Pain is an incredibly challenging symptom that affects over 40% of patients with cancer in active treatment¹ and up to two in three patients with advanced cancer.² Analgesic pain medications including opioids have been the predominant pain management strategy; however, their use is limited by adverse effects; clinician prescription hesitation due to the opioid epidemic; and patient concerns about side effects, polypharmacy, and drug interactions.^3,4 Therefore, non-pharmacological treatments for pain are needed to reduce cancer-related pain and improve patient function and well-being.

The IMPACT Trial

The Integrative Medicine for Pain in Patients With Advanced Cancer Trial (IMPACT) evaluated the comparative effectiveness of acupuncture and massage for moderate-to-severe musculoskeletal pain among patients with advanced cancer.⁵ Over 26 weeks, participants who were randomly assigned to the acupuncture group had reduced their “worst pain” score by 2.53 points (95% confidence interval [CI] 2.15 to 2.92) relative to baseline using a 10-point scale, and participants who were randomly assigned to the massage group had reduced their worst pain score by 3.01 points (95% CI 2.63 to 3.38). Informed by this research, joint clinical guidelines from the Society for Integrative Oncology (SIO), a multidisciplinary international professional organization with a mission to advance evidence-based integrative oncology services, and ASCO recommend acupuncture and massage for management of pain in patients with cancer.⁶ 

Despite this evidence, multiple barriers impede implementation of the IMPACT protocols in real-world clinical settings. First, most licensed acupuncturists and massage therapists are trained in general techniques but may not be familiar with oncology-specific strategies. Second, oncology providers and patients have limited knowledge of the nature and benefits of acupuncture and massage therapy for pain. Third, acupuncturists and massage therapists report feeling isolated within their health systems with few opportunities for peer consultation or interactions with research teams.⁷ 

The IMAGINE Project

The purpose of the Implementing Massage and Acupuncture to Achieve Better Pain Management in Oncology Care (IMAGINE) project is to overcome these barriers and implement the IMPACT protocols in diverse cancer care delivery settings. IMAGINE is a collaboration between Memorial Sloan Kettering Cancer Center and SIO, and the effort also actively engages patient partners and various clinical stakeholders to ensure that the project is utilizing patient-centered approaches.

Among the 35 cancer centers participating as IMAGINE sites, 22 are National Cancer Institute (NCI)–designated centers and 13 are non-NCI centers located in 22 states across rural (n = 6) and urban areas (n = 29). Sites are divided into four cohorts and proceed through the IMAGINE project in two phases: active implementation and maintenance. Active implementation spans 12 months for each cohort, followed by a maintenance phase that extends to the end of the project.

IMAGINE: Evidence-Based Implementation Strategies

IMAGINE utilizes three evidence-based implementation strategies that address barriers to safe and effective acupuncture and massage therapy for people with cancer.⁷ Materials for all implementation strategies are available to sites on the SIO website to maximize ease of use.

First, educational courses train acupuncturists and massage therapists on the IMPACT protocols. The courses are delivered via digital curricula on a virtual learning platform. They are self-paced and can be accessed on-demand, offering flexibility for learners and facilitating access across broad geographic areas with different time zones. Clinicians who complete the courses receive free continuing education units (CEUs).

Second, educational materials are provided to increase awareness in patients, families, and oncology providers of the benefits of acupuncture and massage for managing pain and symptom burden. These materials include patient handouts, short videos describing acupuncture and massage for patients and oncology clinicians, informational blogs, and recommended language for acupuncturists and massage therapists to use when describing these modalities to people with cancer and oncology clinicians. Third, external facilitation meetings allow acupuncturists and massage therapists to identify problems and develop solutions to implementation barriers in a group context with trained facilitators and acupuncturists and massage therapists from across the country.^8,9 External facilitation meetings are held remotely by cohort and occur monthly during the first 6 months of the 12-month active implementation phase and every other month over the last 6 months.

The evaluation plan for IMAGINE is informed by a widely used framework for reporting outcomes of implementation activities, RE-AIM (reach, effectiveness, adoption, implementation, and maintenance). RE-AIM is used for assessing whether an intervention works, reaches the right people, can be adopted and carried out successfully, and can be sustained over time.¹⁰ The primary outcome is defined as the number of patients with cancer and pain who are treated with an IMPACT protocol. In addition, guided by the Consolidated Framework for Implementation Research (CFIR), we will use mixed methods with rapid-cycle, iterative evaluations to assess sites’ experiences with implementation barriers and facilitators and obtain feedback on successful long-term maintenance and scale-up.^11-13 Data will be collected through a quantitative survey and focus groups.

Integrative Oncology and Implementation Science

IMAGINE is the first nationwide integrative oncology implementation project and will advance the fields of integrative oncology and implementation science in multiple ways. First, the utilization of evidence-based implementation strategies to address the identified challenges in integrative oncology will promote high-quality treatment that will improve pain and symptom burden in people with cancer. Second, the diversity across IMAGINE sites will inform future scale-up by allowing us to tailor the implementation strategies for different clinical settings and patient populations. Third, SIO will continue to disseminate information about the IMPACT protocols and IMAGINE project resources after completion of the funding period. This will sustain the implementation process beyond project funding, reaching new patient communities and sites nationally and internationally. Finally, all IMAGINE procedures are conducted within the regular workflow at IMAGINE sites.

Guest Editor

Jun J. Mao, MD, MSCE

Dr. Mao is the Laurance S. Rockefeller Chair in Integrative Medicine and Chief of Integrative Medicine Service at Memorial Sloan Kettering Cancer Center, New York.

This pure focus on implementation provides an opportunity to better understand the nature and outcomes of intervention adaptations across diverse sites, utilization of the implementation strategies, and effective methods of engaging acupuncturists and massage therapists in the course of routine cancer care. As research continues to inform guideline development, systematic implementation is required to translate research findings into a clinical reality and ensure enhanced pain and symptom management for people with cancer. 

DISCLOSURE: This work was funded through Patient-Centered Outcomes Research Institute (PCORI) awards (DI-2024C1-37390 and SMPAI-2018C2-12883). The statements in this work are solely the responsibility of the authors and do not necessarily represent the views of the Patient-Centered Outcomes Research Institute (PCORI), its Board of Governors, or Methodology Committee. Dr. McConnell reported no conflicts of interest. Dr. Mao has received grants from Tibet CheeZheng Tibetan Medicine Co., Ltd. and Zhongke Health International LLC to the Memorial Sloan Kettering Cancer Center outside of the submitted work.

References

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2. Snijders RAH, Brom L, Theunissen M, et al: Update on prevalence of pain in patients with cancer 2022: A systematic literature review and meta-analysis. Cancers 15:591, 2023

3. Paice JA, Bohlke K, Barton D, et al: Use of opioids for adults with pain from cancer or cancer treatment: ASCO Guideline. J Clin Oncol 41:914–930, 2023.

4. Liou KT, Trevino KM, Meghani SH, et al: Fear of analgesic side effects predicts preference for acupuncture: A cross-sectional study of cancer patients with pain in the USA. Support Care Cancer 29:427–435, 2021.

5. Epstein AS, Liou KT, Romero SAD, et al: Acupuncture vs massage for pain in patients living with advanced cancer: The IMPACT randomized clinical trial. JAMA Netw Open 6: e2342482–e2342482, 2023.

6. 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.

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11. Balbale SN, Schäfer WLA, Davis TL, et al: A mixed-method approach to generate and deliver rapid-cycle evaluation feedback: Lessons learned from a multicenter implementation trial in pediatric surgery. Implement Sci Commun 4:82, 2023.

12. Skillman M, Cross-Barnet C, Friedman SR, et al: . A framework for rigorous qualitative research as a component of mixed method rapid-cycle evaluation. Qual Health Res 29:279–289, 2019.

13. Holdsworth LM, Safaeinili N, Winget M, et al: Adapting rapid assessment procedures for implementation research using a team-based approach to analysis: A case example of patient quality and safety interventions in the ICU. Implement Sci 15:12, 2020.

Kelly M. McConnell, PhD, is an Attending Psychologist and Director of the Psycho-Oncology of Cancer and Aging Program; Jun J. Mao, MD, MSCE, is Chief, Integrative Medicine and Wellness Service; Memorial Sloan Kettering Cancer Center, New York, New York.