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Clinical Thinking and Cancer


 
Cancer and Massage

Clinical Thinking And 
               CANCER

 

 

Although different types of massage therapy are often contraindicated for cancer, knowledgeable, skilled touch is in some form rarely contraindicated.

By Tracy Walton
 

 

People with cancer, deserving and desirous of massage therapy, have met fear and uncertainty from the massage therapy profession. For years, the flat contraindication against massage, originating in concern about accelerating cancer spread, has prevailed without supporting evidence or medical corroboration.1 This has robbed many potential clients and massage therapists of the chance to work together. But the contraindication has taken other serious tolls on the profession by interfering with more meaningful discourse on safe practice for people with cancer. It has prevented two important developments in the field. The first is the formation of concrete safe practice guidelines for the profession. The second is the development of sound clinical thinking skills needed for work with people with cancer.
 
These two things would develop hand in hand, but they are distinct phenomena. Guidelines tell massage therapists what to do. Thinking skills are used to understand the basis of guidelines, analyze them, sort and prioritize them when they conflict, apply multiple guidelines where necessary, and determine how to act in clinical situations where there are no guidelines. To think clinically, massage therapists use knowledge of the body's organ systems, and how each might be affected by massage. Moreover, therapists need to know how the systems behave during a disease state, and in response to medical treatment. They require problem-solving skills that can be abstracted to a variety of cases. Many massage therapists state that they did not receive enough practice in this during their training, and have had to develop some of these skills on their own. Most were told to avoid working with people with cancer. The prohibitions have stood, and stifled the development of more sophisticated curriculum.
 
Against this tide, massage therapists, clients, and medical providers have still managed to move the work forward. Earlier massage and bodywork literature began to question the contraindication and describe possible benefits of massage.2, 3, 4 In the last year, at least two books were published on this topic: Gayle MacDonald's Medicine Hands: Massage Therapy for People with Cancer,5 and Debra Curties'  Massage Therapy and Cancer.6 Both elaborate on guidelines, emotional preparation for the work, and the clinical thinking necessary to work with this population. Moreover, several cancer treatment centers include or support massage for their patients.7  The benefits of massage for people with cancer are investigated in more controlled trials, and are being described as relief from pain, anxiety and depression, help with negative body image issues and myriad other effects.8  Other authors have outlined bodywork and movement strategies for clients in rehabilitation.9
 

Clearly, thoughtful work about massage and cancer has already begun. The profession needs to agree on guidelines and clinical thinking skills necessary to work more widely with people with cancer, and to do so safely and well. The flat contraindication is facing increased scrutiny. It is tempting to simply throw off the burden of years of prohibition, follow some guidelines and begin working. But cancer treatment is extremely medically complex, and delicate handling of each case is necessary to prevent injury. Thoughtful education, safe practice principles, and practice in clinical thinking are needed to replace the "hands-off" rule. Then we will be able to step more firmly forward in our work with this population. Dialogue in the field has begun, more is needed, and the time is ripe. 
 
In this rapidly developing field, many massage therapists still rely on a note from the client's doctor, or formal physician orders, as permission and directives for the massage session. This is an important step, deferring correctly to the physician's longer training and wider scope of practice. For a client in recent or current cancer treatment, it is critical to include the physician as well as the client in clinical decisions about massage, accommodate the contraindications, and an often changing and complex medical picture. 
 
Yet one weakness in the "note-from-the-doctor" approach is that many health-care providers are unaware of the effects of massage and corresponding contraindications. It's our duty to educate them about this, as sketchy as we may feel our training was in this area. As professionals, we must do our own homework before consulting the physician, by learning everything we can about the client, cancer, the treatments, the side effects, and the possible massage implications. We do this for our own information, and to work more productively with the medical staff. This homework step lends sophistication to the process of including the client's medical staff. 
 
To that end, this article summarizes some specific safe practice concerns for clients in cancer treatment. The directives are designed to serve as jumping-off points for consultation with a client's physician, rather than ends in themselves. The details of common cancer treatments are outlined, with suggested steps for carrying out safe, effective massage therapy for each situation. 
 
The scope of this article includes clients who are actively or recently in cancer treatment. Four general steps are described, along with some supporting clinical thought processes. Although many of these safe practice guidelines also are tabulated in a sidebar for easy reference, readers are encouraged to seek more advanced reasoning via continuing education or through the available literature about massage and medical conditions. Many massage therapists assert that they were issued only brief "laundry lists" of contraindications at some point in their education, and find themselves applying the information reflexively rather than thoughtfully. To work with the most common clinical picture, including multiple diseases and treatments, requires more than one isolated response to that picture. Far from providing complete answers, brief lists of guidelines merely begin the dialogue among massage therapists, and with other health-care providers.
 
In this developing field, new literature appears regularly about the potential impact of massage on disease processes.10  Massage therapists are discussing massage contraindications, benefits and indications more widely, and seek the information and skills needed to reason through complex clinical scenarios. It makes sense to identify the key issues around massage and cancer.
 
None of the steps listed below is designed to replace a physician's input and permission for massage. Instead, it is designed to strengthen the therapist's communication with the medical team. 

Step 2-Consider Adjusting Massage To The Cancer
After information-gathering, a second step, using clinical thought, is required. Having learned from the client about the type of cancer and its manifestation in the client's body (location, symptoms, etc.), the therapist needs to generate adjustments to the massage session. 
First, identify the location of known or suspected cancer and adjust the massage to this. While cancer such as leukemia is diffused throughout the body, other cancers are in more discrete locations (solid tumors). Massage therapists choosing to work with clients with cancer should learn the system of staging of the cancer. Most cancers are staged using a system of numbers and letters that describe the status of a primary tumor (T), regional lymph nodes involvement (N) or distant metastasis (M). Numerical values are assigned to this TNM system to express extent of the area affected by the cancer.14
By the time a client has a diagnosis of cancer, the location usually has already been determined. The parent tumor, identified at a certain site, often has been removed surgically, or radiation therapy is being employed locally, or both. The system of cancer staging is useful to learn, but it is most important to gather precise information from the treating physician about the location of the cancer. The therapist then considers whether a primary tumor or likely metastatic site is superficial enough to be within reach of their hands, or whether the pressure they use superficially could affect a tumor in deeper layers.15 After checking these considerations with the client's treating physician, the massage therapist can plan a massage session that avoids local and regional pressure or circulatory massage in this region.
Without second-guessing where cancer might metastasize, it is useful for massage therapists to have knowledge of some possible secondary sites. Different cancers have characteristic metastasis patterns. Learn these patterns and remain aware of them. If cancer is suspected at possible secondary sites, then local and regional massage on these sites is contraindicated, especially if these sites are superficial, within reach of pressure from the hands.16
Knowledge of possible secondary sites is useful so that if the client complains of discomfort at those sites, the massage therapist can refer the client back to the oncologist and avoid massaging those sites until findings are available. Secondary sites may remain asymptomatic for long periods of time; you may not have a client's local experience of pain as a cue to avoid the region.17 
Cancer-specific contraindications can be organized around cancer symptoms such as pain or pressure, and each of these should be checked out thoroughly before proceeding. These usually generate location restrictions, from where the primary tumor is, was or where secondary sites are suspected. Moreover, there can be complicated conditions arising from cancer in the advanced stages, that affect vital organs such as liver and kidneys, or even the brain. Where liver function or renal function are compromised, it is important to assess the effect of massage and how to adjust it. This article is more focused on cancer treatment than cancer itself, and the reader is referred to several sources of help in the literature about safe practice issues surrounding cancer.18
In general, massage therapists must do their homework and research all they can about the client's condition. Given these cancer-specific concerns, it is critical to include the physician in the information-gathering and the decision-making about massage.

 Cancer and Massage

Step 3-Consider Adjusting Massage To Cancer Treatment
The third step is to determine safe practice adjustments by treatment. This requirement leads the massage therapist through the most complex information, and into the most involved clinical thinking of any of the guidelines. Whereas many contraindication lists feature individual entries for individual diseases, the massage therapy profession must move beyond this into how massage affects the systems of the body and therefore a disease of a given body system. Moreover, a condition of one body system can cause conditions in related body systems. Cancer treatments affect many body systems concurrently, and those body systems affect each other in complex ways. 
 
This clinical thinking step can seem daunting at first, but begins quite simply. The therapist determines which cancer treatments were being used, and the list of possible side effects for those treatments. Having integrated this information, it is necessary to determine which side effects prevail in this client. Finally, adjust the massage therapy to those side effects. 
Massage therapists should investigate treatments and their potential side effects on their own before checking with the client and the medical staff to see which are actually in force. Doing this ahead of time will secure a more productive exchange with the physician. Because most contraindications arise from treatments and side effects and not the cancer itself this is a critical step. Generate a list of side-effect-specific modifications in your massage (discussed below, and tabulated in the sidebar). Do all of this before consulting the physician, then run the list of possible concerns by them, to obtain input that is focused and useful. 
  
Some leading concerns for clients in cancer treatment are described below, grouped by the courses of treatment surgery, radiation therapy, chemotherapy and bone marrow transplant. This is by no means a complete list of concerns, only a partial list of some basic principles. References noted along the way are strongly recommended.

Surgery
Cancer treatment often begins with surgery to remove the neoplasm, or tumor. Recent surgery carries risks of conditions of concern for the massage therapist: thrombosis and infection. Massage therapists are not in a position to diagnose these conditions, but should be on the lookout for them. Thrombosis is the formation of a clot within a blood vessel and is one of the most serious concerns for massage therapists in a variety of medical conditions. A thrombus can form within a vein of the thigh or leg, for example, and become a mobile mass, or embolus, if dislodged from this spot. The circulating embolus can then lodge in an artery in the pulmonary circulation. This occlusion of blood flow to the lung is called pulmonary embolism. It is life-threatening.
 
The problem with thrombosis is that, while it can be symptomatic and show clear signs, it can also be clinically silent.19 There are no clear, definitive tests that massage therapists can use for thrombosis, so they need to be on the alert, and understand the conditions that can cause it. Surgery is one risk factor for thrombosis, since the incision provokes an increase in clotting factors that circulate in the blood. Thrombosis risk also increases with inactivity, which is why ambulating (walking) is encouraged post-operatively, where possible. Still, even with ambulation, the sedentary nature of post-operative recovery (fatigue and pain limit mobility) heightens the risk of thrombosis. Moreover, some cancers themselves, such as lung, pancreas and gut, pose an increased risk of thrombosis.20
 

Concern about thrombosis contraindicates local and regional massage around an incision site after recent surgery. Massage of the lower limbs also is contraindicated due to possible pooling of blood there, which creates an environment favoring clot formation. Because of this very serious possibility, massage therapists should always consult the client's physician to determine when it is safe to approach these areas. They should ask specific questions of the physician about the risk of thrombosis, and for how long to avoid the low limbs and the region of the incision site. Nursing staff can supplement this information. Get physician orders after surgery, and written permission to massage the lower limbs before doing so. 
 
Infection is another post-operative concern and contraindicates general massage. If infection sets in at the incision site, it is usually within the first few days after surgery. Signs of infection include fever and redness, pain, heat or swelling at the incision site. Without special training in scar work and permission from the physician, a massage therapist should not be working near the incision site at all. If the client shows any signs or symptoms of infection, postpone any circulatory techniques or use of pressure and refer immediately to the client's physician for follow-up. Document this referral in your records, or in the hospital chart if you are approved to use it. Post-operative infection is an issue in the first few days after surgery. It is potentially very serious if untreated, but treatment is usually straightforward and patients usually respond to prescribed antibiotics.
 
An incision site presents the massage therapist with a local contraindication unless they are well-trained in working with adhesions and have the physician's approval. With appropriate training, hands-on practitioners may be able to work directly on an incision site to prevent scarring. Massage therapists in training for scar work should question their instructors closely about possible contraindications and guidelines for timing of treatment after surgery. Skilled, appropriate massage at the incision site can promote healing.21 But most massage therapists with basic massage training need to steer clear of the incision site, especially a recent one, for several reasons. It is at or near a current or former tumor site. It is actively healing, a process which includes clotting, and it may still be inflamed and irritated. It may be a site where extensive tissue has been removed, leading to complex healing and tissue changes.
Lymphedema is a common concern after surgery in which lymph nodes have been removed. (It also can occur after radiation therapy.) Given obstructions to drainage, lymphedema arises in the limb that is distal to the nodes removed. This condition often tempts massage therapists to massage it in order to help circulation and drain the area. The problem with this is that standard Swedish massage, or any massage with pressure, can also easily aggravate existing lymphedema. Usually lymphedema comes and goes, and a client may be on watch for it after surgery. Activity such as gardening or typing may bring it on in a person's arm after mastectomy or even lumpectomy. Plane travel, cuts or infection in the affected limb also can bring it on. 
 
Even if there has been no previous edema, any time there has been surgery at proximal lymph nodes, the therapist should only work under a physician's supervision. Massage therapists working independently, using regular or deep pressure on the limb of the affected side, risk precipitating an episode of lymphedema. A client's physical therapist or trained lymph drainage therapist will be working with a combination of light, carefully choreographed massage, sequential compressions, and bandaging to reduce or eliminate edema. A massage therapist doing other techniques should be working in concert with one of these practitioners rather than in opposition.
 
Another risk of surgery is reduced function, due to inflammation and scar tissue formation, pain and medical devices. Range of motion at the joint can be impaired, as well, due to muscle spasm. Again, specialized massage therapy for scar reduction may be applied. But even without this training, most massage therapists can reduce muscle tension in the associated muscles and support the client's movement. One benefit of movement is developing and maintaining strength in the area. In this way, massage therapy can provide important adjunctive care. It is critical to obtain physician approval before proceeding with massage regional to an incision site. List the specific muscles in the affected area that you would like to massage and describe your techniques clearly, preferably in writing, to the physician as part of the approval process.
Massage therapists should learn all they can about the client's surgery (or surgeries), how recent, any complications, whether nodes were removed, and how well the client has healed. Once they have gathered this information from the client and devised a preliminary massage session plan, the client's oncologist should be consulted for permission. The massage therapist should run their concerns by the oncologist, corroborate information received from the client, and get input into the session design before carrying it out. 

Cancer and Massage

Radiation Therapy
This therapy uses beams of radiation to act directly on tumors to shrink them or prevent their growth. It also can be used over the whole body to treat certain cancers or to prevent rejection of a transplant. It should be noted that most radiation techniques expose only the patient, not others around them, to radiation. The massage therapist needn't fear exposure to the radiation, unless it is delivered in implants or through radioactive iodine; then contact is prohibited until exposure risk has subsided.
  
The most obvious concern for massage therapists massaging clients in radiation therapy is to take care with radiation-treated areas. Skin changes include redness, dryness and irritation. In addition, itching can cause people to scratch, so the skin may be open and irritated. Patients in radiation therapy receive careful instruction from medical staff on the care of the skin, and massage must be within these guidelines. A general guideline for massage therapists is to avoid massaging irradiated sites. Think of it as a burn, much like a sunburn. Very light contact with the area may be possible if the client can tolerate it and medical staff approves. Untimely application of the wrong lubricant could interfere with the therapy by coating the skin so that the effects of the radiation beam are altered.22
 
If large areas of the body, such as the abdomen, are irradiated, fatigue is more likely to be a side effect. See below, adjust massage to client's stamina, for guidelines in this case. Massage should be gentle to avoid further challenge to a fatigued client.
If lymph nodes are damaged by radiation, lymphedema is a risk. As is true after surgery (see table), it is necessary to work with client's medical staff to determine how to treat the limb on the affected side. 
 
Nausea and vomiting can occur with radiation therapy, too, but usually occurs with upper abdomen radiation or total body irradiation.23  If nausea is present, massage therapy, range of motion techniques and other passive movements such as rocking or jostling or stretching are contraindicated, to avoid proprioceptive challenge to the client. When fighting nausea, it can be difficult to have one's body moved through space.
 
Radiation may be directed at a very small focus area, over large areas such as the whole abdomen, or even over most of the body. A client undergoing total body irradiation, for example, in leukemia treatment or as part of the procedure for a stem cell transplant, is undergoing one of the most challenging cancer treatments available. Effects of radiation will be visible over large areas of the body. See the entry below, under bone marrow transplant, for guidance.

Chemotherapy
Chemotherapy is strong treatment, affecting energy level, digestive function, blood cell production, and even some nerve function. It primarily affects fast-growing cells, and therefore used against the rapidly-dividing cells of tumors. It also can be detrimental to other fast-growing cells in the human body, including those responsible for hair growth, those lining the digestive tract, and blood cells. 
 
The first three entries in the accompanying table under chemotherapy result from the effects on blood cell production. White blood cells (leukocytes) and platelets (thrombocytes) are especially affected by this growth-inhibiting property of chemotherapy.24 Two conditions, leukopenia and thrombocytopenia, reflect poor cell numbers and can prevail during chemotherapy. If a cell type is in poor supply, its function is compromised. 
 
In the case of leukopenia, resistance to infection is diminished, so it is extremely important for a massage therapist and any other person sharing space with the person to be free of infection. This means that therapists should avoid contact with a client if the therapist or the therapist's family members are ill.25 It also means that clients may need to be scheduled during low-traffic times in the massage therapist's office. The massage therapist should consult the client's medical staff for a sense of white blood cell levels and corresponding compromised immunity.
 
Low platelet counts direct a different course. Here, clients may bruise or bleed easily, since platelets are responsible for clotting. Even slight pressure from resting against hard furniture may bring about severe bruising. The therapist needs to adapt the pressure of the massage in kind, to avoid damaging tissue. The severity of bruising and bleeding, corresponding to the platelet count, will affect how much the therapist needs to adjust the pressure. Get a sense of this severity from the client's medical staff and ask the client if their activity is restricted or cancer treatment has been modified due to this condition. 
 
Finally, anemia can be a side effect of chemotherapy and result in fatigue, dizziness when standing up, shortness of breath, intolerance to cold, and other characteristic symptoms. Adjustments in massage include gentler pressure to accommodate the fatigue, and warm surroundings. But this is one example where the massage therapist's questioning may take off in a different direction, since prolonged, severe anemia can create a heart condition, as the body attempts to compensate for its oxygen-poor blood by pumping it faster. Investigate the possibility of a heart condition in anemia, whether it is due to the cancer itself or to cancer treatment. Then, with the help of the physician, explore the massage implications of this, as some references list it as a contraindication to massage therapy.26 
 

Skin changes occur during chemotherapy. Dryness, rashes and touch sensitivity and "prickliness" all contraindicate local and regional massage if it causes discomfort. Often chemotherapy causes skin reactions that look like infections but are merely reactions to the medication. Check in with the client and medical staff about the origins of any skin changes, as they can change from day to day. 
 
Open skin lesions contraindicate local and regional massage follow standard precautions against infection so you don't introduce lubricant or common skin flora from your hands or the client's skin into the openings. Consult medical staff about the use of gloves if you work with someone with open, weeping lesions. Even if you avoid the region itself, as you should, fluid from open lesions can be transferred elsewhere on the body by sheets, fingers, etc. 
Hair loss (alopecia) is a potential side effect of chemotherapy. As the most visible and striking indicator of cancer treatment, it can hold profound emotional significance for the client. Hair loss can be limited or widespread, depending upon the treatment. Usually body image is deeply affected by this experience. The massage therapist can play an important role by touching the client's body with care and accepting the client's appearance without judgment. 
With hair loss, the primary caution in force is the need to respect the client's wishes about having their head exposed or touched. A client may want to keep their head covered with a wig or scarf during the touch session. Whether working around a headpiece, or working on the bare skin, the therapist should be prepared to fully remove oil or lotion so that it doesn't damage the hairpiece, hat or scarf. Clients affected by alopecia also may have irritation on the scalp, or it may be irritated as the hair begins to return. It is important to question the client about scalp condition (itchy, irritated and Òprickly, are all possibilities) and their desire for touch in this area. Therapists need to navigate this issue with care and sensitivity, so that the benefits of skilled touch on the body image may be realized. 
 
Mouth sores can occur from chemotherapy and can be quite uncomfortable. In addition, they require close care and attention from the client to avoid infection. The massage therapy session should be planned so that these sores aren't aggravated. For this reason, check in with the client to see that the face cradle does not exert pressure or tug on the sore areas. Jaw or cheek massage may be prohibited for the same reason. 
 
Fever contraindicates any vigorous or circulatory massage therapy. Traditional lore in massage therapy has it that circulatory massage may worsen any infection that is present, and fever, though a side effect of some chemotherapy, also may signify infection. Whether massage could spread infection may not have scientific basis yet, but the contraindication rests on simpler matters: Fever is consuming, and the body needs its resources to heal. Work simply and gently and do not burden the client. Also note that medical referral is necessary if the client shows a fever. Document this referral in your own notes. 
 
Digestive and eliminative functions are influenced by chemotherapy. Nausea and vomiting are likely and require massage therapy adjustments. First, general circulatory massage probably is contraindicated during nausea, as is any other strong stimulation such as range of motion or jostling. Passive movements challenge the body's proprioceptive functions and are inappropriate during nausea. Second, unscented oils or lotions may need to be substituted for scented products, especially around the time of chemotherapy treatment. Be certain the client is hydrated, so that fluid and electrolyte balance is intact before you begin massage. Also, locate easy access to a bathroom. Other eliminative problems such as diarrhea and constipation may be present, and are addressed briefly in the table.
 
One common outcome of the above is extreme weight loss, or cachexia. This presents specific issues for the massage therapist. First, the client's stamina is often affected, whether due to the cachexia, the causes of it or other phenomena, the massage therapist's response should be the same to be gentle and not overwhelm the client's resources. More specifically, pressure may need to be reduced. Nerve and vascular endangerments are no longer protected by as much adipose tissue or muscle as they once were, so be gentle on these sites. In addition, positioning may need to be adapted to more prominent bony prominences, and the client can easily become sore in one position. Give your table extra padding. 
 
Various nervous system phenomena arise as side effects of chemotherapy. These are due to the effects of the medications on nerve function. Central nervous system pathways can be affected as well as peripheral ones. Seek information from the treating physician and client about these concerns. One of the most common side effects of chemotherapy is peripheral neuropathy, which can manifest as pain, tingling, burning or numbness in the hands and feet. This would contraindicate the use of any pressure, especially focused, "pointy" pressure on those regions, although gentle, broader, whole-hand contact may feel good. Massage therapists are advised to gather information about a client's neuropathy and response to touch, since these can be very individual and differ from client to client. There are anecdotal reports of clients responding well to touch techniques, relieving neuropathic pain.
 
Finally, muscle tension is common with chemotherapy and with any treatment that causes fatigue or pain. People in chemotherapy may sleep erratically, and may nap in uncomfortable positions, such as on couches or in waiting rooms. These produce characteristic tension patterns in the neck, shoulders and back. In this scenario, a therapist's clinical skills shine. 
Therapists, familiar with bolstering, can help clients make simple adjustments in a pillow to alleviate muscle pain, or give tips for making the couch more comfortable. Moreover, massage therapists can alleviate muscle tension in these areas once all other safe practice requirements have been satisfied. 

Cancer and Massage

Transplant
Bone marrow or stem cell transplant is one of the most taxing treatments used in conventional medicine. Massage therapists planning work with transplant recipients must do so under close supervision by medical staff. The extreme nature of this treatment is described as nothing short of a healing hell.27 Stem cells are precursors to white blood cells, red blood cells and platelets. They are infused in order to counteract effects of radiation and chemotherapy, which then can be administered at much higher doses to destroy the cancer. Side effects prevail from all of the techniques needed to manage bone-marrow transplant for a successful outcome. These side effects can last for many months and even years after the treatment. 
 
Of these side effects, one of the most forbidding is immunosuppression. Medications that suppress the natural immune responses are necessary to prevent both the host and transplant from launching attacks on each other. Immunosuppression is so profound that some period of isolation is often required. Here, standard precautions against infection are inadequate and are replaced by protective isolation precautions. Even after isolation, patients endure fundamental changes in lifestyle required to avoid infection. They must avoid a host of things including housepets, houseplants, many foods and crowds. A massage therapist can learn a great deal from standard patient information materials available at treating hospitals. These booklets help the therapist think about which elements of the massage session put the client at risk of infection. For example, an unwashed bottle of lubricant, a receptionist with a cold, a bolster without a clean surface can all pose dangers to the immunosuppressed.
 
Other treatments cause added side effects that defy the human imagination and require close monitoring. Total body irradiation causes burning and itching on affected areas. High chemotherapy doses intensify the usual chemotherapy side effects. Many aspects of digestion are affected, causing intense mouth sores, changes in salivation, severe constipation, pain, nausea and vomiting. 
 
A few key massage issues are suggested in the sidebar under transplant, but space limits a balanced discussion of the manifold massage adjustments. Massage therapists working with bone marrow patients are strongly advised to do in-depth research to familiarize themselves with these challenges, then work closely with medical staff to keep the client safe. Massage will need to be extremely gentle, limited by overriding medical issues in force.
On the other hand, structured touch can be profoundly helpful to a client in this therapy. Massage can provide a welcome alternative to the familiar pain and discomfort of medical treatment, one of the few forms of contact that is pleasurable and non-invasive, and a relaxation technique that is passive, when more active methods are too challenging.28 Moreover, massage may promote the client's return to exercise, which can improve function.29
 

Other Cancer Treatments
The four common treatments listed above are not a complete list. Other therapies, including biological therapies and hormone treatment, must each be evaluated by the therapist for side effects and other challenges to the client. There are many medications given alongside these treatments, such as steroids, antidepressants, and narcotics, and the massage therapist needs to think clinically about each of these in session design.30 Other considerations for the therapist are posed by the procedures and devices included in those treatments (such as ports, catheters, prosthetics, etc.) and are not mentioned here. Use similar reasoning for any treatment or device. Always gather full information from the literature, the client, and the treating physician about side effects or other issues and assess those in terms of massage therapy. Investigate possible massage adjustments in the available resources,31 and check them with the physician before the session.
 
Step 4-Consider The Client's Stamina, And Adjust 
So far, we have discussed cancer-specific and treatment-specific guidelines. The fourth step is to adjust the massage session to the stamina of the client. This requires good intake questions and close observation. Ask, Are there any medical prohibitions on your level of activity?  or, How have treatments affected your activity level, if at all?  and follow-up with, Does your energy level run through cycles corresponding to your treatment, or the hour of the day, etc.?  Follow-up questions give the massage therapist information needed to tailor the session for a given day and time. Learn more about energy level by observing the client closely. Notice their attention span, whether their breathing is labored or uneven, or punctuated by sighs. During conversation, notice whether their eyes glaze over easily. 
 
If stamina and strength are compromised, the vigor of the massage must be adjusted in kind, primarily in the following three areas: 

  • Speed (slow speeds are best);

  • Duration (consider shortening the massage by half, or even much more);

  • Pressure (in general, gentler pressure is necessary when people are challenged by cancer treatments and who may experience fatigue and pain, etc.). 

For this calibration, the therapist needs to be exquisitely attuned to the situation. Take the force of each of these massage components down several notches, at least. Use observation and a measure of intuition to judge how lightly to work. In general, do not ask the client's body to do any additional work. Do not press so hard that the client needs to resist. Bolster the client's body so that the client needs no effort to hold a position. Do not employ resisted movements, nor even passively move the limbs through wide ranges of space. In short, do not challenge the client's body confine the therapy to techniques that provide comfort and ease. Nothing needs to be altered or fixed, it just needs attention. Pay close attention to the client's responses to touch. Look for changes in breathing, fluttering eyelids, clenched fists or other tightly held muscles for cues about how the massage is being received. 
 
Intuition, as highly-prized as it is in this profession, can be off-kilter, just as information can be inaccurate. Massage therapists with fairly accurate intuitive powers can still have an "off" day. Intuition is a powerful assessment tool, but it is not foolproof and should not be used in isolation. Any challenging scenario may cloud intuition just as easily as it may refine it. The best combination to assess stamina, a dim parameter, is one of intuition, information, and skill. 
 
To accommodate a client's energy level, note that vigorous massage techniques are inadvisable for most clients in cancer treatment, and may be only sparingly applied in the months of recovery from the last treatment. The year (or more, if a bone marrow recipient) following treatment is often a tender one that demands intensive self-care for the body. Healing and rejuvenation can come slowly, and side effects can take months to subside. Respect the process. This is a period of testing stamina, ups and downs in health, and concern about infection. When a client's body is processing medications and battling cancer, honor their course of recovery. Massage is an opportunity to approach the body with care, attention and acceptance. The client still may need all of their resources to convalesce. 

Crafting The Health History 
Additional guidelines for working with people with cancer, presented in the table, are explained in more depth in the literature.32 Readers are referred to those resources, to the client's medical staff and to the available literature on cancer treatment. 
 
One simple way to begin a history form is to take each safe practice suggestion listed in the literature and convert it to a question. Done for each guideline, this generates a list of questions that the therapist needs to ask before proceeding with the session. To practice clinical thinking in this area, massage therapists should start by creating their own forms first, then checking them for completeness against other forms in common use. 
 
Use care and sensitivity in wording the question, especially when interviewing the client. Wording is everything. Instead of asking if there is metastasis, the practitioner might, instead, ask about the type of cancer and where it's located in the client's body. Establish rapport by asking questions sensitively and conversationally.33
 

With this rapport in mind, it is possible to take each of the principles and assemble a list of questions for the client and the client's treating physicians or nursing staff that will elicit the needed information. In brief, you will need to know the type of cancer, the location, the names of the treating physicians,34 the course of the cancer treatments, any side effects of treatment, and the client's general stamina level. These bits of information will generate another list, of massage restrictions and possible benefits to guide the massage session. It is good practice to write out a complete detailed list, or decision tree, for a sample interview. More streamlined history forms are available, and one may be found in MacDonald's Medicine Hands. There, massage limitations are grouped into site, pressure and positioning restrictions.35 
 

Answers to the medical history questions give the massage therapist key information for planning the massage, but they also provide some idea of the texture of the client's days. This has practical applications: For example, if radiation treatment is daily at 8:30 a.m., it may be possible to schedule massage sessions one hour after that, since radiation treatments tend to stay close to schedule. But other benefits of a complete health history are as important; with this information, a massage therapist may be able to form a stronger, more compassionate connection with the client. 
 
A complete list of necessary questions would present a client with a long, imposing, potentially intrusive form to fill out, and the art of history-taking is not obvious in any list of prescribed questions. Some finesse is necessary in order to avoid an interrogation. A good intake interview is warm, conversational and yields complete information. In the wash of treatments, clients may forget key details or treatments that are important to the therapist. The practitioner should repeat important questions in different styles to be sure to obtain the needed information. Listen reflectively, and use the chance to cultivate that connection. 

Cancer and Massage

Conclusion
It is hoped that this article, along with other work on this topic, brings some depth to the discourse about safe practice for people with cancer. The profession needs to align behind some clear, cohesive guidelines. Moreover, we need to foster the clinical thinking behind those principles, and in the application of them. Reader input on these issues is welcome. 
The massage therapist is cautioned against using these or any other guidelines reflexively, as a list of commandments to follow. Instead, use them as jumping-off points for clinical thinking, and for discussion with the client, physician, other therapists, and massage educators. Use them to begin research on the client's condition, not as an isolated directive for the massage session. Advanced instruction in this topic is highly recommended, and physician input is required before attempting this kind of work. 
 
Different types of massage therapy are often contraindicated for cancer, but knowledgeable, skilled touch is in some form rarely contraindicated. Extreme situations such as severe immunosuppression and isolation might contraindicate contact altogether, yet sometimes even these can be navigated with physician directives and client permission. Usually, only simple massage therapy adjustments are necessary, and massage therapists can easily make these adjustments. Supporting them with more in-depth clinical thought will inform our exchanges with our client and the client's treating medical staff. It will enhance our standing with conventional health-care practitioners. They need us to join them in the care of people with cancer, just as the clients, themselves, need our services during the harrowing experiences of illness and treatment. 
 
By delving into these issues in this depth, we disengage our profession from the unexamined command to withhold massage therapy from anyone with cancer. Some type of presence, of listening, and touch nearly always is available to establish a compassionate connection. Once safe practice guidelines for a given client are clear, corroborated by the client's medical staff and understood by all, the therapist is released from the fear and confusion about massage and cancer. Once liberated, they are free to focus on the quality of their touch, and the fullness of their own presence. They are free, as well, to approach the client's body with reverence for its multiple strengths. A massage therapist is in a unique position, within the sacred medium of physical contact, to witness the client in all of their wholeness. 
 
Cancer does not flatly contraindicate massage therapy. It is true that cancer and cancer treatment limit the massage choices. But within those limits, there are many rich and creative possibilities for touch. 

Tracy Walton, MS, LMT, who provides advanced instruction for massage therapists who work with people with cancer, is academic dean of the Muscular Therapy Institute, 122 Ridge Ave., Cambridge, MA 02140 (617-661-5800). Her E-mail is: tracywalton@msn.com.
 
References

  1. See articles by Debra Curties and Gayle MacDonald in MTJ that directly address this issue.

  2. Chamness, Annette. "Massage Therapy And Persons Living With Cancer: Some Basic Information For The Massage Therapist." Massage Therapy Journal, p. 53-65, Summer 1993, and "Breast Cancer And Massage Therapy." Massage Therapy Journal, p. 44-48, Winter 1996.

  3. Curties, Debra. "Could Massage Therapy Promote Cancer Metastasis?" Journal of Soft Tissue Manipulation, p. 3-6, April/May 1994.

  4. MacDonald, Gayle. "Massage For Cancer Patients: A Review Of Nursing Research." Massage Therapy Journal, p.164-165, Summer 1995.

  5. MacDonald, Gayle. Medicine Hands: Massage Therapy For People With Cancer. Tallahassee, Florida: Findhorn Press, 1999. 

  6. Curties, Debra. Massage Therapy And Cancer. Moncton, New Brunswick: Curties-Overzet Publications, 1999. 

  7. Kirby, Patricia. "Real-World Examples: Cancer Treatment Programs Offer Massage." Massage Magazine, p. 80-82, March/April 2000, and McConnellogue, Kieran. "The Courage To Touch: Massage And Cancer." Massage and Bodywork Quarterly, p. 13-20, December/January 2000.

  8. Williams, Donna. "Touching Cancer Patients: Guidelines For Massage Therapists."' Massage Magazine, p. 74-79, March/April 2000.

  9. Walker Delany, J., B. Chikly, M. Bredin, et al. "Clinical Perspectives: Breast Cancer Reconstructive Rehabilitation." Journal of Bodywork and Movement Therapies, 3(1): 3-23, January 1999.

  10. See the following five texts about general diseases, contraindications and indications to massage: Burch, Sharon. Recognizing Health And Illness: Pathology For Massage Therapists And Bodyworkers. Lawrence, Kansas: Health Positive Publishing, 1997.

  • Newton, Donald. Clinical Pathology For The Professional Bodyworker. Portland: Simran Publications, 1998.

  • Premkumar, Kalyani. Pathology A To ZÑA Handbook For Massage Therapists. Calgary, Alberta: VanPub Books, 1996.

  • Rattray, Fiona. Massage Therapy: An Approach To Treatments. Toronto, Ontario: Massage Therapy Texts and Maverick Consultants, 1997.

  • Werner, Ruth. A Massage Therapist's Guide To Pathology. Washington, D.C.: Lippincott Williams and Wilkins, 1998.

  1. Walton, Tracy H. "Contraindications To Massage Part III: Communicating With A ClientÕs Clinician." Massage Therapy Journal, p. 40-48, Fall 1999

  2.  Dollinger, M., E. Rosenbaum, and G. Cable. Everyone's Guide To Cancer Therapy, 3rd Edition. Kansas City: Andrews McMeel Publishing, 1997.

  3. Curties, MacDonald, McConnellogue and Williams, cited above. 

  4. Dollinger et al., p. 11-12.

  5. Curties, Debra. "Could Massage Therapy Promote Cancer Metastasis?" Journal of Soft Tissue Manipulation, p. 5-6, April/May 1994.

  6. Curties, p. 5-6.

  7. Gerber, Lynn H., and Mary Vargo. "Rehabilitation For Patients With Cancer Diagnoses." Rehabilitation Medicine: Principles and Practice, 3rd Edition. Philadelphia: Lippincott-Raven Publishers, 1998. 

  8. Curties, see endnote 6. 

  9.  Alexander, Doug. "Deep Vein Thrombosis And Massage Therapy." Massage Therapy Journal, p. 56-63, Spring 1993.

  10. Alexander, p. 56-63.

  11. Curties, Debra. Breast Massage. Moncton, New Brunswick: Curties-Overzet Publications, 1998.

  12. MacDonald, p. 94.

  13. Dollinger et al, p. 55.

  14. Dollinger et al, p. 65.

  15. Chamness, p. 59.

  16. Werner, see endnote 10. 

  17. Groopman, Jerome. "Annals Of Medicine: A Healing Hell." The New Yorker, p. 34-39, October 1998.

  18. Ahles, T.A., D. M. Tope, B. Pinkson et al. "Massage Therapy For Patients Undergoing Autologous Bone Marrow Transplantation." Journal of Pain and Symptom Management, 18(3): 157-63, September 1999.

  19. Gerber and Vargo, p. 1307.

  20. MacDonald, Gayle. "Easing The Chemotherapy Experience With Massage." Massage Magazine, p. 85-91, March/April 2000.

  21. Books by MacDonald and Curties, and article by Chamness, cited above.

  22. Books by MacDonald and Curties, cited above.

  23. It is important to note that sensitive questioning should not be undertaken at the expense of clear questioning. Good communication skills are a must in this kind of work. 

  24. Walton, Tracy. "Contraindications To Massage Part III: Communicating With A ClientÕs Clinician." Massage Therapy Journal, p. 40-48, Fall 1999. 

  25. MacDonald, see endnote 5.

  26. Walton, Tracy H. "Contraindications To Massage Part III: Communicating With A Client's Clinician" Massage Therapy Journal, p. 40-48, Fall 1999.

  27. Note that some physicians will not feel comfortable signing this document, perceiving that they would shoulder an additional share of liability for these decisions. This is not intended to be a legally enforceable document, nor is it intended to transfer liability to the physician. It is meant to begin dialogue, so that if a physician refused to sign it, but would agree to discuss the issues raised by the letter and approval form on the telephone or in person, then you have achieved the goal of dialogue. This is a communication tool, beginning in written form and often ending in a verbal exchange of information. It is recommended that the massage therapist record notes from those conversations, date them and include them in the client's chart.

 

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