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Seminars in Oncology Nursing, Vol 28, No 1 (February), 2012: pp 45-54 45

MASSAGE IN SUPPORTIVE
CANCER CARE
WILLIAM COLLINGE, GAYLE MACDONALD, AND TRACY WALTON

OBJECTIVE: To review recent findings on the utilization of massage by cancer


patients, including evidence of effects in supportive and palliative cancer care,
current understanding of safety considerations and adaptations needed,
education of professional and family caregivers to provide this form of
support, and guidelines for oncology nurses in referring patients.
DATA SOURCES: Journal articles, government and special health reports, book
chapters, and web-based resources.
CONCLUSION: The massage profession and the disciplines of clinical oncology
have experienced a rapprochement in recent decades over questions of safety
and efficacy. However, there is now significant recognition of the potential
contributions of massage in supportive care, as well as greater understanding
of the modifications needed in offering massage to cancer patients.
IMPLICATIONS FOR NURSING PRACTICE: Massage offers significant potential for
benefiting quality of life when applied with proper understanding of the
adaptations needed to accommodate the needs and vulnerabilities of cancer
patients.
KEY WORDS: Massage, palliative care, supportive care, integrative oncology,
informal caregiving, spouse caregiving, family caregiver education

O
NE OF the most primal and sponta- powerful salutogenic responses in the body and
neous ways in which humans offer mind of the recipient.
support to another who is ill or Beyond simple caring touch, there are several
suffering has been through touch. modalities that use touch as a deliberate interven-
Florence Nightingale, founder of the modern tion in supportive cancer care. The diverse modal-
nursing profession, recognized this and regarded ities are grounded in different theoretical systems
caring touch as an essential ingredient of good with little uniformity in use of language. As
nursing care.1 Indeed, touch as a simple expres- a result, there is often imprecise use of the term
sion of interpersonal caring without technique massage, blurring boundaries between it and
or manipulation of tissue is now known to evoke other touch-based methods. The National Cancer

William Collinge, PhD, MPH: President, Collinge and Address correspondence to William Collinge, PhD,
Associates, Eugene, OR. Gayle MacDonald, MS, LMT: MPH: e-mail: William@collinge.org
Founder, Oncology Massage Education Associates, 2012 Elsevier Inc. All rights reserved.
Portland, OR. Tracy Walton, MS, LMT: Director, Tracy 0749-2081/2801-$36.00/0.
Walton & Associates, LLC, Cambridge, MA. doi:10.1016/j.soncn.2011.11.005
46 W. COLLINGE, G. MACDONALD, AND T. WALTON

Institutes Office of Cancer Complementary and cancer spread. As explained by Pfeifer, Site
Alternative Medicine has offered a classification predilection does not depend on the anatomy of
system in which some methods commonly the circulation as previously believed. Tumor
referred to as variants of massage methods that cells flow through the circulatory system based
are used by some massage therapists are classi- on venous drainage from the primary tumor.
fied separately.2 For example, Reiki, Therapeutic However, the site and survival of the dissemi-
Touch (TT), and Healing Touch (HT) are classed nated tumor cells depend on the qualities and
as Energy Therapies, reflexology is separated properties unique to the tumor cell itself. Certain
from massage in Manipulative and Body-Based tumor cells possess an affinity for specific organs.
Methods, and aromatherapy is listed as a Mind- The metastatic process is not random.4 If circu-
body Intervention. This ambiguity makes it lation did influence cancer spread, many other
important in clinical communications and normal and accepted activities would also
research to clarify how the term massage is being contribute to metastasis, including hot showers,
used in a given context. In this article, massage exercise, sexual activity, and other aspects of
refers to direct manipulation of soft tissue. daily life, but patients are almost always encour-
While various forms of therapeutic manipula- aged to exercise and remain as active as
tion of soft tissue have been practiced across possible.5
cultures for thousands of years, Swedish (also The concern about metastasis is increasingly re-
referred to as classical) massage is the most garded as myth in the massage profession.3,5-8
common form in the West and is the core of Massage is now recognized as an intervention for
most massage training programs. Swedish quality of life in both palliative and end-of-life
massage was developed in the 19th century by care. The term oncology massage referring to
Per Henrik Ling and introduced as a health care the adaptation of massage techniques to accom-
modality in the United States (US) in the 1850s modate the special considerations of people expe-
by George and Charles Taylor, two physicians riencing cancer or its treatments is relatively
who had studied in Sweden. recent, with the first organized trainings being
Medical interest in massage diminished by the developed in the 1990s.
1930s and 1940s with advances in pharmaceu-
tical and surgical medicine, although it remained
part of the training for the nursing profession, USE OF MASSAGE BY CANCER PATIENTS
including the nightly back rub much-revered by
hospital patients. The establishment of a distinct According to an American Hospital Associa-
profession of massage therapy in the US was tion survey, the number of hospitals offering
advanced in 1943 when the graduating class of complementary therapies grew from 7.7% in
the College of Swedish Massage in Chicago 1998 to 37.3% in 2007, with about 71% of those
formed an association, which eventually became offering massage. Reasons most cited by hospi-
the American Massage Therapy Association. In tals offering massage include stress reduction
the 1970s, interest began to surge with popu- (71%), pain management (66%), cancer patient
larity of the concepts of holistic health and support (57%), and palliative care (41%), among
complementary and alternative therapies. others.9
Important to the history of massage in cancer Massage is among the more popular modalities of
has been the evolution of beliefs regarding complementary therapy among cancer patients.
whether massage could contribute to metastasis. Surveys indicate that 63% to 91% have used some
Such concerns were based on the concept that form of complementary therapy, with one study
increased blood and lymph circulation might reporting an average of 4.8 different comple-
encourage the spread of cancer. This fear was mentary modalities used,10 and reports on use of
widely propagated through the massage profession massage range from 11% to 53% of cancer
and reinforced through oral tradition, classroom patients.11-17 The National Comprehensive Cancer
teaching, and apprenticeship.3 Network (NCCN), a nonprofit alliance of 21 of the
In the last two decades, however, a heightened worlds leading cancer centers, now recommends
emphasis on evidence-based practices has led to massage in its Guidelines for Supportive Care,
critical examination of this issue. Now the speed based on the growing body of evidence of its safety
of circulation is no longer thought to influence and benefits for quality of life.18
MASSAGE IN SUPPORTIVE CANCER CARE 47

Varieties of Touch-Based Modalities


As noted earlier, a wide variety of touch-related TABLE 1.
modalities are commonly offered by complemen- Touch-based Methods Commonly Available to Cancer
Patients From Complementary Therapists
tary therapists to cancer patients. For many
modalities, the evidence base is weak or non- Group A
existent, though they may lead to perceived bene- Methods using principles of subtle energy or very light touch
fits for patients. Touch-related modalities may be and requiring minimal or no adaptation:
roughly allocated to two groups based on the Bowen Technique
Compassionate Touch
degree of contact and soft tissue manipulation Craniosacral Therapy
involved. As listed in Table 1, the methods in Healing Touch
Group A use principles of light or gentle touch, Jin Shin Jyutsu
or in some cases even no direct contact, to balance Polarity Therapy
or harmonize the human energy system or Reflexology
Reiki
nervous system or to provide comfort and relaxa- Therapeutic Touch
tion. There is little or no emphasis on manipu- Group B
lating soft tissue directly, hence little or no need Methods using direct manipulation of soft tissue and requiring
for modification of technique with cancer patients. awareness of needed adaptations in technique:
Of these, TT, Reiki, and HT have the most empir- Acupressure
Ayurvedic massage
ical support, and these modalities are reviewed in Fascial release techniques
a separate article elsewhere in this issue.19 Lomilomi
In contrast, the methods in Group B directly Lymph drainage therapies
manipulate soft tissue and therefore require adap- Neuromuscular therapy
tation of technique to accommodate the vulnera- Seated chair massage
Shiatsu
bilities caused by cancer and its treatments Swedish massage
(discussed later). Swedish massage has the most Trigger point therapy
extensive evidence base and is the baseline Zero balancing
training in most massage schools. Its most recog-
nizable hallmarks are the familiar long, flowing
or gliding strokes of effleurage, and the strokes of
petrissage that lift, roll, or knead the tissue. These randomized clinical trials of massage, with the
methods also are relatively easily learned and largest effects being reduction of anxiety and
hence can be taught to family caregivers, as will depression.21 It is important to note that these
be discussed later. Other common Swedish tech- effects were strongest in studies involving a series
niques include friction, vibration, and tapotement of massages over time rather than a single treat-
(percussion or tapping). ment. Anxiety and depression are common sour-
Because of its pervasiveness, Swedish methods, ces of distress in people with cancer and focus of
are usually what people associate with massage. many quality-of-life interventions.
Swedish methods tend to be the basic approach In cancer, studies consistently demonstrate the
used by massage therapists who work with cancer potential of massage to improve mood and quality
patients, and they figure most prominently in of life. A recent systematic review22 of randomized
research on the effects of massage in supportive clinical trials of Swedish methods for cancer
cancer care. However, while these methods can patients found 14 trials met inclusion criteria.
be adapted to the needs of cancer patients, few While methodological quality was considered
massage therapists have actually received formal poor, the evidence suggests that massage can alle-
training in such modification. viate a wide range of symptoms including pain,
nausea, anxiety, depression, anger, stress, and
fatigue. This followed an earlier Cochrane review
MASSAGE EFFECTS IN SUPPORTIVE CARE that concluded that short-term benefits of massage
include improved psychological well-being (most
Over 80 clinical trials of massage for a wide consistently reduced anxiety), and in some cases
range of health conditions have found consistent reduced severity of physical symptoms.23
benefit for anxiety and depression.20 These find- While an exhaustive review of research in this
ings are supported by a meta-analysis of 37 area is beyond the scope of this article, the studies
48 W. COLLINGE, G. MACDONALD, AND T. WALTON

highlighted below illustrate progress in building two-period, crossover intervention study with
the evidence base for massage in cancer. 230 cancer patients, Post-White et al26 tested the
effects of massage therapy and HT, in comparison
Memorial Sloan-Kettering Study to presence alone or standard care, in inducing
In a large study of massage effects on symptom relaxation and reducing symptoms. Both massage
levels, 1,290 cancer patients from Memorial and HT lowered blood pressure, respiratory rate,
Sloan-Kettering Cancer Center were assessed heart rate, and total mood disturbance. Massage
immediately before and 5 to 15 minutes after lowered anxiety and HT lowered fatigue. Pain
a massage.24 Patients rated the severity of pain, ratings were lower after massage and HT, with
fatigue, stress/anxiety, nausea, depression, and 4-week non-steroidal anti-inflammatory drug use
other symptoms on a 10-point scale. Sessions less during massage treatment. There were no
averaged 20 minutes for inpatients and 60 minutes effects on nausea. Presence alone reduced respira-
for outpatients. Symptom scores were reduced by tory and heart rates but did not differ from stan-
an average of 50%, even for patients reporting high dard care on any measure of pain, nausea, mood
baseline scores. Outpatient scores improved about states, anxiety, or fatigue. The researchers
10% more than inpatient scores. About a quarter of concluded that massage and HT are more effective
the patients were re-assessed 48 hours after treat- than presence alone or standard care in reducing
ment and evidence of lasting effects of massage pain, mood disturbance, and fatigue in patients
was examined. Inpatient data suggested a return receiving cancer chemotherapy.26
toward baseline within a day or so. Outpatients
showed no such trend, and instead had persisting Breast Cancer
benefit across the total of 48 hours studied. An Several well-designed studies have examined
important finding of this study was evidence of the effects of massage in breast cancer patients.
cumulative effects of repeated massages. A general One randomized controlled trial investigated the
linear model of the findings, adjusted for baseline efficacy of classical massage treatment in reducing
score and clustered by patient, suggested that breast cancer-related symptoms and in improving
the effects probably increase for each additional mood disturbances. For 5 weeks the intervention
treatment. The authors conclude that major, clin- group received bi-weekly 30-minute classical
ically relevant, immediate improvements resulted massages in the back and head-neck areas. Signif-
from massage, even in patients with high baseline icantly higher reductions of physical discomfort,
scores, and that outpatients experienced greater fatigue, and mood disturbance were found in the
improvement than inpatients. intervention group versus controls.27
In another randomized controlled trial with 34
Massage Versus Simple Touch stage I and II breast cancer patients, researchers
In an important large, multi-site randomized used a regimen of 30-minute massages three
clinical trial, 380 adults with advanced cancer times per week for 5 weeks. The massages con-
who were experiencing moderate-to-severe pain sisted of stroking, squeezing, and stretching tech-
(90% were enrolled in hospice) were randomized niques to the head, arms, legs/feet, and back.
to six 30-minute sessions of either massage or Immediate effects included reductions in anxiety,
simple touch (without manipulation) over 2 weeks. depressed mood, and anger. Long-term effects
Both groups demonstrated immediate improve- included reduced depression and hostility, and
ment in pain and mood, although massage was increased urinary dopamine, serotonin values,
superior for both symptoms. No between-group natural killer cell numbers, and lymphocytes.28
mean differences occurred over time in sustained Another randomized trial with 39 women with
pain, quality of life, symptom distress, or analgesic breast cancer undergoing chemotherapy found
medication use. This study makes a strong point in significant reduction in nausea after massage.29
favor of touch in general as being beneficial for this An important issue in women undergoing treat-
population, whether or not formal massage inter- ment for breast cancer is lymphedema. In
vention is available.25 a randomized clinical trial of 120 women who
had breast surgery involving dissection of axillary
Massage Versus Healing Touch lymph nodes, a physiotherapy regimen of manual
One of the more widely used energy-based lymph drainage, massage of scar tissue, and
modalities is HT. In a randomized, prospective, progressive active and action-assisted shoulder
MASSAGE IN SUPPORTIVE CANCER CARE 49

exercises led to significant reduction in develop- in the ability of family caregivers to use simple
ment of lymphedema during a year of follow-up.30 methods in palliative care at home. One study40
used a randomized controlled trial with 97 patients
Other Studies of Symptoms and Side Effects and their family caregivers to evaluate effects of
In radiation therapy, a randomized trial with caregivers learning from a 78-minute instructional
100 patients found significant reductions of 45% DVD and manual, The Touch, Caring and Cancer
in anxiety from pre to immediately post massage Program, on simple massage techniques for home
on a visual analog scale, although the impact did use. The program focuses on using light pressures
not appear to affect longer term anxiety scores.31 and uncomplicated methods for general comfort
Wilkie et al32 randomized 29 cancer hospice and relaxation.
patients to routine care or four massages over Control caregivers were assigned to read to the
2 weeks, and found significant reductions in pain patient from literature of the patients choice.
intensity. Weinrich and Weinrich33 randomized Patients rated their symptoms on a 10-point scale
28 patients treated with chemotherapy or radia- before and after each of four 20-minute sessions
tion to a single 10-minute back massage or with their assigned activity. Symptoms rated
a 10-minute visit and found significant reduction included pain, fatigue, stress/anxiety, nausea,
in pain for men but not women (however, men depression, and other. Significant reductions
had greater pain levels at baseline). were seen for all symptoms after both activities,
Meek34 found that after a 3-minute slow-stroke and ranged from 29% to 44% for massage, approach-
back massage, 30 hospice patients had significant ing the magnitude of effects seen in some studies
improvements in several physiologic indices of using professional therapists. Caregivers in the
relaxation ,including systolic and diastolic blood massage condition also showed significant gains
pressure, heart rate, and skin temperature. Smith in their confidence and comfort with using touch
et al35 reported that patients receiving chemo- and massage as part of caregiving at home.
therapy or radiation therapy had significant impro-
vements in pain, sleep quality, and symptom
distress using three 30-minute treatments with SAFETY CONSIDERATIONS AND ADAPTATIONS
Swedish massage. Tope et al36 conducted
a controlled trial of a 20-minute shoulder, neck, In general, the research notes no adverse effects
head, and facial massage for 7 days in bone marrow of massage therapy in cancer patients. 24-26,41
transplant patients and found significant benefits However, there is consensus that massage thera-
for anxiety, distress, fatigue, and nausea. pists should have additional knowledge, skill, and
In hospitalized cancer patients, Ferrell-Torry experience in safely practicing with this popula-
and Glick37 examined the effects of massage to tion.42-44 For most massage therapists this requires
the feet, back, neck, and shoulder areas on pain specialized training in oncology massage.
perception, anxiety, and relaxation levels, and Technique needs to be modified to accommo-
found significant improvements with just two 30- date the symptoms of cancer and side effects of
minute sessions on consecutive evenings. In treatment. Principal adjustments are in use of
a controlled study of 52 cancer patients, a 15- pressure, joint movement, and the position of
minute regimen of massage to hands, feet, shoul- the massage recipient on the massage table or
ders, and neck significantly reduced pain and other surface.6,7 Additional adjustments may be
anxiety.38 A study of the phenomenology of made in session length or timing (working within
cancer showed that 20 minutes of light massage or around cyclical side effects or symptoms),
(gentle stroking to hand/forearm or foot/lower lubricants used, speed or rhythm of massage
part of the leg) led patients to report meaningful strokes, and other factors. Modifications may be
relief from suffering, the experience of being implemented over the whole body, or at specific
special, and positive relationships with those sites affected by cancer or its treatment.
providing the massage,39 all important outcomes The most common element of massage to be
from a quality-of-life point of view. modified in cancer patients is pressure. In sharp
contrast to the deeper pressures routinely used in
Family Caregiver Use conventional massage therapy, lighter pressures
While most research has examined massage are used in many cases. These pressures are well
delivered by professionals, there is growing interest described as those one would apply in light
50 W. COLLINGE, G. MACDONALD, AND T. WALTON

lotioning or heavy lotioning 6,7 during massage, slower stroke speeds and gradual transitions when
and are used when tissues are fragile or unstable. a patient is nauseated, and are more intuitively
Gentle pressures are also used at sites of bone obvious than those for lymphedema or lymphe-
metastasis with fracture risk, sensation changes dema risk. In fact, most massage contraindications
from peripheral neuropathy, over surgical scars, for people with cancer histories are derived from
at sites of deep vein thrombosis risk, and in areas clinical observations, rather than research data.
of cancer pain and discomfort. 6,45 Overall pressure Information on these practices is widely available
is modified for patients with thrombocytopenia, in the oncology massage literature. A summary of
leukemia, or at any time easy bruising and bleeding precautions for massage in cancer is shown in
are present.7 It is important to note that relaxation, Table 2.
with its broad spectrum of benefits, can be
achieved with these light pressures.
Many pressure and joint movement contraindi- TRAINING OF MASSAGE THERAPISTS
cations persist long after cancer treatment is
complete, and some may continue indefinitely. The long-held belief that massage was contrain-
Pressure is modified for long-term side effects dicated has had repercussions that continue to be
and complications of cancer treatment such as felt today. Until the last decade, many therapists
lymphedema, lymphedema risk, osteoporosis, were even afraid to touch cancer patients. Most
and skin sensitivity from radiation therapy.7,46 schools now realize the inaccuracy of this position
Of particular importance is modification of pres- and are reconsidering how to address this issue,
sure any time there is risk of lymphedema. Deep but a large proportion of current practitioners
massage pressure is thought to injure delicate were trained under the old paradigm.
lymphatic structures.47-49 When lymphatic func- Massage schools currently give a variety of
tion is compromised by removal or radiation of messages to their students about this issue. Some
lymph nodes, significant adjustments must be instruct therapists to get approval from the
made in massage pressure, direction of stroke, patients doctor but do not give specific instruction
and other factors. To avoid precipitating a lymphe- or supervised experience in working with this pop-
dema episode or triggering chronic lymphedema, ulation. Others simply offer the guideline to
oncology massage therapists are careful to avoid massage oncology patients with care.46 Because
heat, pressure, and excessive joint movement in the majority of massage training is in deeper
the body region served by the missing or compro- musculoskeletal techniques suitable for a healthy
mised lymph nodes. population, most therapists are unclear exactly
Most often, this precaution limits massage on the what massage with care means or why caution
at-risk extremity and the adjacent trunk quadrant. is needed. Students are intellectually familiar
For example, after breast cancer surgery with axil- with diseases and conditions such as cancer and
lary lymph node dissection, massage pressure is edema, but do not receive structured clinical expe-
limited to light or heavy lotioning over the upper rience with such situations. Only a handful of
extremity and upper trunk quadrant, anterior and schools give oncology massage training within the
posterior, defined by the midline, the clavicle, core curriculum. By and large, most massage
and the lowest rib. Therapists avoid aiming strokes students become licensed without the information
at the area of missing or compromised lymph or experience to safely offer massage as a comple-
nodes. This precaution is followed even with mentary modality for the person affected by
a sentinel node biopsy.6,50 surgery, chemotherapy, or radiation.
While conservative, these modifications for lym- Thus, many therapists providing massage for
phedema risk mirror the widely advised precau- cancer patients do so based on either continuing
tions of avoidance of activities that raise blood education or trial and error. The spectrum of
pressure, exposure to excessive heat, and overuse training in oncology massage is broad, ranging
of the limb. Massage adaptations for lymphedema from short, on-line training or distance learning
history are even more conservative, as traditional with no hands-on practice or supervision, to 400-
Swedish techniques may easily aggravate lymphe- hour certification programs. Unfortunately, only
dema, and results may be irreversible.6 a minority take training to become aware of the
Other modifications are used for other compli- needs of someone going through cancer treatment
cations of cancer and its treatments. These include or recovery.
MASSAGE IN SUPPORTIVE CANCER CARE 51

TABLE 2.
Precautions Checklist for Massage in Cancer53

Condition Avoid But you CAN

 Solid tumor in any area that is  Pressure on the area of the tumor  Touch, hold or stroke with soft hands
accessible to the hands  Use moderate pressure elsewhere
 Known or suspected bone metastasis,  Pressure on the area  Touch, hold or stroke with soft hands
including the spine  Jostling or moving the joints in the area  Use moderate pressure elsewhere
 Swelling or edema, including  Pressure on the area  Massage elsewhere, with patient
lymphedema, current or past  Positions that put pressure on the area comfortably positioned
 Positions where gravity increases the
swelling
 Tendency toward bruising or bleeding  Pressure  Gentle kneading or light stroking with
 Aggressive kneading or gliding just the pressure used to apply lotion
 Holding the body with soft hands
 Fever  Gliding and kneading strokes with  Gliding and kneading strokes with just
pressure the pressure used to apply lotion
 Try resting hands quietly, and imagine
coolness coming through your hands
 Any identified risk of lymphedema  Pressure or rubbing an area at risk of  Use moderate pressure elsewhere
lymphedema
 Radiation site  Pressure or stretching the skin in the  If tolerated, contact with soft, still
area hands, resting over clothing
 If skin is open (e.g., by scratching),  Imagine coolness coming through
avoid any contact with area your hands
 Incision site  Pressure, stretching or kneading the  Massage elsewhere on the body
 Recent surgery area  Handle any device with clean, dry
 Medical devices: IV, chemo port,  Positions (e.g., face down) that press hands; follow doctor guidelines
catheter, oxygen mask, cannula, or pull on the area  Choose positions and pillows that
ostomy  Getting lotion on devices ease discomfort
 Fragile veins or varicose veins  Pressure on the area  Touch or hold with soft hands
 Communicable skin disease  Contact with the skin  Ask doctor what touch is possible
 Undiagnosed skin lesions  Contact with the skin  Refer to your doctor
 Removal or radiation of lymph nodes in  Pressure on the limb and the area  Massage with moderate pressure
the armpit, groin, neck or jaw drained by those lymph nodes elsewhere on the body
 Touch or hold the area with soft hands;
no pressure
 Neuropathy  Pressure on the affected area  Use moderate pressure elsewhere
 Changes in sensation (e.g.,  Pressure and joint movement in the  Report symptoms to doctor and follow
numbness, tingling, weakness) affected area her/his advice
 Easy bruising or bleeding (low  Pressure anywhere on the body  Holding or stroking anywhere with light
platelets, blood thinners, etc.) (because of bruising) or no pressure. Ask doctor about best
pressure.
 Major problems affecting vital organs  Pressure  Massage without much pressure or
(heart, lungs, kidneys, liver, brain) moderate pressure, depending upon
the patients tolerance
 Low white blood count (neutropenia)  Pressure  Same as above
 Fatigue  Pressure  Same as above
 Risk of blood clot in legs (from cancer  Contact with thighs, calves, shins or  Massage with moderate pressure
or cancer treatment) tops of feet, or anywhere blood clots on bottoms (soles) of feet if doctor
are a risk advises it

Despite the hurdles, oncology massage is instructors, provides education and resources,
becoming an established specialty. The Society and hosts an oncology massage therapist locator
for Oncology Massage (S4OM) was formed in service of members who are trained by recognized
2008 to advance the discipline.51 The small but educators to specific standards.
growing organization includes international S4OM has been working steadily to establish
members and educators and currently recognizes standards of practice and continuing education
52 W. COLLINGE, G. MACDONALD, AND T. WALTON

guidelines. These standards are primarily orga- of The Touch, Caring and Cancer Program, lay
nized around safety precautions for people with caregivers can learn simple methods to safely
cancer and cancer histories. Membership in bring comfort and relaxation to cancer patients
S4OM requires completion of a 24-hour live without having to become massage therapists
seminar recognized by the Society that presents themselves.40,52,53 The benefits attained may
information on surgery, chemotherapy, and radia- approach those achieved by professional thera-
tion, their side effects, and how to adjust massage pists, especially given that more frequent use is
techniques so that the session is safe and comfort- possible in the home environment.
able for the patient. Some members take their A key asset in such caregiver education is the
education further to specialize in oncology. motivation of the partner. Studies have docu-
mented the burden of distress borne by loved
ones who feel helpless in witnessing the patient
GUIDELINES FOR REFERRING PATIENTS go through cancer treatment.54-58 Caregiver
training in simple touch techniques has the
Currently there is a limited pool of available
potential to (1) empower the caregiver with skills
massage therapists who are adequately skilled to
that alleviate perceived helplessness and build
work with cancer patients. Until there is uniform
self-efficacy in caregiving, (2) offer the patient
training and credentialing within the profession,
more frequent experience of this form of support
oncology nurses and patients can take several
than they might be able to access from profes-
steps to help find practitioners with the skills to
sionals, and (3) improve the quality of the rela-
work with people living with cancer.
tionship by providing a meaningful and
(1) Look for someone with formal training in satisfying way to connect during the challenges
oncology massage. Use the S4OM websites of cancer. As one spouse stated, Our sessions
locator service to look for an S4OM- have helped maintain a level of intimacy despite
recognized therapist in the area. my husbands chemo side effects.
(2) Interview prospective therapists about their Collaborations among oncology nurses, social
training. Have they had a class specifically for workers, and massage therapists are using support
people with cancer? Are they trained in gentle groups and workshops to teach family caregivers
touch techniques? (See Table 1, Group A.) how to provide the benefits of touch in supportive
(3) Ask about experience working with people care at home. These initiatives foster proactive
affected by cancer. involvement by family members, are cost effective,
(4) Ask about the focus of their practice. The best and help overcome disparities in access to
matches will likely be with therapists whose supportive and palliative care, including for under-
focus is with seniors or the medically frail, served or low income populations.
lymphatic specialists or performers of gentler
types of touch therapy such as those listed in CONCLUSION
Table 1, Group A.
(5) Be aware that therapists with practices in deep The massage profession and the disciplines of
tissue bodywork, sports massage, or a chiro- clinical oncology have experienced a kind of
practic orientation may have difficulty making rapprochement over questions of safety and effi-
the adjustments needed by someone who has cacy. There is now significant recognition of the
been through cancer treatment. They may potential contributions of massage in supportive
need additional training in cancer care. care, as well as greater understanding of the modi-
(6) Briefly describe the patients treatment history fications needed in offering massage to cancer
and ask what modifications the practitioner patients.
would make from standard massage. Weaknesses in the evidence include studies
with heterogeneous samples, limiting the ability
to make definitive statements about outcomes
FAMILY CAREGIVER TRAINING and wide differences across studies in dosing,
techniques, and the training or preparation of
An important resource for touch-based sup- the interventionists. Nevertheless, massage re-
portive care is the spouse, partner, or other family mains one of the most popular and comforting
member in a caregiving role. As seen in the study forms of supportive care in cancer.
MASSAGE IN SUPPORTIVE CANCER CARE 53

Beyond specific therapeutic techniques, evid- of touch in many different forms. As the field of
ence indicates that the experience of touch can integrative oncology matures, new initiatives are
convey significant benefit to patients. Thus, multi- needed to further develop the evidence to more
disciplinary professionals as well as family care- effectively leverage the potential benefits of
givers have an abundance of opportunities to massage and touch in both clinical and home
contribute to patient well-being through the use environments.

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