Touch can also help to restore intimacy, which may be lost due to fear of hurting the patient, or because of separation through periods of medical treatment. Touch itself, as well as massage, may have immediate beneficial effects on pain and mood (Kutner et al 2008), so the deprivation of touch may be very significant. The therapist must work with those close to the patient, and must sometimes relinquish her role and pass it on to the carer. Carers may also be stressed and in need of massage themselves, in which case ‘time out’ should be encouraged. Another option is reciprocal massage, between patient and carer, which may facilitate communication and intimacy. It can be a non-strenuous but fulfilling form of sensuality. It may restore the early experiences in a relationship—exploration, physical awareness and gentle, sensitive responses to each other’s needs. Scented oils and music may enhance the experience. The advice and support of the therapist may facilitate this activity. The relaxation effects of massage can also aid in reducing sleep disturbance (Richards 1998).

McCaffery and Wolf (1992) suggest that massage is especially helpful when the patient is confined to bed (either because of specific treatment or the terminal stage) and lies supine much of the time, as it improves circulation to the skin and reduces skin breakdown. This can enhance nursing strategies to reduce pressure sores such as turning and positioning regimens. Care should be taken if the skin has become reddened, as this can indicate that there is tissue breakdown underneath the skin, and manipulation of skin may worsen the situation.

Modifications usually make a treatment possible and it is always worth pursuing, as a study with female cancer patients showed that massage gave them ‘meaningful relief from suffering’ (Billhult & Dahlberg 2001).

Patients should be respected as individuals and encouraged to direct the best time for the massage and how long it should last, and to decide whether the massage should be conducted in silence or whether it offers a welcome opportunity for talking, either general discussion or expression of feelings. The areas to be massaged may be modified by the presence of any open lesions. The hands and feet may be good options if accessibility to other parts of the body is limited by surgical wounds, drips or drains. These areas are often acceptable to the individual who does not welcome further personal intimacy. The addition of an essential oil to the lubricant may enhance the effects of massage. Wilkinson et al (1999) found that the addition of Roman chamomile essential oil to a carrier oil enhanced the therapeutic effects of reduced anxiety and improved overall QoL. A follow-up RCT study of 288 cancer sufferers found no long-term benefit on anxiety or depression, but a clinically important benefit up to 2 weeks after the intervention (Wilkinson et al 2007).

Is massage a safe intervention for people with cancer?

Early writers on massage placed little emphasis on cancer as a contraindication to massage. It was not listed by Goodall-Copestake (1926) or Tidy (1932), although this omission could indicate the scant attention the disease received generally in physiotherapy texts. Hollis (1987) gives tumour as a contraindication and Tappan (1988) lists melanoma, as this type of cancer metastasises easily through lymphatic and blood vessels. In its traditional use, within orthodox medical care, massage has previously been regarded as being contraindicated for patients with active malignant disease.

Physiotherapists, by taking a detailed medical history and having access to patients’ medical records, have avoided techniques that might increase local metabolic rate or blood flow in the vicinity of active disease. This statement needs some clarification, as massage has been used to reduce local symptoms, or to aid relaxation in the terminally ill patient, when emphasis is on comfort rather than cure. Massage has also proved useful, for example, in spinal cancer which has produced uncomfortable sensory changes such as hyperaesthesia. This can be sufficiently severe to make touch uncomfortable to the point where washing becomes distressing. Gentle rhythmical stroking can prove useful for desensitising the skin, and the use of warm water for massaging the skin gently (via gentle movements in a hydrotherapy pool, for example) may be helpful. Heavier stroking can be used as a counterirritant, acting through the pain gate to reduce pain. Also, after radical mastectomy for example, patients can be given or taught oedema massage for the arm following removal of the lymph glands. Effleurage was formerly the main treatment of choice; it has now largely been superseded by the more superficially applied manual lymphatic drainage. Traditionally, however, massage has been taboo in the earlier active stages of the disease, but acceptable at the later and terminal stages.

Of course, patients with cancer have the right to treatment of other injuries and physical problems unrelated to the cancer. They also have the right to support for symptoms of stress, and help with coping mechanisms. Thus, as long as the tissues are not actively manipulated over any active disease site, an increase in lymphatic and venous flow is avoided in patients with melanoma or Hodgkin’s disease and the lymph nodes are not directly stimulated mechanically, then massage can be a useful adjunct to other therapies. Stationary and light pressure techniques are probably the safest (holding, therapeutic touch, acupressure, for example); the more superficial techniques—as used in gentle stroking, whole body sedative massage or through an oily medium—would be the next treatment of choice from a safety viewpoint. It is unlikely that these techniques would be physiologically more stimulating than everyday activities such as walking or housework. Hadfield (2001) used aromatherapy massage in patients with a primary malignant brain tumour who were attending their first follow-up appointment after radiotherapy. There was a statistically significant reduction in four physical parameters of the autonomic nervous system (ANS) which suggested a relaxation response.

In relation to drug therapy, it has been suggested that massage may increase the rate at which chemotherapeutic agents flow around the body when administered into the bloodstream, that it increases the rate at which drugs enter the bloodstream when administered by other means and that the dosage should be reduced accordingly (McNamara 1994). However, this has not yet been substantiated experimentally. Also, it has been suggested that massage increases the rate at which chemotherapy and its toxins will be lost from the body, although it should be recognised that we have insufficient experimental evidence to support these suppositions. Of course, as in all conditions, techniques and approaches should be modified to match the stage of disease.

Another pertinent study was undertaken by McNamara (1994). She sent out questionnaires to 24 volunteer massage practitioners and asked for their views and knowledge on the use of massage for people with cancer. The main findings in relation to dangers and contraindications were that practitioners had often been taught or had read that massage was contraindicated in the earlier stages of the disease but not in the terminal stages. There was obviously some concern about the lack of research evidence to support or refute this suggestion, but massage was generally being offered to people with cancer.

An absolute contraindication for massage is undiagnosed cancer. It is important that the massage therapist is alert to the possibility and that any patient experiencing symptoms which may relate to a serious condition should be urged to seek advice from a doctor immediately. Look for:

• Intractable pain—no relief on rest, significantly disturbed sleep (this may indicate inflammatory or malignant disease);

• Feeling of being generally unwell;

• Change in temperature;

• Inflammation and heat in the absence of trauma;

• Unexplained weight change; and

• Any lump bigger than 5 cm, especially if it is a recurrence of a previous lump or is deeper than fascia or is increasing in size (Grimer & Dalloway 1995).

Within the physiotherapy profession there has been a long tradition of concern about the safety of massage for patients with cancer. Its unwritten nature leaves an apparent controversy in this area, which has prompted research in the subject (McNamara 1994). The consensus is that massage is not acceptable if:

• The cancer is metastasising;

• The cancer is active;

• The massage is in the region of a contained tumour;

• Cancer is undiagnosed; and

• The therapist is not sensitive to any fragile areas of bone.

Generally, massage is considered quite appropriate for use in the terminal stages of the disease.

If a therapist is unsure of any of these factors and is unable to receive specific guidance from the patient’s doctor, then she should err on the side of caution.

If in doubt, stationary holding or therapeutic touch techniques can be used as there is no evidence to suggest that these are unsafe in any circumstances.

Gentle stroking, a back rub, foot massage or whole body massage are techniques of choice for relaxation.

Heavier stroking or classical Swedish massage techniques can be used to influence the pain gate or to have a counterirritant effect to relieve pain.

The reflex techniques of acupressure may be preferred, to promote relaxation or for their balancing effect to strengthen immunity and improve general health.

Massage should be modified to match the medical condition and desires of the individual patient, and the type of massage and structure of the sessions negotiated beforehand. Essential oils may be found to be pleasant, or they may worsen nausea. If tolerated, specific oils, such as rosemary, can be applied as a shampoo to the head or as a massage oil, to stimulate hair growth following chemotherapy. If applied in excess, however, it may cause convulsions and fitting, so the therapist should be cautious. Massage may be preferred for a whole hour or may be tolerated only for short periods of time.

Tyler and colleagues (1990) demonstrated that the 1-minute back rub (a traditional nursing procedure) showed no statistically significant worsening of mixed venous oxygen saturation and heart rate levels when applied to 173 patients in receipt of critical care. This suggests that massage is safe even in critically ill patients, though the considerable variability shown reinforces the principle of close monitoring of physiological responses in this client group. Dunn et al (1995) also found that massage and aromatherapy with lavender oil did not adversely affect vital signs in patients being nursed on an intensive care unit. Stress or coping measures were not altered to statistically significant levels post-massage, or aromatherapy, or rest; but aromatherapy significantly improved mood and decreased anxiety levels.