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Reflections - First Line of Defense

Early detection of skin cancer by massage therapists can save lives.

In May 2003 Annie Powell, then 26, was in her last semester at the Connecticut Center for Massage Therapy. It was during her externship work with one of her instructors, Scott Raymond, that she had a massage that may have saved her life.

It was during an instructor-student massage in the peaceful ambience of Raymond’s Market Square Wellness Center in Newington, Connecticut, that Raymond noticed Powell had a mole on her back that didn’t look quite right. He waited until the massage was through and then gently asked Powell if she knew about this unusual looking mole. “Do you want me to take a picture of it with your cell phone?” he asked her. Powell was familiar with skin cancer—she had had two spots of skin removed several years earlier that were diagnosed as basal cell carcinoma, the most common and benign form of skin cancer. However, she was unaware of this hard-to-see mole, which, as she saw in the photo on her phone, had irregular borders. This may signal melanoma—the most virulent form of skin cancer.

He waited until the massage was through and then gently asked Powell if she knew about this unusual looking mole. “Do you want me to take a picture of it with your cell phone?” he asked her.

Powell was familiar with skin cancer—she had had two spots of skin removed several years earlier that were diagnosed as basal cell carcinoma, the most common and benign form of skin cancer.

However, she was unaware of this hard-to-see mole, which, as she saw in the photo on her phone, had irregular borders. This may signal melanoma—the most virulent form of skin cancer.

She agreed when Raymond suggested she see a dermatologist to get it checked out. She was scared, but felt calmed by Raymond’s tactful and supportive manner.

“When he approached me about [the mole], I felt there was something wrong, but the way he did it me made me feel confident that everything would be all right,” she says. And it was. Although the dermatologist she saw diagnosed stage-one melanoma, about to progress to the next stage, “my doctor said that it was caught just in time,” she says.

Over the past four years, Powell’s had 10 more malignant tumors removed. She’s considered in remission, but not cured—she’s permanent “melanoma patient.” Her doctor scans her skin every two to three months.

Today, Powell has expanded her massage business (she has her own practice in Connecticut in summers and works for a day spa in New Smyrna, Florida, in the winters) to include a new nonprofit organization, Massage Across America, which is designed to educate other massage therapists on skin cancer.

She figures it’s a gateway to early detection for thou-sands of Americans, one in five of whom will be diagnosed with skin cancer in his or her lifetime, according to the Skin Cancer Foundation.

“I strongly recommend that other therapists become well-versed in approaching clients with abnormalities,” she says, “and to become very confident and educated on the subject, so they don’t feel nervous—or that what they’re doing is inappropriate.”

On the contrary, says Hinsdale, Illinois-based dermatologist Christina Steil, MD. “Massage therapists can play a really important role [in detection],” she says. “They are often one of only a few people who are looking objectively at people with their clothes off. And skin cancer is such a visual thing.”

Coyle S. Connolly, DO, a Linwood, New Jersey-based osteopath and board certified dermatologist, says that the rapport that many people have with their massage therapists is a tremendous asset.

“Patients often have apprehension about showing their bodies,” he says. They often, however, trust their massage therapists, who then can play a key role.

“The more access we have to the skin—the largest organ of the body—the better chance of detecting skin cancer,” he says. “And early detection is essential.”

He himself has had patients referred by their massage therapists. “These are people I might otherwise not have seen,” he says. “I have been able to remove melanomas at the earliest stages, where you can save a life.”


On the Rise

This need for early detection has been made more urgent by an increase in skin cancer, which now strikes more than 1 million Americans per year. In a 2005 Mayo Clinic study, the incidence of basal cell carcinoma in women rose from 13.4 out of 100,000 in 1976 through 1979 to 31.6 out of 100,000 in 2000 through 2003.

Dermatologists diagnose more than 850,000 Americans each year with basal cell carcinoma, which often appears in places on the body exposed to sun, such as the face, arms and legs. It seldom metastasizes, but can be disfiguring—causing structural damage to features, for example—if left untreated.

An additional 250,000 or so are diagnosed with squamous cell carcinoma, the second most common form of skin cancer, which also usually appears in sun-touched areas. Approximately three to four percent of squamous cell carcinoma metastasize.

The skin cancer heavy hitter—melanoma—affects only about 50,000 Americans each year, but has a much greater chance of metastasizing to the organs, blood stream and lymph nodes.

Many of us are at risk for skin cancer simply by living in this day and age where the protective layers of ozone are less, or perhaps by our ethnicity. Light-skinned, fair-haired people of Northern European or Celtic origins, like Powell, are at higher risk.

However, those with African, Latin and Middle-East origins aren’t immune either, says Florida-based massage therapist and dermatology physician assistant Annie Morien, PhD, PA-C, LMT, who teaches a workshop on massage therapy and skin cancer (see sidebar on page 102 for more information). One to three percent of African Americans are diagnosed with skin cancer each year, although these often show up in areas not exposed to sun—such as the feet, toenails and mouth.

Other risks include many moles—usually 50 or more—a relative with melanoma, or any other cancer, says Powell, whose mother and grandmother had other forms of cancer.

And many of us add to our risks by lifestyle choices, such as overexposure to the sun or tanning booths, which are a big no-no in the dermatology world. Smoking is also a risk factor. However, regular exercise helps reduce risk, as does a diet low in fat and high in antioxidants.

Sometimes though, it’s just the luck of the draw. “It’s so common now,” says Steil. “I have 22-year-old volleyball and softball players with skin cancer.” Many elderly are also at risk, often because of sunburns that happened decades before.

“[They say] ‘I haven’t been in the sun for 20 or 30 years,’” says Steil. “Often when you’re younger and get sun damage, your young immune system is healthy, but it may lessen as you age.”


How You Can Help

For massage therapists, this means you need to be vigilant no matter what the age of your client—or his or her ethnicity.

Part of this vigilance is to know what to look for. Your ABCs, for example, the well-known melanoma detection mnemonic: A stands for Asymmetry—normal moles are usually symmetrical; B for borders—irregular borders are suspicious; C is for Color—melanoma can be multicolored; D is for Diameter—larger than 6 mm should signal a second look; and E stands for Evolving—changes in the skin should raise a red flag. (For more information, see sidebar, left.)

Basal cell carcinoma can look like a pimple that doesn’t go away, or an inflamed, pinkish patch of skin. Other signs that warrant a red flag: A mole that bleeds easily, or that is tender, painful, tingling or itchy.

“Anything that changes is suspicious,” says Morien, and so is a spot on the skin that doesn’t look like its neighbors, sort of like Sesame Street’s “one of these things is not like the other.”

Also pay attention to how things feel. “A massage therapist may be massaging the skin and may feel a nodule that’s painful,” says Steil. “That’s not normal, and should be evaluated.”

Linda O. Gutowski, a Decatur, Alabama-based massage therapist, says that she learned early on how important a massage therapist’s role is in detecting skin cancer when she was brand-new to the field, working on her only second client as a professional therapist. The client was a construction worker in Salt Lake City, where she was based at the time, and regularly worked without a shirt in the hot Utah sun. He had a raised black patch of skin on his back that, when he shifted on the massage table, bled.

Although she mentioned the patch of skin in the session—“Isn’t this strange?” she said to him conversationally—when the session was over, she realized she didn’t have his contact information.

“That left such a huge impact on me—because I couldn’t reach him after that. That’s why I make a point of checking people on a regular basis,” she says.

Now, when she sees a suspicious patch of skin, she’s ready to communicate, as she did recently with a long-time client who had a spot on his back that began to change. “One end started to blur a little bit.”

She told him, “You’d do well to check this out.” He did, and his dermatologist diagnosed basal cell carcinoma. “He was very grateful,” Gutowksi says. Now Gutowski says she errs on the side of caution.

Morien does as well, saying she’d rather be safe than sorry. “All I need is one red flag,” she says. She says it’s important when encouraging a client to see a doctor to be both tactful and direct.

“Use comfortable, nonthreatening language,” Morien says. Use curiosity. “Ask, ‘How long have you had this? Has it changed in any way? Are there any sensations associated with it?’” If you get a red ?ag, then you can say, “Why don’t you get it checked it out?”

She also suggests reading up on skin cancer, and providing your clients a pamphlet or websites that offer more information (see sidebar on page 102). You may even consider compiling a list of local dermatologists, with phone numbers. “It’s not in the massage therapist’s job description to give a diagnosis, but rather to send that person to someone who can,” she says.


Lima, Ohio-based massage therapist Deborah McFarland, who recently lost a 31-year-old client to melanoma, says that this line between diagnosing and referring is important, but shouldn’t be prohibitive.

“[Massage therapists] get so worried about stepping over boundaries,” McFarland says, “but there’s an appropriate way to bring [your concerns] to your clients’ attention.”

McFarland, who hangs an American Academy of Dermatology brochure on identifying skin cancer next to her trigger point chart, suggests bringing up the subject in a supportive way, and keeping notes in your clients’ charts so you can check up on them when they return. Asking if they were able to follow up on the spot you talked about at your last appointment is something you may ask in subsequent sessions, she suggests.

Don’t worry about the final diagnosis. “Just say, ‘I’m concerned.’ You don’t have to worry about being right,” says Steil.

Connolly agrees. “There’s no right or wrong way to say anything,” he says “If something on the skin looks like it’s changing, then it’s your obligation to say something, just as you would tell your client that his or her left arm had less range of motion.”

Powell, who has sent three of her clients to dermatologists—two of whom were subsequently diagnosed with cancer—says that her massage teacher’s positive and supportive attitude when he first pointed out her suspicious mole helped her process through skin cancer tremendously.

“Let your client know that you’re there for him or her,” she suggests. This may also include becoming part of the team that keeps an eye on the skin once treatment has been completed, or part of the team that helps the healing.

“Massage has benefited me tremendously,” says Powell, who continued to receive regular work after her diagnosis. It has helped reduce her scar tissue, she says, in addition to the myriad physical and emotional benefits, such as relaxation, improved circulation and de-toxi?cation.

Experts say there are no real contraindications for massage after skin cancer. Use your common sense, says Morien. Don’t massage stitches, for example, or around an open wound. Typically a skin cancer incision will take four to six weeks to heal. Radiation may make the skin sensitive, as might a chemotherapy injection site. “Just use your best judgment,” she says.

In fact, your judgment, along with your massage therapy skills and finely tuned intuition, will play an essential role in dealing with this increasingly important subject.

“Therapists have wonderful powers of observation,” says Connolly. “They’re tuned in, and holistic by nature.” Use this to your clients’ advantage.

In the long run, it’s the therapeutic thing to do. “I’d rather have a therapist say ‘Go get this looked at’ and have the dermatologist say ‘It’s nothing,’ then to have the client miss something important,” he says. “It can be a life saver.”

Powell agrees, wholeheartedly. “If you see something—say something!” she says. “I believe, based on what doctors told me, that a massage therapist saved my life.”


American Academy of Dermatology
1-888-462-DERM (888-462-3376)

National Cancer Institute
1-800-4-CANCER (1-800-422-6237)
TYY: 1-800-332-8615

The Skin Cancer Foundation
1-800-SKIN-490 (800-754-6490)

You can learn more through Morien’s workshop, “A Massage Therapist’s View of Skin Cancer,” at Florida School of Massage, Gainesville.

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