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THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE

Volume 14, Number 2, 2008, pp. 209–214


© Mary Ann Liebert, Inc.
DOI: 10.1089/acm.2007.7176

Role of Massage Therapy in Cancer Care

NANCY C. RUSSELL, Dr.P.H., SAT-SIRI SUMLER, L.M.T., N.C.T.M.B.,


CURTISS M. BEINHORN, L.M.T., N.C.T.M.B., and MOSHE A. FRENKEL, M.D.

ABSTRACT

The care of patients with cancer not only involves dealing with its symptoms but also with complicated in-
formation and uncertainty; isolation; and fear of disease progression, disease recurrence, and death. Patients
whose treatments require them to go without human contact can find a lack of touch to be an especially dis-
tressing factor. Massage therapy is often used to address these patients’ need for human contact, and findings
support the positive value of massage in cancer care. Several reviews of the scientific literature have attributed
numerous positive effects to massage, including improvements in the quality of patients’ relaxation, sleep, and
immune system responses and in the relief of their fatigue, pain, anxiety, and nausea. On the basis of these re-
views, some large cancer centers in the United States have started to integrate massage therapy into conven-
tional settings. In this paper, we recognize the importance of touch, review findings regarding massage for can-
cer patients, describe the massage therapy program in one of these centers, and outline future challenges and
implications for the effective integration of massage therapy in large and small cancer centers.

INTRODUCTION Because the massage techniques used throughout history


and in different settings have varied considerably from each
other, even when described using similar terms,2,4 the con-
A lthough many forms of touch—procedural, caring, and
protective—may occur within a medical setting,1 the
touch used in massage therapy is unique. In massage ther-
clusions drawn about the effectiveness of massage may not be
universally applicable. For example, the unique needs of pa-
apy, touch is the focus of the interaction between patients tients with cancer have led professional massage organizations,
and therapists. It is a nonverbal way of communicating that until recently, to warn against massage for these patients based
teaches, soothes, and supports. Even when massage thera- on a presumed risk of promoting metastasis. Yet, the promo-
pists search for painful or sensitive areas, their touch does tion of metastasis through physical touch has been demon-
not involve poking or “sticking,” as it might during medical strated only through the use of extreme focused pressure, as
procedures. Because massage is focused touch and lasts at is sometimes used during sentinel lymph node mapping.6
least 10–15 minutes, it can amplify the benefits of more or-
dinary touch.
Massage is an ancient preventive and restorative therapy REVIEW OF RESEARCH FINDINGS
that continues to evolve among massage therapists, physi-
cal therapists, nurses, and physicians.2 It has been described Several reviews and overviews of the scientific literature
in ancient Chinese, Indian, Greek, Turkish, and Roman texts have attributed important benefits to massage, including en-
and, later, in European medical journals.3,4 Current massage hanced relaxation7–9; improved sleep quality7,9; decreased
practices have been attributed to Per Henrik Ling of Swe- fatigue7,9–11; relief of pain,7–9,11–13 anxiety,7–9,11,13 nau-
den (1776–1839), a fencer and gymnast, but others attribute sea7–9,11,13; and improvements in immune system re-
them to an Amsterdam physician, Johann Georg Mezger sponse.7,8 However, just two of these articles12,13 described
(1838–1909).5 their search criteria and assessed research quality.

Integrative Medicine Program, Unit 145, The University of Texas M.D. Anderson Cancer Center, Houston, TX.

209
210 RUSSELL ET AL.

The Cochrane Collaboration review of 200413 assessed able patients;22 (3) the massage therapy given was combined
eight randomized controlled trials of massage for symptom with acupuncture, and its separate effects could not be as-
relief in patients with cancer that had been published as of sessed;23 and (4) a study in which subjects who had not been
2002. They concluded that “massage and aromatherapy mas- randomly assigned were added to a previously published
sage confer short-term benefits on psychological well-be- randomized trial.24
ing.” The most consistent specific effect, found in four tri- Although the remaining six randomized trials were not
als, was for reduced anxiety14; two reports found a reduction blinded, they did attempt to control bias in their study de-
in nausea,14,15 and three found a relief of pain.15,16,17 signs. None of them, however, was able to enroll and retain
The most notable study design weakness in these studies enough subjects to meet their own goals for statistically ad-
was a lack of blinding. It would be difficult to blind patients equate sample sizes. Nevertheless, their progress and results
receiving or not receiving massages, but some investigators are instructive and worthwhile. In one trial, for example, in-
have single-blinded the evaluators of patient outcomes. In vestigators recruited 147 women, but 42 dropped out, leav-
one such trial,13 pain intensity scores were significantly ing 105 evaluable subjects instead of the 130 they had
lower than those of patients who received their usual hos- sought. In this trial, women scheduled for abdominal lap-
pice care alone (p  0.05) after the first and third, but not arotomies for suspected cancers were randomly assigned to
after the second and fourth, of their twice-weekly massages. receive standard postoperative care, standard care plus mas-
Regrettably, only 29 of the 173 referred patients completed sage, or standard care plus vibration therapy. Although in-
the 2-week trial.16 vestigators initially found significant differences in relief of
In the second review, Bardia and colleagues identified pain and distress between treatment groups, the differences
four trials of massage16–19 within their larger review of com- were not significant after being adjusted for multiple fac-
plementary therapies for cancer-related pain published as of tors. The authors concluded that this may have been due to
2005. (The Cochrane group had also reviewed two of these their enrolling too few subjects or to the participants having
studies.16,19) Although three of the studies included blinded low baseline pain levels that were adequately relieved with
evaluators,16–18 they included only 29, 28, and 42 partici- standard postoperative care alone.25
pants, respectively, because of high attrition rates.12,17 The Another of the six reports26 described a trial in which 39
fourth trial,19 which did not blind evaluators, randomly as- women receiving chemotherapy for breast cancer were ran-
signed its 230 subjects to sessions of rest alone, massage domly assigned to receive, during treatment, five 20-minute
therapy, or “Healing Touch,” a therapeutic technique based massages or five 20-minute visits, with massage subjects
on the manipulation of energy instead of physical touch. The choosing massage of either the foot and lower leg or the
massage and Healing Touch groups experienced signifi- hand and lower arm. Again, significant differences in par-
cantly greater reductions in pain than the resting-only ticipant anxiety were not detected, perhaps because of the
group.12 The Bardia group summarized by noting that this small sample size or the participants’ low baseline anxiety
study’s reduction in pain,19 though significant, was not long- scores. The study did find that patients who received mas-
lasting and that the included studies were generally charac- sages experienced improvements in nausea after their visits
terized by small sample sizes, high attrition rates, and in- more often than those who received visits without massages
consistency in the presence of research nurses.12 (Although (massage, 73.2%  32.3%; visits only, 49.5%  32.2%;
analyzing the effects of massage on anxiety and fatigue was p  0.025). Notably, this report detailed the massage setting
not a goal of this review, two studies found that massage and specific techniques used.
had significant effects on these symptoms.18) Another small trial assessed moods and their potential ef-
To update these findings, we searched the MEDLINE® fects on immune and hormone measures in 34 women who
and CINAHL databases using “massage” and neoplasia- and had been previously treated for breast cancer.27 Participants
cancer-related terms for reports of randomized trials of mas- were randomized to receive three massages a week for 5
sage in patients with cancer that had been published through weeks or standard care alone with massage offered at the
August 2007, but not previously included in one of the two end of the study period. After 5 weeks, patients receiving
reviews previously described. We excluded studies that massage therapy had reduced mean anxiety, according to
compared one type of massage to another, that lacked non- State-Trait Anxiety Inventory scores [F(1,32)  4.49, p 
massage control groups (e.g., reflexology compared to stan- 0.05]; reduced depression and anger, according to Profile of
dard foot massage), and that involved massage in combina- Moods States scores [depression, F(1,32)  6.36, p  0.05;
tion with other accepted physical therapy specifically for the anger, F(1,32)  3.93, p  0.05]; and reduced depression
relief of lymphedema. (The National Cancer Institute has al- and hostility, according to Symptom Checklist-90-R
ready accepted massage in combination with exercise and [F(1,32)  7.43, p  0.01 and F(1,32)  3.98, p  0.05; re-
other modalities as part of the standard of care for edema.20) spectively]. Participants receiving standard care alone had
Of the 10 reports we identified, we excluded four because no such changes reported other than a slight increase in the
(1) the number of participants was unclear (20 total versus group mean depression score on the SCL-90R (first-day
20 per group);21 (2) the trial was a pilot with only 17 evalu- mean  SD 9  8; last-day mean  SD 11  12). Based on
MASSAGE THERAPY IN CANCER CARE 211

experiments in a natural-killer-cell–sensitive leukemia cell comfort were obtained before and after first and last ses-
line, the mean number of natural killer cells increased sig- sions by a research assistant while the massage therapist or
nificantly in the massage group and decreased in the con- parent was out of the room. Visual analogue scales indicated
trol group, but the difference in the cytotoxicity of the two significant reduction in anxiety after the first professional
groups’ natural killer cells was not significant. Urinary massage (child report, p  0.004; parent report, p  0.0001)
changes in hormones were both difficult to interpret and un- and discomfort (child report, p  0.130; parent report, p 
expected. For example, both stress-relieving hormones 0.004), but not after the first parental massage (anxiety child
(dopamine and serotonin) and stress-promoting hormones report, p  0.410 and parent report, p  0.120; discomfort
(cortisol, norepinephrine, and epinephrine) increased signif- child report, p  0.300 and parent report p  0.160), and
icantly in the massage group. (Patients’ psychotropic, thy- findings were similar for the final session massage ratings.
roid, or serotonin reuptake inhibitor medications may have However, weekly scores of Behavioral, Affective, and So-
affected hormone levels, although the groups had similar matic Experiences Scales (BASES) by parents up until 6
baseline proportions of participants taking these medica- weeks after transplantation were not significantly different
tions.) Unfortunately, only the statistical evaluations of per- between groups even after combining the professional and
centage changes within—and not between—groups were re- parental massage groups. (Limitation of child reports to
ported, which adds to questions concerning the validity and those who were 6 years of age or older left too few remaining
overall implications of these results. Investigators subse- reports for meaningful analysis.) Days in the hospital were
quently combined data from this study27 with a new, non- shorter for the professional massage group (mean  SD,
randomized controlled study with three groups of patients24 27.5  15.9; median, 20.5) compared with the standard care
not included in this review, since it was no longer a ran- controls (mean  SD, 35.8  17.5; median, 33.0) (p 
domized study. 0.06). Days to engraftment were shorter in the parent-ad-
Unlike most trials, which have evaluated the short-term
effects of massage, the fourth randomized controlled trial
evaluated the effects of massage therapy on anxiety and de- TABLE 1. EDUCATION OF MASSAGE PROVIDERS
IN RANDOMIZED CONTROLLED TRIALS
pression 6 and 10 weeks after the last session.28 For this
trial, 288 patients were recruited from four cancer centers Provider education/training and
and one hospice. Half were randomly assigned to receive experience as described by
weekly 1-hour sessions of “aromatherapy massage” and half Study, year published authors of published studies
to receive “usual care” for 4 weeks. Investigators decided Ahles, 199914 Trained healing-arts specialist with
to provide aromatherapy massage without a control group more than 10 years of experience
of massage alone because an earlier double-blind, placebo- Billhult, 200726 Nurses/nurses aids educated and
controlled trial in their center had not found detectable dif- trained for a day by author—
previous experience massaging
ferences between massage with and without aromatherapy.29 cancer patients
They also did not include a control group receiving relax- Corner, 199533 Trained cancer nurse who was
ation therapy in order to decrease the overall sample size experienced masseuse
needed.30 As with other studies, this study lost subjects over Grealish, 200015 Nurse trained in massage techniques
time, with only 124 of the 144 patients in each group com- Hernandez-Reif, 200427 Trained massage therapists
Phipps, 200431 Licensed massage therapists
pleting at least two of the four sessions. In spite of the chal- Post-White, 200319 Certified and credentialed MT and
lenges, significant improvement in anxiety and/or depres- HT practitioners who also were
sion was detected for massage. At 6 weeks, a significantly registered nurses
greater proportion of patients who received aromatherapy Smith, 200332 Registered nurse certified in
massage improved than those who received usual care alone massage therapy
Soden, 200418 Not described
[64% vs. 46%; odds ratio (OR), 1.4; 95% confidence inter- Taylor, 200325 Licensed massage therapists with 5
val (CI)  1.1 to 1.9; p  0.01]. At 10 weeks, a difference or more years experience
remained, but was no longer significant (massage, 68% im- Weinrich, 199017 Senior nursing students with 1-hour
proved vs. controls, 58%; OR, 1.3; 95% CI  0.9 to 1.7; training session in massage,
p  0.1).28 interviewing, and use of visual
analog scale
In the last two of the six additional reports we reviewed, Wilke, 200016 Licensed massage therapists
time to engraftment and related parameters were evaluated Wilkinson, 199929 Nurses holding recognized diplomas
in patients receiving bone marrow transplants.31,32 In one of in massage
these studies, 50 patients between 1 and 19 years old were Wilkinson, 200728 Therapists appropriatelya trained in
randomly assigned to one of three groups: massage by a pro- aromatherapy massage and
working with patients with cancer
fessional massage therapist, massage by a parent who was
trained by a licensed massage therapist, or a control group MT, massage therapy; HT, Healing Touch.
aAuthors’ assessment.
of standard psychosocial care. Ratings of anxiety and dis-
212 RUSSELL ET AL.

TABLE 2. OBSERVATIONS OF MASSAGE THERAPISTS AND PATIENTS ILLUSTRATING HOW


MASSAGE CAN CHANGE THE PATIENTS’ CANCER EXPERIENCE

Change Observations reported by massage therapists

Connection with people “I might as well be on Mars after radiation treatment in which I am required to drink a
radioactive substance out of a lead-lined glass tumbler in a lead cell; then for 2 weeks I can’t
be in public or have physical contact with people or pets. In between these periods of
isolation, I go out as much as possible and use massage to help reconnect.”
Compliance with physician “An inpatient received bad news from her physician but was not open to his recommendations
recommendation for hospice care. I introduced myself to the patient, and told her this particular doctor had
told me he thought she would enjoy massage. As I was massaging her, she reported that she
loved the massage and, ‘How did he know what I needed when I didn’t even know what I
needed?’ She asked me to thank him. Later on in the week, the physician told me that she
became open to his recommendations after she received the massage.”
Experience of symptoms “A 23-year-old inpatient with intense pain was receiving daily massage treatments from me.
affected Before the massage the patient would rate his pain 8 [out of] 10 (with 10 being the worst
possible pain imaginable). After the massage the patient would rate his pain 8 or 9 [out of]
10. However, he was always very appreciative of each treatment. I asked him why he liked
the massage when his pain was the same afterward. He reported that during the treatment he
could forget about the pain and just enjoy the massage.”
“An inpatient with neuropathy of the hands and feet reported, ‘I don’t know how to say it—but
you get through the numbness.”
Patient’s experience at a Patient receives a weekly massage each Friday before her chemotherapy treatment, and Friday is
cancer center the day she loves because she gets massage.
• “My time at the center is also my spa time.” “I feel so pampered . . . a nutritionist came by
to improve my diet, a counselor came by to check on how I was doing, and now a massage
therapist. . .I would have never done this for myself before being diagnosed.”
Family interaction “Before diagnosis, the patient would massage his wife’s back every night. Now the wife
complains he won’t because he is too weak and fatigued. She tried to tell him that just a light
touch would be nice, but he thought it had to be the heavy macho massage he’d been giving
her for years. After she received a very light back massage from me, and really enjoyed it, he
was able to see the value of a light massage for his wife. The wife came to Place. . .of
Wellness to thank me three separate times, because her husband would touch her again.”
“A patient had expired with family members in the room who all pointed to a younger
gentleman sitting in a chair and said, ‘He’s been our rock of Gibraltar through all of this and
he definitely needs a massage.’ As I’m massaging his neck and shoulders, he is literally
trembling and sighing heavily, and others see him allowing himself to finally relax. One by
one, some of them move toward the deceased patient and begin stroking his hands and
forehead and whispering to him. The room is very quiet.”

ministered massage group (mean  SD, 15.9  7.5 days; the massage group had an improved mean central nervous
median, 14.5 days) compared with the standard care con- system/neurologic complications score (massage, 0.94;
trols (mean  SD, 20.1  7.1; median, 19 days) (p  Therapeutic Touch, 1.31; friendly visit, 1.61; F  4.02, p 
0.04).31 0.022; pairwise comparison, p  0.031). Additionally, they
Investigators in the other bone marrow transplant study reported that the massage group had higher mean comfort
randomly assigned 88 adult participants to receive massage, subscale scores than the friendly visit group (p  0.000), as
Therapeutic Touch (an energy approach not involving phys- did the Therapeutic Touch group (p  0.007). The massage
ical touch), or a friendly visit for the same amount of time. group also had higher total mean perceived benefits scores
Withdrawals were problematic, as in other studies. Of the than the friendly visit group (p  0.003). Considering the
27 participants who withdrew, 13 left before the interven- small limited study sample size and challenge of overcom-
tions had begun because they were not assigned to receive ing the toxicities of chemotherapy regimens for all groups,
the treatment they wanted; subsequently, 1 withdrew from it is noteworthy that any differences were detected.32
the massage group, 9 from the Therapeutic Touch group, Although licensed or certified massage therapists pro-
and 4 from the friendly visit group. The study found only vided massage in most of these trials, the extent of the ther-
slight, nonsignificant differences in the mean time to en- apists’ education, training, and experience were rarely de-
graftment (massage, 15.5 days; Therapeutic Touch, 14.00 scribed. A few studies used unlicensed providers who had
days; friendly visit, 14.88 days; F  0.08, p  0.42) and no had only brief training, which could have affected outcomes.
significant differences in 10 of the 11 categories of compli- Table 1 summarizes the education and training of massage
cations (F  0.84, p  0.43). They did, however, find that therapy providers as described in these studies.
MASSAGE THERAPY IN CANCER CARE 213

In spite of the limitations of these trials, The University Although our center has not yet conducted its own re-
of Texas M. D. Anderson Cancer Center and other institu- search concerning the effectiveness of massage therapy for
tions have accepted the available evidence and the expressed specific outcomes, we have distributed client satisfaction
needs of their own patients as an indication that massage surveys. Survey respondents have been universally positive
therapy can be beneficial for patients with cancer. about their massage experiences, but the surveys have not
been universally distributed or consistently completed by all
participants, so these results may not be representative of all
MASSAGE THERAPY IN A who have received massages. In addition, the surveys used
CANCER CENTER are the same as those for other institutional programs, with
generalized questions (e.g., “Did this program meet your ex-
As in many hospitals, physical therapists in the Depart- pectations?”) so the responses have not been helpful re-
ment of Rehabilitation Services at M. D. Anderson Cancer garding issues specific to massage therapy. Therefore, we
Center provide therapeutic massage for certain muscu- are testing a new form that asks about pre- and postsession
loskeletal conditions, including edema, muscle fiber con- pain scales and has questions derived from the comments of
traction due to radiation, and nerve compression due to a former massage therapy clients, such as, “Right now do you
variety of causes. However, time and other constraints have feel like you could easily sleep?” Instructive statements of
limited the use of massage in physical therapy programs for selected patients who have articulated their experiences are
the general reduction of stress. To address this need, M. D. summarized in Table 2.
Anderson began in June 2001 by providing brief relaxation
chair massages at its Place . . . of wellness and clinical wait-
ing areas, with brief relaxation massages at patient beds; in IMPLICATIONS FOR THE FUTURE
January 2004, the program was expanded to include full-
body massages. The program’s primary goals are to improve Massage therapy is becoming an increasingly accepted
circulation and decrease muscle tension, pain, anxiety, and practice, both in our institution and in other large cancer
stress; its secondary goals are to decrease insomnia and im- centers in the United States. Restoring the ancient practice
prove gastrointestinal functioning. of massage to medical settings has the potential to address
All massages given as part of M. D. Anderson’s program the critical need of patients with cancer for human-to-hu-
are provided by nationally certified massage therapists hold- man touch in the healing process.
ing current Texas licenses. Their training requires comple- However, additional research is needed to clarify whether
tion of the center’s class on massage for patients with can- the benefits of massage to patients extend beyond the tem-
cer, standard courses required for all patient care providers porary relief of pain, anxiety, and distress. As many of the
at the institution, and an orientation to cancer care by the reports reviewed in this article have indicated, this research
Department of Physical Therapy. Massage therapists must will require sample sizes large enough to detect significant
also follow guidelines relating to constraints imposed by pa- differences in study groups. Enrolling an adequate number
tients’ diseases and treatment regimens; precautions can in- of participants may require that investigators in different in-
volve medications, low platelet or neutrophil counts, bony stitutions use collaborative protocols and that participating
metastases, and suspicious lumps. If massage therapists en- massage therapists have comparable education, training, and
counter lesions or lumps, they ask massage recipients if they experience.
are aware of the lump and if their physician has diagnosed After 7 years of experience with massage within our cen-
it. If the recipient is an inpatient who was unaware of the ter, its safety is now accepted within our general and cancer-
lump, the therapist tells the patient’s nurse or physician and specific guidelines. Overall benefits are likely based on feed-
documents it in the patient’s medical record. If the recipi- back from patients, but we need to develop more systematic
ent is an outpatient or caregiver who was unaware of the feedback mechanisms without being intrusive on the massage
lump or lesion, he or she is advised to notify a primary care experience. In addition to effects of massage on clinical out-
physician as soon as possible. comes, institutional questions about cost-effectiveness, cre-
Although professional massage may be more effective dentialing, and continuing education for practitioners and
than self- or parent-administered massage, M. D. Ander- other members of the health care team will be needed.
son provides classes in massage for caregivers so that they
can provide safe massages to loved ones at home. Clini-
cians, patients, and others who believe that a patient may ACKNOWLEDGMENTS
benefit from massage can initiate a massage request. Brief
relaxation massages at bedside or in a chair are at no cost All authors receive salary support from The University
to the patient; full-body massage is provided at current of Texas M. D. Anderson Cancer Center. No financial or
market rates. Each massage therapist completed a progress other associations occurred that could lead to a conflict of
note after each session. interest.
214 RUSSELL ET AL.

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