Scaling Integrative Oncology: Implementation and Patient-Reported Outcomes

The field of integrative oncology is increasingly adopting a comprehensive evidence-based care model that integrates behavioral and mind-body interventions with conventional treatment. In an interview with CancerNetwork®, Linda Carlson, PhD, RPsych, noted how the clinical focus has transitioned from establishing efficacy to optimizing implementation. Current Society for Integrative Oncology (SIO) and American Society of Clinical Oncology (ASCO) guidelines now formally recommend mindfulness-based interventions (MBIs), yoga, and exercise to mitigate anxiety, depression, and fatigue.^1,2

Carlson highlighted a landmark advancement in 2025, the phase 3 CHALLENGE trial (NCT00819208), which reported a significant survival advantage for patients with colorectal cancer who participated in structured exercise.³ This finding underscored the clinical value of integrative interventions that may offer high utility with negligible adverse effects (AEs). Additionally, she touched upon the IMAGINE trial, in which investigators are actively translating acupuncture and massage into routine practice across 35 US cancer centers, shifting these therapies from clinical trial settings to standard workflows.⁴

Emerging research is also addressing existential distress in advanced disease through psychedelic-assisted therapies, supported by networks like The CAnadian Network for Psychedelic-Assisted Cancer Therapy (CAN-PACT).⁵ By treating patient-reported outcomes (PROs) as critical prognostic indicators rather than secondary data, the multidisciplinary team can bridge the gap between survivorship and quality of life. Future SIO/ASCO joint guidelines, such as those for sleep and fatigue, are expected to prioritize these behavioral and integrative strategies over traditional pharmacological approaches.

Carlson is the Enbridge Research Chair in Psychosocial Oncology and a professor in the Department of Oncology, Cumming School of Medicine at the University of Calgary.

CancerNetwork: What key advances in AE-reducing integrative strategies have emerged for anxiety and depression among patients undergoing treatment for cancer?

Carlson: It makes sense to go back to the guidelines that we published—the joint guidelines with SIO and ASCO—specifically for anxiety and depression. Some of the recommendations there were for things like mind-body therapies, mindfulness-based interventions, and yoga. With the guidelines being out there for a year or so now, the focus is on implementation; how do we get access to these evidence-based therapies for more people at different cancer centers…throughout the world?

Another thing is conducting research on some of the populations that we don’t know as much about. Those guidelines are largely based on research on women with breast cancer. There tends to be more [women] in this research. There tends to be [patients] with more common cancers, like breast cancer, and tends to be more early stage. What kinds of therapies would help people more in palliative stages, for example? Also, what about different types of cancer, the less common ones? What about people with lung cancer, head and neck cancer, and underrepresented groups or [those with] different ethno-racial backgrounds? There’s still a lot we don’t know about the best types of integrative therapies for people from diverse backgrounds.

How have mindfulness strategies impacted quality of life and psychosocial symptoms among patients with cancer?

Mindfulness-based interventions are a good example because some of the strongest evidence and the strongest recommendations, both for anxiety and depression but also for managing fatigue, are around these types of interventions. What we mean when we say mindfulness-based intervention is not necessarily [only] listening to guided meditations or going on a mindfulness app. These kinds of interventions tend to be structured multi-week group programs. People will do 8 weeks in a row with a group of 15 or 20 other participants, and they’re trained in not only doing the practice of mindfulness meditation, but also certain attitudes that a person [might benefit from adopting], things like acceptance, compassion, non-judgment, uncertainty, tolerance…and how to deal with loss of control.

They are not [only] strategies to decrease the physiological arousal but also cognitive strategies to look at the stories we tell ourselves and the different attitudes we might want to apply. A mindfulness-based intervention is a multi-component program. There’s also movement; gentle yoga is incorporated in those programs over a series of weeks, and that’s what’s been investigated as multimodal group-based mindfulness training programs. That’s what we mean by mindfulness-based interventions. We know that those can be super beneficial for people across the board, for a wide range of outcomes. As I said, the issue now is, “Okay, how can we assure that there’s increasing access to those kinds of programs?”

Given the personalized nature of integrative care, what steps does your institution take to standardize the reporting of patient outcomes and AEs in a way that is comparable to data generated in conventional oncology clinical trials?

This idea of patient-reported outcomes, which have been around for [approximately] 100 years in psychology, as not being as important or as reliable as hard outcomes, whether that’s survival or response, is a mistake. Increasingly, research is showing that [for] symptom reports––anxiety, depression, fatigue, pain, nausea, and vomiting––the only way we can measure these things is by asking people how they feel. There’s no other way to measure pain.

The gold standard is asking people about their pain, but research is showing now that those symptom reports at the time of diagnosis can be very accurate predictors of survival down the road. They are prognostic indicators; they are “hard” outcomes that are valuable. If you ask a person what’s more important to them, how long they live or how well they live, people will often prioritize their quality of life or living well. That’s what we’re really focusing on in integrative medicine.

[Additionally,] when we look at integrative therapies, they tend to be safe and inexpensive to administer. I can elaborate on a seminal clinical trial that came out this year looking at exercise: the CHALLENGE trial.³ It was a large multi-site trial where [patients] did exercise and exercise intervention. In this case, it was for people with colorectal cancer, and they did 2 years of supervised exercise with a trainer compared with people who were randomly [assigned] to just usual care.

In that case, we did see significant survival advantages for the people who exercised regularly. There’s now a push, again, around implementation. There’s been a lot of other research linking exercise to better outcomes, but this is the first large phase 3 multi-site trial in this patient population. Now, the push is why aren’t we prescribing regular exercise when it has [nearly] zero [adverse] effects, and it can be as effective as some expensive and chemotherapy-type regimens that are associated with a high level of [adverse] effects?

If a drug was available that does what exercise does, everyone would be prescribed that drug. So, why isn’t everybody prescribed exercise?

How has patient-driven innovation emphasizing a greater desire to preserve quality of life impacted clinical practice in integrative oncology?

Patients want to do the things that they can to personally manage their disease [and] to have the power and control over what kind of treatments or therapies that they partake in to potentially improve quality of life. People are wanting to play an active role in their treatment, and this is one way that they can do that.

What were the advances in integrative oncology in 2025 that you believe had or will have the biggest impact on clinical practice going forward?

I mentioned the CHALLENGE trial and exercise. That’s huge. Another great project that is taking guideline recommendations to practice is called the IMAGINE trial, and it’s funded by the Patient-Centered Outcomes Research Institute [PCORI] out of NIH.⁴ it’s run out of Memorial Sloan Kettering, and what they’re doing with IMAGINE is implementing evidence-based treatment. [This includes] maintenance for pain—acupuncture and massage—across 35 different cancer centers that are participating across the US. They’re taking these evidence-based interventions and working with people at each of these cancer centers to figure out how to get people trained and how to best deliver it to patients. That crossing from efficacy to effectiveness and implementation is important. That trial is an important landmark this year in that that effort.

Another area has become popular when we’re talking about anxiety and depression. We haven’t looked a lot at [patients] with more advanced disease or [who are near] the end of life, and many of these people [have] existential issues and anxiety around death, dying, meaning, and purpose. We see an increased interest in psychedelic-assisted therapies, things like psilocybin, in combination with the mindfulness-based interventions. [This research is] funded across Canada for a clinical network called CAN-PACT.⁵ We’re developing clinical trials across Canada where, in our pilot work, we’re going to look at the effects of psychedelic-assisted therapy on its own vs psychedelic-assisted therapy plus mindfulness training in [patients] with advanced cancer. There’s a lot of interest. You’ll see these studies popping up all over the place around psychedelics, but it’s still early.

There have only been 2 clinical trials done out of the states. One was from Johns Hopkins, and the other was from New York University, and they were quite small clinical trials in this population.^6,7 There’s a lot of ongoing work and larger trials. But the evidence is starting to accumulate.

Is there anything else that you would like to highlight that you might not have touched upon?

This issue around integrating integrative therapies with conventional or mainstream medicine is important. One other step towards that I didn’t highlight is the guideline that we created on fatigue with ASCO.² The interesting thing about that is [we have] other guidelines [for] anxiety, depression, and pain, separate guidelines just on integrative therapies, and then other ones on more conventional therapies. But for fatigue, we combined them.

The fatigue guideline [relates to] any treatment for fatigue, whether it’s drugs, meditation, or exercise. In that guideline, the recommended therapies are almost all behavioral; the ones that have the evidence. Again, mindfulness-based interventions, cognitive behavior therapy, exercise, and the recommendations against [them] are almost all pharmacological. There’s no evidence for psychostimulants and these medications for treating fatigue.

That approach of looking at the bigger picture is helpful because you don’t have to go somewhere for mainstream [care] and somewhere else for integrative [care]. We like to say that it’s just best care or evidence-based care. The new guideline we’re working on now is for sleep, and we’re doing the same thing: we’re combining conventional medication approaches to sleep with more behavioral and complementary approaches to sleep while looking at the evidence for all of those together.

References

1. Carlson LE, Ismaila N, Addington EL, et al. Integrative oncology care of symptoms of anxiety and depression in adults with cancer: society for integrative oncology–ASCO Guideline. J Clin Oncol. 2023;41(28):4562-4591. doi:10.1200/JCO.23.00857
2. Bower JE, Lacchetti C, Alici Y, et al. Management of fatigue in adult survivors of cancer: ASCO–Society for Integrative Oncology Guideline update. J Clin Oncol. 2024;42(20):2456-2487. doi:10.1200/JCO.24.00541
3. Courneya KS, Vardy JL, O’Callaghan CJ, et al. Structured exercise after adjuvant chemotherapy for colon cancer. N Engl J Med. 2025;393(1):13-25. doi:10.1056/NEJMoa2502760
4. IMAGINE Project. Society for Integrative Oncology. Accessed March 25, 2026. https://tinyurl.com/4sheeb8t
5. Carlson LE, Richardson H, Shore R, et al. The CAnadian Network for Psychedelic-Assisted Cancer Therapy (CAN-PACT): a multi-phase program overview. Curr Oncol. 2025;33(1):7. doi:10.3390/curroncol33010007
6. Gukasyan N, Davis AK, Griffiths RR, et al. Efficacy and safety of psilocybin-assisted treatment for major depressive disorder: prospective 12-month follow-up. J Psychopharmacol. 2022;36(2):151-158. doi:10.1177/02698811211073759
7. Petridis PD, Grinband J, Agin-Liebes G, et al. Psilocybin-assisted psychotherapy improves psychiatric symptoms across multiple dimensions in patients with cancer. Nat Mental Health. 2024;2:1408-1414. doi:10.1038/s44220-024-00331-0