Although different types of massage therapy are often contraindicated for cancer, knowledgeable, skilled touch is in some form rarely contraindicated.

By Tracy Walton
 

People with cancer, deserving and desirous of massage therapy, have met fear and uncertainty from the massage therapy profession. For years, the flat contraindication against massage, originating in concern about accelerating cancer spread, has prevailed without supporting evidence or medical corroboration.¹ This has robbed many potential clients and massage therapists of the chance to work together. But the contraindication has taken other serious tolls on the profession by interfering with more meaningful discourse on safe practice for people with cancer. It has prevented two important developments in the field. The first is the formation of concrete safe practice guidelines for the profession. The second is the development of sound clinical thinking skills needed for work with people with cancer.
 
These two things would develop hand in hand, but they are distinct phenomena. Guidelines tell massage therapists what to do. Thinking skills are used to understand the basis of guidelines, analyze them, sort and prioritize them when they conflict, apply multiple guidelines where necessary, and determine how to act in clinical situations where there are no guidelines. To think clinically, massage therapists use knowledge of the body's organ systems, and how each might be affected by massage. Moreover, therapists need to know how the systems behave during a disease state, and in response to medical treatment. They require problem-solving skills that can be abstracted to a variety of cases. Many massage therapists state that they did not receive enough practice in this during their training, and have had to develop some of these skills on their own. Most were told to avoid working with people with cancer. The prohibitions have stood, and stifled the development of more sophisticated curriculum.
 
Against this tide, massage therapists, clients, and medical providers have still managed to move the work forward. Earlier massage and bodywork literature began to question the contraindication and describe possible benefits of massage.2, 3, 4 In the last year, at least two books were published on this topic: Gayle MacDonald's Medicine Hands: Massage Therapy for People with Cancer,⁵ and Debra Curties'  Massage Therapy and Cancer^.6 Both elaborate on guidelines, emotional preparation for the work, and the clinical thinking necessary to work with this population. Moreover, several cancer treatment centers include or support massage for their patients.⁷  The benefits of massage for people with cancer are investigated in more controlled trials, and are being described as relief from pain, anxiety and depression, help with negative body image issues and myriad other effects.⁸  Other authors have outlined bodywork and movement strategies for clients in rehabilitation.⁹
 
Clearly, thoughtful work about massage and cancer has already begun. The profession needs to agree on guidelines and clinical thinking skills necessary to work more widely with people with cancer, and to do so safely and well. The flat contraindication is facing increased scrutiny. It is tempting to simply throw off the burden of years of prohibition, follow some guidelines and begin working. But cancer treatment is extremely medically complex, and delicate handling of each case is necessary to prevent injury. Thoughtful education, safe practice principles, and practice in clinical thinking are needed to replace the "hands-off" rule. Then we will be able to step more firmly forward in our work with this population. Dialogue in the field has begun, more is needed, and the time is ripe. 
 
In this rapidly developing field, many massage therapists still rely on a note from the client's doctor, or formal physician orders, as permission and directives for the massage session. This is an important step, deferring correctly to the physician's longer training and wider scope of practice. For a client in recent or current cancer treatment, it is critical to include the physician as well as the client in clinical decisions about massage, accommodate the contraindications, and an often changing and complex medical picture. 
 
Yet one weakness in the "note-from-the-doctor" approach is that many health-care providers are unaware of the effects of massage and corresponding contraindications. It's our duty to educate them about this, as sketchy as we may feel our training was in this area. As professionals, we must do our own homework before consulting the physician, by learning everything we can about the client, cancer, the treatments, the side effects, and the possible massage implications. We do this for our own information, and to work more productively with the medical staff. This homework step lends sophistication to the process of including the client's medical staff. 
 
To that end, this article summarizes some specific safe practice concerns for clients in cancer treatment. The directives are designed to serve as jumping-off points for consultation with a client's physician, rather than ends in themselves. The details of common cancer treatments are outlined, with suggested steps for carrying out safe, effective massage therapy for each situation. 
 
The scope of this article includes clients who are actively or recently in cancer treatment. Four general steps are described, along with some supporting clinical thought processes. Although many of these safe practice guidelines also are tabulated in a sidebar for easy reference, readers are encouraged to seek more advanced reasoning via continuing education or through the available literature about massage and medical conditions. Many massage therapists assert that they were issued only brief "laundry lists" of contraindications at some point in their education, and find themselves applying the information reflexively rather than thoughtfully. To work with the most common clinical picture, including multiple diseases and treatments, requires more than one isolated response to that picture. Far from providing complete answers, brief lists of guidelines merely begin the dialogue among massage therapists, and with other health-care providers.
 
In this developing field, new literature appears regularly about the potential impact of massage on disease processes.¹⁰  Massage therapists are discussing massage contraindications, benefits and indications more widely, and seek the information and skills needed to reason through complex clinical scenarios. It makes sense to identify the key issues around massage and cancer.
 
None of the steps listed below is designed to replace a physician's input and permission for massage. Instead, it is designed to strengthen the therapist's communication with the medical team. 

Step 2-Consider Adjusting Massage To The Cancer
After information-gathering, a second step, using clinical thought, is required. Having learned from the client about the type of cancer and its manifestation in the client's body (location, symptoms, etc.), the therapist needs to generate adjustments to the massage session. 
First, identify the location of known or suspected cancer and adjust the massage to this. While cancer such as leukemia is diffused throughout the body, other cancers are in more discrete locations (solid tumors). Massage therapists choosing to work with clients with cancer should learn the system of staging of the cancer. Most cancers are staged using a system of numbers and letters that describe the status of a primary tumor (T), regional lymph nodes involvement (N) or distant metastasis (M). Numerical values are assigned to this TNM system to express extent of the area affected by the cancer.¹⁴
By the time a client has a diagnosis of cancer, the location usually has already been determined. The parent tumor, identified at a certain site, often has been removed surgically, or radiation therapy is being employed locally, or both. The system of cancer staging is useful to learn, but it is most important to gather precise information from the treating physician about the location of the cancer. The therapist then considers whether a primary tumor or likely metastatic site is superficial enough to be within reach of their hands, or whether the pressure they use superficially could affect a tumor in deeper layers.¹⁵ After checking these considerations with the client's treating physician, the massage therapist can plan a massage session that avoids local and regional pressure or circulatory massage in this region.
Without second-guessing where cancer might metastasize, it is useful for massage therapists to have knowledge of some possible secondary sites. Different cancers have characteristic metastasis patterns. Learn these patterns and remain aware of them. If cancer is suspected at possible secondary sites, then local and regional massage on these sites is contraindicated, especially if these sites are superficial, within reach of pressure from the hands.¹⁶
Knowledge of possible secondary sites is useful so that if the client complains of discomfort at those sites, the massage therapist can refer the client back to the oncologist and avoid massaging those sites until findings are available. Secondary sites may remain asymptomatic for long periods of time; you may not have a client's local experience of pain as a cue to avoid the region.¹⁷ 
Cancer-specific contraindications can be organized around cancer symptoms such as pain or pressure, and each of these should be checked out thoroughly before proceeding. These usually generate location restrictions, from where the primary tumor is, was or where secondary sites are suspected. Moreover, there can be complicated conditions arising from cancer in the advanced stages, that affect vital organs such as liver and kidneys, or even the brain. Where liver function or renal function are compromised, it is important to assess the effect of massage and how to adjust it. This article is more focused on cancer treatment than cancer itself, and the reader is referred to several sources of help in the literature about safe practice issues surrounding cancer.¹⁸
In general, massage therapists must do their homework and research all they can about the client's condition. Given these cancer-specific concerns, it is critical to include the physician in the information-gathering and the decision-making about massage.