Integrative Oncology & Oncology Massage

Gabriel Lopez, MDAssistant Professor, Integrative Medicine Program

Department of Palliative, Rehabilitation and Integrative Medicine

Section of Integrative Medicine

August 22, 2015

Objectives

• Introduction to Integrative Medicine & Oncology Massage

• Evidence Based review of massage in symptom management

• Discuss our Integrative Medicine model for inclusion of massage in cancer care

Case

63 year old man with progressive,

metastatic prostate cancer.

He experiences some relief with opioid medications for

painful bone metastases and has also received radiationto specific sites of disease.

• He is worried about his disease progressing • He would like to avoid taking more medications for pain or anxiety• He has benefitted from massage in the past but has heard it is not safe for

cancer patients. He is fearful massage will spread his cancer even more.

Pre- Massage Symptom Scores (score 0 to 10, 10 is worst):

Pain 6 Depression 7Anxiety 8 Financial distress 2Fatigue 5 Spiritual pain 4

Distress

Integrative Medicine in the Media

Massage will spread my cancer…

100 Under

ground

Cures f

or C

ance

r

Myth versus Reality

Why?

(1) Improve quality of life and prolong life(2) Boost the immune system(3) Relieve symptoms(4) Hope after conventional treatment fails(5) Aid conventional medical treatment(6) Recommendation from family or friend(7) “Might help, can’t hurt”

Why?

Molassiotis Annals of Onc 2005; Richardson JCO 2000

Complementary and Alternative Medicine (CAM)

Definition A group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine.

* NCCAM prior to December 2014

NCCIM & Massage

• Numerous systematic reviews and clinical studies have suggested that at least for the short term, massage therapy for cancer patients may reduce pain, promote relaxation, and boost mood.

• The National Cancer Institute urges massage therapists to take specific precautions with cancer patients and avoid massaging:– Open wounds, bruises, or areas with skin breakdown– Directly over the tumor site– Areas with a blood clot in a vein– Sensitive areas following radiation therapy.https://nccih.nih.gov/health/massage/

massageintroduction.htm

 NCCIMComplementary Health Approach Categories

 Examples

Natural ProductsHerbal medicinesVitaminsMineralsProbiotics

Mind and Body MedicineMeditationYogaAcupunctureQi gongTai chiMassageSpinal manipulation Chiropractic Osteopathic Physical therapyEnergy Therapies (Magnet therapy, Reiki, Healing touch)Movement Therapies (Feldenkrais method)

Other Complementary PracticesWhole medical systems Ayurvedic medicine Traditional Chinese Medicine Homeopathy Naturopathy

Difference Between Alternative, Complementary, and Integrative

• Alternative medicine is used in place of conventional medicine.

• Complementary medicine is used together with conventional medicine.

• Integrative medicine is …

Difference Between Alternative, Complementary, and Integrative

• Alternative medicine is used in place of conventional medicine.

• Complementary medicine is used together with conventional medicine.

• Integrative medicine is used together with conventional medicine in a deliberate manner that is personalized, evidence-based, and safe.

Prevalence of CAM/CIM Use

• General population 38%• Cancer patients up to 64%• MD Anderson Cancer Center survey

Richardson et al. JCO 2000

Movement/physical therapies Massage, Chiropractor, Exercise, Yoga, Qigong/Tai-chi

Oncology Massage Therapy

What is Oncology Massage?• Oncology massage is the modification of existing massage

therapy techniques in order to safely work with complications of cancer and cancer treatment.  

• Anyone who has ever received cancer treatment, from those in active treatment to those in recovery or survivorship, as well as those at the end of life, are best served by a massage therapist who has received special training in oncology massage. 

From www.s4om.org

Massage Precautions

• Solid tumor• Bone metastasis• Radiation site• Incision site• Limb swelling• Lymphedema risk• Blood clot• Blood counts(platelets, INR, neutrophils)

• Neuropathy• Medications(anticoagulants)

• Medical devices(chemoport, ostomy, IV)

Massage in Supp Cancer Care 2012

Massage Pressure levels

Level 1: slight skin movement

Level 2: slight movement superficial adipose and muscle

Level 3: slight movement medium layer adipose, muscle, & blood vessels

Level 4: move deep layers to fascia, move adjacent joints

Level 5: move deepest layers, engage bone

Medical Conditions and Massage Therapy: A Decision Tree Approach ,Tracy Walton

Objectives

• Introduction to Integrative Medicine & Oncology Massage

• Evidence Based review of massage in symptom management

• Discuss our Integrative Medicine model for inclusion of massage in cancer care

Massage impact on multiple symptoms

• Population: – 1290 cancer patients, 3609 massage encounters over 3 years– 74% inpatient, 26% outpatient

• Study design: – single center, outpatient or inpatient setting

• Intervention: – Outpatient massage approx 60 minutes or inpatient massage approx 20

minutes– Massage type? Standard (Swedish), light touch, foot– By whom? Licensed massage therapist

• Methods:– Recorded symptoms with pre- and post symptom report cards

~50% reduction symptom scores

• Subset of patients receiving outpatient massage– Time course of

treatment effect to 48 hours

Benefit persists

Massage for Pain and Mood

The REST Study(reducing end-of-life symptoms with touch)

REST Study: Pain & Mood

Population: 380 adults with advanced cancer experiencing moderate-to-severe pain (pain ≥ 4, 0-10 scale); 90% in hospice

Study design: National, Multi-site, randomized, single-blinded clinical trial

Intervention: Six (30-min) massage sessions over 2 weeks.• Massage Therapy (MT) – experimental group• Simple touch (ST) – control group

By Whom? Licensed massage therapist, > 6 months cancer patient experiencePrimary Outcome Measures: Decreased pain

• Immediate: memorial pain assessment card (MPAC)• Sustained : brief pain inventory (BPI)

Secondary Outcome Measures:

1. Immediate change in mood (MPAC scale)

2. Improved quality of life (McGill QOL)

3. Decreased physical symptom distress (MSAS-Physical)

4. Decreased emotional symptom distress (MSAS-Psych)

5. Less total analgesic medication use.Kutner 2008

Memorial Pain Assessment Card (MPAC)

Massage vs. Simple Touch: Immediate Beneficial Effect

ImmediateMeasures

Change Massage

Change Simple Touch

p value

MPAC Pain* -1.87 -0.97 <0.0001

MPAC Mood*

1.58 0.97 <0.0001

* Significant difference between massage and simple touch for immediate measures of pain and mood

• No significant difference between massage and simple touch groups for other measures

ww.massagetherapyfoundation.org/pdf/.../SmithMTF92609.ppt Kutner 2008

Massage for Anxiety/Depression

Massage for Anxiety/Depression

Massage for Anxiety/Depression

• Population:• 288 adults with clinical anxiety and/or depression, prognosis > 3 months recruited from

four cancer centers and one hospice

• Study design: • National (United Kingdom), Multi-site, randomized, single-blinded clinical trial

• Intervention: 4 weeks, two groups• Group 1: Weekly 1 hour aromatherapy massage sessions• Group 2: Usual careBy Whom? 12 therapists

• Primary Outcome Measure: • Change in clinical anxiety and/or depression at 10 weeks

• Secondary Outcome Measures: At 6 and 10 weeks • Change in clinical anxiety and/or depression at 6 weeks• Change in self reported anxiety• Change in self reported depression• Change in self-reported symptoms (QOL, etc.)

Wilkinson JCO 2007

Massage for Anxiety/Depression:

Results

Wilkinson JCO 2007

• 43% of patients with advanced cancer; 55% with breast cancer• 124 of the 144 (86%) patients in each group completing at least two of the

four sessions.

Massage for Anxiety/Depression:

Results

Wilkinson JCO 2007

• At 6 weeks: clinical anxiety/depression and self reported anxiety improved in aromatherapy versus usual care

• At 10 weeks (primary outcome): only self reported anxiety significantly improved

Massage in Cancer Symptom Management: Summary

• Improves symptoms including– Pain– Mood

• Anxiety• Depression

• Single massage: symptomatic benefit may persist ≥ 48 hours

• Series of massages: benefit for anxiety may persist up to 10 weeks post-treatment

• More research is needed to understand mechanism of massage effect

Objectives

• Introduction to Integrative Medicine & Oncology Massage

• Evidence Based review of massage in symptom management

• Discuss our Integrative Medicine model for inclusion of massage in cancer care

The Integrative Medicine Program at

MD Anderson Cancer Center

• Clinical Delivery• Research• Education

Clinical Delivery: Integrative Medicine Center Philosophy

“The Integrative Medicine Center aims to work collaboratively with the oncology team to build a comprehensive and integrative care plan that is personalized, evidence-based, and safe with the goal of improving clinical outcomes.”

Physical

Psycho-Spiritual

Social

Integrative Medicine Center Model

Health

“the physician’s basic professional knowledge andskills must span the social, psychological, and biological, for his decisions and actions on the patient’s behalf involve all three.”

Optimal Health & Healing

● Integrative Oncology Consultation

Integrative Medicine Center Model

= Improved Clinical Outcomes

Psycho-Spiritual

● Chaplaincy

● Psychiatry

● Tai Chi

● Meditation● Yoga

Social

● Music Therapy

● Family/Friends

● Patient Advocacy

● Social Work

● Education

● Support Groups

● Pharmacy

●Chemotherapy ●

Surgery ● Radiation

Physical● Nutrition

● Acupuncture

● Massage

● Exercise

● Rehabilitation

● Smoking Cessation

●Environmental Exposures

● Rest/Sleep

● Psychology

Integrative Oncology Physician Consultation

• Educate

• Provide personalized therapeutic recommendations• Outpatient and Inpatient setting• Interdisciplinary Approach

– Regular team meetings to discuss patients in inpatient and outpatient setting

• Communication with the primary team

• Integrative Medicine • Herbs/Supplements• Nutrition• Exercise

• Acupuncture• Oncology Massage• Music Therapy• Meditation

Integrative Medicine, when?Continuum of Cancer Care

DiagnosisSurgery

ChemotherapyRadiation

MeditationMusic Therapy

MassageAcupuncture

Active TreatmentPrevention Survivors

Recurrence / Metastasis

PreventionAdvanced Cancer

Survivorship

Active Treatment

Oncology Massage Therapy

Discuss how it may help with:

• Mood Disturbance• Anxiety• Depression

• Pain

Where & how is oncology massage available?

• Inpatients – Treatment in hospital room.

• Physician order needed• Integrative Medicine inpatient consultation service providing

acupuncture, music therapy, psychology, oncology massage• For patient only

• Outpatients – Treatment in our clinical center: 30 or 60 minutes

• Patients must obtain a physician's order before scheduling an oncology massage treatment.

• Also available to caregivers

– Relaxation Chair massage: 10 min• No physician order needed• Free for patients and caregivers, supported by philanthropy

Assessment tool

ESAS• We ask massage

participants about their symptoms

– Participants complete a pre- and post- massage questionnaire

– Responses collected as part of a database

Glo

bal S

ympt

om D

istre

ss S

core

**

* P < 0.0001

Global Symptom Distress: Before and After 10 minute Brief Relaxation Massage

Massage Clinical Trials

www.mdanderson.org/integrativemed

11th Annual Conference

Provides licensed acupuncturists and massage therapists with an overview of evidence-based practice in cancer care. Topics of recent research findings, recommendations for treating common side-effects, ethical issues, safety issues and case presentations are presented.

Acupuncture • Modern Acupuncture • TCM Research • Ethics • Dietary Recommendations for GI Side Effects of

Cancer Treatment • Acupuncture for Symptom Management in Cancer

Patients • Acupuncture Safety Guidelines: Precautions and

Contraindications • Case Presentations • Quality/Safety/Interaction Issues – Herbs are

Drugs! • Huachansu and Other Studies of Chinese Herbs

in Cancer Care • Acupuncture and Healthcare Reform

Massage Therapy • Overview of Recent Research: Oncology Massage • Panel of People with Cancer • Oncology Massage Safety Guidelines: Precautions &

Contraindications • Medicines & Massage • Chemotherapy-Induced Peripheral Neuropathy • Dermatology Issues in People with Cancer • Five Levels of Touch • Understanding Head, Neck & Upper Extremity

Lymphedema • Massage Modifications for Lymphedema Risk • Standards of Practice & Admin Considerations • Case Presentations • Oncology Massage Treatment Planning • Practicum: Standardized Patients

July 2016

Case

63 year old man with progressive,

metastatic prostate cancer.

He experiences some relief with opioid medications for

painful bone metastases and has also received radiationto specific sites of disease.

• He is worried about his disease progressing • He would like to avoid taking more medications for pain or anxiety• He has benefitted from massage in the past but has heard it is not safe for

cancer patients. He is fearful massage will spread his cancer even more.

Pre- & Post- Massage scores (score 0 to 10, 10 is worst):

Pain 6 2 Depression 7 4Anxiety 8 4 Financial distress 2 2Fatigue 5 3 Spiritual Pain 4 2

DecreaseSymptom

Distress

Massage & Cancer Care: Take Aways

• Integrative approach: Safe and Evidence-based – Importance of recognizing unique needs of

individuals affected by cancer– Seek opportunities to learn & build your confidence

• Use a team based approach – Create connections with oncology programs in your

community, build trust

• Track outcomes– Show others the value in what you do

Our Team

Lorenzo CohenRichard LeePeiying YangAlejandro ChaoulKay GarciaAmy SpelmanJane WilliamsStephanie MaxsonRoma PolanskaKira TaniguchiCurtiss BeinhornSat-Siri SumlerMary Jo CoxIngrid MoellerMichael RichardsonJill FlurySanober AjaniCatherine Powers-James

Kathrin MilburyMichael SpanoDonna CappsSarah PrinslooQi WeiRosalinda EngleSmitha MallaiahCharles MikeskaStephanie GabelRobin HaddadMarilyn KenebrewJibin DingLin TanYan JiangTejal PatelTaylor AustinAndrew Cusimano

Anne Marie AlcalaPatrea RheaEdrea GonzalesXanthia Baptiste-GordonTanier WilliamsYong PanCarol EddySusan UnderwoodYousra HashmiKathryn Moss

Eduardo BrueraNatalie SchurenPatrick HwuWendy Austin

Thank you!