Cancer and Massage: Mastectomy Massage
Sooner or later, most massage therapists will have to treat a client with breast cancer. Here's how to do it correctly.
By Cheryl Chapman and Eileen Kennedy
Breast cancer is the most common cancer among women in the United States, and is the second-leading cause of death in women. Each year, more than 180,000 women are diagnosed with breast cancer. With these sobering statistics, the likelihood of encountering a client with breast cancer also increases.
This article presents an overview of breast cancer and breast surgeries, explores the physical and psychological impacts of surgeries on clients, and describes a few simple, yet highly effective techniques that may be beneficial when working with mastectomy clients. Legal issues, client intake forms, and marketing strategies and other resources are addressed.
Background And History Of Breast Cancer
Breast cancer surgery dates back to the 1600s, when Wilheim Fabry, the "father of German surgery" developed a special forcep for amputating a cancerous breast. The instrument constricted the base of the breast while a blade swept the organ off the chest wall. Enlarged lymph nodes also were excised.
Physicians in the mid-19th century viewed breast cancer as arising in one location. If left untreated, it would spread through the lymph system to distant nodes, sites and organs. This led to the theory of the radical mastectomy, or the surgical removal of all the breast tissue, underlying chest muscle and lymph nodes before the cancer could spread.
Dr. William Stuart Halsted developed this radical surgical procedure, the "Halsted Mastectomy." First performed in England in 1857, this procedure was the surgical standard for more than 60 years. Even today, more than 100 years later, this surgery continues to be a choice for some women with advanced cancer. Depending on the staging and location of cancer, a more modified partial mastectomy or lumpectomy may be performed. The first modified radical mastectomy was performed in the 1940s.
In 1930, the medical profession began using radiation to alter the DNA of cancerous cells, preventing them from multiplying and spreading to distant sites, while shrinking the tumorous growths.
In 1943, the first chemotherapeutic agent a combination of plant antibiotics and nitrogen mustard compounds was used at Yale New Haven Medical Center. Today, about 80 chemotherapy drugs are used. Although a single drug can be used to treat cancer, chemotherapy drugs usually are more powerful when used in combination with other drugs.
Why Mastectomy Massage?
The benefits of mastectomy massage are numerous. The therapist's intentions and the quality of touch provided can make a world of difference to a client who has recently experienced a variety of invasive and painful tests and procedures. Remember that your intention is not to "fix" the client, but to provide love, nurturing, relaxation and quality of life.
Massage can relieve post-operative pain and edema, and promote the removal of toxins as it assists in the flow of lymph, blood and oxygen. Over time, clients will experience increased range of motion, reduced scar tissue, restored feeling and sensation by stimulating nerve endings, an improved body image and may become more aware and reconnected to themselves. Aside from massage generally promoting better health and overall well-being, it just feels good!
Because of the physical impact of breast surgery we have found in our practice that, when possible, we encourage clients in our practice to consider the "Three Massage Rule." That is, three massages (bodywork sessions) administered preoperatively to help prepare the women physically and emotionally for surgery. This is an ideal plan! However, in most cases we are able to see a client only twice, or sometimes even once.
The number of sessions will depend on the surgical schedule of the client, and the content will depend on the physical and emotional status of the woman prior to surgery. For example, clients who have been receiving regular massage may have a greater need for energy balancing rather than deeper therapy. What modality is used, depends on the needs of the client at that time. There is no set order to the routine. Remember, it's important to listen to the client and offer them what they need.
If you are able to see the client three times, one of the three sessions might cover the physical aspects including myofascial release, trigger-point therapy, Amma therapy, or a Swedish-based massage with a gentle, soft, nurturing touch. A subsequent session may cover an energy balancing technique such as craniosacral, reiki, polarity, therapeutic touch, Trager therapy, or Jin-Shin Jyitsu. A third session may include a gentle touch such as manual lymph drainage (MLD).
It's very possible that a presurgical session may consist of simply listening, as you may be the only one to whom the client can relate their fears, concerns and feelings. In this case, being there and allowing the client to share may be all that you do.
It's important to remember, above all else, that your client has cancer! Any client who is in the acute phase of their therapy, (e.g., in active treatment via surgery, chemotherapy and/or radiation with continued monitoring by their physician) should have the length, depth and speed of the massage routine adjusted to their needs.
Along with that diagnosis is the most obvious physical impact É the surgical amputation and loss of a breast. Accompanying emotional and psychological impacts can include fear of loss of loved ones and family, disconnect from self, denial, anger, and all of the accompanying emotional and psychological implications.
The goal is to help the women feel connected to her body, since she may feel disconnected.
Can Massage Spread Cancer?
The concern that increasing circulation via massage will cause the spread of cancer is unfounded. Cancer can spread with little or no activity, such as sleeping, breathing, eating, walking, etc. Therefore, there is every reason to believe that gentle, light or compassionate touch can be administered safely and effectively, provided that no direct pressure or massage is applied to the traumatized area affected by disease.
Light massage may actually have a protective effect, as it keeps the blood and lymph circulating. Touch may help prevent tumor proliferation, as it reduces the body's levels of glucocorticoids and cortisolÑhormonal measurements of the body's stress levels. Conversely, high levels of these substances in the body have been linked to tumor growth.
Deep massage is always contraindicated in people with active cancer or undergoing chemotherapy or radiation. Massage only will tax a system already overloaded by the trauma of cancer and treatment, and it can induce an inflammatory response. Therefore, it can't be stressed enough that the therapist must take a good client history, adjust the depth of touch, and select the appropriate touch modality, with the individual client in mind. Cancer massage guidelines should always be top of mind.
Of Treatment Surgeries
Methods of treatment for breast cancer may be localized or systemic. Local treatment is used to remove, destroy or control cancer cells in a specific area. Surgery and radiation therapy are considered local treatment. Systemic treatments are used to destroy or control cancer cells throughout the body. Chemotherapy is an example of systemic treatments. Treatment choices and decisions are complex. The treatment choice will depend on the age and menopausal status of the woman, the general health of the client, the size, location and stage of the tumor, whether the doctor can feel lymph nodes, and the size of the breast. Surgery is the most common treatment for breast cancer.
The massage techniques selected will be individualized according to the magnitude of the surgical procedures. For example, a woman who received a Halsted procedure 20 years ago may experience decreased mobility and frozen shoulder because she has lost the pectoral muscles. Keloid scarring and disfigurement are not uncommon as plastic surgery and reconstructive procedures were not refined at that time. This is not necessarily true of all women.
The major techniques used most often now include:
Mastectomy. Surgical removal of one or both breasts.
Radical Mastectomy. Surgery to remove all the breast, chest muscles the lymph nodes in the armpit. Also called the Halsted radical mastectomy, and was the only available surgery 20-plus years ago.
Modified Radical Mastectomy (also called the total mastectomy with axillary dissection). Surgical procedure in which the breast, some of the lymph nodes in the armpit, and the lining over the chest muscles are removed.
Partial Mastectomy or Lumpectomy (also known as segmental, wide excision or quadrantectomy). Removal of the cancerous lump and some of the healthy tissue surrounding the tumor, while the breast is left intact. Some of the lymph nodes in the axilla will usually be removed.
Some women decide to have breast reconstruction to rebuild a breast's shape after mastectomy. Many times, the client opts for reconstruction at the same time as the mastectomy surgery, in order to minimize the number of procedures and the accompanying pain or discomfort. Reconstruction has both pros and cons, and the decision that is right for one woman may not be right for another.
Each of the following procedures, commonly referred to as "flap methods" are autogeneous tissue reconstruction, where the woman's own body tissue is transferred from one part of the body to the breast.
Transverse Rectus Abdominis Myocutaneous Flap (often referred to as a "TRAM Flap" or "tummy tuck"). TRAM involves the migration of tissue and its corresponding blood supply, from the rectus abdominis muscle to the breast. This technique is the most common one.
Latissimus Dorsi Muscle Flap (or LDM). The second-most-common procedure, the LDM flap is selected when there is a skin deficit that can be corrected with the transportation of large amounts of skin, fat, muscle, and blood supply, to the chest wall area. The LDM procedure transports a segment of skin from the upper back to the anterior chest.
Gluteal Free Flap. When other flap techniques are not appropriate, the breast can be reconstructed with fat and skin from the buttocks. This option is known as the gluteal free flap. The appropriate tissue needed for this breast reconstruction, along with a segment of the gluteus maximus muscle, transported to the chest and connected to the internal mammary artery.
Post-Traumatic Edema vs. Lymphedema
Edema, the presence of large amounts of fluid in the intercellular tissue spaces of the body, is not uncommon after the trauma of surgery. This collection of fluids normally dissipates slowly after surgery, without intervention. Light massage, however, is capable of reducing the edema more quickly and effectively than without touch.
Lymphedema, on the other hand, is the abnormal collection of protein-rich fluid, causing the swelling of a body part, usually an extremity. In the case of mastectomy, the operative arm is affected. As surgery, chemotherapy and/or radiation cause damage to the lymphatic nodes and vessels, a blockage of lymphatic fluid occurs. Subcutaneous tissue becomes hard and fibrotic and restricts the flow of oxygen and blood to the area. This becomes a good medium for the growth of bacterial and fungal infections. Decongestive therapy by a certified manual lymph drainage therapist is the only effective therapy, to date. Antibiotics are effective for an infection, but do not treat the lymphedema.
The most important point is that regular massage therapy is a contraindication for lymphedema and may very well exacerbate the condition. This does not mean that massage can't be administered to the rest of the body, but the surgical arm is best approached with a light touch from proximal to the distal (axilla to fingertips) and at the same time keep the light touch always toward the axilla. When lymphedema is present, the lymphatic arm will be approached last. In this way, the lymph channels are open and receptive to lymph drainage. Once contracted, lymphedema is a lifelong condition. It is treatable but not curable. All that is needed is for one lymph node to be removed or destroyed and the client is at risk. Lymphedema may occur at anytime (e.g., weeks, months, years) after one or more nodes have been removed. No one knows the cause. There are women who have had radical surgery 30 years ago, with all the lymph nodes removed and have not signs of lymphedema. Then you may see a 30-year-old woman with only one node removed who develops lymphedema.
As a treatment for breast cancer, the drug slows or stops the growth of cancer cells that are already present in the body. As adjuvant therapy, tamoxifen has been shown to keep the original breast cancer from returning and also prevent the development of new cancers in the opposite breast. Oral chemotherapy allows the client to resume normal or regular massage without the side effects of intravenous chemotherapy.
While client is undergoing radiation, the affected areas should not be touched until after touch is tolerated by the client. This area is similar to a bad sunburn. Covering the breast with a soft cloth is suggested, as a heavy covering or towel may cause additional discomfort to the area. A combination of calendula, St. John's Wort, arnica, and comfrey ointment, administered frequently before and during the radiation phase, has been shown to prevent and reduce the effects of burning. Refrain from using heat or cold packs. As with chemotherapy, deep pressure is to be avoided to prevent bruising or possible fractures.
The first record of chemotherapy being employed as a treatment for cancer dates back to 1600 B.C. in Egypt, and consisted of a mixture of fresh dates, limestone and water that was injected into the tumor mass, followed by surgical intervention.
Intravenous chemotherapy causes a decrease in platelets, red, and white blood cells. Therefore, deep massage may cause bruising. Chemotherapy also leaches calcium from the bones, leading to osteoporosis. Deep pressure may result in a bone fracture.
The optimal time for a massage is the day before chemotherapy treatment. Massage may be resumed only when the client is feeling ready for light touch. This time frame may vary for each client responds differently to the type of chemotherapy administered.
Oral chemotherapy (e.g., Tamoxifen, Raloxifene) may be given in combination with other chemotherapeutic agents or alone. Tamoxifen is used to treat patients with advanced breast cancer and works against the effects of estrogen on breast cancer cells.
The methods that are listed here are most often effective when used on women being treated for breast cancer. They are: 1) basic massage strokes except deep tissue; 2) myofascial softening and spreading; 3) acupressure/trigger point-modified; 4) manual lymph drainage; and 5) cross-fiber frictioning and skin rolling, for scar tissue release.
Massage Techniques For Mastectomy
Positioning should always be based on the comfort of the woman. For a new or fresh mastectomy, ask client to position her arm comfortably on her own, as this is the best indicator of comfort and mobility. The arm should be supported with a small pillow under the forearm and elbow.
For two weeks post-surgical and forward, the woman should be worked on in the supine position, or side-lying position with the operative side up, comfortably supported with the Body Support Cushion System or pillows. Do not ask your client to assume the prone position until she reports being able to sleep on her stomach. At that point, the specially-designed Body Support Breast Cushion is used in our practice.
For the client who has just had a TRAM, be certain that the client is supine, with the knees flexed and bolstered in an elevated position to reduce any stress on the abdominal incision.
Techniques Specific To The Breast And Shoulder
This section is not intended to be a complete protocol, and only presents a few examples of simple, yet effective techniques.
Myofascial softening, spreading and circular compressions on the pectoral region using the back of the hand. The hand is kept open, relaxed in the prone position. This will enable the therapist to safely and gently touch the breast tissue without being invasive to the woman. Fingers and fingertips limit accessibility onto the breast tissue. The back of hand position is most effective when used in the axillary area. Refrain from digging fingers into the axilla.
Frictioning of sternum and intercostals. Begin at sternoclavicular joint and above the xiphoid process. This move will release fascia, connective tissue and trigger points.
Thumping of the clavicle, sternum and thymus. Shoulder Traction and Side Pulls. Stand on opposite side to be worked on, cradle shoulder with both hands and slowly draw shoulder up and over, perpendicular to the table. Hold and stretch a minimum of 30 seconds. Continue this movement slowly, down the thoracolumbar region to the lumbar spine. Repeat on other shoulder.
Racking of Rib Cage combined with shoulder traction/side pulls. Sculpting of Rib Cage and Diaphragm. Stand on opposite side to be worked on, with upper hand, pinky side down, forming a knife edge, on the lower ribs (e.g., ribs 8 to 10) will provide skin slack. Ask client to inhale. Upon client's exhalation, the lower hand, beginning at the end of the xiphoid process will sculpt under the ribcage and diaphragm. This should be done a minimum of three times each side.
TALO Sweep (Tricep Axillary, Latissimus, Obliques). Begin back of hand movement on tricep and sweep down to axilla, latissimus dorsi, and begin movement up from obliques back to axillary area.
Angel Wing Fluff. Gently place both hand in flat position on the medial border of the scapula. Gently and slowly move fingers to mobilize the scapula. Movement resembles fluffing a pillow.
Any touch administered to a woman who has experienced the devastation and trauma of breast cancer surgery can be effective. Each woman heals at her own rate and the therapist should be sensitive to the physical, psychological and emotional dynamics at hand. It matters not whether the touch is technically or energetically administered, as long as the intention of the therapist is not to fixÑbut to empower the women to reclaim her self again.
Cheryl Chapman, RN, HNC, NCTMB, integrates both holistic nursing and massage into her work. She has a private practice in Springfield, New Jersey, and specializes in touch, bodywork and massage for people with cancer and mastectomies. She is a pioneer in promoting massage for people with cancer, and maintains an active teaching schedule instructing practitioners nationwide.
Eileen Kennedy, MA, MBA, NCTMB, APP, shares a private practice with Chapman, providing research support in the development and administration of massage teaching programs. She has more than 20 years experience in the pharmaceutical sector. She actively integrates therapeutic touch and her certification in polarity therapy into her work with cancer and breast surgery clients. Both can be reached at: 973-912-9060, or via E-mail at: touch2RN@aol.com.
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