Background

Comprehensive oncologic care increasingly includes integrative medicine (IM) modalities to provide patients with holistic support and effective symptom management. By combining evidence-based complementary therapies with conventional cancer care, IM services can help manage symptoms and thereby maximize quality of life throughout the illness trajectory. Children with cancer and hematologic illness are at high risk for physical and emotional symptoms.^1,2 They experience both acute and chronic symptoms caused by their disease and/or its treatment, which can be difficult to manage.^3,4 Physical symptoms—especially pain—can significantly decrease quality of life, as they interfere with sleep, daily activities, and the ability to experience joy.³ Common physical symptoms treated during cancer therapy include refractory nausea/vomiting, pain, mucositis, and fatigue.

Suffering from physical symptoms can also exacerbate emotional disturbances. In children and adolescents with cancer, 48% meet criteria for anxiety or depressive disorders during the first year after diagnosis,⁴ which has been linked to an increased perception of pain intensity and worsened mood dysregulation.^5,6

When attempting to manage symptoms pharmacologically, polypharmacy may add to cumulative side effects and create overlapping toxicity. IM endorses multimodal symptom interventions, combining conventional approaches (eg, medications, physical rehabilitation, psychotherapy) with complementary approaches (eg, acupuncture, massage, mindfulness, yoga), with an emphasis on treating the whole person rather than just the diseased organ system.^7,8 One goal of IM is to better manage refractory symptoms and moderate polypharmacy by reducing or replacing medications when possible.⁹

Recommendations for the incorporation of evidence-based IM services are included in guidelines from the Society for Integrative Oncology (SIO),¹⁰ ASCO,¹¹ and several supportive care guidelines from NCCN.^12–14 A 2017 review of NCI-designated Comprehensive Cancer Centers found that most had IM content on their websites, indicating the availability of various IM services.¹⁵ A 2021 comparison of comprehensive cancer centers and community hospitals demonstrated decreased IM service availability in community-based hospitals.¹⁶ Both studies relied on website content, which may not accurately reflect actual IM service provision, availability, or utilization.

In December 2020, we launched a new IM service at St. Jude Children’s Research Hospital (St. Jude), a national comprehensive cancer center that serves pediatric, adolescent, and young adult patients with hematologic and oncologic conditions. The St. Jude IM service implements evidence-informed practices, including acupoint therapy (meaning acupuncture or acupressure, depending on patient preference), massage, yoga, and aromatherapy. The service also educates patients and families about the risks and benefits of complementary therapies used alongside disease-directed treatment. We conducted a retrospective review of 18 months of IM service metrics to assess referral trends and patterns of use by examining patient characteristics and aggregating clinical utilization data. The findings will help fill a knowledge gap regarding the use of IM consultative services and complementary therapies in a comprehensive cancer center.

Methods

The Pediatric Integrative Medicine program provides comprehensive integrative oncology consultations for all new referrals, including both inpatient and outpatient care. Referrals can be made by physicians or advanced practice providers. The outpatient clinic is available 2 days per week. Initial consultations are 60 minutes in length and assess key pediatric pillars of health for hematology and oncology patients. These include diet, physical activity, sleep, mind–body practices, family relationships, and any questions related to dietary supplements, vitamins/minerals, or alternative cancer practices that families may be considering. The consultation also elicits focused information about cancer therapy and disease- or treatment-related symptoms. Complementary therapies are then offered to address identified concerns and may include pediatric massage, acupoint therapy, aromatherapy, and/or yoga training. Consultations are conducted by a pediatric oncologist who is dual board-certified in Hospice & Palliative Medicine and Integrative Medicine and is also certified in acupuncture. Subsequent visits are offered for 30-minute massage sessions (provided by pediatric-trained licensed massage therapists), 30-minute acupoint sessions (provided by 2 medical acupuncturists), ≥30-minute yoga training sessions (led by dual-trained physical therapists and yoga teachers), and 30-minute follow-up sessions with the pediatric integrative oncologist (PIO) for further information about potential modalities of interest. All patients at St. Jude have access to a dedicated social worker, a psychologist (with the option for ongoing psychologic care), and a dietician in both the inpatient and outpatient settings. Specific questions regarding cancer-related dietary modifications are addressed by pediatric dieticians in conjunction with the PIO in the IM clinic. However, all patients, regardless of referral, have access to routine nutritional support and are monitored for weight loss and/or malnutrition. All integrative services are provided free of charge to St. Jude patients.

To collect utilization data for this clinical intervention, a retrospective review was conducted of electronic medical progress notes and orders for patients who received IM consultations between December 2020 and June 2022. Demographic variables collected included age, sex, race/ethnicity, religion, and primary language. Disease-related variables included diagnosis, primary service, disease status, and operational goal at the time of consultation. Referral characteristics included referring provider discipline, reason for referral, and comanagement by psychosocial services.

A detailed data dictionary was created for variable extraction to ensure data integrity. Referred patients were identified by IM consultation orders, and inclusion was confirmed by the presence of an IM consultation note. Participant charts were reviewed for IM service utilization, including acupuncture/pressure, pediatric massage, and/or yoga sessions. Data were audited for accuracy and analyzed using descriptive statistics, including means, medians, counts, and ranges. Associations between patient characteristics were assessed using the Kruskal-Wallis test for continuous variables and the Fisher exact test for categorical variables. A P value of <.05 was considered statistically significant. All analyses were conducted using R version 4.3.0 (R Foundation for Statistical Computing).

Results

From December 2020 to June 2022, 174 pediatric patients were referred for IM consultation, of whom 155 had documented IM consultations; 19 patients were referred but not seen, resulting in a 10.9% no-show rate. There were no statistically significant differences in demographic factors between patients who received IM consultations and no-show referrals (Supplementary Table S1, available in the supplementary materials).

The mean age of IM consult patients was 12.9 years (range, 4 months–25 years; Table 1). Most self-described as White (67.7%), non-Hispanic (85.8%), and female (52.9%). Christianity was the predominant religion, whereas 20.6% did not disclose a religious affiliation. English was the primary language for 92.3% of patients (Table 1). Patients were referred from all primary services, with the highest proportion from Neuro-Oncology (31.6%), followed by Leukemia/Lymphoma (20.0%), Solid Tumor (20.0%), Bone Marrow Transplant/Cellular Therapies (TCT; 13.5%); Hematology (11.0%); and Radiation Oncology (3.9%) (Table 1).

When comparing the patients who received IM consultations (n=155) with the 1,470 new patients presenting to St. Jude during the same period, significant differences were observed in primary service, race, age (all P<.001), and religion (P=.03). Patients from Neuro-Oncology and TCT proportionately received IM consultations at higher-than-expected rates (P<.001) (Table 1), while referrals from Hematology were underrepresented. IM patients were more likely to be White, biracial/mixed race, or Asian (P<.001) and were older on average compared with the broader patient population (P<.001).

The most common diagnoses among IM patients were brain tumors (33.6%) and sickle cell disease (SCD; 14.8%). Notably, patients with SCD could be referred to IM by TCT services, if they were receiving bone marrow transplantation or gene therapy (Table 2). At the time of IM referral, 57.4% (n=89) of patients were receiving primary disease-directed therapy, 21.3% (n=33) were receiving salvage therapy for refractory disease, 5.2% (n=8) were off therapy with no evidence of disease, and 1 (0.6%) patient had progressive disease and was not receiving further cancer-directed treatment. Documented goals of care included cure in 66.5% (n=103) of patients and life prolongation in 10.3% (n=16). Hematology patients typically did not have a documented goal of care (Table 2).

Most IM referrals were made by advanced practice providers (46.5%), followed by attending physicians (28.4%) and fellows (12.3%) (Table 2). The most common reason for IM referral, as indicated in the provider order, was refractory symptoms (49.7%) (Figure 1). Among these, pain (20.9%) and anxiety (8.0%) were the most frequently specified symptoms when documented. Approximately 1 in 5 consultations involved discussions with parents interested in the use of alternative therapies (Figure 1).

View Full Size

Reasons for referral to integrative medicine as defined by pediatric hematology-oncology providers.

Citation: Journal of the National Comprehensive Cancer Network 2025; 10.6004/jnccn.2025.7021

Following comprehensive IM consultation, patients could choose to receive therapeutic services, including massage, acupoint therapy (ie, acupuncture and/or acupressure), and/or yoga. Any therapy services or body areas that required modification (eg, sites of tumor or fracture, low blood counts based on PIO medical chart review) were communicated to the massage and acupuncture providers after initial consultation. If a patient returned for a “hands-on” IM therapy (eg, massage, acupoint, or yoga), that visit was documented by service received. Follow-up visits with the PIO were recorded if the patient returned for further discussion or medical management without receiving hands-on therapy services. Regarding IM service utilization, 30.4% of participants had at least 1 follow-up visit with the PIO (mean visits, 0.51; median, 0 [range, 0–8]). However, 56.1% of participants returned for massage therapy (mean visits, 3.07; median, 1 [range, 0–23]), and 50.3% for acupoint therapy (mean visits, 5.07; median, 1 [range, 0–24]). The mean cumulative number of IM encounters per patient was 9.15 (median, 5 [range, 1–84]) (Table 3). Notably, no serious adverse events (eg, bleeding, significant bruising, or infection) were recorded after any therapy session.

Indications for acupoint therapy were assessed through chart review. Of the 462 completed acupoint sessions, 53.7% addressed patient-described musculoskeletal or neurologic issues (Table 4), including musculoskeletal pain (26.0%); paresis/weakness, paresthesia (eg, foot drop, neuropathy), and/or spasticity (13.2%); and musculoskeletal tension, such as shoulder tension, jaw tightness, or myalgias (6.7%). Gastrointestinal complaints were the second most common reason for acupoint services (24.7%), with 9.1% of sessions for nausea/vomiting.

Nearly all patients who received IM services were seen by Psychology (95.5%) and Physical Therapy (85.8%). In addition, 45.2% received subspecialty Palliative Care, 44.5% received Psychiatry services, and 41.9% received Pain Management services (Figure 2).

View Full Size

Involvement of psychosocial services in the care of pediatric hematology-oncology patients referred to integrative medicine services.

Citation: Journal of the National Comprehensive Cancer Network 2025; 10.6004/jnccn.2025.7021

Discussion

Designing and implementing a new IM program in a comprehensive cancer center presented both opportunities and challenges. The goal of IM is to seamlessly integrate complementary modalities into conventional care to alleviate symptoms and promote wellness.^7,8 Integrative oncology aims to optimize health, self-efficacy, and quality of life across the continuum of anticancer treatment.^8,17 Patients and families seeking nonpharmacologic means of managing refractory symptoms may benefit from these therapies.

By integrating the body, mind, and spirit in healing, IM empowers patients and equips them to better cope with their disease.^18–20 Many pediatric institutions are developing IM programs, yet few are specifically designed for the needs of hematology/oncology patients. Disease-directed treatment of cancer or hematologic disorders can complicate the use of IM due to substantial concerns about severe neutropenia and/or thrombocytopenia, and the related risk of serious infection or bleeding, combined with the use of many concurrent medications. However, pediatric hematology/oncology patients are also ideal candidates for IM services due to their high symptom burden^21–24 and unmet physical and emotional needs.^25–29

Despite guidelines recommending incorporation of IM into comprehensive cancer care,^10–14 it is unknown how many cancer centers routinely offer IM for children undergoing oncologic therapy. Anecdotally, IM services are predominantly adult-facing, and children’s needs may go unmet due to lack of availability or referral biases. A recent publication defining pediatric integrative oncology notes that IM should be offered throughout a child’s cancer trajectory to allow patients to be active participants in their care.⁸ Although a review of all US NCI-designated Comprehensive Cancer Centers revealed that most have IM services available, data on actual IM utilization for children undergoing cancer therapy are lacking. Inspired by these guidelines and using available literature, patient/family input, and expert clinician guidance, we formally established an IM program in December 2020.

Although IM referrals spanned a wide age range, the mean and median ages of 12 and 14 years, respectively, were not surprising, given that many IM services require patient assent and participation. IM service utilization has been shown to differ by age due to the uptake of developmentally appropriate services. Studies document that younger children prefer dance and/or music therapy, whereas school-age children and adolescents are more likely to participate in mind-body therapies, massage, and acupoint therapy.³⁰ Children as young as 5 years have received acupuncture in our clinic without issue, but participation is optional, based on the child’s maturity and temperament, and requires the child’s real-time assent. In this way, the IM clinic encourages patient control and bodily autonomy in treatment. Patients who completed an initial IM consultation were followed clinically at their discretion, with more than half proceeding with regular IM therapy visits. Children suffer during anticancer therapy, and despite recent evidence that “normalization” of symptom-based distress occurs, patients and families strive to improve quality of life throughout the course of therapy and often opt into care deemed beneficial.²²

We hypothesized that most referrals would come from our Neuro-Oncology service because patients with certain aggressive brain tumors (eg, diffuse midline gliomas) have few standard options for curative chemotherapy-based treatment, leading to increased inquiries about alternative treatments. Therefore, it was not surprising that the largest referral source (31.6%) was Neuro-Oncology, despite only 13.9% of new patients with neuro-oncology diagnoses during the same timeframe. However, it was surprising that Leukemia/Lymphoma and TCT patients comprised 20% and 13.5%, respectively, of IM referrals. We anticipated fewer referrals from these services due to the required medically aggressive inpatient care, prolonged periods of neutropenia and thrombocytopenia, and resultant concerns about infection and/or acute illness.³¹ Yet, TCT patients have high symptom burdens,³² so perhaps refractory suffering prompted the IM referrals.

During the study period, benign hematology patients were the most common (44%) new referrals to the institution, yet they comprised only 11% of IM referrals. Some hematology consultations involve patients not diagnosed with chronic hematologic disorders requiring subspecialty level follow-up. As IM consultations are part of ongoing care for chronic hematology-oncology disorders, patients seen for one-time hematology consultations without return appointments at our institution are not offered IM referrals. However, SCD affects the entire body; pain is a primary morbidity, and significant organ dysfunction can limit life expectancy. Because IM portends a wellness focus for those living with chronic illness, patients with SCD are a priority for referral. Pilot clinics offering comprehensive integrative services to patients with SCD have shown that patients and families deem IM involvement as positively contributing to care.^33,34 To decrease logistical burdens and help promote IM for patients with SCD, IM providers will be embedded into the SCD Teen Clinic with the goals of streamlining access and facilitating collection of longitudinal symptom management data, which are currently lacking.

We anticipated that most patients referred to IM services would have relapsed or refractory disease, given that IM use may be associated with “salvage” therapy when cure-directed treatments are unavailable.^35,36 We also hypothesized that most IM referrals would come from patients engaged with the subspecialty Palliative Care team due to disease trajectory. However, most patients with cancer referred to IM services were receiving primary disease-directed therapy and had a goal of cure. Fewer than half of the patients seen by the IM team were receiving subspecialty Palliative Care services. Our data suggest that patients in earlier phases of treatment or those with good prognosis are referred to and are interested in complementary therapies alongside cancer-directed therapy. Despite a philosophical overlap, IM is not synonymous with palliative care or exclusive to children with poor prognosis who lack cancer-directed options. Our data also highlight the willingness of clinicians to refer patients with refractory symptoms, regardless of their current disease-based treatment.

Parents inquiring about supplements or frankly alternative practices are referred to the IM service for in-depth conversations with practitioners trained to share evidence-based knowledge in this area. The IM team rarely recommends additional medications or supplements during cancer treatment due to concerns about interactions and the lack of robust dosing and efficacy data in children with cancer. However, IM providers comprehensively document all medications and supplements patients are currently taking and discuss concerns regarding products that families are considering. Adult cancer studies show that although many patients take supplements concurrently with anticancer therapy, they rarely disclose it to their care team.³⁷ Among children experiencing frontline anticancer therapy failure, as many as 65% use supplements or herbal medications, with 60% never discussing it with their oncology providers.³⁸ There is also concerning data showing that significant medication–herb interactions are found in up to 27% of adult patients with cancer disclosing herbal medication use during therapy.³⁹ In the IM clinic, we encourage parents to openly share what they administer (or hope to), and nonjudgmentally listen to enable evidence-informed discussions about the risks and benefits of specific products during anticancer therapy. Importantly, patients seen in the IM clinic have their supplement and botanical history documented (including “no use”) in the medical record.

Of the IM services offered, massage is the most popular. Patients are seen for specific musculoskeletal complaints or for general relaxation. Echoing what has been published by other institutions, including pediatric massage therapy in the care of PHO patients is feasible and well received by patients and parents.^40–45

Acupuncture is increasingly used in conjunction with Western medicine for managing acute and chronic pain,^9,46,47 and is recommended in the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Antiemesis for refractory chemotherapy-induced nausea and vomiting,¹² though few high-quality studies focus its the use in children with cancer.^48,49 Studies have shown that even with severe thrombocytopenia, acupuncture precipitates minimal evidence of bleeding in children with cancer.^50–53 To date, no serious adverse reactions to acupoint therapy (including infection or bleeding) have been reported in 462 documented acupoint encounters in our clinic.

Acupoint therapy was the second most requested IM service, with half of the patients having at least 1 acupoint session (mean >5 sessions). Similar to our findings, among acupuncture-naïve pediatric oncology patients, 54% chose to undergo acupuncture when it was offered to help with common symptoms,⁵¹ with pain, nausea, lack of energy, and irritability being the primary precipitating symptoms.⁵¹ We similarly found that patients presenting for acupoint therapy most often reported musculoskeletal, neurologic, and gastrointestinal complaints, although a range of other symptoms were also noted (Table 4).

Finally, most IM-referred patients were engaged with other services that offer psychosocial, physical, or emotional support as a result of St. Jude’s integrated model of psychosocial care,⁵⁴ which includes psychological assessments and universal interventions for all patients undergoing oncology or bone marrow transplantation care.⁵⁵ Importantly, members of these services comprise our institution’s Integrative Medicine Working Group and have been integral in planning, implementing, and providing IM services. Foundational to the practice of IM is multidisciplinary providers working in a coordinated way to ensure that available evidence-informed options are offered.⁷ In no way does IM replace other vital psychosocial services provided to families.

Conclusions

IM services can be incorporated and used effectively in a comprehensive cancer center to optimize patient wellness, mitigate symptoms, and improve quality of life. We conclude that if IM services are made available to pediatric patients, hematology/oncology providers will refer patients to them and patients will engage with these services. Future research and strategic program expansion should focus on targeted services for populations with high symptom burdens and the collection of symptom outcome data to assess the impact of IM services longitudinally.