Whole Health Library

Introduction

Nearly 56,000 Veterans in the VA system are diagnosed with cancer each year.[104]  97.5% of cancers diagnosed in VA are diagnosed in men, and the most common cancers found in Veterans are similar to the most common types found in the general U.S. male population.[105]  The five most common cancers are prostate (32%), lung (19%), colorectal (9%), bladder (4%), and melanoma (3.6%).[1]  Of course, female Veterans like Pam are also affected.  The most common cancers in woman Veterans enrolled in the VA health system are breast (30%), lung (16%), gastrointestinal (12%) and gynecological (12%).[106]

Cancer risk is connected to many aspects of self-care.  People who are actively being treated for cancer and survivors, who are focusing on dealing with the consequences of had cancer and are trying to avoid recurrence, also can benefit from a whole-person approach.  Reviews have highlighted that it is important for people with cancer (and those with multiple chronic conditions in general) to have excellent communication with their teams,  a clear sense of roles of their different provides, access to accurate information, and care that is tailored to their specific needs.[107]  Truly, a Whole Health approach can make important contributions to optimal cancer care, recognizing that cancer arises in the context of family dynamics, self-care needs, emotional and spiritual challenges, mental health concerns, structural/social determinants of health, and the presence of a person’s other chronic medical problems.  Research indicates that quality of life is adversely affected in cancer survivors for years after diagnosis.[108]  A Whole Health approach can make quality of life significantly better.

Mission, Aspiration, Purpose

Those with cancer often describe the experience as a journey.  The journey is unique for each individual.[109]  Even if the cancer is cured, patients commonly find themselves adjusting to a “new normal” while they become accustomed to residual side effects from treatment and watch for symptoms that may or may not be concerning for a recurrence.  Coping strategies are highly variable from person to person.[110]  It can be helpful to explore cancer care within a framework of post-traumatic growth, which is closely associated with meaning in life in cancer patients, and which has been linked to attributes such spirituality, optimism, and positive coping style.[111-114]

At any stage of a person’s cancer experience their mission, aspiration, and purpose (MAP) play a key role.  As one review notes, “Meaning and purpose in life are associated with the mental and physical health of patients with cancer and survivors and also constitute highly valued outcomes in themselves.”[115]  Meaning and Purpose Therapy, which is built around group therapy sessions for people with cancer, has shown promise in small trials.[116]

Demoralization syndrome, characterized by feelings of hopelessness and a sense of loss of meaning and purpose, is a risk for people with cancer.  While reviews find a great deal of variability among studies, it appears that people are at less risk for demoralization if they are employed, are active socially, have a significant other, and adequately treat any depression and anxiety they might have.[117]  When working with people with cancer, it is important to explore these and other means for keeping MAP at the forefront.  A cross-sectional study found that breast cancer survivors with a higher sense of purpose in life are more likely to be happier overall, and this is likely to be true for people with any type of cancer.[118]

The cancer journey has different parts, ranging from detection and treatment to recovery or death, as noted in Figure 1.  As the health plan is being co-created, team members must remain attuned to where on the spectrum of care each person is.  For example, at diagnosis, people may be much more focused on navigating the system, or handling work and parenting obligations.  Survival may be the total focus, and only after time might it be possible to explore other aspects of a person’s MAP, including their most prized values, in greater detail.  

Self-Care

Moving the Body

Surroundings

Personal Development

Food and Drink

Mediterranean Diet

A Mediterranean diet (MD) is low in saturated and omega-6 fats (red meat and dairy) and high in plant sources of monounsaturated fats, omega-3 fats, fiber, antioxidants, and polyphenols (fruit, vegetables, olive oil, and wine).  Figure 2 shows the key elements of the MD in the form of a diet pyramid.  More research is needed, but the MD is associated with a lower risk or is risk-neutral for most types of cancer.[198]  High MD adherence has been linked to an overall reduction in cancer mortality.[199]  A 2023 umbrella review found that adherence to an MD is related to reduced risk of breast cancer, especially in postmenopausal women.[200]  Eating the MD also correlates with a reduction of colorectal[82] and pancreatic cancer risk.[83]  The MD is not associated with the risk of advanced prostate cancer or disease progression; however, greater adherence to the MD after diagnosis of nonmetastatic prostate cancer was associated with a 220% lower risk of overall mortality.[84]   

The MD seems to exert some of its benefits because of its effects on weight loss, and it has been noted to be safe, feasible, and adhered to well by patients.[201]  It reduces oxidation and inflammation that can damage DNA and it affects cell proliferation, metastasis, and angiogenesis.[202]  

Recharge

Family, Friends, and Co-Workers

Spirit and Soul

Power of the Mind

A 2022 review of 65 studies found that both overall cancer risk and risk for 12 different individual cancer types are associated with psychological stress.[240]  Part of this relationship is likely tied in with stress-related behaviors, including smoking, poor eating, low activity, alcohol consumption, and obesity. 

For many people, the diagnosis of cancer is a deeply stressful and emotional experience, which causes anxiety, depression, and anger.  It raises concerns around time (past, present, and future) space (home life, how a person fits into the world) and existence.[241]  People fear the diagnosis because of its associated mortality risks and the potential side effects of treatments.  Depending on where a given person with cancer is in the process of diagnosis and treatment, different concerns will come to the forefront.  These concerns can interfere with the patient’s overall well-being and may hamper effective participation their own healing process.  Mind-body interventions are important for helping patients optimize their course to recovery, in part because they enhance the mind’s capacity to affect bodily functions. 

Pain. A 2021 review found that, for cancer pain, some of the best research supports mindfulness-based cognitive therapy, guided imagery, progressive muscle relaxation, and emotional and symptom focused engagement (EASE).[242]   A 2021 review and meta-analysis concluded that a variety of psychosocial interventions, ranging from relaxation techniques and cognitive behavioral therapy to music therapy, group therapy, and mindfulness-based interventions had small but significant effects on pain intensity.[243] 

Posttraumatic growth.  Posttraumatic growth is positive psychological change people experience because they have struggled with highly stressful and challenging experiences; in patients with cancer, it is correlated with certain perspectives and personality traits.  A review of nearly 1700 articles concluded that resilience, a tendency to be positive, hardiness, and a tendency to be grateful were all connected to growth after being diagnosed with cancer.[244] 

Psychological Approaches

Psycho-oncology.  Psycho-oncology is an interdisciplinary field that focuses on helping people with cancer navigate all of its different stages.[245]  It weaves in many mind-body approaches, focusing on areas such as managing pain, sexual issues, fear of cancer progression, and handling fatigue.  Physicians who provide care of cancer survivors tend to regard psycho-oncology services favorably, though it is noted that there is such a great need for mental health support for people with cancer that all clinicians could consider playing some part in addressing patients’ psychosocial needs.[246]

Cognitive Behavioral Therapy (CBT).  A 2024 review concluded, looking at 132 trials, that CBT affords moderate improvement of mental health and quality of life in cancer patients.[247]  Efficacy is influenced by patient age (it is more effective in younger patients) and format.  A 2024 study specific to older cancer patients found improvements in quality of life and mental health for them as well.[248]

Positive Psychology.  A 2024 review of 29 trials concluded that positive psychological interventions have the potential to favorably influence quality of life, enhancing positive psychological outcomes and reducing negative ones.[249]

The Power of the Mind overview provides more information about different types of psychotherapies and their potential roles in the care of Veterans.

Meditation

Meditation is a mind-body technique that trains the mind in awareness and attention through mental focus on an object, sound, word, phrase, or the breath. Mindfulness meditation involves attending to the whole of an experience nonjudgmentally, without a sense of subject and object. Its primary benefits include relaxation, psychological insight, and decreased stress and pain. Mindfulness-Based Stress Reduction (MBSR) is the most studied form of meditation for cancer patients, and it is a structured 8-week group program of weekly 2.5-hour sessions and one all-day silent retreat. Cancer patients who train in MBSR experience less tension, anger, depression, anxiety, fear, emotional instability, habitual stress behavioral patterns, and fewer concentration problems, and improved immune function.[127][128] MBSR significantly reduces anxiety and depression, and promoted sleep quality in patients with cancer, with effects maintained up to 6-12 months after the course.[31][129][130][131] For more information, refer to the “Mindful Awareness” Whole Health overview.

Clinical Hypnosis

Hypnosis is a natural state of aroused, attentive focal concentration coupled with relative suspension of peripheral awareness and aims to achieve symptom relief.  Relaxation can pair with imagery to reduce the distressing symptom.  In cancer patients, clinical hypnosis is effective for reducing pain, anxiety, depression, anticipatory or chemotherapy-related nausea and vomiting, procedural-related pain and distress, and hot flashes.[91]  Cancer care clinicians should pay attention to what their words may be suggesting to patients, whether or not a formal hypnotic induction is used.  Negative suggestions include ‘‘little sting here’’ or ‘‘sharp scratch there’’ while more neutral descriptors are ‘‘some feeling of warmth, coolness, or tingling.’’  A 2022 randomized controlled trial found that recorded hypnosis and relaxation recordings were both effective in reducing pain and anxiety in cancer survivors who had chronic pain.[250]

Guided Imagery

Guided Imagery (GI) involves engaging the imagination to create a sensory experience that helps one gain insight or achieve a clinical goal.  The goal can be specific, such as reducing pain, or general, such as achieving emotional well-being.  Often, if coupled with progressive muscle relaxation (PMR), it induces the relaxation response, and both PMR and GI have been found to be helpful for anxiety in people receiving chemotherapy.[251]  GI has been found helpful for anticipatory and chemotherapy-related nausea and vomiting; reducing anxiety, depression, and discomfort; and improving quality of life.[92,96]  Guided Imagery CDs specific to the various phases of cancer care, including radiation and chemotherapy, have been created by Belleruth Naparstek and can be found at the Health Journeys website, which offers discounts to Veterans.

Music therapy

Music therapy is the clinical use of music interventions to address physical, social, emotional, and cognitive needs of a person within a therapeutic relationship facilitated by a credentialed professional.  A 2020 systematic review and meta-analysis concluded that music therapy can improve quality of life, pain, depression, and anxiety in people with cancer, and optimal intervention duration is 1-2 months.  It has similar benefits in the breast cancer population, according to a 2024 review.[252,253]  A 2011 Cochrane review found that music interventions may benefit anxiety, pain, mood, and quality of life in people with cancer, with further effects on heart rate, respiratory rate, and blood pressure.[34]  Music therapy also seems to beneficial for children with cancer and caregivers of people with life-threatening illnesses.[254,255] 

Within a cancer center, a music therapy program can be used to promote patient self-expression, assist patients with music choices to enhance mood and reduce stress, facilitate group interactions with music serving as the catalyst, and promote physical and emotional well-being.  Passive music therapy has been shown to reduce anxiety during radiation, chemotherapy, and post-surgery.  It is affordable, easy to implement, non-invasive, and does not have any negative effects.[27]

For More Information: Self-Care and cancer

The Power of the Mind Whole Health overview has additional information that is broadly applicable to cancer care.  For further information on self-care options for people with specific cancers, see the Whole Health tools entitled “Colorectal Cancer Care and Prevention” and “Lung Cancer Care and Prevention.”

Professional Care

Studies have historically indicated that professional care for cancer is not always as patient-centered, coordinated, evidence-based or accessible as it could be.[256]  Cancer’s complexity impedes the formulation of effective plans of care that can be carried out efficiently, safely and with attention to quality. 

Important elements in a Whole Health approach to cancer care[3,256]

• A plan, which the Veteran and clinical team agree upon, that outlines goals of care
• Engagement of patients and families
• Empowerment of patients and their families, with opportunities to strategically plan around how a person can live with their cancer and navigate day-to-day life
• Equipping people with all the resources needed to carry out the plan
• Commitment to helping people have access to trials and trial findings, as appropriate
• A process for effectively coordinating care.

Full disclosure of information about all appropriate treatment options, including evidence-informed guidance around complementary approaches.

Complementary and Integrative Approaches

More than half of cancer patients in the United States use complementary and integrative health (CIH) approaches during the survivorship period following acute cancer therapies.[2]  Various studies show that at least 40% of people with cancer are using complementary approaches, and in specific demographic groups, that usage rate may be as high as 80%.[257-259]  However, a 2022 review of multiple studies found that 50-60% of the people using CIH for cancer care do not inform their health care team.[260]  

Several factors seem to influence this.  Highly educated white women, people whose cancer has metastasized, and those receiving active therapy are more likely to share.  Men, particularly from minority groups, are less likely to disclose use.[261]  People are more likely to report using certain CIH therapies, like dietary supplements, and less likely to report use of nonbiological approaches like yoga and various mind-body therapies.[262]

One major reason patients do not share is simply because they are never asked about by their clinical team about CIH use; team members are encouraged to add this to the questions they routinely ask Veterans.[262]  A Whole Health approach matters, because patients are more likely to disclose their use of complementary approaches when they feel they are viewed “as a person” and are treated with respect and open-mindedness by someone who is genuinely curious and engaged.[261]  Discussing the use of these approaches leads both patients and physicians to feel they have a better relationship, and physicians report greater levels of satisfaction with the care provided.[263]  When people encounter physicians whose communication styles are less supportive or more negative around CIH use for cancer care, they may be more likely to switch physicians or to choose not to use conventional biomedical therapies at all, as was highlighted in a small Nordic study.[264]  A systematic review concluded that poor communication poses serious risk to people who want to integrate complementary and conventional approaches to their cancer care.[265]

Patients use complementary therapies for many reasons.  They may be trying to treat the cancer itself, or they may be trying to address effects of the cancer, such as fatigue, weight loss, or pain.  They may be using these approaches to manage side effects of conventional therapies, such as chemotherapy-induced nausea and vomiting or fatigue.  They may also choose CIH to help prevent cancer from either occurring in the first place, or to prevent it from recurring.  Use of CIH can challenge and frustrate care team members who may have limited knowledge of complementary medicine, or have concerns about the quality of data regarding the safety and efficacy of these approaches. 

It is critical to inquire about the use of complementary approaches as a routine part of initial evaluations of cancer patients and to decide together on therapeutic management options at each stage of cancer care.  The dangers of not engaging patients in an open discussion of integrative treatments include patients holding false beliefs in a “cure-all” therapy, interactions of supplements and botanicals with chemotherapy and radiation, and patient mistrust of conventional therapies reducing compliance to treatment.   Some of the approaches used most commonly by cancer patient include yoga, acupuncture, massage, biofield therapies, Traditional Chinese Medicine, mind-body interventions, and dietary supplements.[266,267]

One of the most important ways for team members to improve cancer care as it relates to appropriate and safe CIH use is by ensuring they are familiar with various approaches people are using; education makes a difference at many levels.  The ECHO mnemonic – Efficacy, Cost, Harms, and Opinions – can be useful here.  A large survey of oncologists in the U.S. found that 93% were concerned about herb-drug interactions, but only 64% felt they could answer patients’ questions about them, and only 14% who took the survey could correctly answer quiz items regarding which dietary supplements people should avoid during cancer treatment.[268] 

Integrative oncology focuses on integrating complementary and conventional approaches through education, research, and a focus on implementation of evidence-based interventions that are part of a comprehensive approach to care.[269]  Organizations such as the Society for Integrative Oncology (SIO)a multi-disciplinary organization, now host conferences and training programs to support these initiatives.  They are a useful resource for clinical team members who want to expand their understanding of the role of CIH in cancer care.  Thes groups periodically release guidelines, including SIO’s 2017 “Clinical Practice Guidelines on the Evidence-Based use of Integrative Therapies During and After Breast Cancer Treatment.”[270]

To help cancer patients be truly informed and autonomous, clinicians should incorporate the following into the care they provide:

• Learn about conventional treatments that someone has tried, failed, or rejected because of safety, quality of life, cost, or other issues
• Discover the levels of support that the patient relies on from family, community, faith, and friends
• Ask patients about their use of complementary approaches or interest in using complementary therapies
• Identify the patient's beliefs, fears, hopes, expectations, and experience with complementary versus conventional approaches
• Acknowledge the patient's spiritual and religious values and beliefs, including views about quality of life and end of life, and seek to understand how these issues affect health care choices
• Stay attuned to cultural and religious factors that may influence care choices.[4]

The NatMed Database, which reviews various therapies based on a broad-based survey of the existing evidence base, notes the following:[271]

• Acupressure and acupuncture are possibly effective for cancer-related fatigue.
• Acupuncture is possibly effective for cancer-related pain.
• Reflexology (the application of pressure to points on the fee, ears, and hands to areas that are said to correlate/connect with other parts of the body) is possibly effective for cancer related pain.
• Aromatherapy for cancer-related pain and moxibustion (burning mugwort over acupuncture points) to treat cancer more generally are rated as “Possibly Ineffective.”

Ratings for dietary supplements and additional details surrounding some key research for complementary therapies are provided in more detail in the next sections.

Alternative versus complementary cancer care

While it comes up less often than it used to in integrative health practices, patients may ask about what they can do instead of, rather than as a complement to, conventional therapies like radio- and chemotherapies.  Most integrative health clinicians tend to focus on how therapies can complement or be integrated with biomedical treatments, versus replacing them.  Often, there is limited evidence of efficacy or safety to guide choices around the various treatments that are marketed at holistic cancer centers, some of which patients seek outside of the U.S. and are therefore subject to different quality and safety regulations.

Clinicians should be familiar with therapies patients might ask about, including the following, noting that these approaches are highly controversial and may not be readily available to people.  They are not familiar to most clinicians.  Examples include:

• Ozone therapy, or oxygen-ozone autohemotherapy. Ozone exposure elicits certain anti-oxidant pathways and is thought to influence immune system function in various ways.  It can be administered in various ways.  With autohemotherapy, blood is drawn, exposed to an oxygen-ozone mixture, and then put black into the bloodstream.[273]  It can also be given via topical, intramuscular, and rectal insufflation.[274]  Studies to date note small numbers of trials and suggest it may serve as an adjuvant to chemotherapy and radiation therapy, but this remains controversial, and the Food and Drug Administration does not support its use for medical indications.[275,276]
• Hyperbaric oxygen therapy. A person breathes pure oxygen in a pressurized cabin, with the intent of bringing more oxygen to the tissues.  It is recommended for some complications of radiation therapy.[277,278] 
• Gerson therapy. Created in the early twentieth century by Dr. Max B. Gerson, this approach to cancer treatment includes three main components.[279]
  • A diet of organic fruits, vegetable, and whole grains with low sodium and high potassium content
  • Supplements that are intended to correct cellular metabolism (including potassium, iodine solution, injections of coenzyme Q10 and B12, flaxseed oil, pancreatic enzymes, and pepsin (a stomach enzyme).
  • Detoxification through techniques like coffee or chamomile enemas.

Gerson first developed the therapy to treat his migraine headaches and was publicly used to treat tuberculosis in the 1930s.  According to the National Cancer Institute, research has not been sufficiently supportive to support the therapy’s use.  At least three deaths have been reported from coffee enemas.

• Ultraviolet blood irradiation. Used primarily for infection treatments prior to the advent of antibiotics, this therapy involves exposure of blood that has been removed from the body to ultraviolet rays.[280]  The blood is then returned to the body.  Extracorporeal photopheresis has been used to treat certain forms of T-cell lymphoma and is supported by the National Institute for Health and Clinical Excellence for this.[281]  Data regarding use of this therapy for other types of cancer is limited but some reviews note that it has potential.[282]
• Intravenous vitamin C/High-dose ascorbic acid therapy (HAAT). A 2018 review noted this was a “...safe supportive intervention to decrease inflammation in the patient and to improve symptoms related to antioxidant deficiency, disease processes, and side effects of standard cancer treatments.”[283]  Most reviews note safety but call for additional trials to gauge effectiveness.[284]

Biologically based approaches: Dietary supplements

Note: Please review to the Passport to Whole Health, Chapter 15 on Dietary Supplements for more information about how to determine whether or not a specific supplement is appropriate for a given individual.  Supplements are not regulated with the same degree of oversight as medications, and it is important that clinicians keep this in mind.  Products vary greatly in terms of accuracy of labeling, presence of adulterants, and the legitimacy of claims made by the manufacturer.

That NatMed Database, which compiles and reviews research related to dietary supplements, lists the follow supplements as “Likely Effective.”[271]  Effectiveness is related to cancer care in general unless otherwise noted.

• Beta-carotene, modest breast cancer risk reduction
• Black tea, ovarian cancer
• Calcium, colorectal cancer prevention for people with sufficient vitamin D and normal weight
• Green tea, endometrial and ovarian cancer prevention
• Lycopene, prostate cancer development or recurrence
• Magnesium, colon cancer prevention (but not rectal cancer)
• Melatonin, seems to lead to improved survival and tumor regression when combined with chemotherapy
• Niacinamide, skin cancers
• Strontium, slows prostate cancer progression in its IV strontium-89 form
• Turkey tail mushroom’s constituent PSK may improve cancer therapy response rates and survival

Antioxidants

The use of antioxidants (vitamins A, C, E, selenium, and carotenoids) during cancer treatment is controversial due to the theoretical risk of reducing the number of free radicals created by chemoradiotherapy.  Since free radicals target and kill cancer cells, suppressing production may reduce the effectiveness of cancer treatment.  A 2018 meta-analysis and systematic review of 69 studies concluded that higher dietary intake and blood concentrations of vitamin C, carotenoids, and alpha-tocopherol (a form of vitamin E) were tied to a reduced risk of total cancer mortality and supported increasing fruit and vegetable intake to keep levels up.[285]  It did not support antioxidant supplement use, however.

Do not recommend that your patients start on antioxidants to prevent cancer, but rather encourage a high intake of fruits (especially berries and dark grapes) and brightly colored vegetables to obtain them naturally.

More information is available in the Supplement/Botanical Interactions with Chemotherapy and Radiation Whole Health tool.

Curcumin

Curcumin is a polyphenol and the major component of the Indian spice turmeric (Curcuma longa).  It has anti-inflammatory, chemopreventative, and antimicrobial properties.[286]  Curcumin regulates the expression of p53 and inhibits COX-2 activity and TNF-alpha signaling pathways and tumor suppressing gene (making it a potentially beneficial anti-inflammatory as well).[102]  It has also been shown to protect organs such as liver, kidney, oral mucosa, and heart from chemoradiotherapy-induced toxicity.[104]  A 2023 systematic review concluded that “...available clinical evidence is not strong enough to support the therapeutic use of curcumin in cancer.”[287]  However, given its good safety profile and potential based on its many mechanisms of action to reduce inflammation, it is reasonable to consider taking it.[288]

Dose: 500-3,000 mg daily combined with piperine (black pepper) to increase bioavailability and taken during meals containing healthy fats to enhance absorption.

Green tea

Green tea consists of unfermented Camellia sinensis tea leaves with a high polyphenol content, 40% of which is epigallocatechin gallate (EGCG); it has multiple antioxidant and anti-inflammatory effects.[289]  A 2021 review found that current epidemiological evidence was supportive for some benefits, including prevention of lung, uterine, oral, and ovarian cancers, as well as non-Hodgkin’s lymphoma.[290]  Mixed findings have been found for breast, liver, stomach, and esophageal cancers and there was no association found for colorectal, pancreatic, and prostate cancer.  As a food, green tea is safe to consume and does not seem to have significant adverse effects.   

Dose: Recommended green tea intake is 3 to 5 cups per day (up to 1,200 ml daily), providing a minimum of 250 mg daily catechins. Liver enzymes should be monitored in patients taking high-dose green tea supplements, and decaffeinated versions may be more appropriate for some people.

Melatonin

Melatonin is a hormone secreted by the pineal gland that regulates sleep patterns.  Its actions include stimulating growth hormone production, triggering apoptosis, up-regulation of antioxidant enzymes, suppression of tumor and endothelial growth factors, and down-regulation of pro-oxidative enzymes.[103]  It suppresses oxidative stress and stimulates DNA damage responses, potentially helping normal tissue to tolerate radiation therapy better.[291]  Melatonin leads to higher tumor remission rates and overall survival rates for cancers in general; it also reduces chemotherapy side effects like neurotoxicity, fatigue, and decreased platelet numbers.[292]

Dose: The adjuvant dose of melatonin is 20 mg at night, which is higher than dosing to assist with sleep and circadian rhythm.  For insomnia, the dose is 1-10 mg at night.  Melatonin can cause sedation, vivid dreams, and headaches.  The effective dose varies greatly from one person to another, in terms of sleep effects.

Vitamin D

A 2019 study in the New England Journal of Medicine did not find that vitamin D lowers the incidence of invasive cancers, but a 2019 review in the British Medical Journal concluded that, while it was not associated with lowering all-cause mortality, it did significantly reduce the risk of cancer death by 16%.[293,294]  A 2024 review found there were inverse correlations between levels of vitamin D in the blood and mortality for breast, lung, prostate, pancreatic, and colorectal cancer, noting that most of the studies available are observational studies and causality is difficult to establish.[295]  Thyroid cancer has a similar association.[295]  A study of Veterans with bladder cancer found that a higher vitamin D level was linked to longer survival.[98] 

Some foods (eggs, fortified dairy, mushrooms, and fish) provide small amounts of vitamin D2 (ergocalciferol), but ultraviolet light from the sun is the best source of vitamin D3 (cholecalciferol). Vitamin D production is impaired with age, obesity, and pigmentation, so oral supplementation is advised. 

Dose: Each 1000 IU of vitamin D3 should increase 25-hydroxyvitamin D levels by 10 ng/ml.  A safe recommendation is to achieve a 25-hydroxyvitamin D level in the 50-80 ng/ml range.
For more information about cancer supplements, check out the “Mycomedicinals (Mushrooms) for Cancer” and “Supplement/Botanical Interactions with Chemotherapy and Radiation” Whole Health tools.

Manipulaion and body-based therapies

Massage

Pain.  A 2019 evidence map created for massage therapy compiled data from 32 systematic reviews, noting that high quality reviews indicate there was low strength of evidence of potential benefits for a variety of types of pain, including cancer pain.[296]  Researchers often did not clarify methodology or outline the specific of interventions used.  A 2023 meta-analysis concluded that there is sufficient data to conclude that massage therapy can be used as a complementary therapy to reduce pain in people with digestive system, breast, and hematological cancers.[297]  Durations of therapy for 10-30 minutes over longer than a one-week period seem to be most effective in the studies reviewed.  A more commonly used protocol of classic massage is twice weekly 30-minute sessions for at least 5 weeks immediately following cancer treatment,[27] but tailoring care to patients’ needs and circumstances is of course necessary.  Massage was found to be a useful tool for reducing anxiety and postsurgical pain for women undergoing treatment for breast cancer.[298] 

Fatigue.  For fatigue management in breast cancer survivors, massage therapy was found in a 2021 study of 10 trials to have a positive effect compared to routine care or sham massage, with reviewers noting that studies had many design flaws.[299] A 2023 review concluded that a several forms of massage significantly improve fatigue in cancer patients.[300]  A 2020 review concluded that massage is also beneficial for sleep for cancer survivors in general.[301] 

General findings. A large randomized clinical trial comparing acupuncture and massage for people living with advanced cancer, the IMPACT trial, found that both therapies reduced pain reduction, fatigue, and insomnia and improved quality of life, but there was no significant difference between the two treatments.[302]  Therapies were administered weekly for 10 weeks and then “booster” sessions were offered for up to a total of 26 weeks.  Swedish massage for cancer patients has been found to alleviate a wide range of symptoms including pain, nausea, anxiety, depression, anger, stress, and fatigue.[100]  A 2004 Cochrane review concluded that massage improves psychological well-being by reducing pain and relieving anxiety.[101]  

Massage therapy for pain is covered in the VA benefits package.  The National Comprehensive Cancer Network (NCCN) now recommends massage in its ‘‘Guidelines for Supportive Care,’’ based on the growing body of evidence of massage safety and benefits for quality of life.  

Massage therapists should have additional knowledge, skill, and experience in safely practicing with cancer patients, which requires specialized training in oncology massage. Typically, pressure should be lighter over bone metastases, areas with peripheral neuropathy, surgical scars, sites of deep vein thrombosis risk, and areas of cancer pain and discomfort.  Overall pressure is modified for patients with thrombocytopenia, leukemia, or whenever easy bruising and bleeding are likely.  To avoid precipitating a lymphedema episode or triggering chronic lymphedema, oncology massage therapists are careful to avoid heat, pressure, and excessive joint movement in the body region served by the missing or compromised lymph nodes.

Biofield Therapies

Biofield therapies are said to help health and healing by allowing for manipulation of the body’s energy field.  Examples include Reiki, Healing Touch, and Therapeutic Touch, and while, in general, more research is needed to gauge their effects, many of these approaches are used in various health care settings.[303,304] 

Reiki.  A 2023 systematic review concluded that Reiki has a positive effect on pain in people with cancer, but the number of studies is limited.[305]  A 2024 review of Reiki for cancer-related fatigue noted that fatigue, stress, and pain seem to be reduced, with improvements in quality of life, but of 794 studies, only 5 met inclusion criteria and again, more research needed.[306]  A study of 42 caregivers concluded that Reiki reduced cancer caregiver stress.[307]  Reiki, massage, and yoga were all reported to decrease anxiety, benefit mood, and enhance self-ratings of quality of life and health in a cancer resource center, and a single-blind, randomized controlled study of 156 participants found that both acupressure and Reiki improved fatigue and reduced pain and analgesic use for people with cancer receiving palliative care.[308,309] 

Healing Touch (HT).  A study of 572 cancer outpatients concluded that HT and oncology massage both provided immediate pain relief, though more studies are needed to assess the duration of this effect.[310]  A similar study specifically for breast cancer found similar results.[311]  During radiation therapy, HT was found to improve subjective symptoms but not objective measures of outcomes such as toxicity or pain.[312]  A study of HT for women undergoing cervical cancer chemoradiation found that cytotoxicity symptoms and depression decreased compared to patients doing relaxation therapy or standard care.[313]  HT also seems to provide improvements in pain, stress, and fatigue for children with cancers and their caregivers.[314]

Therapeutic Touch (TT).  A 2016 literature review concluded that TT is a useful non-invasive intervention for cancer and that it has positive effects on pain, anxiety, fatigue, and nausea.[315]  A 2008 study of 90 patients undergoing chemotherapy found that TT was more effective than placebo in decreasing pain and fatigue.[316]  A 2015 study in mice found that TT slowed rates of breast cancer metastasis but did not change primary tumor size.[317]

As long as they are not used in place of conventional approaches, biofield therapies tend to be quite safe.  To learn more about biofield therapies, see Chapter 17 in the Passport to Whole Health. 

Healing Systems

Chinese Medicine

Chinese medicine (CM) encompasses the use of herbs, moxibustion, and acupuncture, among many other techniques, to individualize therapy for each person. CM can be very effective at reducing the side effects of cancer treatment including pain, nausea, anxiety/depression, and neuropathy.[318-322]  Most studies of Chinese Medicine for cancer focus on acupuncture.

For further information on incorporating CM into cancer care, refer to the “Managing Side Effects of Chemotherapy and Radiation” Whole Health tool.

Acupuncture

Acupuncture has been widely studied for its potential benefits for people with cancer.  There has been a deluge of large-scale reviews and meta-analyses in recent years, the majority of which are quite favorable.  Some important large-scale research findings include the following:

• General reviews. An overview of 51 systematic reviews done in 2022 concluded that acupuncture has benefit for cancer survivors with overall quality of life, arthralgia, swallowing problems, insomnia, fatigue, cancer-related pain, bone marrow suppression, nausea and vomiting, and menopausal symptoms.[323]  Potential benefit was also seen for dry mouth, lymphedema, and overall digestive function. 
• Adverse effects of chemotherapy or radiotherapy. A 2023 systematic review concluded, based on the results of 23 studies, that acupuncture is safe and can reduce chemotherapy-induced neuropathy, dry mouth, fatigue, insomnia, gastrointestinal symptoms, and pain, as well as improve cognitive capacity.[324,325]  A 2023 review and meta-analysis concluded that “Acupuncture in addition to usual care may increase the complete control of chemo-therapy induced acute vomiting and delayed vomiting but the certainty of evidence was very low.”[326]  It also helps with opioid-induced constipation.[327]
• Cancer-related fatigue. A 2023 review of 34 trials concluded that acupuncture is a safe and effective treatment for cancer-related fatigue.[328]
• Cancer-related insomnia. A large 2022 review of 22 studies found that “Acupuncture has great potential to be used to manage cancer-related insomnia for cancer patients or survivors.”[329]  A 2024 review and network meta-analysis found that ear acupuncture combined with moxibustion and ear acupuncture alone were more effective than control, medications, sham acupuncture, or usual care.[330]
• Cancer Pain. Acupuncture is likely to be helpful for pain reduction in people with cancer who are receiving palliative care, though more studies are needed to gauge this, according to a 2021 systematic review involving 189 participants.[331]  Both ear acupuncture and electroacupuncture were found to be beneficial for pain in a study of 360 cancer survivors, the PEACE randomized clinical trial.[332]  A large 2024 review also found positive benefit.  A large systematic review and meta-analysis from 2020, featured in JAMA Oncology, found that both acupressure and acupuncture have a moderate level of evidence supporting their benefits for cancer pain and the reduction of analgesic use.[333]  A clinical practice guideline focused on acupuncture for pain was developed in 2022 and can be a useful resource.[334]  Acupuncture has a good safety profile in the management of cancer pain.[335] 
• Breast cancer-specific findings. A large systematic review and meta-analysis reported in 2021 found benefit for an array of symptoms and concerns, including quality of life, fatigue, sleep problems, anxiety, hot flashes, and pain.[336]
• Lung cancer-specific findings. A 2022 review of 33 trials found promising benefits for pain, insomnia, anxiety and depression, nausea and vomiting, fatigue, constipation, and overall quality of life in a group of 3,002 lung cancer patients.[337]

More information on acupuncture’s role in the management of cancer treatment side effects is available in the Managing Chemotherapy-Induced Nausea and Vomiting, and Managing Side Effects of Chemotherapy and Radiation Whole Health tools.

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