Radiation therapy, often abbreviated as XRT for "X-Ray Therapy," is sometimes brushed aside as having fewer side effects than other cancer treatments. But radiation therapy can have strong effects on the body and some require significant adjustments in the massage session.

Myths and misinformation about massage and cancer treatment prevent patients from receiving good, supportive massage therapy care.

Radiation therapy is roughly classified as external beam radiation therapy (EBRT or EBT) and internal radiation therapy. External radiation is the more common of the two, where the patient lies on a surface and a machine, called a linear accelerator, delivers a beam of radiation to the tumor.

It can be used to shrink a tumor before surgery, prevent recurrence after surgery, or it can be used as palliative care when lesions cause pain.

Two Types of Radiation Therapy

External radiation treatments are usually only a few minutes long — most of the patient's session is spent making sure they are properly lined up on the treatment table.

A radiation oncologist typically maps out a specific field of treatment to treat the tumor from a number of angles. This is done to best target the tumor and spare the healthy tissue surrounding it. The sessions themselves are also usually painless.

Internal radiation often involves the placement of small radioactive implants inside the body near the tumor cells. This internal application, also called brachy therapy, allows for a higher dose of radiation and a more focused approach without the risk of damaging too much neighboring tissue.

Internal radiation seeds can be implanted and left in the body (such as with prostate cancer), a wand can be placed and removed (such as with gynecologic cancer), or a radioactive iodine solution can be ingested (as with thyroid cancer).

Touch and Radiation Therapy

Education about massage and cancer is limited in most basic training programs. As a result, a common misconception among massage therapists is that any client going through radiation therapy is "hot" and "radioactive" and either the practitioner should only touch them while wearing gloves, or the client should not be touched at all.

But the truth is that, in the case of EBRT, the radiation source is the linear accelerator which stays in the room. The client is not "contaminated" and the therapist should make appropriate massage adjustments for other factors in cancer treatment. It is safe for a massage therapist to touch the client.

In the case of internal radiation therapy, clients are considered "hot" if the implants are still in and if they are still radioactive (and not expired seeds, as in the case of prostate cancer). You should ask the client ahead of the session.

Ask where and when the internal radiation was implanted, and if there are any contact precautions in place. Most people are already following these precautions and clients are unlikely to seek out massage unless they are cleared for contact.

Side Effects

Radiation is aimed at the cancer cells, but nearby tissues in the path of the beam may be affected as well. Clients can experience swelling, reddening or change in pigmentation and dry and/or itchy skin. They may lose hair in the radiation field.

Another common side effect is overall fatigue. It often starts up a few weeks after treatment begins and can linger for weeks or even months after treatment is complete.

Some side effects depend on where the radiation field is located. Here are some examples:

• Radiation to the mouth or throat can damage salivary glands or cause mouth sores making eating challenging or uncomfortable.
• Radiation to the abdomen can cause a host of symptoms (bladder pain, GI problems).
• Radiation to the chest can affect heart or lung function.
• Radiation can thin bones and make them susceptible to fracture.

One complication of XRT is of particular note for massage therapists: Radiation treatment can injure lymph nodes, and lymph nodes in the neck, axilla or groin are often included in the field. This can put a client at lifelong risk for lymphedema, a disfiguring, debilitating and often painful condition that can cause a host of complications.

There is little specific research on massage for clients in XRT, but our clients tell us that the contact of skilled touch can be healing. Relaxation during a stressful time and relief from side effects such as nausea, fatigue and pain provide welcome possibilities for clients.

The key is making sure we apply this touch safely. Finding out how to best serve our clients going through radiation therapy, or who have recently completed therapy, starts with asking the right questions in the intake interview. Here is a "starter list" of questions for these clients:

• Was it external or internal radiation?
• Where on your body was it? (Have them point to the location on their body if possible.)
• When did you have this treatment? How long did it last? When was your last radiation treatment?
• How did this treatment affect you?
• Do you have any skin markings or tattoos?
• Where were the entry and exit points for the beam?
• Were any lymph nodes treated with radiation or included in the radiation field (list neck, underarm, groin, pelvis/abdomen).
• Are there any lingering effects?

Massage Adjustments

Therapists will find many massage adjustments for radiation treatment echo common sense: On a current or recent radiation field, we use no friction, pressure, no heat, hot stones or cold therapy, nothing besides hospital-approved lubricants (metals are contraindicated and fragrances can be irritating) and generally no direct contact if it's a current field.

A simple hold through the drape may be possible over a dry radiation field, and the hands-on contact may be soothing. Any other sort of technique brings with it the risk of disturbing healing skin and other tissues, or further exacerbation of skin changes such as flaking, itching, blistering or weeping.

Because the risk of lymphedema is very real in many clients after XRT therapy, it is important to fully understand the condition before attempting to work with clients with histories of cancer treatment. Lymphedema risk is an example of a "hidden contraindication." The adjustments are not intuitively obvious and working safely requires good interviewing and hands-on skills.

If key lymph nodes were in the radiation field, there are strict massage adjustments in pressure, stroke direction, joint movement and position.

It is essential to avoid anything that would redden the skin or injure the intact lymphatic structures. "Just working lightly" is not a complete guideline here and the wrong pressure, thermal application, joint movement or stroke direction could trigger irreversible, chronic lymphedema.

For specifics, refer to Gayle MacDonald's Medicine Hands: Massage Therapy for People with Cancer.

Language is Important

When speaking with a client, we do not ask about "radiation burns" or refer to any areas as "burned." Although we essentially treat these areas as if burned, in cancer care these areas are referred to by more neutral terms: "skin changes" or "skin effects."

For complete massage therapy guidelines, therapists are referred to the Society for Oncology Massage, to the literature on oncology massage and to the growing availability of specialized training.

Because radiation treatment can place a significant demand on the body and effects are often cumulative, oncology massage therapy is careful and does not introduce any more stressors.