Could Massage Spread Cancer in the Newly Diagnosed?
December 1, 2017
Could Massage Spread Cancer in the Newly Diagnosed?
December 1, 2017
For decades, an old myth held that massage therapists should steer clear of providing massage to people with cancer. This practice — of turning away people with this diagnosis — was based on fear of spreading the disease through an increase in circulation.
About 25 years of thought and literature have begun to settle our doubts, but in some circles, people continue to believe in a flat, absolute massage contraindication for cancer. In pockets within massage schools, the concern about cancer spread continues to be taught.
In oncology massage therapy (OMT) training, we dismantle this myth. We learn plenty of precautions to use, but they are not so broad as to turn people away. With some delicate adjustments in client communication and hands-on practice, we can work with people after cancer diagnosis, during treatment, and post-treatment.
Our ultimate goal is to help clients with symptom relief, including improvements in pain, nausea, fatigue, anxiety, and even depression. We seek to help without doing harm, and a growing body of research shows promising support for these goals. OMT has been growing, and the Society for Oncology Massage (S4OM) has guided it with standards of practice and standards of instruction.
The Window Between Diagnosis and Treatment
OMT practice and teaching have been questioned. Claiming that we might be doing harm by increasing cancer spread, authors Jeffrey M. Cullers and Ross Turchaninov raised a specific concern about massage during the window between diagnosis and treatment.
In "The Science of Oncology Massage, Part I, Massage Therapy in Cases of a Newly Diagnosed Cancer," they claim that massage in the wrong areas of the body could exert pressure on lymph and blood flow and increase cancer spread before cancer treatments had a chance to work.
Much of their argument rested on a scientific paper from May 2014, "Manipulation Therapy Prior to Diagnosis Induced Primary Osteosarcoma Metastasis — From Clinical to Basic Research. In my previous column, "Does Massage Spread Cancer? An Update," I argued that this paper offers poor reasoning and vague reporting. It does not provide a plausible reason to change OMT practice.
The Three Arguments Against Massage
Here, I will address three arguments raised by the authors.
- One, is their concern about raising blood circulation and spreading cancer, especially in the time span between cancer diagnosis and the beginning of treatment. They state that massage during this time makes patients especially vulnerable to harm from a massage-induced boost in circulation.
- The second is their belief that, once cancer treatment begins, their concern about cancer spread ends.
- A third concern is the criticism that in OMT, our standards of practice are built on personal opinion, not research.
First, a temporary boost in blood or lymph flow is not treated as a concern in cancer care at any time, and certainly prior to the commencement of cancer treatment.
I remember a clinic client, years ago, who had been diagnosed with a brain tumor. Surgery was planned for several weeks after diagnosis, and he used the interim to run, do martial arts and stretching. He wanted to be as strong as possible before surgery, and he moved plenty of blood and lymph on his way to that goal.
Cullers and Turchaninov claim it is unsafe to provide "circulatory" massage strokes anywhere near a tumor site before cancer treatment has begun. They mention increased pressure on the lymphatic and blood circulation near the tumor. They are vehement in this concern: "If there is a 1% chance that cancer cells will spread (metastasize) after MT while the patient is not undergoing oncology treatment yet, such therapy must stop."
Instead, they advise massage only if it is well away from the tumor site. For example, if a mass exists above the clavicle, they argue that massage should be performed only on the extremities, not on the head, neck, or trunk. If a mass exists below the clavicles, they argue that only the head and neck may be massaged. This is an effort to avoid a bump in circulation anywhere near the primary tumor.
In our view, this is an unnecessarily cautious approach. Coming from OMTs, who already hold a cautious, conservative perspective, this is saying a lot. In contrast, in OMT we might massage much of the client's body. But the way we massage makes a difference. OMT standards of practice are carefully spelled out by S4OM and followed by its educational providers, including myself.
First, even if increased circulation did pose a problem, in OMT, we often work more gently than the medium-to-deep, classical Swedish massage pressure considered "circulatory" in massage therapy school. A tumor site does not require avoiding large swaths of the body. And if, in fact, our lighter work is circulatory in nature, we offer up our "Exercise Argument."
The Exercise Argument recognizes blood and lymph flow as signs of good health. In healthy bodies, even those fighting disease, blood and lymph are supposed to move, not stagnate. Both are served by the movement of skeletal muscle through daily activities and exercise. Lymphatic flow, in particular, relies heavily on normal skeletal muscle movements. Otherwise limbs swell and puffiness results. Presumably this is why, upon receiving a cancer diagnosis, patients are not ordered to lie still and breathe shallowly until treatment is complete. Instead, they are often encouraged to exercise.
In their article, Cullers and Turchaninov report concern about any rise in pressure in the tumor region. But at most, massage might crudely mimic the usual movements of skeletal muscle against the surrounding tissues and vessels. At most, it might offer a brief, temporary boost in circulation. We are not advocating direct massage over an accessible tumor site, but the effect of massage in the general region (e.g. the trunk, for a tumor deep in the thoracic cavity) should be comparable or even less than the effect of typical skeletal movements during normal activity.
Cullers and Turchaninov then argue that it does no good to compare massage to exercise to justify doing massage in this case. They bring up a couple of small studies that suggest exercise does spread cancer. These studies suggest a link between exercise and tumor growth.
Yet the studies they cite, published long ago, show no sign of being credible enough to be replicated or expanded upon since. In fact, they are countered by other studies suggesting the opposite effect. Perhaps this is why there is no compelling raft of evidence discouraging exercise in people with cancer. They claim, "We have never met a responsible oncologist who will recommend exercise before cancer treatment starts." This statement is woefully out of step with current cancer care practice.
There are plenty of responsible oncologists and plenty of exercise recommendations. In particular, the growing "prehabilitation" movement in cancer care encourages movement and exercise precisely during that window before treatment, especially during the days or weeks of waiting for surgery. Such targeted movement, along with building overall strength and flexibility, appears to benefit patients by reducing complications, and improving function. It is also aimed at managing the anxiety and helplessness people often feel when faced with a health crisis.
The authors' concern about boosting circulation ends when cancer treatment starts. They state that their conservative, segmented precautions should remain in place until treatment starts. Yet there is nothing magical about the beginning of cancer treatment. It may compromise a tumor's ability to spread, but it does not throw a switch, reducing the risk of spread to zero. Cancer spreads in the absence of treatment. Cancer spreads in the presence of treatment. Cancer spreads, sometimes against the odds. Sometimes cancer does not spread during these conditions.
We share the spirit of these authors' risk-averse reasoning, but not their application of it. Their approach is not supported by current thought or practice in cancer care. If massage were truly thought to spread cancer through boosting blood or lymph, then it shouldn't be performed at any point in an oncology patient's life. It shouldn't be offered after treatment starts, when cancer sometimes spreads. It shouldn't be offered after treatment ends, when cancer could return. Nor should it be offered at end of life. Or at any point, really, which throws us back to the time when massage was flatly contraindicated, and we were turning patients away.
If you follow their reasoning, exercise should also be prohibited for everyone with a cancer history or a risk of recurrence. A cancer diagnosis would mean no yoga, no walking, no targeted exercises for regaining function. Our client "prehabbing" at the gym before brain surgery? Under this reasoning, he would be told to be sedentary. Post-treatment? To be 100 percent safe, don't exercise again, or cancer will spread more readily in the event of recurrence.
I know that sounds extreme. But with an inordinate focus on the role of blood and lymph flow in cancer spread, the authors' reasoning leads us down a slippery slope that we can't hope to climb up again. Exercise and massage therapy both have the potential to support a person's quality of life before, during, and after cancer treatment. Movement and touch provide a means of connection. Touch might reduce feelings of stigma. Exercise and massage therapy might help empower people during a time of feeling helpless.
All these potential benefits, and more, would be lost if we adopted the authors' approach. Their article includes yet another heartbreaking moment of turning a client away. In contrast, using S4OM guidelines, we would carefully interview the client, reason through the precautions, and carefully apply massage.
The authors claim that OMT practice is based on personal opinion, lacking the necessary evidence to support it. They state: "…Suggestions of full body massage therapy during the initial period of cancer therapy are personal opinions which are not supported by scientific data."
We agree that there is not much good data on either side about how to safely manipulate tissues near a tumor site at any point. On the plus side, research suggests negligible adverse reactions among oncology clients, especially when massage is provided by knowledgeable MTs. But in general, there is little data on the local mechanisms of massage, and little data on adverse reactions to massage.
In the absence of data on working with a medically complex population, it's important not to go rogue, or work too vigorously. We understand why the authors would adopt such a conservative approach, but we do not share that approach.
What gives us the confidence to work as we do? First, S4OM has not developed our OMT practices in isolation. Our caution, baked into our approach, is borrowed from standard practices in nursing, medicine, and PT. Here are just a few examples of how we "borrow the concerns of cancer care" to fashion our work:
- If cancer makes a patient's bones vulnerable to fracture, cancer care professionals advise the patient to take care with movement and impact. Likewise, in OMT, we take care with pressure, joint movement, and positioning. We ask targeted interview questions to identify any vulnerable areas.
- If cancer treatment leaves a patient without lymph nodes and at risk of lymphedema, cancer care professionals advise them to avoid blood pressure, heat, certain positions, and overexertion in that area, along with a host of other precautions. Likewise, in OMT, we take care with our pressure. We avoid heat treatments, compromising joint movements, and certain positions. We ask targeted interview questions to identify a risk of lymphedema.
- Malignant masses can cause pain, bleeding, and injury to nearby structures. In cancer care, an area of tumor site is treated with care. Likewise, in OMT, we treat an area with care. We don't press directly on tumor sites. We position carefully. We ask targeted interview questions to be sure we avoid pressure in the area and we steer clear of choreographed "lymphatic" techniques that are thought to move lymph.
Not Working In Isolation
To gain access to the thousands of patients we've served over the last couple of decades, we have not worked alone. These protocols come from asking questions and working with cancer care providers. We've talked with hospital pharmacists about effects of chemotherapy on the skin. We've discussed cancer rehab and prehab with physical therapists. We've discussed low platelets, tissue stability, and massage pressure with countless physicians and nurses.
Along the way, we've earned the trust of skeptics, clinicians, and legal teams at hospitals. We have relied on good research to guide our thinking. We've learned that cancer spread is a function of tissue affinity, tumor genetics, and favorable host environments, not the speed of blood flow. This is clearly spelled out in the text, "Medicine Hands: Massage Therapy for People with Cancer," now in its third edition.
Over years and conversations, in conferences and in the literature, we've revisited the concern about massage, circulation, and cancer spread. Many, many times. In OMT, we can't afford to make things up. We've modeled our work after the best in patient care. We've had to, and we're glad to, and our approach is measured and thoughtful.
Although we disagree, I appreciate this chance to answer questions about OMT, and to ease the concerns raised by Cullers and Turchaninov. It's clear from their article that they are aligned in the commitment to good care for oncology patients. In this, all of us — the authors, the Society for Oncology Massage, OMT instructors, and thousands of OMTs — are in agreement.
In oncology massage therapy, we work cautiously and sensitively to bring out good outcomes without doing harm. We can do this after diagnosis; before or during treatment. We can provide this at end of life, or in the months or years post-treatment. We can work at any time. There is no need to turn anyone away.
- Cullers JM, Turchaninov R. "Science of Oncology Massage, Part 1: Massage Therapy in Cases of a Newly Diagnosed Cancer." Science of Massage Institute News, June 2017; (2).
- Koelwyn GJ, Quali DF, et al. "Exercise-dependent regulation of the tumour microenvironment." Nature Reviews Cancer, 2017; pp. 620–632.
- MacDonald G. "Medicine hands: massage therapy for people with cancer (3e)." Forres, Scotland: Findhorn Press, 2014.
- Silver JK, Baima J. "Cancer Prehabilitation: An Opportunity to Decrease Treatment-Related Morbidity, Increase Cancer Treatment Options, and Improve Physical and Psychological Health Outcomes." Am J Phys Med Rehabil, 2018; 92(8):715-27.