Definitions for the strength of evidence and recommendation grades (1A-2C) follow the recommendations.
A distinction between "complementary" and "alternative" therapies is required. Complementary therapies, used as adjuncts to mainstream care, are supportive measures that help control symptoms, enhance well-being, and contribute to overall patient care. Alternative therapies, conversely, are often unproved or disproved, promoted for use instead of mainstream treatment, or are offered as viable therapeutic options. This is especially problematic in oncology, when delayed treatment can diminish the possibility of remission and cure. Over time, some complementary therapies are proven safe and effective. These become integrated into mainstream care, producing integrative oncology, a combination of the best of mainstream cancer care and rational, data-based, adjunctive complementary therapies. Most complementary and alternative medicine (CAM) practices can be loosely grouped into five categories according to the National Institutes of Health (NIH) National Center for Complementary and Alternative Medicine (see Table below).
Table: Categories and Examples of Complementary and Alternative Therapies
| Biologically based practices |
Herbal remedies, vitamins, other dietary supplements |
| Mind-body techniques |
Meditation guided imagery |
| Manipulative and body-based practices |
Massage, reflexology |
| Energy therapies |
Magnetic field therapy |
| Ancient medical systems |
Traditional Chinese medicine, ayurvedic medicine, acupuncture |
- It is recommended that all patients with lung cancer be specifically asked about the use of CAM. Grade of recommendation, 1C
- It is recommended that all patients with lung cancer be given guidance about the advantages and disadvantages of complementary therapies in an open, evidence-based, and patient-centered manner by a qualified professional. Grade of recommendation, 1C
- In lung cancer patients, mind-body modalities are recommended as part of a multi-modality approach to reduce anxiety, mood disturbances, or chronic pain. Grade of recommendation, 1B
- In lung cancer patients experiencing anxiety or pain, massage therapy delivered by an oncology-trained massage therapist is recommended as part of a multimodality treatment approach. Grade of recommendation, 1C
- The application of deep or intense pressure is not recommended near cancer lesions or anatomic distortions, such as postoperative changes, as well as in patients with a bleeding tendency. Grade of recommendation, 2C
- For lung cancer patients, therapies based on putative manipulation of bioenergy fields are not recommended. Grade of recommendation, 1C
- Acupuncture is recommended as a complementary therapy when pain is poorly controlled or when side effects, such as neuropathy or xerostomia from other modalities, are clinically significant. Grade of recommendation, 1A
- Acupuncture is recommended as a complementary therapy when nausea and vomiting associated with chemotherapy are poorly controlled. Grade of recommendation, 1B
- Electrostimulation wristbands are not recommended for managing chemotherapy-induced nausea and vomiting. Grade of recommendation, 1B
- When the patient with lung cancer does not stop smoking despite use of other options, a trial of acupuncture is recommended to assist in smoking cessation. Grade of recommendation, 2C
- In patients with lung cancer with symptoms such as dyspnea, fatigue, chemotherapy-induced neuropathy, or postthoracotomy pain, a trial of acupuncture is recommended. Grade of recommendation, 2C
- In patients with a bleeding tendency, it is recommended that acupuncture be performed by qualified practitioners and used cautiously. Grade of recommendation, 1C
- It is recommended that dietary supplements, particularly herbal products, be evaluated for side effects and potential interactions with other drugs. Those that are likely to interact with other drugs, such as chemotherapeutic agents, should not be used concurrently during chemotherapy or radiation, or before surgery. Grade of recommendation, 1B
- In patients with lung cancer who either do not respond to or decline antitumor therapies, it is recommended that use of botanical agents occur only in the context of clinical trials. Grade of recommendation, 1C
- It is recommended that patients be advised to avoid therapies promoted as "alternatives" to mainstream care. Grade of recommendation, 1A
Definitions:
Quality of Evidence Scale
High - Randomized controlled trials (RCTs) without important limitations or overwhelming evidence from observational studies*
Moderate - RCTs with important limitations (inconsistent results, methodologic flaws, indirect, or imprecise) or exceptionally strong evidence from observational studies*
Low or very low - Observational studies or case series
*Although the determination of magnitude of the effect based on observational studies is often a matter of judgment, the guideline developers offer the following suggested rule to assist this decision: a large effect would be a relative risk > 2 (risk ratio < 0.5) [which would justify moving from weak to moderate], and a very large effect is a relative risk > 5 (risk ratio < 0.2) [which would justify moving from weak to strong]. There is some theoretical justification in the statistical literature for these thresholds (the magnitude of effect that is unlikely or very unlikely to be due to residual confounding after adjusted analysis). However, once the decision is made, authors should be explicit in justifying their decisions.
Grade of Recommendations Scale
| Grade |
Recommendation |
| 1A |
Strong |
| 1B |
Strong |
| 1C |
Strong |
| 2A |
Weak |
| 2B |
Weak |
| 2C |
Weak |
Relationship of Strength of the Supporting Evidence to the Balance of Benefits to Risks and Burdens
| Balance of Benefits to Risks and Burdens |
| Quality of Evidence |
Benefits Outweigh Risks/Burdens |
Risks/Burdens Outweigh Benefits |
Evenly Balanced |
Uncertain |
| High |
1A |
1A |
2A |
|
| Moderate |
1B |
1B |
2B |
|
| Low or very low |
1C |
1C |
2C |
2C |
