THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINEVolume 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. Patientswhose 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 findingssupport the positive value of massage in cancer care. Several reviews of the scientific literature have attributednumerous positive effects to massage, including improvements in the quality of patients’ relaxation, sleep, andimmune 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 andimplications for the effective integration of massage therapy in large and small cancer centers.

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INTRODUCTION

Although many forms of touch—procedural, caring, andprotective—may occur within a medical setting,1 the

touch used in massage therapy is unique. In massage ther-apy, touch is the focus of the interaction between patientsand therapists. It is a nonverbal way of communicating thatteaches, soothes, and supports. Even when massage thera-pists search for painful or sensitive areas, their touch doesnot involve poking or “sticking,” as it might during medicalprocedures. Because massage is focused touch and lasts atleast 10–15 minutes, it can amplify the benefits of more or-dinary touch.

Massage is an ancient preventive and restorative therapythat continues to evolve among massage therapists, physi-cal therapists, nurses, and physicians.2 It has been describedin ancient Chinese, Indian, Greek, Turkish, and Roman textsand, later, in European medical journals.3,4 Current massagepractices have been attributed to Per Henrik Ling of Swe-den (1776–1839), a fencer and gymnast, but others attributethem to an Amsterdam physician, Johann Georg Mezger(1838–1909).5

Because the massage techniques used throughout historyand in different settings have varied considerably from eachother, even when described using similar terms,2,4 the con-clusions drawn about the effectiveness of massage may not beuniversally applicable. For example, the unique needs of pa-tients with cancer have led professional massage organizations,until recently, to warn against massage for these patients basedon a presumed risk of promoting metastasis. Yet, the promo-tion of metastasis through physical touch has been demon-strated only through the use of extreme focused pressure, asis sometimes used during sentinel lymph node mapping.6

REVIEW OF RESEARCH FINDINGS

Several reviews and overviews of the scientific literaturehave attributed important benefits to massage, including en-hanced relaxation7–9; improved sleep quality7,9; decreasedfatigue7,9–11; relief of pain,7–9,11–13 anxiety,7–9,11,13 nau-sea7–9,11,13; and improvements in immune system re-sponse.7,8 However, just two of these articles12,13 describedtheir search criteria and assessed research quality.

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

The Cochrane Collaboration review of 200413 assessedeight randomized controlled trials of massage for symptomrelief in patients with cancer that had been published as of2002. They concluded that “massage and aromatherapy mas-sage confer short-term benefits on psychological well-be-ing.” The most consistent specific effect, found in four tri-als, was for reduced anxiety14; two reports found a reductionin nausea,14,15 and three found a relief of pain.15,16,17

The most notable study design weakness in these studieswas a lack of blinding. It would be difficult to blind patientsreceiving or not receiving massages, but some investigatorshave single-blinded the evaluators of patient outcomes. Inone such trial,13 pain intensity scores were significantlylower than those of patients who received their usual hos-pice care alone (p � 0.05) after the first and third, but notafter the second and fourth, of their twice-weekly massages.Regrettably, only 29 of the 173 referred patients completedthe 2-week trial.16

In the second review, Bardia and colleagues identifiedfour trials of massage16–19 within their larger review of com-plementary therapies for cancer-related pain published as of2005. (The Cochrane group had also reviewed two of thesestudies.16,19) Although three of the studies included blindedevaluators,16–18 they included only 29, 28, and 42 partici-pants, respectively, because of high attrition rates.12,17 Thefourth trial,19 which did not blind evaluators, randomly as-signed its 230 subjects to sessions of rest alone, massagetherapy, or “Healing Touch,” a therapeutic technique basedon the manipulation of energy instead of physical touch. Themassage and Healing Touch groups experienced signifi-cantly greater reductions in pain than the resting-onlygroup.12 The Bardia group summarized by noting that thisstudy’s reduction in pain,19 though significant, was not long-lasting and that the included studies were generally charac-terized by small sample sizes, high attrition rates, and in-consistency in the presence of research nurses.12 (Althoughanalyzing the effects of massage on anxiety and fatigue wasnot a goal of this review, two studies found that massagehad significant effects on these symptoms.18)

To update these findings, we searched the MEDLINE®

and CINAHL databases using “massage” and neoplasia- andcancer-related terms for reports of randomized trials of mas-sage in patients with cancer that had been published throughAugust 2007, but not previously included in one of the tworeviews previously described. We excluded studies thatcompared one type of massage to another, that lacked non-massage control groups (e.g., reflexology compared to stan-dard foot massage), and that involved massage in combina-tion with other accepted physical therapy specifically for therelief of lymphedema. (The National Cancer Institute has al-ready accepted massage in combination with exercise andother modalities as part of the standard of care for edema.20)

Of the 10 reports we identified, we excluded four because(1) the number of participants was unclear (20 total versus20 per group);21 (2) the trial was a pilot with only 17 evalu-

able patients;22 (3) the massage therapy given was combinedwith acupuncture, and its separate effects could not be as-sessed;23 and (4) a study in which subjects who had not beenrandomly assigned were added to a previously publishedrandomized trial.24

Although the remaining six randomized trials were notblinded, they did attempt to control bias in their study de-signs. None of them, however, was able to enroll and retainenough subjects to meet their own goals for statistically ad-equate sample sizes. Nevertheless, their progress and resultsare instructive and worthwhile. In one trial, for example, in-vestigators recruited 147 women, but 42 dropped out, leav-ing 105 evaluable subjects instead of the 130 they hadsought. In this trial, women scheduled for abdominal lap-arotomies for suspected cancers were randomly assigned toreceive standard postoperative care, standard care plus mas-sage, or standard care plus vibration therapy. Although in-vestigators initially found significant differences in relief ofpain and distress between treatment groups, the differenceswere not significant after being adjusted for multiple fac-tors. The authors concluded that this may have been due totheir enrolling too few subjects or to the participants havinglow baseline pain levels that were adequately relieved withstandard postoperative care alone.25

Another of the six reports26 described a trial in which 39women receiving chemotherapy for breast cancer were ran-domly assigned to receive, during treatment, five 20-minutemassages or five 20-minute visits, with massage subjectschoosing massage of either the foot and lower leg or thehand and lower arm. Again, significant differences in par-ticipant anxiety were not detected, perhaps because of thesmall sample size or the participants’ low baseline anxietyscores. The study did find that patients who received mas-sages experienced improvements in nausea after their visitsmore often than those who received visits without massages(massage, 73.2% � 32.3%; visits only, 49.5% � 32.2%;p � 0.025). Notably, this report detailed the massage settingand specific techniques used.

Another small trial assessed moods and their potential ef-fects on immune and hormone measures in 34 women whohad been previously treated for breast cancer.27 Participantswere randomized to receive three massages a week for 5weeks or standard care alone with massage offered at theend of the study period. After 5 weeks, patients receivingmassage therapy had reduced mean anxiety, according toState-Trait Anxiety Inventory scores [F(1,32) � 4.49, p �0.05]; reduced depression and anger, according to Profile ofMoods States scores [depression, F(1,32) � 6.36, p � 0.05;anger, F(1,32) � 3.93, p � 0.05]; and reduced depressionand hostility, according to Symptom Checklist-90-R[F(1,32) � 7.43, p � 0.01 and F(1,32) � 3.98, p � 0.05; re-spectively]. Participants receiving standard care alone hadno such changes reported other than a slight increase in thegroup mean depression score on the SCL-90R (first-daymean � SD 9 � 8; last-day mean � SD 11 � 12). Based on

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experiments in a natural-killer-cell–sensitive leukemia cellline, the mean number of natural killer cells increased sig-nificantly in the massage group and decreased in the con-trol group, but the difference in the cytotoxicity of the twogroups’ natural killer cells was not significant. Urinarychanges in hormones were both difficult to interpret and un-expected. For example, both stress-relieving hormones(dopamine and serotonin) and stress-promoting hormones(cortisol, norepinephrine, and epinephrine) increased signif-icantly in the massage group. (Patients’ psychotropic, thy-roid, or serotonin reuptake inhibitor medications may haveaffected hormone levels, although the groups had similarbaseline proportions of participants taking these medica-tions.) Unfortunately, only the statistical evaluations of per-centage changes within—and not between—groups were re-ported, which adds to questions concerning the validity andoverall implications of these results. Investigators subse-quently combined data from this study27 with a new, non-randomized controlled study with three groups of patients24

not included in this review, since it was no longer a ran-domized study.

Unlike most trials, which have evaluated the short-termeffects of massage, the fourth randomized controlled trialevaluated the effects of massage therapy on anxiety and de-pression 6 and 10 weeks after the last session.28 For thistrial, 288 patients were recruited from four cancer centersand one hospice. Half were randomly assigned to receiveweekly 1-hour sessions of “aromatherapy massage” and halfto receive “usual care” for 4 weeks. Investigators decidedto provide aromatherapy massage without a control groupof massage alone because an earlier double-blind, placebo-controlled trial in their center had not found detectable dif-ferences between massage with and without aromatherapy.29

They also did not include a control group receiving relax-ation therapy in order to decrease the overall sample sizeneeded.30 As with other studies, this study lost subjects overtime, with only 124 of the 144 patients in each group com-pleting at least two of the four sessions. In spite of the chal-lenges, significant improvement in anxiety and/or depres-sion was detected for massage. At 6 weeks, a significantlygreater proportion of patients who received aromatherapymassage improved than those who received usual care alone[64% vs. 46%; odds ratio (OR), 1.4; 95% confidence inter-val (CI) � 1.1 to 1.9; p � 0.01]. At 10 weeks, a differenceremained, but was no longer significant (massage, 68% im-proved vs. controls, 58%; OR, 1.3; 95% CI � 0.9 to 1.7;p � 0.1).28

In the last two of the six additional reports we reviewed,time to engraftment and related parameters were evaluatedin patients receiving bone marrow transplants.31,32 In one ofthese studies, 50 patients between 1 and 19 years old wererandomly assigned to one of three groups: massage by a pro-fessional massage therapist, massage by a parent who wastrained by a licensed massage therapist, or a control groupof standard psychosocial care. Ratings of anxiety and dis-

comfort were obtained before and after first and last ses-sions by a research assistant while the massage therapist orparent was out of the room. Visual analogue scales indicatedsignificant reduction in anxiety after the first professionalmassage (child report, p � 0.004; parent report, p � 0.0001)and discomfort (child report, p � 0.130; parent report, p �0.004), but not after the first parental massage (anxiety childreport, p � 0.410 and parent report, p � 0.120; discomfortchild report, p � 0.300 and parent report p � 0.160), andfindings were similar for the final session massage ratings.However, weekly scores of Behavioral, Affective, and So-matic Experiences Scales (BASES) by parents up until 6weeks after transplantation were not significantly differentbetween groups even after combining the professional andparental massage groups. (Limitation of child reports tothose who were 6 years of age or older left too few remainingreports for meaningful analysis.) Days in the hospital wereshorter for the professional massage group (mean � SD,27.5 � 15.9; median, 20.5) compared with the standard carecontrols (mean � SD, 35.8 � 17.5; median, 33.0) (p �0.06). Days to engraftment were shorter in the parent-ad-

MASSAGE THERAPY IN CANCER CARE 211

TABLE 1. EDUCATION OF MASSAGE PROVIDERS

IN RANDOMIZED CONTROLLED TRIALS

Provider education/training andexperience as described by

Study, year published authors of published studies

Ahles, 199914 Trained healing-arts specialist withmore than 10 years of experience

Billhult, 200726 Nurses/nurses aids educated and trained for a day by author—previous experience massaging cancer patients

Corner, 199533 Trained cancer nurse who was experienced masseuse

Grealish, 200015 Nurse trained in massage techniquesHernandez-Reif, 200427 Trained massage therapistsPhipps, 200431 Licensed massage therapistsPost-White, 200319 Certified and credentialed MT and

HT practitioners who also were registered nurses

Smith, 200332 Registered nurse certified in massage therapy

Soden, 200418 Not describedTaylor, 200325 Licensed massage therapists with 5

or more years experienceWeinrich, 199017 Senior nursing students with 1-hour

training session in massage, interviewing, and use of visual analog scale

Wilke, 200016 Licensed massage therapistsWilkinson, 199929 Nurses holding recognized diplomas

in massageWilkinson, 200728 Therapists appropriatelya trained in

aromatherapy massage and working with patients with cancer

MT, massage therapy; HT, Healing Touch.aAuthors’ assessment.

ministered massage group (mean � SD, 15.9 � 7.5 days;median, 14.5 days) compared with the standard care con-trols (mean � SD, 20.1 � 7.1; median, 19 days) (p �0.04).31

Investigators in the other bone marrow transplant studyrandomly assigned 88 adult participants to receive massage,Therapeutic Touch (an energy approach not involving phys-ical touch), or a friendly visit for the same amount of time.Withdrawals were problematic, as in other studies. Of the27 participants who withdrew, 13 left before the interven-tions had begun because they were not assigned to receivethe treatment they wanted; subsequently, 1 withdrew fromthe massage group, 9 from the Therapeutic Touch group,and 4 from the friendly visit group. The study found onlyslight, nonsignificant differences in the mean time to en-graftment (massage, 15.5 days; Therapeutic Touch, 14.00days; friendly visit, 14.88 days; F � 0.08, p � 0.42) and nosignificant differences in 10 of the 11 categories of compli-cations (F � 0.84, p � 0.43). They did, however, find that

the massage group had an improved mean central nervoussystem/neurologic complications score (massage, 0.94;Therapeutic Touch, 1.31; friendly visit, 1.61; F � 4.02, p �0.022; pairwise comparison, p � 0.031). Additionally, theyreported that the massage group had higher mean comfortsubscale scores than the friendly visit group (p � 0.000), asdid the Therapeutic Touch group (p � 0.007). The massagegroup also had higher total mean perceived benefits scoresthan the friendly visit group (p � 0.003). Considering thesmall limited study sample size and challenge of overcom-ing the toxicities of chemotherapy regimens for all groups,it is noteworthy that any differences were detected.32

Although licensed or certified massage therapists pro-vided massage in most of these trials, the extent of the ther-apists’ education, training, and experience were rarely de-scribed. A few studies used unlicensed providers who hadhad only brief training, which could have affected outcomes.Table 1 summarizes the education and training of massagetherapy providers as described in these studies.

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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 aradioactive substance out of a lead-lined glass tumbler in a lead cell; then for 2 weeks I can’tbe in public or have physical contact with people or pets. In between these periods ofisolation, 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 recommendationsrecommendation 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 sheloved the massage and, ‘How did he know what I needed when I didn’t even know what Ineeded?’ She asked me to thank him. Later on in the week, the physician told me that shebecame 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 likedthe massage when his pain was the same afterward. He reported that during the treatment hecould 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—butyou get through the numbness.”

Patient’s experience at a Patient receives a weekly massage each Friday before her chemotherapy treatment, and Friday iscancer 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 byto improve my diet, a counselor came by to check on how I was doing, and now a massagetherapist. . .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 wifecomplains he won’t because he is too weak and fatigued. She tried to tell him that just a lighttouch would be nice, but he thought it had to be the heavy macho massage he’d been givingher for years. After she received a very light back massage from me, and really enjoyed it, hewas able to see the value of a light massage for his wife. The wife came to Place. . .ofWellness 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 andhe definitely needs a massage.’ As I’m massaging his neck and shoulders, he is literallytrembling and sighing heavily, and others see him allowing himself to finally relax. One byone, some of them move toward the deceased patient and begin stroking his hands andforehead and whispering to him. The room is very quiet.”

In spite of the limitations of these trials, The Universityof Texas M. D. Anderson Cancer Center and other institu-tions have accepted the available evidence and the expressedneeds of their own patients as an indication that massagetherapy can be beneficial for patients with cancer.

MASSAGE THERAPY IN A CANCER CENTER

As in many hospitals, physical therapists in the Depart-ment of Rehabilitation Services at M. D. Anderson CancerCenter provide therapeutic massage for certain muscu-loskeletal conditions, including edema, muscle fiber con-traction due to radiation, and nerve compression due to avariety of causes. However, time and other constraints havelimited the use of massage in physical therapy programs forthe general reduction of stress. To address this need, M. D.Anderson began in June 2001 by providing brief relaxationchair massages at its Place . . . of wellness and clinical wait-ing areas, with brief relaxation massages at patient beds; inJanuary 2004, the program was expanded to include full-body massages. The program’s primary goals are to improvecirculation and decrease muscle tension, pain, anxiety, andstress; its secondary goals are to decrease insomnia and im-prove gastrointestinal functioning.

All massages given as part of M. D. Anderson’s programare provided by nationally certified massage therapists hold-ing current Texas licenses. Their training requires comple-tion of the center’s class on massage for patients with can-cer, standard courses required for all patient care providersat the institution, and an orientation to cancer care by theDepartment of Physical Therapy. Massage therapists mustalso follow guidelines relating to constraints imposed by pa-tients’ diseases and treatment regimens; precautions can in-volve medications, low platelet or neutrophil counts, bonymetastases, and suspicious lumps. If massage therapists en-counter lesions or lumps, they ask massage recipients if theyare aware of the lump and if their physician has diagnosedit. If the recipient is an inpatient who was unaware of thelump, the therapist tells the patient’s nurse or physician anddocuments it in the patient’s medical record. If the recipi-ent is an outpatient or caregiver who was unaware of thelump or lesion, he or she is advised to notify a primary carephysician as soon as possible.

Although professional massage may be more effectivethan self- or parent-administered massage, M. D. Ander-son provides classes in massage for caregivers so that theycan provide safe massages to loved ones at home. Clini-cians, patients, and others who believe that a patient maybenefit from massage can initiate a massage request. Briefrelaxation massages at bedside or in a chair are at no costto the patient; full-body massage is provided at currentmarket rates. Each massage therapist completed a progressnote after each session.

Although our center has not yet conducted its own re-search concerning the effectiveness of massage therapy forspecific outcomes, we have distributed client satisfactionsurveys. Survey respondents have been universally positiveabout their massage experiences, but the surveys have notbeen universally distributed or consistently completed by allparticipants, so these results may not be representative of allwho have received massages. In addition, the surveys usedare the same as those for other institutional programs, withgeneralized questions (e.g., “Did this program meet your ex-pectations?”) so the responses have not been helpful re-garding issues specific to massage therapy. Therefore, weare testing a new form that asks about pre- and postsessionpain scales and has questions derived from the comments offormer massage therapy clients, such as, “Right now do youfeel like you could easily sleep?” Instructive statements ofselected patients who have articulated their experiences aresummarized in Table 2.

IMPLICATIONS FOR THE FUTURE

Massage therapy is becoming an increasingly acceptedpractice, both in our institution and in other large cancercenters in the United States. Restoring the ancient practiceof massage to medical settings has the potential to addressthe critical need of patients with cancer for human-to-hu-man touch in the healing process.

However, additional research is needed to clarify whetherthe benefits of massage to patients extend beyond the tem-porary relief of pain, anxiety, and distress. As many of thereports reviewed in this article have indicated, this researchwill require sample sizes large enough to detect significantdifferences in study groups. Enrolling an adequate numberof participants may require that investigators in different in-stitutions use collaborative protocols and that participatingmassage therapists have comparable education, training, andexperience.

After 7 years of experience with massage within our cen-ter, its safety is now accepted within our general and cancer-specific guidelines. Overall benefits are likely based on feed-back from patients, but we need to develop more systematicfeedback mechanisms without being intrusive on the massageexperience. In addition to effects of massage on clinical out-comes, institutional questions about cost-effectiveness, cre-dentialing, and continuing education for practitioners andother members of the health care team will be needed.

ACKNOWLEDGMENTS

All authors receive salary support from The Universityof Texas M. D. Anderson Cancer Center. No financial orother associations occurred that could lead to a conflict ofinterest.

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Address reprint requests to:Moshe A. Frenkel, M.D.

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

1515 Holcombe BoulevardHouston, TX 77030

E-mail: mfrenkel@mdanderson.org

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