently, however, only two small RCTs have been published on its use. In the largest trial to date, Griffiths et al135 compared low- to high-dose psilocybin with supportive psychotherapy in 51 people with advanced cancer in a crossover design. They found large decreases in multiple measures of anxiety, which persisted at 6-month and 4-year follow-up assessments. Ross et al136 conducted a similar trial with 29 people living with advanced cancer, also finding large effect sizes on anxiety and depression. Many other larger RCTs are currently underway, but at this point, the evidence is inconclusive.
Massage.
There were three RCTs of massage therapy to reduce anxiety symptoms in participants undergoing active treatment, including chemotherapy in two trials117,118 and port placement in one trial.119 Two SRs also reported on massage or oil aromatherapy massage to reduce anxiety.115,116 Two trials during active chemotherapy reported no improvement in anxiety symptoms. One SR (eight studies; N = 498)115 reported no evidence of a treatment effect for anxiety in patients with breast cancer undergoing chemotherapy (SMD, –0.08 [95% CI, –0.44 to 0.28]; I2 = 72%). A second SR compared massage or aromatherapy massage to no massage or massage without aromatherapy.116 There was no evidence of a treatment effect of massage studies (three studies, n = 98; MD STAI, –5.4 [95% CI, –16.1 to 5.3]; I2 = 88%) and aromatherapy massage versus standard massage (two studies; n = 145; no meta-analysis performed). Two trials (n = 253) of oil aromatherapy massage versus no massage reported a pooled MD (STAI-S) of –4.5 (95% CI, –7.7 to –1.3). Strength of evidence for all comparisons was rated as very low. There were no studies of massage that included anxiety in post-treatment phase patients.
Natural products.
Multiple eligible trials tested a variety of natural products and supplements with one negative trial of probiotics,122 one negative trial of chamomile tea,123 one positive trial of fermented red Panax ginseng extract,124 one negative trial of white P. ginseng extract125 with significant dose variation, one positive low-risk-of-bias trial of 30 mg crocin (found in crocus flowers and saffron),126 and one negative trial for Yokukansan extract.127 The use of rigorous methodology and rational formulation, dosing, and strain specificity and their appropriate application to specific patient groups are needed to provide clinically relevant guidance.
Melatonin.
In a clinical trial of 128 participants with colorectal cancer, 6 mg of melatonin at bedtime was tested against zolpidem for sleep during chemotherapy, with anxiety considered as a secondary outcome.106 This study demonstrated no impact on anxiety; however, the trial was not designed for individuals with this condition. One RCT107 found no impact on anxiety with the use of perioperative melatonin for breast cancer in a small sample of 54 women. This study tested the use of 6 mg of melatonin over the course of 1 week preoperatively and 3 months postoperatively with depression as the primary outcome and anxiety among other outcomes a secondary consideration. This trial, which overall had a low risk of bias, did suffer from a disproportionate number of dropouts in the placebo group compared with the melatonin group.107 Another RCT tested the impact of melatonin among patients with lung cancer post resection and found no impact on anxiety in a small subset of participants.108 The subset that was assessed for anxiety consisted of <10% (67/709) of the total sample. In addition, anxiety was a relatively minor secondary outcome that was not a presenting concern for the participants upon enrollment, and thus, the intensity of anxiety among the group was relatively low.
Dance/movement therapy.
One SR104 and one RCT105 were identified that examined the effect of dance/movement therapy on anxiety and/or stress. The 2015 Cochrane Review by Bradt, Shim, and Goodill104 included two RCTs and one quasi-experimental study (N = 207) that compared the effect of various types of dance/movement therapies to standard care on psychologic and physical outcomes among women with breast cancer who were within 5 years of diagnosis. The SR included two meta-analyses related to anxiety and stress that pooled the results of two of the three studies (n = 170). No evidence of effect was found for the dance/movement interventions regarding anxiety (SMD, 0.21 [95% CI, –0.09 to 0.51]; P = .18; I2 = 0%). All three studies included in the SR were rated as being at high risk of bias, mainly due to lack of masking of study participants and outcome assessors. The RCT conducted by Ho et al105 compared the effect of a 90-minute dance/movement session offered twice a week over 3 weeks to standard care on anxiety and stress among 139 Chinese women living with breast cancer receiving adjuvant radiotherapy treatment. No significant difference between study arms was found for anxiety. Overall, there has been limited high-quality research evaluating the effect of dance/movement interventions on anxiety and/or stress, especially in cancer populations beyond women living with breast cancer.
Laughter therapy.
One study113 was identified that evaluated the impact of a laughter program on people with cancer undergoing active treatment and the effect on anxiety and depression. The pilot trial113 evaluated patients with breast cancer (N = 62) undergoing postoperative radiation therapy assigned to a therapeutic laughter program (TLP) consisting of periods of loud, prolonged laughter with information about the effects of TLP compared with a control arm. The authors observed that as the number of TLP sessions attended increased, numeric rating scale scores for anxiety and depression significantly decreased.
Healing touch.
There is insufficient evidence to recommend for or against the use of healing touch or therapeutic touch for treating anxiety symptoms in people with cancer. In many of these studies, anxiety is a secondary outcome. These studies have been conducted preoperatively and postoperatively and post-treatment. Post-White et al110 performed a randomized prospective two-period crossover intervention study in a mixed cancer population, testing therapeutic massage and healing touch. The massage therapy group showed a lowering of anxiety post-treatment (t(61) = 2.3, P = .023). There was no lowering of anxiety symptoms from healing touch.
Acupressure.
One RCT evaluated the effects of acupressure at LI4 and HT7 in people with cancer who were undergoing bone marrow biopsy and aspirate with both sham and usual care controls (N = 90, 30/30/30 group split).103 Acupressure, compared with sham or usual care, resulted in a statistically significant reduction in anxiety as measured by the STAI, with no serious side effects reported. This protocol may offer a practical short-term intervention for consideration in the periprocedural setting but further research is needed, and study results must be interpreted with caution, given the high risk of bias in two domains.

Depression

Clinical Question 3

What integrative therapies are recommended for managing symptoms of depression experienced after diagnosis or during active treatment in adults with cancer?
Recommendation 3.1.
MBIs should be offered to people with cancer to improve depression symptoms during active treatment (Type: Evidence based; Quality of evidence: High; benefits outweigh harms; Strength of recommendation: Strong).
Literature review and clinical interpretation.
This recommendation is based on seven SRs published since 2017,48-54 which reviewed a range of 7-29 individual RCTs including from 1,097 to 3,476 individual participants. These same SRs support Recommendation 1.1, management of symptoms of anxiety during active treatment, and the same comments regarding study composition apply. In the largest SR by Oberoi et al,48 two studies that solely enrolled patients during active treatment were included in the analysis of the association of MBIs with depression in the short and medium term. These studies137,152 exclusively enrolled patients with nonmetastatic cancer in 8-week MBIs (MBSR and MBCT). The larger study, Liu et al, reported SMDs of 1.24 and 1.55, favoring the MBI for management of depression in the short and medium term, respectively, compared with the control group. In the studies that included mixed groups of participants both on and off treatment for metastatic or nonmetastatic cancer,149,153,154 SMDs for depression in the short term were in the medium size range of about 0.4-0.7, in favor of the MBI.
Recommendation 3.2.
Yoga may be offered to people with breast cancer to improve depression symptoms during active treatment (Type: Evidence based; Quality of evidence: Intermediate; benefits outweigh harms; Strength of recommendation: Moderate).
Qualifying statement: For people with cancer types other than breast, the quality of evidence is low, and the strength of recommendation is weak.
Literature review and clinical interpretation.
The SR of yoga in women undergoing chemotherapy for breast cancer included six RCTs with 446 total participants and reported a significant effect on depression (SMD, –0.50).99 Notably, only one of these RCTs included an active control group (supportive education).155 Two SRs that examined yoga in women with breast cancer, regardless of treatment phase, also reported benefits for depression (k = 12, n = 761, SMD, –0.98; k = 10, SMD, –0.17).98,101 The evidence for yoga to improve depression during treatment for breast cancer was, therefore, graded as intermediate. Fewer studies have been conducted in people with other cancer types, but one SR including mixed cancer types conducted a subgroup analysis of the effects of yoga on depression during active treatment and reported a medium effect (n = 11, g = –0.384)96; only two of the 11 RCTs in this subgroup analyses enrolled participants with types of cancer other than breast (central nervous system, thoracic). Because most studies focused on women with breast cancer, the overall evidence for yoga to improve depression symptoms during active treatment was graded as low quality. In trials reporting adverse events, no serious events occurred. Therefore, the Expert Panel recommends that clinicians may offer yoga to improve depressive symptoms during active cancer treatment.
Recommendation 3.3.
Music therapy or music-based interventions may be offered to people with cancer to improve depression symptoms during active treatment (Type: Evidence based; Quality of evidence: Low; benefits outweigh harms; Strength of recommendation: Moderate).
Literature review and clinical interpretation.
There were three SRs on music therapy and music-based interventions that reported treatment effects for depression.62-64 A SR from 202162 that examined the effects of music interventions on psychologic and physical outcomes in people with cancer included a meta-analysis of 12 trials with 1,021 participants for depression. Interventions included music therapy with a trained music therapist and listening to prerecorded music. The pooled effect size of the included trials suggested that music therapy and music-based interventions may have a small-to-moderate treatment effect on depression (SMD, –0.41). Another SR64 including six trials with 555 participants reported a large treatment effect (SMD, –1.12) for depression. Finally, an SR63 only including the use of traditional Chinese five-element music also reported a large treatment effect (SMD, –1.11) for depression. Because of the treatment effects reported in these SRs, music therapy and music-based interventions may be recommended to help manage depression in people with cancer during active treatment.
Recommendation 3.4.
Relaxation therapies may be offered to people with cancer to improve depression symptoms during active treatment (Type: Evidence based; Quality of evidence: Low; benefits outweigh harms; Strength of recommendation: Weak).
Literature review and clinical interpretation.
The evidence for relaxation therapies during treatment for depression symptoms is not as strong as for anxiety, but enough studies exist to make a weaker recommendation. In the 2022 SR of PMR,78 two included studies (n = 492) measured depression as an outcome during active treatment and saw statistical improvements, but meta-analysis could not be performed due to variability in outcome measures.
The 2018 review of seven different RCTs only in breast cancer (n = 255) of PMR and/or visualization therapies during chemotherapy similarly reported improvements in depression symptoms and mood in the five studies that included that outcome, but meta-analysis was not conducted.79 The SR and meta-analysis of 15 RCTs assessing breathing exercises for people undergoing treatment for lung cancer included four studies of 159 people that measured depression as a secondary outcome; but while half of them showed benefit, the results were highly heterogeneous and the overall SMD did not significantly favor the treatment.81
Individual studies not included in the SRs also found greater improvements in depression in treatment over control conditions.82,84,86
Recommendation 3.5.
Reflexology may be offered to people with cancer to improve depression symptoms during active treatment (Type: Evidence based; Quality of evidence: Low; benefits outweigh harms; Strength of recommendation: Weak).
Literature review and clinical interpretation.
Four RCTs reported on the benefit of reflexology for treatment of depressive symptoms in participants receiving active cancer treatment. Two trials with low risk of bias reported no benefit of reflexology in patients with breast cancer undergoing chemotherapy (N = 286)73 and surgery (N = 183).74 One trial of hospitalized patients (N = 66) with a variety of gynecologic cancers conducted in Korea reported a small benefit (0.38-point difference on HADS-depression) of aromatherapy and self-performed reflexology over 6 weeks (moderate risk of bias).75 A second trial of patients (N = 62) with gynecologic cancers receiving outpatient chemotherapy in Turkey reported a small benefit (18% reduction in BAI) in depressive symptoms after 4 weeks of reflexology (high risk of bias).76
Reflexology may be considered as an adjunct treatment for depressive symptoms for patients with an interest in this therapy. However, larger, high-quality studies are needed before recommending widespread implementation.

Clinical Question 4

What integrative therapies are recommended in managing symptoms of depression experienced post treatment in adults with cancer?
Recommendation 4.1.
MBIs should be offered to people with cancer to improve depression symptoms post treatment (Type: Evidence based; Quality of evidence: High; benefits outweigh harms; Strength of recommendation: Strong).
Literature review and clinical interpretation.
This is the second strongest recommendation in the guideline, supported by seven SRs published since 2017,48-54 summarizing a range of 7-29 individual RCTs including from 1,097 to 3,476 individual participants. These same meta-analyses support Recommendation 2.1, management of symptoms of anxiety post-treatment, and the same comments regarding study design and composition apply. Overall SMDs for depression reduction in the short term ranged from 0.3453 to 0.74.54 Most values fell into the medium-sized range. Fewer of the original RCTs reported on medium-term (up to 6 months post-intervention) or long-term (>6 months) management of symptoms of depression, but those that did reported SMDs of 0.26 (four studies),53 0.32 (seven studies),51 and 0.85 (eight studies)48 for the medium term. Not enough studies reported on the long-term management of depressive symptoms to conclude efficacy beyond the medium term.
Of the individual studies included within these meta-analyses, the largest was by Würtzen et al,156 which found a significant within-group effect size of 0.55 on depression over the entire 12-month follow-up period in the MBI group. Most studies compared an MBI to either usual care or waitlist control groups. A notable exception is Bower et al,55 which focused on addressing depressive symptoms in 247 younger (age ≤50 years at diagnosis) breast cancer survivors. Both the MBI and survivorship education significantly reduced depressive symptoms relative to the waitlist control, with a trend toward greater and more durable reduction with the MBI.
As with Recommendation 2.1, the recommendations are strongest for women with breast cancer, but there are enough male participants and people with other types of cancers to include all people with cancer broadly within the recommendation.
Recommendation 4.2.
Yoga may be offered to people with breast cancer to improve depression symptoms post treatment (Type: Evidence based; Quality of evidence: Intermediate; benefits outweigh harms; Strength of recommendation: Moderate).
Qualifying statement: For people with other cancers the quality of evidence is low, and the strength of recommendation is weak.
Literature review and clinical interpretation.
In an SR and meta-analysis of effects of yoga on depressive symptoms, regardless of cancer type, subgroup analysis (n = 8, g = –0.428) of post-treatment studies identified a significant medium effect.96 However, only two of the eight RCTs included in this analysis included people with types of cancer other than breast (one trial of people with head and neck cancer, one with people with breast and other types of cancer). In addition, two SRs have focused on yoga for women with breast cancer.98,101 Although neither conducted subgroup analyses for different treatment phases, both included multiple post-treatment trials and identified overall significant effects in depressive symptoms. The Expert Panel rated the evidence for yoga to improve post-treatment depression as low overall and intermediate in women with breast cancer. Adults with any cancer type, therefore, may be offered yoga as an approach to reduce symptoms of depression post-treatment.
Recommendation 4.3.
Tai chi and/or qigong may be offered to people with breast cancer to improve depression symptoms post treatment (Type: Evidence based; Quality of evidence: Intermediate; benefits outweigh harms; Strength of recommendation: Weak).
Literature review and clinical interpretation.
A 2018 SR and meta-analysis87 including 15 RCTs (n = 1,283) evaluating qigong and/or tai-chi exercises showed significant improvement in depression scores (ES = −0.27; P = .001), despite heterogeneity of comparison groups. Cancer-related depression was specifically evaluated by seven RCTs (N = 783). Many different standardized questionnaires were used to measure depression, and a variety of cancers were studied, mostly breast cancer. A 2021 SR and meta-analysis89 specific to patients with breast cancer reviewed six studies with 540 participants and concluded there is significant effect of qigong on depression symptoms (n = 540, SMD, –0.32 [95% CI, –0.59 to –0.04]; P = .02). On the other hand, two other meta-analyses found no difference (Zeng et al: three RCTs, N = 31490 and Cheung et al88: four RCTs, N = 326), due primarily to significant heterogeneity in effects across studies such that confidence intervals were wide and crossed zero.
Two adequately powered studies included in the 2018 SR and meta-analysis by Wayne et al87 showed an effect on measures of depression with use of qigong compared with conventional care; however, these are considered low-quality studies due to lack of masking, confounding factors (such as extra care v none), and high drop-out rates. One RCT of medical qigong in patients with a variety of cancers, including breast cancer (34%), colorectal (12%), lung (9%), and prostate cancer (9%), compared with usual care, involving 162 patients, showed significant improvement in POMS scores in the depression domain at 10 weeks postintervention.95 A recent prospective, RCT involving 80 patients with gastrointestinal cancer92 used a specific form of Chinese traditional qigong exercise known as monkey-frolic in the intervention group. Conventional care included coping strategies, routine education, emotional support, cognitive therapy, and stress management. All patients were considered high risk of depression based on questionnaire scores. After 4 weeks, statistically significant improvements in depressive symptoms were reported for those participating in five weekly qigong exercise sessions, compared with controls.
Recommendation 4.4.
Expressive writing should not be offered to people with cancer to improve depression symptoms at any point in the course of care (Type: Evidence based; Quality of evidence: Intermediate; no net benefit; Strength of recommendation: Moderate).
Literature review and clinical interpretation.
There was one SR36 that included 16 studies (total n = 2,392), and two RCTs37,38 of expressive writing interventions (also part of the SR) that examined its specific effect on depression in cancer. The writing interventions used largely followed the original paradigm developed by Pennebaker157 in which participants are instructed in three to four home- or lab-based sessions across 2-3 weeks to write about their cancer or some other traumatic experience. Control participants are instructed to write about neutral topics such as daily activities, health behaviors, or time management. Participants varied by age, sex, cancer type, and stage, and ranged across the survivorship trajectory from active treatment to end-of-life care. Expressive writing failed to produce significant improvement in overall psychologic well-being, anxiety, or depressive symptoms in any of the studies reviewed. At this point, the Expert Panel does not advise the use of expressive writing interventions to manage anxiety or depression in cancer.
Inconclusive.
There is inconclusive evidence to make recommendations for or against reflexology to improve depression symptoms in people with cancer who are post treatment. There is also inconclusive evidence for nutritional interventions, light therapy, psilocybin-assisted therapy, massage therapy, biofeedback, autogenic training, energy healing, melatonin, and other natural products and supplements to improve depression symptoms in people with cancer, regardless of when in the course of care these therapies are provided.
Literature review and clinical interpretation.
Reflexology.
One randomized trial (N = 86) demonstrated a moderate effect of six weekly reflexology sessions compared with a relaxation control.77 Participants with multiple cancer types were recruited from an outpatient palliative care unit in Greece. It is unclear if participants were receiving active cancer treatment during the trial. High risk of bias elements included lack of masking and unclear randomization and allocation concealment methods.
Nutritional interventions.
Four eligible trials (combined n = 604) of nutritional interventions that examined effects on depression symptoms in people with cancer were analyzed.131-134 Two of the trials incorporated both dietary and physical activity interventions and showed positive effects on improvement in depression outcomes.132,133 While three out of four trials showed a positive effect on depression outcomes, due to significant heterogeneity of methodology, including the nature and duration of nutritional interventions given in the trials, as well as variability in the patient groups who received the intervention, it is not possible to draw robust conclusions. Further research should focus on specific and well-defined dietary interventions studied in adequately powered trials that monitor for nutritional compliance, as well as measuring both anxiety and depression outcomes during and after the intervention to assess the likely duration of effects.
Light therapy or psilocybin-assisted therapy.
The same caveats apply to depression as anxiety outcomes for both light therapy and psilocybin-assisted therapy as summarized in the anxiety section. The trials are few and small, but both therapies show some promise and require further research.
Massage.
One RCT of massage therapy investigated a 2-week intervention (three 30-minute sessions per week by a licensed massage therapist) versus a simple touch control in patients with a variety of metastatic cancers undergoing palliative care.120 Although the study reported immediate benefits in mood, those improvements were not sustained over time. There was no difference in improvements in symptom distress compared with the control group. Two RCTs117,118 and two SRs (eight trials, 540 participants115; and nine trials, 582 participants116) reported on the benefits of massage for depressive symptoms. No studies found statistically significant results in favor of massage. Although most trials had unclear or high risk of bias, further studies are unlikely to demonstrate a clear benefit of massage for depressive symptoms in this patient population.
Natural products and supplements.
Multiple trials tested a variety of natural products and supplements, including two negative trials of probiotics with variable formulations,122,128 one negative trial of 1-g L-carnitine BD,129 one poor-quality positive trial of chamomile tea,123 three trials of P. ginseng with variable quality and outcomes and significant differences in preparation and dosing,124,125,130 one positive low-risk-of-bias trial of 30-mg crocin,126 and one meta-analysis examining 18 RCTs testing 12 types of Chinese herbal medicine formulae with significant methodologic limitations (including lack of masking), heterogeneity in prescribing method, patient population, and formulae used.121 It is important to note that analyses combining different Chinese herbal medicine formulae given to different patient populations within a different framework (personalized v generic prescriptions) in different doses are usually of little clinical utility. Adequately powered trials that explore promising areas with rigorous methodology, attention to formulation, dosing, and probiotic strain specificity and their appropriate application to specific patient groups are needed to provide clinically relevant guidance.
Melatonin.
In one small RCT (N = 54), there was a significant reduction in the number of women with depression according to the Major Depression Inventory107 in the perioperative period for women with breast cancer. This trial, which had a low overall risk of bias, did suffer from a disproportionate number of dropouts in the melatonin group. When different sensitivity analyses were applied, however, the effect was still found to be significant. In another trial, melatonin given at 6 mg once daily at night was tested against zolpidem for sleep among 128 participants with colorectal cancer while receiving chemotherapy.106 In this trial, depression was assessed as a secondary outcome with no changes observed during the 30-day application. One clinical trial tested the impact of melatonin among a subset of patients with lung cancer post resection and found no impact on depression.108 The subset assessed for depression was small at <10% of the total sample (67/709) and was tested as a secondary outcome where this was not a major presenting concern. In a trial exploring melatonin for sleep, mood, and hot flashes, 3 mg of melatonin taken daily did not show any effect on depression; however, the sample was not selected based on this condition and not powered to demonstrate an effect for this outcome.109 A small multicomponent, multifactorial trial tested the effect of melatonin on depression as a secondary outcome in patients with advanced cancer. This trial did not demonstrate a difference in depression among this group, but it was not powered to assess this outcome and was designed to approximate effect size for a larger future planned trial.158
Multimodal interventions.
Two trials of multicomponent, complex interventions were identified. Because each trial was composed of vastly different components, it was not possible to draw broad conclusions about the effectiveness of multicomponent interventions. In one trial of 116 individuals with colorectal cancer undergoing chemotherapy in India, participants were randomly assigned to yoga plus bundled naturopathic interventions including diet, manipulative therapy, massage, mudpack, and bathing versus standard psychosocial counseling over an 18-month period.159 Although authors reported statistically significant between-group differences for secondary outcomes such as anxiety (STAI) and depression (Beck Depression Inventory), the values reported in table and graphic formats are inconsistent. Additional important limitations to the study are poorly defined intervention procedures, large postrandomization exclusions, unclear blinding, unclear balance of groups at baseline, and multiple testing. Another multicomponent trial investigated the effects of PMR plus Chinese medicine five-element music versus peaceful rest over 8 weeks in participants with a variety of cancer types in China.160 Although authors reported greater improvements in anxiety and depression for the intervention group compared with the control group, individual HADS component scores were not reported and differences in composite HADS scores did not appear to be clinically meaningful. Additional important limitations included poorly defined interventions, lack of blinding, and multiple testing.
Based on the current body of evidence, no recommendations can be made regarding multimodal interventions. Due to significant methodologic concerns of the studies identified, it is unlikely additional studies similar to the ones currently available can be performed due to the poorly described interventions.

Discussion

These guidelines summarize recommendations for integrative therapies that should or may be used in conjunction with conventional care to improve symptoms of anxiety and depression in people with cancer, either during or after treatment, with MBIs, music therapy, yoga, relaxation, hypnosis, tai chi and qigong, and reflexology among those being recommended. This is important not only for improving overall psychosocial adjustment and quality of life, but because untreated depression and anxiety symptoms are consistently associated with higher overall mortality in people with cancer.161,162 Interest among those diagnosed and treated for cancer in these complementary forms of care has grown steadily in the past decade.23 From the perspective of the individual with cancer, these therapies offer a measure of perceived control over the impact of illness and/or side effects, have few if any side effects, and can be received in a variety of settings. Although many of these therapies may be readily available in some urban and suburban settings, some are still not universally available. Furthermore, out-of-pocket costs can limit their uptake. A survey of 45 National Cancer Institute–designated cancer centers found that the most commonly offered integrative therapies were acupuncture and/or massage (73.3% each), meditation and/or yoga (68.9% each), and consultations about nutrition (91.1%), dietary supplements (84.4%), and herbs (66.7%). Compared with 2009, there was a statistically significant increase in the number of websites mentioning acupuncture, dance therapy, healing touch, hypnosis, massage, meditation, qigong, and yoga.163
One of the strongest recommendations in this guideline is for the use of MBIs in the management of anxiety and depression in adults with cancer. This finding is synergistic with the updated ASCO guideline review of the psychosocial, behavioral, and pharmacologic management of anxiety and depression in adult cancer survivors in which MBSR interventions, among other cognitive-behavioral and individual psychologic therapies, were strongly recommended by the review committee.16 The acknowledged utility of yoga for management of anxiety and depression across care could be considered paralleling the support found for the role of exercise for this purpose in this latter updated guideline, if considering the physical activity aspect of yoga.
Given the appeal of their use, the lack of support for expressive writing interventions was a surprise. Although no adverse effects were reported, the large numbers of participants (n = 2,392) involved in the 16 studies reviewed, diversity of samples involved, use of well-accepted psychologic measurement tools, and the consistency of findings suggest that pursuing more studies in this area is not likely to change outcomes. Arguably, this type of intervention may be helpful for individuals with cancer in processing, and more deeply exploring the impact or meaning of their illness. However, the brevity of the intervention is not well matched to more chronic conditions, such as depression, whose symptoms tend to persist over weeks and months. If expressive writing were to become a habit, which takes weeks to establish, it is possible that this might prove more useful in managing longer-term emotional distress. But such studies remain to be conducted. It is also noted that keeping diaries of symptoms, side effects, and treatments received can help organize cancer care.164,165
The current guideline has many consistencies with the prior 2017 SIO integrative therapy guidelines created for people with breast cancer.166 In those guidelines, the US Preventive Services Task Force grading system was used,167 which is different from the currently used system in that it assigns grades to the evidence base, but both assess strength of evidence as determined by the number of trials, quality of trials, magnitude of effect, statistical significance, sample size, and consistency of results across studies. For anxiety, only meditation (including MBIs) received a grade A recommendation, followed by music therapy, stress management, and yoga, all of which received a grade B recommendation, and acupuncture, massage, and relaxation received a grade C. Similarly, for depression and mood disturbance, MBIs and relaxation received grade A recommendations, yoga, massage, and music therapy grade B, and acupuncture, healing touch, and stress management received grade C recommendations. Similarly, in the current guidelines, with the inclusion of all cancer types and a review of the updated literature, MBIs received the strongest recommendations. Other therapies remained equivalent to the grade B category at this time, receiving recommendations of “may be offered” rather than “should be offered.” While in some cases the lower grade is related to low study quality scores influenced by the inability to mask participants to integrative interventions, there continues to be a paucity of research among people with cancer other than breast.
There are also many gaps in the evidence base, and the Expert Panel was unable to make recommendations for or against several popular treatment modalities, as not enough studies have been conducted. The Expert Panel specifically recommends more research be conducted in the areas of promising as well as commonly used and accessible therapies such as yoga during active treatment, healing touch and therapeutic touch, tai chi and qigong, natural health products, and creative arts-based therapies, such as art therapy and dance/movement therapy. Studies are also significantly lacking in people with cancers other than breast, in the context of metastatic disease, and among people from diverse backgrounds.

Patient and Clinician Communication

For most people, cancer is the most difficult and frightening experience they have ever encountered. Anxiety and depression associated with cancer are largely centered around feelings of guilt from past lifestyle choices, hopelessness, and helplessness in the face of a cancer diagnosis, and fear and uncertainty about the future. These feelings can affect the way a person thinks, acts, interacts with others, and even the way their body functions during and after cancer treatment. The research synthesized in these guidelines suggests various integrative approaches that can be applied to manage anxiety and depression during and after cancer treatment. People with cancer will need to find their own level of comfort with these approaches based on their belief systems and personal ways of coping and their choices of therapies to use or not use should be respected by their families, cancer care team, and others who support them through the cancer experience.
Moreover, it is critical that the cancer care team monitor people at each stage of diagnosis, treatment, and survivorship to discuss and offer different types of emotional, social, and physical support as needs change and evolve throughout the cancer journey. For example, a person newly diagnosed with cancer may benefit from relaxation techniques while undergoing chemotherapy but might benefit from a more active therapy such as yoga once treatment is over, to relieve symptoms from side effects. People who have completed treatment may feel they need the social support of a group or one-on-one counseling to deal with their fear and uncertainty of their cancer returning. At times of critical treatment and diagnostic junctures, for example, at the time of first diagnosis, when diagnosed with recurrent or metastatic disease, and at the start and end of treatments, cancer care teams should be routinely screening for anxiety and depression symptoms to ensure patients follow-through with cancer treatment, and to support use by these individuals of self-management strategies that improve quality of life.
Advances in cancer treatment suggest that a diagnosis does not equal a death sentence, but for many people, cancer does equate to a chronic condition that influences their quality of life and needs to be managed mentally, emotionally, and physically. People with cancer and advocates of integrative oncology strategies will need to continue to raise awareness among mainstream physicians for the need to address and treat the psychiatric consequences of cancer. For recommendations and strategies to optimize patient-clinician communication, see the ASCO guideline by Gilligan et al.168

Health Disparities

Although SIO-ASCO clinical practice guidelines represent expert recommendations on the best practices in disease management to provide the highest level of cancer care, it is important to note that many patients have limited access to medical care or receive fragmented care. The same is true of participants in research studies, with inequities in research participation across social determinants of health such that marginalized groups are under-represented in clinical trials.169 Disparities in mental health care are significantly exacerbated by a lack of uniform insurance coverage for behavioral care and ongoing societal stigma. Individual factors such as race, ethnicity, age, socioeconomic status, sexual orientation, gender identity, geographic location, education, literacy (including digital), numeracy, environmental exposure, insurance access, and lack of trust in the health care system are known to impact cancer care outcomes.170 Clinician factors such as unconscious and conscious bias can contribute to missed diagnoses and differences in care.171 Despite similar access, prescription treatment for major depression and frequency of treatment has been documented to be lower in minoritized Black and Latino communities.172 Health system barriers can also disproportionately impact minoritized communities who may experience the intersection of multiple identities and structural inequities.
A review of racial and socioeconomic factors related to the use of complementary therapies for cancer pain management found lower income and educational levels had a greater influence on complementary therapy use than race. People who had a higher educational degree and income typically used body manipulation techniques or practitioner-based therapies that cost money or required insurance, whereas users with inadequate financial resources reported greater use of free methods for symptom management, such as meditation and relaxation techniques. Prayer and spirituality, when included as complementary modalities, were also more often used by racial minority groups. A general limitation of the included studies was the lack of integration between race and socioeconomic factors, wherein social determinants of health and the link between minority status and socioeconomic status were essentially overlooked.173 People with cancer who are members of minoritized communities may also be more likely to seek care from someone who looks like them. The lack of diversity in the health professional workforce serves as another source of health inequity. These same individuals who are experiencing substantial obstacles to care may also be at greater risk for concurrent illnesses and comorbidities.170,174 This clinical practice guideline should be considered with awareness and understanding of the patient, clinician, and health system factors that contribute to inequitable care and limit access to care. Even in countries with universal health care, integrative approaches are not uniformly covered leaving access to those who can pay out of pocket.
As discussed in the previous section, disparities in cancer care treatment can be caused or exacerbated by a lack of open and supportive patient-provider communication. It is extremely important that cancer care teams diligently focus on those diagnosed with rare cancers, minoritized groups (including people with cancer from Black and indigenous communities, sexual and gender minorities), and adolescents as their symptoms of anxiety and depression are less likely to be addressed.
Health professionals are committed to delivering the highest level of care to each person living with cancer. All stakeholders are called to work together to ensure equitable access to both high-quality cancer care and cancer clinical research and address the structural barriers that maintain health inequities.170

Multiple Chronic Conditions

Creating evidence-based recommendations to inform treatment of individuals with additional chronic conditions, a situation in which a person may have two or more such conditions—referred to as multiple chronic conditions (MCC)—is challenging. In the setting of cancer, a disease of aging, MCC is also the norm. US population-based statistics estimate that of the adult population (those age 18 years and older), 23.1% have two or more chronic conditions. For those age 65 years and older, this figure rises dramatically to 63.7%.175 Of the estimated 18.1 million cancer survivors in the United States in January 2022, 67% were age 65 years or older.176 As cancer survivors live longer and the world population ages, the number of older people with cancer will continue to climb.
People with MCC are a complex and heterogeneous population, making it difficult to account for all the possible permutations to develop specific recommendations for care. In addition, the best available evidence for treating index conditions, such as cancer, is often from clinical trials whose study selection criteria frequently exclude these very same individuals, in order to avoid potential interaction effects or confounding of results associated with MCC. As a result, the reliability of outcome data from these studies may be limited, thereby creating constraints for expert groups to make recommendations for care in this heterogeneous population.
As many individuals with cancer for whom guideline recommendations apply present with MCC, any treatment plan needs to take into account the complexity and uncertainty created by the presence of MCC and highlights the importance of good patient-provider communication and shared decision making regarding guideline use and implementation. Therefore, in consideration of recommended care for anxiety and depression in cancer, clinicians should review all other chronic conditions present and take those conditions into account when formulating treatment and follow-up plans. When planning care for a person with MCC, clinicians often worry about drug-drug interactions or the effects of polypharmacy. An advantage to the use of nonbiologically based integrative therapies is that few create this particular challenge; however, other limitations may need to be taken into consideration. For example, a person with metastatic disease to the bones may not be able to engage in some standard yoga poses and would need a tailored program. Those with comorbid neurodegenerative diseases may also need to be cautious in the use of movement-based practices, but on the whole, these also seem to have the potential to benefit older adults with movement disorders.177,178 The use of pragmatic research designs, which are less likely to exclude people with MCC, is also a way to advance the care of this group.

Cost Implications

Increasingly, people with cancer are required to pay a larger proportion of their treatment costs out of pocket through deductibles and coinsurance.179,180 Even in Canada with universal health insurance, out-of-pocket costs for people on treatment averaged almost $800 in Canadian dollars (CAD) per month—with an additional $1,700 (CAD) lost in monthly income.181 Of those costs, complementary therapies were one of the larger expenses (after travel costs). Higher out-of-pocket costs are often a barrier to initiating and adhering to recommended cancer treatments.182,183
Out-of-pocket costs may vary depending on where one lives and the type of health insurance coverage one holds. For example, some plans may cover the expense of visiting a naturopathic doctor for consultation and tests, but not the costs of natural health products. Similarly, some plans cover acupuncture for symptom management, but often only for a diagnosis of chronic pain. Unless programs are offered as part of cancer care, mind-body therapies such as yoga, tai chi and/or qigong, and mindfulness are usually accessed through private classes or practitioners in the community. Some medical doctors and cancer care providers offer group support or meditation programs, which can be classified as group medical visits and thereby covered by insurance. Many cancer centers provide financial counseling and will help people apply for grants or bursaries as well as compassionate pricing that may help cover these expenses, but these services vary depending on where individuals receive their cancer care.
Given that some recommendations in this guideline indicate that therapies should be offered to treat symptoms of anxiety and depression, comprehensive cancer centers and governing administrative bodies should consider prioritizing these specific therapies in their financial and operational planning, providing access to people with cancer without significant financial barriers. Research also shows that complementary and supportive therapies can be cost-effective and provide medical cost offsets by preventing future use of services, such as psychoactive medication, emergency room, psychiatry, and family practice visits.184,185 For example, one RCT of online and face-to-face mindfulness therapy versus usual treatment found lower societal costs and less paid work-related productivity losses in both intervention groups, coupled with net monetary benefits compared with usual care.149 Increasing awareness of the potential for cost offsets with the use of integrative programs to address anxiety and depression can make them more appealing to clinicians and administrators alike, and even to health insurers.

Guideline Implementation

SIO-ASCO guidelines are developed for implementation across health settings. Key barriers to implementation include the need to increase awareness of the guideline recommendations among point-of-care practitioners and survivors of cancer and their caregivers, and to provide adequate services in the face of limited resources. The guideline Bottom Line Box was designed to facilitate implementation of recommendations, along with other materials generated by both ASCO and SIO, including a pocket guide, visual abstract, and continuing education modules. This guideline will be distributed widely through the ASCO Practice Guidelines Implementation Network. ASCO guidelines are posted on the ASCO website.
Despite these efforts, the Expert Panel understands that implementation of evidence-based interventions is not automatic once guidelines are disseminated, and often fails to happen altogether.186 The Expert Panel, therefore, encourages researchers in this area to design implementation trials tailored to different settings using implementation science frameworks, such as the Knowledge to Action Framework187 or the Consolidated Framework for Implementation Research.188 These frameworks help to identify local contextual factors relevant to implementation in order to develop and test tailored implementation strategies. Strategies must consider the innovation domain itself (practice guidelines), characteristics (barriers and facilitators) of the inner and outer implementation setting (the hospital and broader community, for example), and specific individuals and roles within the setting that are important to achieve implementation. Partnering with experts in implementation science is recommended to avoid the all-too-common trial-and-error approach to implementation.186
The Expert Panel also encourages more pragmatic research in domains that already achieve strong recommendations in these guidelines. For example, there is little need for more efficacy trials on MBIs for women with breast cancer in academic settings, but pragmatic research studying the effectiveness and adaptations necessary to facilitate implementation of such interventions in real-world community settings, with existing resources and real-world patients, would be helpful.

Provider Training, Licensing, and Credentialing

A critical challenge to the use of integrative interventions broadly is the training and credentialing of those providing them. This is in contrast to the more common psychologic, behavioral, and pharmacologic interventions for anxiety and depression, typically provided by licensed mental health practitioners. While some interventions have certified or accredited training and credentialing programs associated with their use (eg, acupuncture, art therapy, music therapy, dance/movement therapy, yoga, MBSR), not all practitioners come with the same experience. Further, training can vary and often is not nationally or internationally standardized.
For all these reasons, it is appropriate to inquire about the credentials, training, and experience of practitioners to whom people with cancer will be referred, including information about the provider's experience with those treated for cancer. One of the roles of the SIO is to promote more research on the use of these interventions, as well as bring providers together to advocate for training standards in the field that will, ideally, lead to both standardization of care and increased access to this care (https://integrativeonc.org/).
In an important step toward this latter goal, SIO conducted a systematic literature review and international consensus process among members of seven relevant professions on professional competencies for integrative oncology care. The process resulted in a total of 37 core competencies in the areas of knowledge (n = 11), skills (n = 17), and abilities (n = 9), combining both fundamental oncology knowledge and integrative medicine competencies that are necessary to provide effective and safe integrative oncology care for people with cancer. The committee agreed that these could be used as a starting point to develop profession-specific learning objectives and to establish integrative oncology education and training programs to meet the needs of people with cancer and health professionals.189 SIO is currently developing a training curriculum for integrative oncology health care providers based on these competencies, which will serve as a starting point for adaptations to other professional groups of integrative therapy providers.
In the 2017 SIO breast cancer integrative therapy guideline, a detailed table of training, licensure and accreditation regulations, and a listing of professional societies for all grade A and B therapies were included (Greenlee et al166; Table 2). This includes relevant information for acupuncture, hypnosis, massage, meditation, music therapy, relaxation and stress management, and yoga.

Quality Assurance of Natural Products

Efficacy trials of natural products should adhere to the same rigorous standards as other conventional drug intervention trials, including adequate description of all relevant methods pertaining to the natural product under investigation. However, it remains common that intervention methods and details of natural products are sometimes not properly conducted or reported.190 Improper or poorly reported methods can be important sources of bias in studies of natural products.
Although the complexity and variability inherent in multicomponent natural products exceed that of single-substance natural products, methods describing both types of products share a number of similarities. Common elements include an accurate description of all components within a natural product (eg, botanical and/or scientific names and amount or proportion within the product), methods for creation of the product (eg, plant part used, extraction method), laboratory authentication of the product components including evaluation of potential contaminants (eg, authentication methods, certificate of analysis), and clear descriptions for dosing and dosing rationale.191 All information necessary to ensure reproducibility and safety of a product must be included in study reports. If commercially produced over-the-counter natural products are used in research (rather than research-specific formulations), production and batch details should also be reported.

Limitations of the Research and Future Research

Throughout these recommendations, notes regarding the limitations of the literature in specific modalities are included. However, many issues cut across multiple modalities and are summarized in this section.

Assessment of Risk of Bias

The issue of the inability to mask participants to many integrative interventions has been raised repeatedly. This is ubiquitous across a range of therapy modalities, as it is sometimes impossible or undesirable to mask participants to interventions. This is particularly the case for many mind-body therapies that require active participation, such as yoga, mindfulness, tai chi and/or qigong, music therapy, and others. It is artificial to ask participants to actively undertake a practice not knowing what it is they are doing and does not mirror real-life program delivery where participants choose preferred modalities. Additionally, whether they know the name of the intervention or not, they are aware that the activities they are engaging in are expected to provide some benefit, which may lead to demand characteristics and subsequent positive reporting biases. Some exceptions, where participants have been masked to treatment with sham interventions, include acupuncture, Reiki, and other healing touch modalities. Typically, in these cases, the setting of the sham treatment is identical to the real intervention in order to elicit expectancy, but with incorrect acupoints or hand positioning, for example.
However, even with the inability to mask participants to the intervention, there are still methods available to protect studies from selection bias (such as allocation concealment) and measurement bias (by masking outcome assessors when possible). Of course, this is not possible when outcomes are measured by self-report, which is often the case in integrative therapy studies. Potential steps to try to account for not masking could be taken, for example measuring treatment preference, credibility, and expectancy for benefit prior to randomization, then determining the effects of these on outcomes. Additionally, few studies that do mask evaluate the success of masking by conducting a manipulation check, which is simple to do.
As a result of the inability to mask individuals to the treatments they are receiving, integrative therapy interventions often score poorly on standardized risk-of-bias assessments, as several of the indicators rate methods related to masking of participants and data collectors. The implications of this can be magnified in a ripple-down effect as follows: (1) studies are rated as low or moderate quality because of lack of masking; (2) evidence in SRs are consequently rated as low or moderate quality; (3) guidelines based on these SRs then lower the strength of the recommendation for the modality in question; and (4) the recommendation is then made that more high-quality research is needed to strengthen the recommendation. However, this is impossible to achieve when continuing to use the same tools to rate study quality and risk of bias that penalize lack of masking. Ultimately, this provides payors a reason not to reimburse interventions.
Solutions to this problem include improving study rigor in ways that are possible without masking, as detailed earlier. It would also be optimal to use risk of bias rating scales specifically developed to assess the design of behavioral intervention trials. While scales of this type do exist,192 they are not yet routinely used in reviews or guideline development. Alternately, risk of bias can be evaluated using tools that highlight important bias domains for consideration and discussion, rather than provide summary scores from rating scales. This can allow a more refined estimation of the effect of specific biases on study effect measures.
The overall issue of whether and how to mask participants in behavioral intervention research is ongoing. One helpful framework to decide how to approach this is by using the explanatory-efficacy continuum described in the section on pragmatic trials in Future Directions. This framework structures decisions around study design depending on the ultimate goal of the research on the continuum.193,194

Standardization of Therapies

Lack of intervention standardization is noted in the commentaries of a number of the specific recommendations, and the section on natural health products, but this is a larger issue across many treatment modalities. Lack of intervention standardization makes comparisons across studies and replication difficult, if not impossible, and relates closely to the issue of adequate and standardized training of program facilitators (see section on provider training, licensing, and credentialing) as well as careful documentation of intervention components used and details of their delivery. For optimal internal validity in efficacy studies, treatment fidelity to the manual should also be monitored and reported.
Specific treatment characteristics that should be reported for mind-body therapies include number and duration of sessions, detailed content of each session, format (individual, group), delivery modality (in-person, online), assigned practice (eg, homework assigned) between sessions, and theoretical underpinnings. Ideally, treatments are manualized, and manuals are made available for replication studies. For natural products, source, composition, dose, and duration should be reported, as previously discussed. For yoga, meditation, and tai chi and/or qigong, the specific orientation of the instructor is important to document (eg, Tibetan v Hatha yoga; transcendental v Vipassana meditation). In yoga, the degree that each of the eight arms of yoga are incorporated (ie, breathing, meditation, ethics, postures) should be documented. If postures (asanas) are incorporated, the specific sequence of postures used should be documented. In this way, the dose of the therapy can be determined and potentially quantified, allowing for assessment of minimally efficacious doses needed for treatment effects for specific conditions and individuals.
There is tension, however, between providing standardized, manualized treatments, and tailoring integrative interventions to each individual's needs. This is not unlike the tension between pragmatic (real-world) and explanatory (efficacy) studies, where there may be a place for both depending on the ultimate goals of the research (to establish causality, determine real-world effectiveness, or something in between). Many traditional practices are individually tailored based on symptoms, goals of treatment, and individual limitations and characteristics, including acupuncture, yoga, and others. This makes manualizing these interventions difficult, artificial, and potentially less beneficial. One compromise is to standardize individualization; that is, part of the manualized treatment is to gauge individual needs and tailor some elements of the treatment specifically to those needs. This has been done in acupuncture studies for pain, for example, where the acupuncturist assesses the location and quality of the pain, then provides treatment to the acupoints appropriate for that type of pain.195

Lack of Diversity

Another issue that has arisen repeatedly in our literature review is the lack of diversity in study samples. The bulk of the research across modalities has been conducted on White, educated, middle-aged, upper and middle-class women with breast cancer. In the field of MBIs, a compelling commentary on Wealthy White Western Women summarizes the problem.196 It is not unique to psychosocial and integrative oncology research, but is a larger problem across oncology and psychology, more generally. Hence, it has been difficult to make recommendations for people outside this demographic, as the research is quite simply lacking. Also, in terms of types of cancer, most research included enrolled women with breast cancer, with fewer studies including colorectal, prostate, and mixed groups of people with cancer.
The Expert Panel encourages researchers to begin filling these gaps by focusing on people from more diverse socioeconomic and racial backgrounds, with types of cancer other than breast. This poses challenges to recruitment and retention in trials, but with a recent shift toward developing methods of reaching and partnering with communities of color and other marginalized groups,197 and a recognition of, and growing emphasis on, this priority from researchers and funders,198 a cultural shift in this direction is gaining momentum.
Another area where more diversity is needed is in the therapies studied—there are many that fell into the inconclusive list, but are commonly used, accessible, and of interest to people with cancer, such as natural products, healing touch, reflexology, acupressure, and creative therapies. More rigorous study of these therapies is warranted.

Inactive or Usual Care Controls

The bulk of the research included in this work used study designs in which the intervention of interest was compared with either usual care, treatment as usual, or waitlist control—that is, no other active intervention. What this tells us is that these therapies are typically better than usual care (which could range from nothing at all beyond chemotherapy, radiation, and/or surgery, to high-quality psychosocial and supportive care). The usual care or waitlist condition is typically not well described in these studies if it is described at all. One can only assume that usual care includes usual conventional care, but the range of usual care around supportive interventions varies vastly across treatment settings.
Assuming that usual care typically means no additional supportive care, what this evidence tells us is that a range of integrative modalities is better than nothing for treating anxiety and depression in people with cancer. It is time to move beyond this understanding, to determine which modalities may be best, for which patients, which symptoms, and when. Currently, the research is not anywhere near this level of sophistication. Some studies have used comparative effectiveness designs to test different integrative modalities head-to-head, which also enables the ability to assess which intervention may be better for whom, but this approach is rare.145,199 Studies comparing exercise to yoga or other mind-body therapies, for example, would be interesting and useful, as would comparisons of natural products to mind-body therapies. Comparisons of integrative modalities to conventional antidepressant or antianxiety medications, which many people are prescribed to treat these symptoms, would also be potentially influential. This has been done in the larger context of anxiety disorders, for example, where an MBI proved noninferior to antianxiety medication, with far fewer adverse events and side effects.200

Future Directions

In addition to the areas mentioned previously (better treatment reporting and standardization, greater diversity of study participants and interventions, active comparator groups), there are opportunities to enhance use and reach of integrative therapies in addressing anxiety and depression in cancer in the areas of digital health interventions (DHIs), pragmatic designs, and focus on patient-oriented research, as well as incorporation of precision integrative oncology.
DHIs include both asynchronous (individually paced) and synchronous (live, real time) interventions over the Internet, telephone, or mobile device via apps. Many studies are emerging, greatly accelerated by the COVID-19 pandemic, investigating the delivery and efficacy of integrative interventions through DHIs, and a number of the studies included in these guidelines used digital delivery modalities.58,149,150 SIO conducted an international survey early in the pandemic regarding how programs were adapting interventions for delivery via videoconferencing and other digital platforms and published recommendations on the topic in 2021.201 These practical guidelines provide suggestions for online treatment and/or consultation, including ethical and medical-legal aspects, preparing the online treatment setting, maintaining effective communication, promoting specific treatment effects, and ensuring continuity of care, among others.
Pragmatic research, broadly defined as research that occurs in real-world settings with real-world patients, has lately been recognized as a better conduit to practice change and implementation than traditional explanatory models of efficacy research. Pragmatic research designs are identified by real-world characteristics across nine domains: the choice of eligibility criteria, recruitment method, setting, study organization, flexibility of treatment delivery, flexibility of treatment adherence, extent of follow-up, choice of primary outcome, and primary analysis methods.193 Choices in each of these domains can range from very explanatory and tightly controlled, to pragmatic and less controlled. Explanatory research is necessary to determine strict causation by ensuring internal validity, whereas pragmatic research focuses more on external validity. As mentioned in the implementation section, pragmatic designs can help bridge evidence-based treatments from efficacy to implementation.
With greater incorporation of patient-reported outcomes in the oncology setting, the lived experience of growing numbers of people with cancer is being better understood.202,203 Studies show that there can often be a disconnect between clinician- and patient-report of symptoms.204-206 This has led to awareness of the need to ask people themselves about how they are faring, and importantly, when and for what they would like assistance. In this context, it is of note that while some integrative approaches provide only minimal benefit to the management of anxiety and depression, they may result in significant improvements in other domains, most specifically overall quality of life, which in turn, is a predictor of cancer-related morbidity and mortality.207,208
For all of these promising directions to come to fruition, more public and private funding for integrative oncology intervention research is needed. Given that millions of people with cancer seek out and use these modalities every year and institutions are offering access to integrative services, understanding how best to guide and strengthen this investment would benefit both the recipients and providers—and their respective institutions—of this care.
SIO and ASCO believe that cancer clinical trials are vital to inform clinical decisions and improve cancer care, and that all people with cancer should have the opportunity to participate.

Additional Resources

More information, including a supplement with additional evidence tables, slide sets, and clinical tools and resources, is available at www.asco.org/survivorship-guidelines and https://integrativeonc.org/practice-guidelines/guidelines. Patient information is available at www.cancer.net and https://integrativeonc.org/knowledge-center/patients.

RELATED Society for Integrative Oncology AND ASCO GUIDELINES

Integrative Medicine for Pain Management in Oncology209 (http://ascopubs.org/doi/10.1200/JCO.22.01357)
Integrative Therapies During and After Breast Cancer Treatment210 (http://ascopubs.org/doi/10.1200/JCO.2018.79.2721)
Clinical practice guidelines on the evidence-based use of integrative therapies during and after breast cancer treatment166 (https://acsjournals.onlinelibrary.wiley.com/doi/full/10.3322/caac.21397)
Patient-Clinician Communication168 (http://ascopubs.org/doi/10.1200/JCO.2017.75.2311)
Complementary therapies and integrative medicine in lung cancer: Diagnosis and management of lung cancer, 3rd ed211 (https://pubmed.ncbi.nlm.nih.gov/23649450/)
Evidence-Based Clinical Practice Guidelines for Integrative Oncology: Complementary Therapies and Botanicals212 (https://integrativeonc.org/docman-library/docs/65-sio-guidelines-2009/file)

Acknowledgment

The Expert Panel wishes to thank Drs Aki Morikawa and Sandip Patel, the Society for Integrative Oncology Clinical Practice Guideline Committee, and the American Society of Clinical Oncology Evidence Based Medicine Committee for their thoughtful reviews and insightful comments on this guideline.
Society for Integrative Oncology Clinical Practice Guideline Committee approval:
March 9, 2023
ASCO Evidence Based Medicine Committee approval: March 31, 2023

Data Supplement

Authors retain all rights in any data supplements associated with their articles.

The ideas and opinions expressed in this Data Supplement do not necessarily reflect those of the American Society of Clinical Oncology (ASCO). The mention of any product, service, or therapy in this Data Supplement should not be construed as an endorsement of the products mentioned. It is the responsibility of the treating physician or other health care provider, relying on independent experience and knowledge of the patient, to determine drug dosages and the best treatment for the patient. Readers are advised to check the appropriate medical literature and the product information currently provided by the manufacturer of each drug to be administered to verify approved uses, the dosage, method, and duration of administration, or contraindications. Readers are also encouraged to contact the manufacturer with questions about the features or limitations of any products. ASCO and JCO assume no responsibility for any injury or damage to persons or property arising out of or related to any use of the material contained in this publication or to any errors or omissions. Readers should contact the corresponding author with any comments related to Data Supplement materials.

Clinical Tools Resources

Editor’s Note

This joint Society for Integrative Oncology and American Society of Clinical Oncology Clinical Practice Guideline provides recommendations, with comprehensive review and analyses of the relevant literature for each recommendation. Additional information, including a supplement with additional evidence tables, slide sets, clinical tools and resources, and links to patient information at https://integrativeonc.org/knowledge-center/patients and www.cancer.net, is available at https://integrativeonc.org/practice-guidelines/guidelines and www.asco.org/survivorship-guidelines.

Support

Supported by the Samueli Foundation to develop clinical practice guidelines.

Authors' Disclosures of Potential Conflicts of Interest

Integrative Oncology Care of Symptoms of Anxiety and Depression in Adults With Cancer: Society for Integrative Oncology–ASCO Guideline

The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated unless otherwise noted. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/jco/authors/author-center.
Open Payments is a public database containing information reported by companies about payments made to US-licensed physicians (Open Payments).

Linda E. Carlson

Patents, Royalties, Other Intellectual Property: Book Royalties from American Psychological Association Books, Book Royalties from New Harbinger Books, Royalties on online MBCR program from eMindful.com
Uncompensated Relationships: Rocket VR Health, Mobio Interactive

Nofisat Ismaila

Employment: GlaxoSmithKline (I)
Stock and Other Ownership Interests: GlaxoSmithKline (I)

Chloe Atreya

This author is a member of the Journal of Clinical Oncology Editorial Board. Journal policy recused the author from having any role in the peer review of this manuscript.
Stock and Other Ownership Interests: Pionyr
Consulting or Advisory Role: Pfizer, Inivata, Sumitomo Dainippon Pharma Oncology, Foundation Medicine
Research Funding: Novartis (Inst), Merck (Inst), Bristol Myers Squibb (Inst), Guardant Health (Inst), Gossamer Bio (Inst), Erasca, Inc (Inst)
Travel, Accommodations, Expenses: Roche

Lynda G. Balneaves

Uncompensated Relationships: Canadian Consortium for the Investigation of Cannabinoids

Nina Fuller-Shavel

Employment: Synthesis Clinic (Director)
Stock and Other Ownership Interests: Zoe Ltd (joinzoe.com)
Honoraria: Datar Cancer Genetics (Inst), Helixor (Inst)
Uncompensated Relationships: Kiteline Health

Alissa Huston

Honoraria: Mediflix, MJH Healthcare Holdings, LLC

Ashwin Mehta

Stock and Other Ownership Interests: Fidelity Index Fund

Channing J. Paller

Consulting or Advisory Role: Dendreon, Omnitura, Exelixis
Research Funding: Lilly (Inst)

Kimberly Richardson

Honoraria: Bayer

Dugald Seely

Consulting or Advisory Role: Vitazan Professional

Chelsea J. Siwik

Consulting or Advisory Role: Senior Coastsiders

Jennifer S. Temel

Research Funding: Blue Note Therapeutics
No other potential conflicts of interest were reported.

Appendix

Table A1. GLIDES Rating Definitions
Table A2. Integrative Oncology Care of Symptoms of Anxiety and Depression in Adults with Cancer Guideline Expert Panel Membership
Table A3. Index of Terms
Table A4. Interventions
Table A5. Commonly Used Standardized Measuring Tools

References

1.
Sung H, Ferlay J, Siegel RL, et al: Global Cancer Statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 71:209-249, 2021
2.
Bluethmann SM, Mariotto AB, Rowland JH: Anticipating the "Silver Tsunami": Prevalence trajectories and comorbidity burden among older cancer survivors in the United States. Cancer Epidemiol Biomarkers Prev 25:1029-1036, 2016
3.
Siegel RL, Miller KD, Fuchs HE, et al: Cancer Statistics, 2021. CA Cancer J Clin 71:7-33, 2021
4.
Vehling S, Mehnert-Theuerkauf A, Philipp R, et al: Prevalence of mental disorders in patients with cancer compared to matched controls—Secondary analysis of two nationally representative surveys. Acta Oncol 61:7-13, 2022
5.
Riedl D, Schuessler G: Prevalence of depression and cancer—A systematic review. Z fur Psychosom Med Psychother 68:74-86, 2022
6.
Mitchell AJ, Chan M, Bhatti H, et al: Prevalence of depression, anxiety, and adjustment disorder in oncological, haematological, and palliative-care settings: A meta-analysis of 94 interview-based studies. Lancet Oncol 12:160-174, 2011
7.
Walker ZJ, Xue S, Jones MP, et al: Depression, anxiety, and other mental disorders in patients with cancer in low- and lower-middle-income countries: A systematic review and meta-analysis. JCO Glob Oncol 7:1233-1250, 2021
8.
Mitchell AJ, Ferguson DW, Gill J, et al: Depression and anxiety in long-term cancer survivors compared with spouses and healthy controls: A systematic review and meta-analysis. Lancet Oncol 14:721-732, 2013
9.
Brandenbarg D, Maass S, Geerse OP, et al: A systematic review on the prevalence of symptoms of depression, anxiety and distress in long-term cancer survivors: Implications for primary care. Eur J Cancer Care (Engl) 28:e13086, 2019
10.
Carlson LE, Waller A, Groff SL, et al: What goes up does not always come down: Patterns of distress, physical and psychosocial morbidity in people with cancer over a one year period. Psychooncology 22:168-176, 2013
11.
Momen NC, Plana-Ripoll O, Agerbo E, et al: Mortality associated with mental disorders and comorbid general medical conditions. JAMA Psychiatry 79:444-453, 2022
12.
Wang Y, Duan Z, Ma Z, et al: Epidemiology of mental health problems among patients with cancer during COVID-19 pandemic. Transl Psychiatry 10:263, 2020
13.
Lefebvre C, Heitzmann P, Pelletier S, et al: Experiences of patients with cancer during the first COVID-19 lockdown: What was the impact on the patients' healthcare pathway, mental condition, and access to supportive care in cancer? Bull Cancer 110:193-200, 2023
14.
Cheung T, Cheng CPW, Fong TKH, et al: Psychological impact on healthcare workers, general population and affected individuals of SARS and COVID-19: A systematic review and meta-analysis. Front Public Health 10:1004558, 2022
15.
Sampogna G, Pompili M, Fiorillo A: The short-term consequences of COVID-19 on mental health: State of the art from available studies. Int J Environ Res Public Health 19:15860, 2022
16.
Andersen BL, Lacchetti C, Ashing K, et al: Management of anxiety and depression in adult survivors of cancer: ASCO guideline update. J Clin Oncol 41:3426-3453, 2023
17.
Andersen BL, DeRubeis RJ, Berman BS, et al: Screening, assessment, and care of anxiety and depressive symptoms in adults with cancer: An American Society of Clinical Oncology guideline adaptation. J Clin Oncol 32:1605-1619, 2014
18.
Witt CM, Balneaves LG, Cardoso MJ, et al: A comprehensive definition for integrative oncology. J Natl Cancer Inst Monogr 52:3-8, 2017
19.
Kristoffersen AE, Wider B, Nilsen JV, et al: Prevalence of late and long-term effects of cancer (treatment) and use of complementary and alternative medicine in Norway. BMC Complement Med Ther 22:322, 2022
20.
Perlman A, Lontok O, Huhmann M, et al: Prevalence and correlates of postdiagnosis initiation of complementary and alternative medicine among patients at a comprehensive cancer center. J Oncol Pract 9:34-41, 2013
21.
Hill J, Mills C, Li Q, et al: Prevalence of traditional, complementary, and alternative medicine use by cancer patients in low income and lower-middle income countries. Glob Public Health 14:418-430, 2019
22.
Horneber M, Bueschel G, Dennert G, et al: How many cancer patients use complementary and alternative medicine: A systematic review and metaanalysis. Integr Cancer Ther 11:187-203, 2012
23.
Keene MR, Heslop IM, Sabesan SS, et al: Complementary and alternative medicine use in cancer: A systematic review. Complement Ther Clin Pract 35:33-47, 2019
24.
Shiffman RN, Michel G, Rosenfeld RM, et al: Building better guidelines with BRIDGE-Wiz: Development and evaluation of a software assistant to promote clarity, transparency, and implementability. J Am Med Inform Assoc 19:94-101, 2012
25.
Higgins JP, Altman DG, Gotzsche PC, et al: The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ 343:d5928, 2011
26.
Shea BJ, Reeves BC, Wells G, et al: AMSTAR 2: A critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ 358:j4008, 2017
27.
Molassiotis A, Bardy J, Finnegan-John J, et al: Acupuncture for cancer-related fatigue in patients with breast cancer: A pragmatic randomized controlled trial. J Clin Oncol 30:4470-4476, 2012
28.
Mao JJ, Farrar JT, Bruner D, et al: Electroacupuncture for fatigue, sleep, and psychological distress in breast cancer patients with aromatase inhibitor-related arthralgia: A randomized trial. Cancer 120:3744-3751, 2014
29.
Hoxtermann MD, Buner K, Haller H, et al: Efficacy and safety of auricular acupuncture for the treatment of insomnia in breast cancer survivors: A randomized controlled trial. Cancers 13:4082, 2021
30.
Ozkaraman A, Dügüm Ö, Özen Yılmaz H, et al: Aromatherapy: The effect of lavender on anxiety and sleep quality in patients treated with chemotherapy. Clin J Oncol Nurs 22:203-210, 2018
31.
Beyliklioğlu A, Arslan S: Effect of lavender oil on the anxiety of patients before breast surgery. J Perianesth Nurs 34:587-593, 2019
32.
Abbaszadeh R, Tabari F, Asadpour A: The effect of lavender aroma on anxiety of patients having bone marrow biopsy. Asian Pac J Cancer Prev 21:771-775, 2020
33.
Deng C, Xie Y, Liu Y, et al: Aromatherapy plus music therapy improve pain intensity and anxiety scores in patients with breast cancer during perioperative periods: A randomized controlled trial. Clin Breast Cancer 22:115-120, 2022
34.
Trambert R, Kowalski MO, Wu B, et al: A randomized controlled trial provides evidence to support aromatherapy to minimize anxiety in women undergoing breast biopsy. Worldviews Evid Based Nurs 14:394-402, 2017
35.
Graham PH, Browne L, Cox H, et al: Inhalation aromatherapy during radiotherapy: Results of a placebo-controlled double-blind randomized trial. J Clin Oncol 21:2372-2376, 2003
36.
Zachariae R, O'Toole MS: The effect of expressive writing intervention on psychological and physical health outcomes in cancer patients—A systematic review and meta-analysis. Psychooncology 24:1349-1359, 2015
37.
Lepore SJ, Revenson TA, Roberts KJ, et al: Randomised controlled trial of expressive writing and quality of life in men and women treated for colon or rectal cancer. Psychol Health 30:284-300, 2015
38.
Milbury K, Spelman A, Wood C, et al: Randomized controlled trial of expressive writing for patients with renal cell carcinoma. J Clin Oncol 32:663-670, 2014
39.
Stalpers LJ, da Costa HC, Merbis MA, et al: Hypnotherapy in radiotherapy patients: A randomized trial. Int J Radiat Oncol Biol Phys 61:499-506, 2005
40.
Snow A, Dorfman D, Warbet R, et al: A randomized trial of hypnosis for relief of pain and anxiety in adult cancer patients undergoing bone marrow procedures. J Psychosoc Oncol 30:281-293, 2012
41.
Lang EV, Berbaum KS, Pauker SG, et al: Beneficial effects of hypnosis and adverse effects of empathic attention during percutaneous tumor treatment: When being nice does not suffice. J Vasc Interv Radiol 19:897-905, 2008
42.
Hizli F, Ozcan O, Selvi I, et al: The effects of hypnotherapy during transrectal ultrasound-guided prostate needle biopsy for pain and anxiety. Int Urol Nephrol 47:1773-1777, 2015
43.
Hoslin L, Motamed C, Maurice-Szamburski A, et al: Impact of hypnosis on patient experience after venous access port implantation. Anaesth Crit Care Pain Med 38:609-613, 2019
44.
Amraoui J, Pouliquen C, Fraisse J, et al: Effects of a hypnosis session before general anesthesia on postoperative outcomes in patients who underwent minor breast cancer surgery: The HYPNOSEIN Randomized Clinical Trial. JAMA Netw Open 1:e181164, 2018
45.
Etienne R, Laurent M, Henry A, et al: Interest of a standardized hypnotic message for the reduction of pain and anxiety in cancer patients treated by capsaicin patch for neuropathic pain: A randomized controlled trial. BMC Complement Med Ther 21:154, 2021
46.
Sánchez-Jáuregui T, Téllez A, Juárez-García D, et al: Clinical hypnosis and music in breast biopsy: A randomized clinical trial. Am J Clin Hypn 61:244-257, 2019
47.
Liossi C, White P: Efficacy of clinical hypnosis in the enhancement of quality of life of terminally ill cancer patients. Contemp Hypn 18:145-160, 2001
48.
Oberoi S, Yang J, Woodgate RL, et al: Association of mindfulness-based interventions with anxiety severity in adults with cancer: A systematic review and meta-analysis. JAMA Netw Open 3:e2012598, 2020
49.
Xunlin NG, Lau Y, Klainin-Yobas P: The effectiveness of mindfulness-based interventions among cancer patients and survivors: A systematic review and meta-analysis. Support Care Cancer 28:1563-1578, 2020
50.
Cillessen L, Johannsen M, Speckens AEM, et al: Mindfulness-based interventions for psychological and physical health outcomes in cancer patients and survivors: A systematic review and meta-analysis of randomized controlled trials. Psychooncology 28:2257-2269, 2019
51.
Schell LK, Monsef I, Wöckel A, et al: Mindfulness-based stress reduction for women diagnosed with breast cancer. Cochrane Database Syst Rev 3:CD011518, 2019
52.
Zhang Q, Zhao H, Zheng Y: Effectiveness of mindfulness-based stress reduction (MBSR) on symptom variables and health-related quality of life in breast cancer patients—A systematic review and meta-analysis. Support Care Cancer 27:771-781, 2019
53.
Haller H, Winkler MM, Klose P, et al: Mindfulness-based interventions for women with breast cancer: An updated systematic review and meta-analysis. Acta Oncol 56:1665-1676, 2017
54.
McCloy K, Hughes C, Dunwoody L, et al: Effects of mindfulness-based interventions on fatigue and psychological wellbeing in women with cancer: A systematic review and meta-analysis of randomised control trials. Psychooncology 31:1821-1834, 2022
55.
Bower JE, Partridge AH, Wolff AC, et al: Targeting depressive symptoms in younger breast cancer survivors: The pathways to wellness randomized controlled trial of mindfulness meditation and survivorship education. J Clin Oncol 39:3473-3484, 2021
56.
Witek Janusek L, Tell D, Mathews HL: Mindfulness based stress reduction provides psychological benefit and restores immune function of women newly diagnosed with breast cancer: A randomized trial with active control. Brain Behav Immun 80:358-373, 2019
57.
Park S, Sato Y, Takita Y, et al: Mindfulness-based cognitive therapy for psychological distress, fear of cancer recurrence, fatigue, spiritual well-being, and quality of life in patients with breast cancer—A randomized controlled trial. J Pain Symptom Manage 60:381-389, 2020
58.
Price-Blackshear MA, Pratscher SD, Oyler DL, et al: Online couples mindfulness-based intervention for young breast cancer survivors and their partners: A randomized-control trial. J Psychosoc Oncol 38:592-611, 2020
59.
Shao D, Zhang H, Cui N, et al: The efficacy and mechanisms of a guided self-help intervention based on mindfulness in patients with breast cancer: A randomized controlled trial. Cancer 127:1377-1386, 2020
60.
Sheikhzadeh M, Zanjani Z, Baari A: Efficacy of mindfulness-based cognitive therapy and cognitive behavioral therapy for anxiety, depression, and fatigue in cancer patients: A randomized clinical trial. Iranian J Psychiatry 16:271-280, 2021
61.
Wang L, Zhang Y: The factors influencing psychological resilience in breast cancer patients undergoing mastectomy and the effects of mindfulness-based stress reduction on the patients’ psychological resilience and anxiety. Int J Clin Exp Med 13:8924-8932, 2020
62.
Bradt J, Dileo C, Myers-Coffman K, et al: Music interventions for improving psychological and physical outcomes in people with cancer. Cochrane Database Syst Rev 10:CD006911, 2021
63.
Yang T, Wang S, Wang R, et al: Effectiveness of five-element music therapy in cancer patients: A systematic review and meta-analysis. Complement Ther Clin Pract 44:101416, 2021
64.
Li Y, Xing X, Shi X, et al: The effectiveness of music therapy for patients with cancer: A systematic review and meta-analysis. J Adv Nurs 76:1111-1123, 2020
65.
Sheikh-Wu SF, Kauffman MA, Anglade D, et al: Effectiveness of different music interventions on managing symptoms in cancer survivors: A meta-analysis. Eur J Oncol Nurs 52:101968, 2021
66.
O'Steen L, Lockney NA, Morris CG, et al: A prospective randomized trial of the influence of music on anxiety in patients starting radiation therapy for cancer. Int J Radiat Oncol Biol Phys 109:670-674, 2021
67.
Al-Jubouri MBA, Isam SR, Hussein SM, et al: Recitation of quran and music to reduce chemotherapy-induced anxiety among adult patients with cancer: A clinical trial. Nurs Open 8:1606-1614, 2021
68.
Tang H, Chen L, Wang Y, et al: The efficacy of music therapy to relieve pain, anxiety, and promote sleep quality, in patients with small cell lung cancer receiving platinum-based chemotherapy. Support Care Cancer 29:7299-7306, 2021
69.
Tsay SL, Chen HL, Chen SC, et al: Effects of reflexotherapy on acute postoperative pain and anxiety among patients with digestive cancer. Cancer Nurs 31:109-115, 2008
70.
Samancioglu Baglama S, Bakir E: Caregiver-delivered foot reflexology: Effects on patients and caregivers. Holist Nurs Pract 33:338-345, 2019
71.
Stephenson NL, Swanson M, Dalton J, et al: Partner-delivered reflexology: Effects on cancer pain and anxiety. Oncol Nurs Forum 34:127-132, 2007
72.
Jahani S, Salari F, Elahi N, et al: The effect of reflexology in intensity of pain and anxiety among patients suffering from metastatic cancer in adults’ hematology ward. Asian J Pharm Clin Res 11:401-405, 2018
73.
Wyatt G, Sikorskii A, Rahbar MH, et al: Health-related quality-of-life outcomes: A reflexology trial with patients with advanced-stage breast cancer. Oncol Nurs Forum 39:568-577, 2012
74.
Sharp DM, Walker MB, Chaturvedi A, et al: A randomised, controlled trial of the psychological effects of reflexology in early breast cancer. Eur J Cancer 46:312-322, 2010
75.
Noh GO, Park KS: Effects of aroma self-foot reflexology on peripheral neuropathy, peripheral skin temperature, anxiety, and depression in gynaecologic cancer patients undergoing chemotherapy: A randomised controlled trial. Eur J Oncol Nurs 42:82-89, 2019
76.
Göral Türkcü S, Özkan S: The effects of reflexology on anxiety, depression and quality of life in patients with gynecological cancers with reference to Watson's theory of human caring. Complement Ther Clin Pract 44:101428, 2021
77.
Mantoudi A, Parpa E, Tsilika E, et al: Complementary therapies for patients with cancer: Reflexology and relaxation in integrative palliative care. A randomized controlled comparative study. J Altern Complement Med 26:794-800, 2020
78.
Tan L, Fang P, Cui J, et al: Effects of progressive muscle relaxation on health-related outcomes in cancer patients: A systematic review and meta-analysis of randomized controlled trials. Complement Ther Clin Pract 49:101676, 2022
79.
Kapogiannis A, Tsoli S, Chrousos G: Investigating the effects of the progressive muscle relaxation-guided imagery combination on patients with cancer receiving chemotherapy treatment: A systematic review of randomized controlled trials. Explore (NY) 14:137-143, 2018
80.
Pelekasis P, Matsouka I, Koumarianou A: Progressive muscle relaxation as a supportive intervention for cancer patients undergoing chemotherapy: A systematic review. Palliat Support Care 15:465-473, 2017
81.
Liu X, Wang YQ, Xie J: Effects of breathing exercises on patients with lung cancer. Oncol Nurs Forum 46:303-317, 2019
82.
Petersen RW, Quinlivan JA: Preventing anxiety and depression in gynaecological cancer: A randomised controlled trial. BJOG 109:386-394, 2002
83.
Prystupa E, Odynets T, Briskin Y, et al: Effects of an individualised physical rehabilitation intervention enhanced by progressive muscular relaxation and visualisation exercises on psycho-emotional state in women after breast cancer surgery. Physiother Pract Res 40:21-27, 2019
84.
Mahdizadeh MJ, Tirgari B, Abadi O, et al: Guided imagery: Reducing anxiety, depression, and selected side effects associated with chemotherapy. Clin J Oncol Nurs 23:E87-E92, 2019
85.
Burish TG, Jenkins RA: Effectiveness of biofeedback and relaxation training in reducing the side effects of cancer chemotherapy. Health Psychol 11:17-23, 1992
86.
León-Pizarro C, Gich I, Barthe E, et al: A randomized trial of the effect of training in relaxation and guided imagery techniques in improving psychological and quality-of-life indices for gynecologic and breast brachytherapy patients. Psychooncology 16:971-979, 2007
87.
Wayne PM, Lee MS, Novakowski J, et al: Tai chi and qigong for cancer-related symptoms and quality of life: A systematic review and meta-analysis. J Cancer Surviv 12:256-267, 2018
88.
Cheung DST, Takemura N, Smith R, et al: Effect of qigong for sleep disturbance-related symptom clusters in cancer: A systematic review and meta-analysis. Sleep Med 85:108-122, 2021
89.
Meng T, Hu SF, Cheng YQ, et al: Qigong for women with breast cancer: An updated systematic review and meta-analysis. Complement Ther Med 60:102743, 2021
90.
Zeng Y, Luo T, Xie H, et al: Health benefits of qigong or tai chi for cancer patients: A systematic review and meta-analyses. Complement Ther Med 22:173-186, 2014
91.
Chen Z, Meng Z, Milbury K, et al: Qigong improves quality of life in women undergoing radiotherapy for breast cancer: Results of a randomized controlled trial. Cancer 119:1690-1698, 2013
92.
Yang LH, Duan PB, Hou QM, et al: Qigong exercise for patients with gastrointestinal cancer undergoing chemotherapy and at high risk for depression: A randomized clinical trial. J Altern Complement Med 27:750-759, 2021
93.
Ying W, Min QW, Lei T, et al: The health effects of Baduanjin exercise (a type of Qigong exercise) in breast cancer survivors: A randomized, controlled, single-blinded trial. Eur J Oncol Nurs 39:90-97, 2019
94.
Molassiotis A, Vu DV, Ching SSY: The effectiveness of Qigong in managing a cluster of symptoms (breathlessness-fatigue-anxiety) in patients with lung cancer: A randomized controlled trial. Integr Cancer Ther 20:153473542110082, 2021
95.
Oh B, Butow P, Mullan B, et al: Promising study of the impact of medical qigong as compared with usual care to improve the QoL of cancer patients. Focus Altern Complement Ther 15:146-148, 2010
96.
Gonzalez M, Pascoe MC, Yang G, et al: Yoga for depression and anxiety symptoms in people with cancer: A systematic review and meta-analysis. Psychooncology 30:1196-1208, 2021
97.
Galliford M, Robinson S, Bridge P, et al: Salute to the sun: A new dawn in yoga therapy for breast cancer. J Med Radiat Sci 64:232-238, 2017
98.
Hsueh EJ, Loh EW, Lin JJ, et al: Effects of yoga on improving quality of life in patients with breast cancer: A meta-analysis of randomized controlled trials. Breast Cancer 28:264-276, 2021
99.
Yi LJ, Tian X, Jin YF, et al: Effects of yoga on health-related quality, physical health and psychological health in women with breast cancer receiving chemotherapy: A systematic review and meta-analysis. Ann Palliat Med 10:1961-1975, 2021
100.
Ford CG, Vowles KE, Smith BW, et al: Mindfulness and meditative movement interventions for men living with cancer: A meta-analysis. Ann Behav Med 54:360-373, 2020
101.
Pan Y, Yang K, Wang Y, et al: Could yoga practice improve treatment-related side effects and quality of life for women with breast cancer? A systematic review and meta-analysis. Asia Pac J Clin Oncol 13:e79-e95, 2017
102.
Zetzl T, Renner A, Pittig A, et al: Yoga effectively reduces fatigue and symptoms of depression in patients with different types of cancer. Support Care Cancer 29:2973-2982, 2020
103.
Sharifi Rizi M, Shamsalinia A, Ghaffari F, et al: The effect of acupressure on pain, anxiety, and the physiological indexes of patients with cancer undergoing bone marrow biopsy. Complement Ther Clin Pract 29:136-141, 2017
104.
Bradt J, Shim M, Goodill SW: Dance/movement therapy for improving psychological and physical outcomes in cancer patients. Cochrane Database Syst Rev 1:CD007103, 2015
105.
Ho RT, Fong TC, Cheung IK, et al: Effects of a short-term dance movement therapy program on symptoms and stress in patients with breast cancer undergoing radiotherapy: A randomized, controlled, single-blind trial. J Pain Symptom Manage 51:824-831, 2016
106.
Shahrokhi M, Ghaeli P, Arya P, et al: Comparing the effects of melatonin and zolpidem on sleep quality, depression, and anxiety in patients with colorectal cancer under going chemotherapy. Basic Clin Neurosci J 12:105-114, 2021
107.
Hansen MV, Andersen LT, Madsen MT, et al: Effect of melatonin on depressive symptoms and anxiety in patients undergoing breast cancer surgery: A randomized, double-blind, placebo-controlled trial. Breast Cancer Res Treat 145:683-695, 2014
108.
Seely D, Legacy M, Auer RC, et al: Adjuvant melatonin for the prevention of recurrence and mortality following lung cancer resection (AMPLCaRe): A randomized placebo controlled clinical trial. EClinicalMedicine 33:100763, 2021
109.
Chen WY, Giobbie-Hurder A, Gantman K, et al: A randomized, placebo-controlled trial of melatonin on breast cancer survivors: Impact on sleep, mood, and hot flashes. Breast Cancer Res Treat 145:381-388, 2014
110.
Post-White J, Kinney ME, Savik K, et al: Therapeutic massage and healing touch improve symptoms in cancer. Integr Cancer Ther 2:332-344, 2003
111.
Garcia ACM, Simão-Miranda TP, Carvalho AMP, et al: The effect of therapeutic listening on anxiety and fear among surgical patients: Randomized controlled trial. Rev Lat Am Enfermagem 26:e3027, 2018
112.
Lutgendorf SK, Mullen-Houser E, Russell D, et al: Preservation of immune function in cervical cancer patients during chemoradiation using a novel integrative approach. Brain Behav Immun 24:1231-1240, 2010
113.
Kim SH, Kim YH, Kim HJ: Laughter and stress relief in cancer patients: A pilot study. Evid Based Complement Alternat Med 2015:1-6, 2015
114.
Johnson JA, Garland SN, Carlson LE, et al: Bright light therapy improves cancer-related fatigue in cancer survivors: A randomized controlled trial. J Cancer Surviv 12:206-215, 2018
115.
Pan YQ, Yang KH, Wang YL, et al: Massage interventions and treatment-related side effects of breast cancer: A systematic review and meta-analysis. Int J Clin Oncol 19:829-841, 2014
116.
Shin ES, Seo KH, Lee SH, et al: Massage with or without aromatherapy for symptom relief in people with cancer. Cochrane Database Syst Rev 3:CD009873, 2016
117.
Khiewkhern S, Promthet S, Sukprasert A, et al: Effectiveness of aromatherapy with light Thai massage for cellular immunity improvement in colorectal cancer patients receiving chemotherapy. Asian Pac J Cancer Prev 14:3903-3907, 2013
118.
Wilkinson SM, Love SB, Westcombe AM, et al: Effectiveness of aromatherapy massage in the management of anxiety and depression in patients with cancer: A multicenter randomized controlled trial. J Clin Oncol 25:532-539, 2007
119.
Rosen J, Lawrence R, Bouchard M, et al: Massage for perioperative pain and anxiety in placement of vascular access devices. Adv Mind Body Med 27:12-23, 2013
120.
Kutner JS, Smith MC, Corbin L, et al: Massage therapy versus simple touch to improve pain and mood in patients with advanced cancer: A randomized trial. Ann Intern Med 149:369-379, 2008
121.
Li M, Chen Z, Liu Z, et al: Twelve Chinese herbal preparations for the treatment of depression or depressive symptoms in cancer patients: A systematic review and meta-analysis of randomized controlled trials. BMC Complement Altern Med 19:28, 2019
122.
Juan Z, Chen J, Ding B, et al: Probiotic supplement attenuates chemotherapy-related cognitive impairment in patients with breast cancer: A randomised, double-blind, and placebo-controlled trial. Eur J Cancer 161:10-22, 2022
123.
Ghamchini VM, Salami M, Mohammadi GR, et al: The effect of chamomile tea on anxiety and depression in cancer patients treated with chemotherapy. J Young Pharm 11:309-312, 2019
124.
Jiang SL, Liu HJ, Liu ZC, et al: Adjuvant effects of fermented red ginseng extract on advanced non-small cell lung cancer patients treated with chemotherapy. Chin J Integr Med 23:331-337, 2017
125.
Yennurajalingam S, Tannir NM, Williams JL, et al: A double-blind, randomized, placebo-controlled trial of panax ginseng for cancer-related fatigue in patients with advanced cancer. J Natl Compr Cancer Netw 15:1111-1120, 2017
126.
Salek R, Dehghani M, Mohajeri SA, et al: Amelioration of anxiety, depression, and chemotherapy related toxicity after crocin administration during chemotherapy of breast cancer: A double blind, randomized clinical trial. Phytother Res 35:5143-5153, 2021
127.
Wada S, Sadahiro R, Matsuoka YJ, et al: Yokukansan for treatment of preoperative anxiety and prevention of postoperative delirium in cancer patients undergoing highly invasive surgery. J-SUPPORT 1605 (ProD study): A randomized, double-blind, placebo-controlled trial. J Pain Symptom Manage 61:71-80, 2021
128.
Lee JY, Chu SH, Jeon JY, et al: Effects of 12 weeks of probiotic supplementation on quality of life in colorectal cancer survivors: A double-blind, randomized, placebo-controlled trial. Dig Liver Dis 46:1126-1132, 2014
129.
Cruciani RA, Zhang JJ, Manola J, et al: L-carnitine supplementation for the management of fatigue in patients with cancer: An eastern cooperative oncology group phase III, randomized, double-blind, placebo-controlled trial. J Clin Oncol 30:3864-3869, 2012
130.
Pourmohamadi K, Ahmadzadeh A, Latifi M: Investigating the effects of oral ginseng on the cancer-related fatigue and quality of life in patients with non-metastatic cancer. Int J Hematol Oncol Stem Cell Res 12:313-317, 2018
131.
Kristensen MB, Wessel I, Beck AM, et al: Effects of a multidisciplinary residential nutritional rehabilitation program in head and neck cancer survivors-results from the NUTRI-HAB randomized controlled trial. Nutrients 12:2117, 2020
132.
Carayol M, Ninot G, Senesse P, et al: Short- and long-term impact of adapted physical activity and diet counseling during adjuvant breast cancer therapy: The "APAD1" randomized controlled trial. BMC Cancer 19:737, 2019
133.
Ho M, Ho JWC, Fong DYT, et al: Effects of dietary and physical activity interventions on generic and cancer-specific health-related quality of life, anxiety, and depression in colorectal cancer survivors: A randomized controlled trial. J Cancer Surviv 14:424-433, 2020
134.
Saxton JM, Scott EJ, Daley AJ, et al: Effects of an exercise and hypocaloric healthy eating intervention on indices of psychological health status, hypothalamic-pituitary-adrenal axis regulation and immune function after early-stage breast cancer: A randomised controlled trial. Breast Cancer Res 16:3393, 2014
135.
Griffiths RR, Johnson MW, Carducci MA, et al: Psilocybin produces substantial and sustained decreases in depression and anxiety in patients with life-threatening cancer: A randomized double-blind trial. J Psychopharmacol 30:1181-1197, 2016
136.
Ross S, Bossis A, Guss J, et al: Rapid and sustained symptom reduction following psilocybin treatment for anxiety and depression in patients with life-threatening cancer: A randomized controlled trial. J Psychopharmacol 30:1165-1180, 2016
137.
Liu T, Zhang W, Xiao S, et al: Mindfulness-based stress reduction in patients with differentiated thyroid cancer receiving radioactive iodine therapy: A randomized controlled trial. Cancer Manag Res 11:467-474, 2019
138.
Zhang R, Yin J, Zhou Y: Effects of mindfulness-based psychological care on mood and sleep of leukemia patients in chemotherapy. Int J Nurs Sci 4:357-361, 2017
139.
Lorca AM, Lorca M, Criado JJ, et al: Using mindfulness to reduce anxiety during PET/CT studies. Mindfulness 10:1163-1168, 2019
140.
Banerjee B, Vadiraj HS, Ram A, et al: Effects of an integrated yoga program in modulating psychological stress and radiation-induced genotoxic stress in breast cancer patients undergoing radiotherapy. Integr Cancer Ther 6:242-250, 2007
141.
Porter LS, Carson JW, Olsen M, et al: Feasibility of a mindful yoga program for women with metastatic breast cancer: Results of a randomized pilot study. Support Care Cancer 27:4307-4316, 2019
142.
Hou N, Wang H, Wang Y: Effects of progressive muscle relaxation training on anxiety, depression and quality of life of breast cancer patients during perioperative period. Chin J Mod Nurs 4:489-493, 2017
143.
Charalambous A, Giannakopoulou M, Bozas E, et al: A randomized controlled trial for the effectiveness of progressive muscle relaxation and guided imagery as anxiety reducing interventions in breast and prostate cancer patients undergoing chemotherapy. Evid Based Complement Alternat Med 2015:270876, 2015
144.
Carlson LE, Tamagawa R, Stephen J, et al: Randomized-controlled trial of mindfulness-based cancer recovery versus supportive expressive group therapy among distressed breast cancer survivors (MINDSET): Long-term follow-up results. Psychooncology 25:750-759, 2016
145.
Carlson LE, Doll R, Stephen J, et al: Randomized controlled trial of mindfulness-based cancer recovery versus supportive expressive group therapy for distressed survivors of breast cancer (MINDSET). J Clin Oncol 31:3119-3126, 2013
146.
Henderson VP, Clemow L, Massion AO, et al: The effects of mindfulness-based stress reduction on psychosocial outcomes and quality of life in early-stage breast cancer patients: A randomized trial. Breast Cancer Res Treat 131:99-109, 2012
147.
Würtzen H, Dalton SO, Andersen KK, et al: The effect of mindfulness based stress reduction (MBSR) on somatic symptoms among women 3-18 months post diagnosis of breast cancer: Results from a randomized controlled trial (mica, nct00990977). Psychooncology 22:104-105, 2013
148.
Lengacher CA, Reich RR, Paterson CL, et al: Examination of broad symptom improvement resulting from mindfulness-based stress reduction in breast cancer survivors: A randomized controlled trial. J Clin Oncol 34:2827-2834, 2016
149.
Compen F, Bisseling E, Schellekens M, et al: Face-to-face and internet-based mindfulness-based cognitive therapy compared with treatment as usual in reducing psychological distress in patients with cancer: A multicenter randomized controlled trial. J Clin Oncol 36:2413-2421, 2018
150.
Zernicke KA, Campbell TS, Speca M, et al: A randomized wait-list controlled trial of feasibility and efficacy of an online mindfulness-based cancer recovery program: The eTherapy for cancer applying mindfulness trial. Psychosom Med 76:257-267, 2014
151.
Chambers SK, Occhipinti S, Foley E, et al: Mindfulness-based cognitive therapy in advanced prostate cancer: A randomized controlled trial. J Clin Oncol 35:291-297, 2017
152.
Sadat Vaziri Z, Mashhadi A, Sepehri Shamloo Z, et al: Mindfulness-based cognitive therapy, cognitive emotion regulation and clinical symptoms in females with breast cancer. Iran J Psychiat Behav Sci 11:e4158, 2017
153.
Monti DA, Kash KM, Kunkel EJ, et al: Psychosocial benefits of a novel mindfulness intervention versus standard support in distressed women with breast cancer. Psychooncology 22:2565-2575, 2013
154.
Speca M, Carlson LE, Goodey E, et al: A randomized, wait-list controlled clinical trial: The effect of a mindfulness meditation-based stress reduction program on mood and symptoms of stress in cancer outpatients. Psychosom Med 62:613-622, 2000
155.
Danhauer SC, Griffin LP, Avis NE, et al: Feasibility of implementing a community-based randomized trial of yoga for women undergoing chemotherapy for breast cancer. J Community Support Oncol 13:139-147, 2015
156.
Würtzen H, Dalton SO, Elsass P, et al: Mindfulness significantly reduces self-reported levels of anxiety and depression: Results of a randomised controlled trial among 336 Danish women treated for stage I-III breast cancer. Eur J Cancer 49:1365-1373, 2013
157.
Pennebaker JW: Writing about emotional experiences as a therapeutic process. Psychol Sci 8:162-166, 1997
158.
Yennurajalingam S, Carmack C, Balachandran D, et al: Sleep disturbance in patients with cancer: A feasibility study of multimodal therapy. BMJ Support Palliat Care 11:170-179, 2020
159.
Raghunath K, Sumathi C, Rajappa SJ, et al: Impact of naturopathy, yoga, and dietary interventions as adjuvant chemotherapy in the management of stage II and III adenocarcinoma of the colon. Int J Colorectal Dis 35:2309-2322, 2020
160.
Liao J, Wu Y, Zhao Y, et al: Progressive muscle relaxation combined with Chinese medicine five-element music on depression for cancer patients: A randomized controlled trial. Chin J Integr Med 24:343-347, 2018
161.
Wang X, Wang N, Zhong L, et al: Prognostic value of depression and anxiety on breast cancer recurrence and mortality: A systematic review and meta-analysis of 282,203 patients. Mol Psychiatry 25:3186-3197, 2020
162.
Wang YH, Li JQ, Shi JF, et al: Depression and anxiety in relation to cancer incidence and mortality: A systematic review and meta-analysis of cohort studies. Mol Psychiatry 25:1487-1499, 2020
163.
Yun H, Sun L, Mao JJ: Growth of integrative medicine at leading cancer centers between 2009 and 2016: A systematic analysis of NCI-designated comprehensive cancer center websites. J Natl Cancer Inst Monogr 2017:lgx004, 2017
164.
Milzer M, Steindorf K, Reinke P, et al: The cancer patients' perspective on feasibility of using a fatigue diary and the benefits on self-management: Results from a longitudinal study. Support Care Cancer 30:10213-10221, 2022
165.
Steffen LE, Cheavens JS, Vowles KE, et al: Hope-related goal cognitions and daily experiences of fatigue, pain, and functional concern among lung cancer patients. Support Care Cancer 28:827-835, 2020
166.
Greenlee H, DuPont-Reyes MJ, Balneaves LG, et al: Clinical practice guidelines on the evidence-based use of integrative therapies during and after breast cancer treatment. CA Cancer J Clin 67:194-232, 2017
168.
Gilligan T, Coyle N, Frankel RM, et al: Patient-clinician communication: American Society of Clinical Oncology consensus guideline. J Clin Oncol 35:3618-3632, 2017
169.
George S, Duran N, Norris K: A systematic review of barriers and facilitators to minority research participation among African Americans, Latinos, Asian Americans, and Pacific Islanders. Am J Public Health 104:e16-e31, 2014
170.
Patel MI, Lopez AM, Blackstock W, et al: Cancer disparities and health equity: A policy statement from the American Society of Clinical Oncology. J Clin Oncol 38:3439-3448, 2020
171.
Hairston DR, Gibbs TA, Wong SS, et al: Clinician bias in diagnosis and treatment, in Medlock MM, Shtasel D, Trinh N-HT, et al (eds): Racism and Psychiatry: Contemporary Issues and Interventions. Cham, Switzerland, Springer International Publishing, 2019, pp 105-137
172.
BlueCross BlueShield: Racial disparities in diagnosis and treatment of major depression. https://www.bcbs.com/the-health-of-america/reports/racial-disparities-diagnosis-and-treatment-of-major-depression
173.
Ludwick A, Corey K, Meghani S: Racial and socioeconomic factors associated with the use of complementary and alternative modalities for pain in cancer outpatients: An integrative review. Pain Manag Nurs 21:142-150, 2020
174.
Mead H, Cartwright-Smith L, Jones K, et al: Racial and Ethnic Disparities in U.S. Health Care: A Chartbook. New York, NY, Commonwealth Fund, 2008
175.
Boersma P, Black LI, Ward BW: Prevalence of multiple chronic conditions among US adults, 2020. Prev Chronic Dis 17:200130, 2020
176.
American Cancer Society: Cancer Facts & Figures 2020. Atlanta, GA, American Cancer Society, 2020
177.
Deuel LM, Seeberger LC: Complementary therapies in Parkinson disease: A review of acupuncture, tai chi, qi gong, yoga, and cannabis. Neurotherapeutics 17:1434-1455, 2020
178.
Legault Z, Znaty A, Smith S, et al: Yoga interventions used for the rehabilitation of stroke, Parkinson's disease, and multiple sclerosis: A scoping review of clinical research. J Altern Complement Med 27:1023-1057, 2021
179.
Schnipper LE, Davidson NE, Wollins DS, et al: Updating the American Society of Clinical Oncology value framework: Revisions and Reflections in response to comments received. J Clin Oncol 34:2925-2934, 2016
180.
Schnipper LE, Davidson NE, Wollins DS, et al: American Society of Clinical Oncology statement: A conceptual framework to assess the value of cancer treatment options. J Clin Oncol 33:2563-2577, 2015
181.
Longo CJ, Fitch MI, Loree JM, et al: Patient and family financial burden associated with cancer treatment in Canada: A national study. Support Care Cancer 29:3377-3386, 2021
182.
Streeter SB, Schwartzberg L, Husain N, et al: Patient and plan characteristics affecting abandonment of oral oncolytic prescriptions. J Oncol Pract 7:46s-51s, 2011
183.
Dusetzina SB, Winn AN, Abel GA, et al: Cost sharing and adherence to tyrosine kinase inhibitors for patients with chronic myeloid leukemia. J Clin Oncol 32:306-311, 2014
184.
Compen F, Adang E, Bisseling E, et al: Cost-utility of individual internet-based and face-to-face mindfulness-based cognitive therapy compared with treatment as usual in reducing psychological distress in cancer patients. Psychooncology 29:294-303, 2020
185.
Carlson LE, Bultz BD: Efficacy and medical cost offset of psychosocial interventions in cancer care: Making the case for economic analyses. Psychooncology 13:837-849, 2004; discussion 850-856
186.
Nilsen P: Making sense of implementation theories, models and frameworks. Implement Sci 10:53, 2015
187.
Graham ID, Logan J, Harrison MB, et al: Lost in knowledge translation: Time for a map? J Contin Educ Health Prof 26:13-24, 2006
188.
Damschroder LJ, Reardon CM, Widerquist MAO, et al: The updated Consolidated Framework for Implementation Research based on user feedback. Implement Sci 17:75, 2022
189.
Witt CM, Balneaves LG, Carlson LE, et al: Education competencies for integrative oncology-results of a systematic review and an international and interprofessional consensus procedure. J Cancer Educ 37:499-507, 2020
190.
Gagnier JJ, Moher D, Boon H, et al: Randomized controlled trials of herbal interventions underreport important details of the intervention. J Clin Epidemiol 64:760-769, 2011
191.
Gagnier JJ, Boon H, Rochon P, et al: Reporting randomized, controlled trials of herbal interventions: An elaborated CONSORT statement. Ann Intern Med 144:364-367, 2006
192.
Kennedy CE, Fonner VA, Armstrong KA, et al: The evidence project risk of bias tool: Assessing study rigor for both randomized and non-randomized intervention studies. Syst Rev 8:3, 2019
193.
Loudon K, Treweek S, Sullivan F, et al: The PRECIS-2 tool: Designing trials that are fit for purpose. BMJ 350:h2147, 2015
194.
Dal-Ré R: Pragmatic trials, blinding, placebos, and the usefulness of the PRECIS-2 tool. Eur J Clin Pharmacol 77:1071-1072, 2021
195.
Reed EN, Landmann J, Oberoi D, et al: Group versus individual acupuncture (AP) for cancer pain: A randomized noninferiority trial. Evid Based Complement Alternat Med 2020:1-12, 2020
196.
Carlson LE: Uptake of mindfulness-based interventions: A phenomenon of wealthy white western women? Clin Psychol Sci Pract 25:e12258, 2018
197.
Martini R, Gebregzabher E, Newman L, et al: Enhancing the trajectories of cancer health disparities research: Improving clinical applications of diversity, equity, inclusion, and accessibility. Cancer Discov 12:1428-1434, 2022
198.
El-Deiry WS, Giaccone G: Challenges in diversity, equity, and inclusion in research and clinical oncology. Front Oncol 11:642112, 2021
199.
Carlson LE, Tamagawa R, Stephen J, et al: Tailoring mind-body therapies to individual needs: Patients' program preference and psychological traits as moderators of the effects of mindfulness-based cancer recovery and supportive-expressive therapy in distressed breast cancer survivors. JNCI Monogr 2014, 308-314, 2014
200.
Hoge EA, Bui E, Mete M, et al: Mindfulness-based stress reduction vs escitalopram for the treatment of adults with anxiety disorders: A randomized clinical trial. JAMA Psychiatry 80:13-21, 2023
201.
Ben-Arye E, Paller CJ, Lopez AM, et al: The Society for Integrative Oncology Practice Recommendations for online consultation and treatment during the COVID-19 pandemic. Support Care Cancer 29:6155-6165, 2021
202.
Brundage MD, Crossnohere NL, O’Donnell J, et al: Listening to the patient voice adds value to cancer clinical trials. J Natl Cancer Inst 114:1323-1332, 2022
203.
Lipscomb J, Reeve BB, Clauser SB, et al: Patient-reported outcomes assessment in cancer trials: Taking stock, moving forward. J Clin Oncol 25:5133-5140, 2007
204.
Fromme EK, Eilers KM, Mori M, et al: How accurate is clinician reporting of chemotherapy adverse effects? A comparison with patient-reported symptoms from the Quality-of-Life Questionnaire C30. J Clin Oncol 22:3485-3490, 2004
205.
Pakhomov SV, Jacobsen SJ, Chute CG, et al: Agreement between patient-reported symptoms and their documentation in the medical record. Am J Manag Care 14:530-539, 2008
206.
Basch E, Iasonos A, McDonough T, et al: Patient versus clinician symptom reporting using the National Cancer Institute Common terminology Criteria for Adverse Events: Results of a questionnaire-based study. Lancet Oncol 7:903-909, 2006
207.
Montazeri A: Quality of life data as prognostic indicators of survival in cancer patients: An overview of the literature from 1982 to 2008. Health Qual Life Outcomes 7:102, 2009
208.
Sitlinger A, Zafar SY: Health-related quality of life: The impact on morbidity and mortality. Surg Oncol Clin N Am 27:675-684, 2018
209.
Mao JJ, Ismaila N, Bao T, et al: Integrative medicine for pain management in oncology: Society for Integrative Oncology–ASCO guideline. J Clin Oncol 40:3998-4024, 2022
210.
Lyman GH, Greenlee H, Bohlke K, et al: Integrative therapies during and after breast cancer treatment: ASCO endorsement of the SIO clinical practice guideline. J Clin Oncol 36:2647-2655, 2018
211.
Deng GE, Rausch SM, Jones LW, et al: Complementary therapies and integrative medicine in lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 143:e420S-e436S, 2013
212.
Deng G, Frenkel M, Cohen L, et al: Evidence-based clinical practice guidelines for integrative oncology: Complementary therapies and botanicals. J Soc Integr Oncol 7:85-120, 2009
213.
National Center for Complementary and Integrative Health: Acupuncture: What you need to know. https://www.nccih.nih.gov/health/acupuncture-what-you-need-to-know
214.
PDQ Integrative, Alternative, and Complementary Therapies Editorial Board: PDQ Aromatherapy With Essential Oils. Bethesda, MD: National Cancer Institute, 2023. https://www.cancer.gov/about-cancer/treatment/cam/hp/aromatherapy-pdq
215.
American Art Therapy Association: Art therapy in action. https://arttherapy.org/art-therapy-action/
216.
American Art Therapy Association: About art therapy. https://arttherapy.org/about-art-therapy/
217.
National Center for Complementary and Integrative Health: Relaxation techniques: What you need to know. https://www.nccih.nih.gov/health/relaxation-techniques-what-you-need-to-know
218.
National Center for Complementary and Integrative Health: Dietary and herbal supplements. https://www.nccih.nih.gov/health/dietary-and-herbal-supplements
219.
National Cancer Institute: NCI Dictionary of Cancer Terms: Humor therapy. 2021. https://www.cancer.gov/publications/dictionaries/cancer-terms/def/humor-therapy
220.
Wikipedia, the free encyclopedia: Hypnosis. https://en.wikipedia.org/wiki/Hypnosis
221.
Wikipedia, the free encyclopedia: Light therapy. https://en.wikipedia.org/wiki/Light_therapy
222.
Wikipedia, the free encyclopedia: Reflexology. https://en.wikipedia.org/wiki/Reflexology
223.
Wikipedia, the free encyclopedia: Reiki. https://en.wikipedia.org/wiki/Reiki
224.
National Center for Complementary and Integrative Health: Qigong: What you need to know. https://www.nccih.nih.gov/health/qigong-what-you-need-to-know
225.
Yang G-Y, Hunter J, Bu F-L, et al: Determining the safety and effectiveness of tai chi: A critical overview of 210 systematic reviews of controlled clinical trials. Syst Rev 11:260, 2022
226.
National Center for Complementary and Integrative Health: Yoga: What you need to know. https://www.nccih.nih.gov/health/yoga-what-you-need-to-know

Information & Authors

Information

Published In

Journal of Clinical Oncology
Pages: 4562 - 4591
PubMed: 37582238

History

Published online: August 15, 2023
Published in print: October 01, 2023

Permissions

Request permissions for this article.

Authors

Affiliations

Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
American Society of Clinical Oncology, Alexandria, VA
Elizabeth L. Addington, PhD https://orcid.org/0000-0002-5839-5485
Northwestern University Feinberg School of Medicine, Chicago, IL
Gary N. Asher, MD, MPH
Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
Chloe Atreya, MD, PhD
University of California San Francisco, San Francisco, CA
Lynda G. Balneaves, RN, PhD https://orcid.org/0000-0002-6535-2096
College of Nursing, University of Manitoba, Winnipeg, MB, Canada
Joke Bradt, MT-BC, PhD
Department of Creative Arts Therapies, Drexel University, Philadelphia, PA
Nina Fuller-Shavel, MB BChir, MA https://orcid.org/0000-0002-5877-1567
Synthesis Clinic, Winchester, United Kingdom
The George Washington University, Washington, DC
Caroline J. Hoffman, OAM, RN, BSW, PhD
Paul's Cancer Support, London, United Kingdom
University of Rochester Medical Center, Rochester, NY
Ashwin Mehta, MD
Memorial Healthcare System, Hollywood, FL
Sidney Kimmel Comprehensive Cancer Center, John Hopkins University, Baltimore, MD
Kimberly Richardson, MA
Patient Representative, University of Illinois Cancer Center, Chicago, IL
University of Ottawa, Ottawa, ON, Canada
Canadian College of Naturopathic Medicine, Toronto, ON, Canada
Osher Center for Integrative Health, University of California, San Francisco, San Francisco, CA
Massachusetts General Hospital and Harvard Medical School, Boston, MA
Smith Center for Healing and the Arts, Washington, DC

Notes

Society for Integrative Oncology, 4301 50th St NW, Suite 300 PMB 1032, Washington, DC 20016; e-mail: [email protected].
Listen to the podcast by Dr Rowland at guideline.libsyn.com
*
L.E.C. and J.H.R. were Expert Panel cochairs.

Author Contributions

Conception and design: All authors
Provision of study materials or patients: All authors
Collection and assembly of data: All authors
Data analysis and interpretation: All authors
Manuscript writing: All authors
Final approval of manuscript: All authors
Accountable for all aspects of the work: All authors

Disclosures

Linda E. Carlson
Patents, Royalties, Other Intellectual Property: Book Royalties from American Psychological Association Books, Book Royalties from New Harbinger Books, Royalties on online MBCR program from eMindful.com
Uncompensated Relationships: Rocket VR Health, Mobio Interactive
Nofisat Ismaila
Employment: GlaxoSmithKline (I)
Stock and Other Ownership Interests: GlaxoSmithKline (I)
Chloe Atreya
This author is a member of the Journal of Clinical Oncology Editorial Board. Journal policy recused the author from having any role in the peer review of this manuscript.
Stock and Other Ownership Interests: Pionyr
Consulting or Advisory Role: Pfizer, Inivata, Sumitomo Dainippon Pharma Oncology, Foundation Medicine
Research Funding: Novartis (Inst), Merck (Inst), Bristol Myers Squibb (Inst), Guardant Health (Inst), Gossamer Bio (Inst), Erasca, Inc (Inst)
Travel, Accommodations, Expenses: Roche
Lynda G. Balneaves
Uncompensated Relationships: Canadian Consortium for the Investigation of Cannabinoids
Nina Fuller-Shavel
Employment: Synthesis Clinic (Director)
Stock and Other Ownership Interests: Zoe Ltd (joinzoe.com)
Honoraria: Datar Cancer Genetics (Inst), Helixor (Inst)
Uncompensated Relationships: Kiteline Health
Alissa Huston
Honoraria: Mediflix, MJH Healthcare Holdings, LLC
Ashwin Mehta
Stock and Other Ownership Interests: Fidelity Index Fund
Channing J. Paller
Consulting or Advisory Role: Dendreon, Omnitura, Exelixis
Research Funding: Lilly (Inst)
Kimberly Richardson
Honoraria: Bayer
Dugald Seely
Consulting or Advisory Role: Vitazan Professional
Chelsea J. Siwik
Consulting or Advisory Role: Senior Coastsiders
Jennifer S. Temel
Research Funding: Blue Note Therapeutics
No other potential conflicts of interest were reported.

Metrics & Citations

Metrics

Altmetric

Citations

Article Citation

Download Citation

If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download.

For more information or tips please see 'Downloading to a citation manager' in the Help menu.

Format





Download article citation data for:
Linda E. Carlson, Nofisat Ismaila, Elizabeth L. Addington, Gary N. Asher, Chloe Atreya, Lynda G. Balneaves, Joke Bradt, Nina Fuller-Shavel, Joseph Goodman, Caroline J. Hoffman, Alissa Huston, Ashwin Mehta, Channing J. Paller, Kimberly Richardson, Dugald Seely, Chelsea J. Siwik, Jennifer S. Temel, Julia H. Rowland
Journal of Clinical Oncology 2023 41:28, 4562-4591

View Options

View options

PDF

View PDF

Media

Figures

Other

Tables

Share

Share

Share article link

Share