Cancer & Massage Therapy Safety and Risks

Leaders in massage therapy are developing new guidelines that will outline the
educational preparation, clinical skills, and critical thinking needed to work with patients
with cancer (Walton, 2000). Despite this, many massage therapists still rely on a
physician’s order or note that contains directions for the therapy and permission to treat
patients with cancer. The factors that a massage therapist considers in determining what
technique can be used safely and effectively for a patient with cancer are tumor location,
cancer stage, and location of any metastatic sites. Walton reported that having knowledge
about cancer and metastatic patterns is very important for a massage therapist treating a
patient with cancer, and to avoid local and regional pressure in the area of the tumor, and
that the cause of any pain or discomfort must be determined before therapy may resume.
Therapists must also have an understanding of the types of cancer treatment and potential
side effects before beginning a treatment session (Curties, 2000, Walton, 2000).

Principal risk considerations include:

• exacerbation cancer metastasis due to mechanical stimulation
• exacerbation lymphedema due to mechanical stimulation

Appropriate treatment plan adjustments concerning safe practice considerations include:

• chemotherapy or radiation therapy
• surgical or medical procedures
• lymphedema and lymphatic complications

Massage administered by a registered (or licensed) massage therapist is very safe;

complications are rare (Ernst, 2003). Healthy patients may occasionally experience
bruising, swelling of massaged muscles, a temporary increase in muscular pain, or an
allergic reaction to skin lubricants. Case reports have documented serious adverse events
that include fractures and dislocations, internal hemorrhage and hepatic hematoma
(Trotter, 1999), dislodging of deep venous thromboses and resultant embolism of the
renal artery (Mikhail, Reidy, et al, 1997), and displacement of a ureteral stent (Kerr,
1997) . Adverse effects were associated mainly with massage delivered by laypeople and
with techniques other than Swedish massage.

Practitioners need to be aware of the following special situations with cancer patients:
• Coagulation disorders, complicated by bruising and internal hemorrhage
• Low platelet count
• Medications: coumadin, acetylsalicylic acid, heparin
• Metastases to bone, complicated by fracture
• Open wounds or radiation dermatitis, complicated by pain and infection

In these situations, avoiding massage or lightening the touch over regions of risk may
prevent complications. No evidence suggests that massage therapy can spread cancer,
although avoiding direct pressure over a tumour is a sensible precaution. Comfort-
oriented massage or touch therapy can be administered to people with cancer regardless
of the severity of their condition.
Massage therapy has long been rumored to initiate or accelerate cancer metastases in
patients with cancer (Walton, 2000), with some therapists concerned that massage, even
just touch, will trigger additional cancer cell release from a primary tumor site
(MacDonald, 1999). Metastases occur in three stages. Cancer cells are shed from the
primary tumor, and as these cells travel via the blood or lymph channels, the cells
progressively migrate and settle in secondary sites. Theoretically, massage therapy
applied locally to a primary tumor and with sufficient intensity could aggravate cell
shedding, especially a superficial tumor (Curties, 2000).

Cancers spread from the original tumor site by four mechanisms: progressive direct local
invasion of nearby structures; through body cavities; to distant sites via the bloodstream
(hematogenous metastasis); to distant sites via the lymphatic system (lymphogenous
metastasis) (Curties, 2000). The processes involved in metastasis are highly complex,
and still incompletely understood despite a great deal of research. This ongoing research
is motivated by the fact that metastasis is almost always what causes cancer death.
“Modern surgery and/or radiation therapy successfully eradicates the majority of primary
tumors, but the inability to control metastases is the principal reason why there has been
little progress in reducing cancer mortality in the last 30 years.” (Wolberg,W., S. Kahn et
al, 1989). This statement explains why prognosis typically is based on degree of, or
likelihood of, metastasis in a case. (Curties, 2000).

A common myth shared by many patients and healthcare providers is that women with
breast cancer who have undergone lymph node dissection cannot receive massage
therapy. These women can indeed safely receive massage therapy by therapists
specifically trained in oncological therapy, as the length, depth, and speed of the massage
many be adjusted, particularly for patients receiving breast cancer treatment (Chapman &
Kennedy, 2000). Additionally, if the patient has lymphedema secondary to axillary node
dissection, specific therapy for lymphedema should be used as a separate modality or
treatment.

The majority of lethal cancers involve blood circulation metastasis. Currently, there is a
good prognosis with prompt treatment in cancers limited to local lymph node spread, but
with increasingly distant lymphogenous metastasis the survival rate decreases, especially
as the neoplastic cells eventually join the bloodstream. Massage therapy and associated
modalities such as hydrotherapy and remedial exercise can act as strong stimuli to blood
and lymph flow, and thus at whether massage therapy could promote metastatic
processes. The set of events and possibilities in distant metastasis is complex, and with
each stage the body’s defense systems are capable of eradicating the malignant cells.
Evidence suggests that far more are killed than survive, as “successful” cells must
overcome many harrowing challenges. In one study by Fidler in 1978 (Netland, Zetter,
1989) host cancer cells where injected to invoke proliferation and record rate of
metastatic processes, and monitored resultantly radiolabeled cancer cells, discovering
most cells were destroyed within 24 hours, and after three days less than 0.1 percent
remained viable. This result has been substantiated in several high quality studies
(Curties, 2000, Netland, Zetter, 1989, Wolberg,W., S. Kahn et al, 1989)
Tumor cells for the various cancer types have their own characteristic rates and time
frames for metastatic development. It is possible that only a certain percentage of cells
are capable of the splitting off mechanism, and that this percentage varies in different
cancers. These factors are beyond the control of the massage therapist. The question
remains, however: Could direct pressure or another strong stimulus, such as intense
hydrotherapy, enhance the potential for cell shedding from a malignant tumor? One
instructive reference was found in the physiotherapy context.

“This process [of cancerous cells entering the bloodstream] is influenced by

several factors, such as biomechanical processes or gross mechanical
manipulation, which can drive a large number of cells into circulation.”
(Plesnicar, S, 1989)

The implication is that sufficient direct pressure will traumatize the tumor and promote
release of cells. It may also be inferred by “biomechanical processes” that an intense
movement modality (for example, passive forced stretching) or a highly stimulating local
hydrotherapy application might be unsafe. In response to a question from a physician,
this medical opinion was offered in the Journal of the American Medical Association in
1977: “I firmly believe that heat and massage should not be used if there is any
possibility that a primary or metastatic neoplasm exists in the skin or subcutaneous tissue
at the site of application.” (Abramson, 1977). This is an old source, but it reflects a
current concern. The implication is that the closer the cancer is to the skin surface, the
greater the risk from massage therapy. It would be more satisfying to be able to consider
a larger volume of research and opinion. However, the possibility clearly exists that some
components of massage treatment, if applied locally and with sufficient intensity,
especially to a superficial tumor, could provoke cell shedding.

As previously discussed, it has been accepted that the rate of survival of metastatic cells
in the bloodstream is somewhere under one percent. This extremely high mortality rate is
hypothesized to be the result of several hostile factors. These include attack by the host’s
immune system, incapacity of the sessile (not designed for movement) cancer cells to
absorb nutrients while in circulation, and trauma from continuous movement. The
relevant question for massage therapy could be stated as: Could an increase in blood or
lymph flow aid the survival of circulating cancerous cells? No specific reference was
found in answer to this question, but several pieces of related research and opinion
would suggest not. The massive destruction of cancer cells in the blood and lymph
indicates that these environments are always highly antagonistic. Given these hostile
factors, increased speed or volume of flow would be as likely to jeopardize cell
survival as support it. If an increased risk does exist, massage would not be isolated in
creating this type of effect. Were it to be true that stimulation of the circulation
encourages metastasis, hot showers, exercise, sexual activity and many other aspects of
daily life would confer equivalent risks. Individuals with cancer are almost always
encouraged to exercise and remain as active they can; such advice from the medical
community would seem to place other values ahead of a risk of promoting metastasis
from a general circulation increase (Simonton, Matthews-Simonton,1980, Plesnicar,
1989).
About the role of exercise specifically, Dr. Carl Simonton makes the following statement:

“The overall picture is that people engaged in regular exercise programs tend to
develop a healthier psychological profile in general—one often identified with a
favorable prognosis for thecourse of the malignancy.” (Plesnicar, 1989)

Similar claims can likely be made about regular massage therapy. One study (Tope,
1994) makes reference to the following effects of repeated massage treatments for cancer
clients: promotion of the relaxation response, decreased muscle tension, nausea, anxiety,
andpsychological distress, and reduction in feelings of isolation. It also has been argued
that promoting better circulatory efficiency, especially in lymph flow, may aid the host
immune response, and therefore encourage better eradication of cancerous cells. These
arguments are presently based on personal opinion and clinical observation. Current
research on manual lymph drainage techniques may offer some answers.

Patients with cancer often use massage therapy as an adjunct treatment. Oncology
nurses can be advocates for patients seeking massage therapy by educating them to be
informed consumers of massage therapy. They can stress that patients with cancer use
massage therapists who have graduated from accredited programs, meet state licensure
requirements, and have specialized training in the massage of patients with cancer. As
benefits are weighed against the risks, the right to informed consent to treatment always
ultimately rests with the patient.

References
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