Introduction

Dr. Julia Rowland shares the newest evidence-based recommendations from SIO and ASCO on integrative therapies for managing anxiety and depression symptoms in adults with cancer. Listen in to hear recommended options, such as acupuncture, aromatherapy, hypnosis, mindfulness, music therapy, relaxation, reflexology, Tai Chi and/or Qigong, and yoga. Dr. Rowland also discusses therapies the panel investigated but found insufficient evidence to support a recommendation for use in treating anxiety and depression. We also review how this guideline complements the recent ASCO guideline on conventional therapies for managing anxiety and depression, and the impact for patients and clinicians. Read the full guideline, "Integrative Oncology Care of Symptoms of Anxiety and Depression in Adults with Cancer: SIO-ASCO Guideline" at www.asco.org/survivorship-guidelines

TRANSCRIPT

This guideline, clinical tools, and resources are available at www.asco.org/survivorship-guidelines. Read the full text of the update and review authors' disclosures of potential conflicts of interest disclosures in the Journal of Clinical Oncology, https://ascopubs.org/doi/10.1200/JCO.23.00857

Brittany Harvey: Hello and welcome to the ASCO Guidelines Podcast, one of ASCO's podcasts delivering timely information to keep you up to date on the latest changes, challenges, and advances in oncology. You can find all the shows, including this one, at asco.org/podcasts.

My name is Brittany Harvey and today I'm interviewing Dr. Julia Rowland from the Smith Center for Healing in the Arts, Co-chair on "Integrative Oncology Care of Anxiety and Depressive Symptoms in Adult Patients with Cancer: Society for Integrative Oncology – American Society of Clinical Oncology Guideline."

Thank you for being here, Dr. Rowland.

Dr. Julia Rowland: Lovely to be here, Brittany. Thanks for this opportunity.

Brittany Harvey: We're glad to have you on.

Then before we discuss this guideline, I'd just like to note that ASCO takes great care in the development of its guidelines and ensuring that the ASCO conflict of interest policy is followed for each guideline. The disclosures of potential conflicts of interest for the guideline panel, including the guest on this episode, are available in line with the publication of the guideline in the Journal of Clinical Oncology, which is linked in the show notes.

So then I'd like to jump into the content of this guideline. So Dr. Rowland, what is the purpose of this joint SIO and ASCO guideline?

Dr. Julia Rowland: The purpose of the joint guideline, Brittany, published in the Journal of Clinical Oncology is to provide evidence-based recommendations to healthcare providers on integrative approaches to managing anxiety and depression symptoms in their adult cancer patients. By integrative approaches, we mean such interventions as yoga, relaxation, hypnosis, mindfulness, acupuncture, music therapy in treating anxiety and depression. Many of these therapies are already being used by people with cancer both during and after their treatment, with rates increasing over time. While use of integrative interventions can serve to improve quality of life, reduce stress, and provide individuals with a sense of control over their health, and they're often reported by patients as doing just that, it's important to note that for the purpose of this guideline, we examine specifically the ability of these interventions to significantly reduce symptoms of anxiety and depression.

Brittany Harvey: Great. And then, as you just mentioned, this guideline covers both anxiety and depression. So then I'd like to review the recommendations made by the expert panel and we'll go in order of those. So starting with those recommendations for anxiety, what integrative therapies are recommended for managing symptoms of anxiety experienced after diagnosis or during active treatment?

Dr. Julia Rowland: The strongest recommendations in the guideline are for the use of mindfulness-based interventions, which include mindfulness-based stress reduction, meditation, and mindful movement. These interventions were recommended across the board to treat both anxiety and depression symptoms in patients in active treatment, and those post-treatment due to the strong evidence to show their benefits to patients. Yoga was also recommended for patients with breast cancer to treat both anxiety and depression symptoms, although the strength of the evidence was moderate. Data was less compelling for its use during or after treatment in other cancers, likely due to the lack of small numbers of non-breast cancer survivors included in study samples. There was also evidence for the use of relaxation, music therapy, and reflexology for treating anxiety symptoms during active treatment, and that the use of hypnosis and aromatherapy using inhalation were of modest to some benefit during diagnostic or treatment procedures.

Brittany Harvey: Understood. Thank you for reviewing those recommendations. And you already mentioned a few items that are helpful and recommended for adults with cancer experiencing anxiety post-treatment, but which additional integrative therapies are recommended for this patient population?

Dr. Julia Rowland: In addition to mindfulness-based interventions and yoga, acupuncture, Tai Chi, and/or Qigong, and reflexology are recommended for treating anxiety symptoms post-treatment.

Brittany Harvey: Excellent. Thank you for that summary of recommendations. So then, moving into the recommendations on depression, what does the expert panel recommend for adults with cancer experiencing symptoms of depression?

Dr. Julia Rowland: For depression symptoms during treatment, the panel recommended mindfulness-based interventions, yoga, music therapy, relaxation, and reflexology, while post-treatment mindfulness-based interventions, yoga, and Tai Chi or Qigong were recommended.

Brittany Harvey: Excellent. Thank you for reviewing all the recommendations that the panel put forward. So this guideline reviewed a large breadth of integrative therapies. Are there any therapies that the panel reviewed but couldn't make a recommendation for, for this particular guideline?

Dr. Julia Rowland: Thank you for asking that question because as people listen to this podcast, they may realize that there are some therapies that may be widely used by their population or in their center or clinic, including such things as natural products and supplements, melatonin, healing touch, massage, light therapy, to name a few. Where the panel found in its review of the literature of over 110 studies or systematic reviews, there was insufficient evidence for the vast majority of these to make any conclusive recommendation. It just means we have a lot more work to do in assessing the efficacy of these, especially in treating anxiety and depression.

One intervention stands out in particular that's widely used and that's expressive writing. While this may be very helpful for improving quality of life or making sense of the cancer experience and providing an outlet for self-expression, the data does not support its use for treating anxiety and depression. It may be because it's too brief an intervention for conditions that have more depth and permanence. It doesn't mean you can't use it for other purposes, but the panel did not recommend its use for treating anxiety and depression.

Brittany Harvey: Understood. That makes sense that there are some integrative therapies that work across different parts of the treatment spectrum and that there are some areas in which we just don't have the evidence yet. So, thank you for reviewing all of those recommendations.

So then, how does this guideline complement the recently published ASCO Guideline on the Management of Anxiety and Depression in Adult Survivors of Cancer?

Dr. Julia Rowland: That's a terrific question. The recently published ASCO Guideline on Management of Anxiety and Depression in Adult Cancer Survivors represents an update of our original 2014 guideline. The ASCO guideline provided recommendations regarding the use of conventional therapies, psychological, behavioral, and psychopharmacologic interventions for managing anxiety and depression. The current SIO and ASCO guidelines sought to expand upon and essentially complement these recommendations by identifying those integrative therapies that might also be effective in the management of anxiety and depression in adults treated for cancer. Further, the SIO and ASCO guidelines attempted to determine when, in the course of care, during diagnosis and active treatment and/or post-treatment, these interventions worked best. Both sets of recommendations strongly endorse the benefits of mind-body interventions in addressing both anxiety and depression, specifically mindfulness-based interventions in this SIO and ASCO guideline and cognitive, behavioral, behavioral activation, and mindfulness-based stress management programs in the ASCO guideline.

Brittany Harvey: It's great to have these complementary guidelines available at the same time for a complete approach to managing anxiety and depression during treatment and post-treatment. So then, in your view, Dr. Rowland, what is the importance of this guideline and how will it impact clinicians and patients with symptoms of anxiety and/or depression?

Dr. Julia Rowland: Brittany, cancer takes a significant psychological toll on affected individuals. Research has shown that cancer survivors have a significantly elevated risk of developing mental health disorders compared with the general population. Despite this, their psychological symptoms are often under-recognized and undertreated. As the number of cancer survivors continues to grow, so does the challenge to healthcare providers of meeting their mental health needs. Anxiety and depression symptoms have long been associated with lower quality of life and higher mortality in people with cancer. Treating symptoms of anxiety and depression using evidence-based, integrative therapies has the potential to not only improve patients' quality of life and help them better manage their care but may also improve length of life.

With the publication of this guideline, we now know which therapies could have the biggest impact. An added benefit of incorporating, or at least considering, integrative therapies to manage anxiety and depression are that they have few, if any, side effects, can be readily modified to accommodate individuals with multiple comorbidities, are well received by the majority of patients, and can be received in a variety of settings, including at home and online.

Brittany Harvey: Those are key points that you just made. These recommendations are key for improving quality of life for patients, and it's great to have options for patients, including, as you mentioned, at home.

So then finally, what are the outstanding questions for the use of integrative approaches in managing anxiety and depression in patients with cancer?

Dr. Julia Rowland: As I look at these new guidelines, both the SIO and ASCO, as well as the renewed ASCO guidelines, perhaps the biggest question raised is how to increase the use of recommended care. And I think there are three parts to this challenge. One critical first part is raising awareness about these guidelines, which it's hoped this podcast will help us achieve. A second, equally critical step, however, is identifying available treatment resources. While most treatment clinics and centers have access to mental health resources in a number of settings, this may be quite limited. Further, it's not clear how many such programs include integrative programs and services.

In addition to the questions about availability, lack of familiarity with some of these therapeutic modalities may leave clinicians reluctant to refer their patients for such care and raise questions for them about how to assess the training and qualifications of integrative care providers and the rigor of the therapy they provide. An important recommendation made by both ASCO and the SIO and ASCO Anxiety and Depression Management Guideline panels is that oncology clinicians should conduct a landscape analysis of who is and what types of programs are available to provide the recommended therapies to their patients. Arguably, not knowing where to refer a patient suffering from anxiety and depression is the most significant area to that patient's receipt of optimal care. The landscape review should include in-house or affiliated mental health providers, integrative program leads if present, local professionals, and organizations offering this care, as well as access to community-wide and national groups providing integrative care remotely via online and telephone. Asking patients themselves who they have seen and found helpful in improving their emotional well-being can also broaden resource lists generated.

A third challenge is how best to identify and refer those patients most in need. Recommendations regarding screening and assessment of anxiety and depression were not within the scope of the SIO and ASCO guidelines. However, in the two published ASCO Guidelines on use of conventional interventions for managing anxiety and depression, both the 2014 original and the updated 2023 revised, the expert panels emphasize the critical need to routinely screen for both anxiety and depression using standardized measures such as the GAD-7 and the PHQ-9.

ASCO's QOPI or Quality Oncology Practice Initiative already includes screening for emotional distress early in the course of care as a key practice standard. Other appropriate times for screening include changes in disease or treatment status, transition to palliative and end-of-life care, and when clinically indicated. Screening is the critical and necessary first step to identification and referral for appropriate and timely care of cancer patients and survivors suffering from anxiety and depression. Figuring out how to do this well and systematically should be a priority for reducing the burden of cancer nationally.

Brittany Harvey: Absolutely. As you mentioned, screening is critical for identifying patients experiencing anxiety and depression, and I appreciate you reviewing those implementation barriers and how clinicians and practices can work to reduce these barriers and increase the uptake of these recommendations. We'll have some of those resources linked in the guideline also on the ASCO website and in the show notes of this episode.

So I want to thank you so much for your insights on this guideline and for your time today, Dr. Rowland.

Dr. Julia Rowland: My pleasure, Brittany. I hope the word gets out and we'll see more uptake of these affected therapies and in broader use. Thank you.

Brittany Harvey: Definitely. That's the goal of all of these guidelines.

I also want to thank all of our listeners for tuning into the ASCO Guidelines Podcast. To read the full guideline, go to www.asco.org/survivorship-guidelines. You can also find many of our guidelines and interactive resources in the newly redesigned ASCO Guidelines app available for free in the Apple App Store or the Google Play Store. If you have enjoyed what you've heard today, please rate and review the podcast, and be sure to subscribe so you never miss an episode.

The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of medical conditions.

Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.