In accordance with the fair use exception to copyright for teaching purposes, I am engaging with it here to bring out points that are directly relevant educationally to stakeholders in the massage community, and to provide links to clarify specialized knowledge as needed.
That way, when we're trying to navigate among terms, concepts, and referents in discussing this article to get at what it all means, we have the advantage of a shared vocabulary and approach to help us work together with each other.
ANNALS of SURGERY VOL. LXXV FEBRUARY, 1922 No. 2
THE RELATIONSHIP OF MASSAGE TO METASTASIS IN MALIGNANT TUMORS*
* From Columbia University, Institute of Cancer Research, F. C. Wood, M.D., Director, New York.
BY LEILA CHARLTON KNOX, M.D. OF NEW YORK, N. Y.
One of the most important aspects of the practical study of tumors is the determination of the anatomical and biological conditions which facilitate or prevent metastases. These phenomena have long been studied in man without much definite information having been collected. About all we know is that, in general, carcinomata are prone to metastasize through the lymph-channels and sarcomata through the blood-vessels, and that metastases do not always follow in the direction of flow of the current, but in a certain proportion of instances the emboli travel by a retrograde course or the tumors progress by direct extension, the so-called permeation of the lymphatics.
What are the important points that Knox is making here?
Structually, what part of the research article that you would expect to see here is missing? What might be a reason that this research review article does not have the structure that you would normally expect?
It has been generally assumed, without direct experimental proof, that a number of the factors favoring the production of metastasis are purely physical, for instance, the size and connective-tissue relations of the tumor cells, the pulsating or contractile movements of the organs in which they are implanted, the number of the blood-vessels and the thickness of their walls, with consequent susceptibility to trauma by pressure or massage. On the other hand, accurate clinical study and experimental work as well have caused the occult and convenient theories of tissue predispositions and specific "immunity" of organs to assume a less creditable position than they formerly held, and quite properly, for until it is shown that simple mechanical and biological facts do not account for the peculiarities in the occurrence and distribution of metastases vague theories should not be substituted.
What exactly is she saying here about material mechanical and biological facts?
Is she arguing from a realist position or not? How do you know?
At this point, unless we have some specific knowledge of particular claims about metastasis made at this time in history, it's unclear exactly what she means by "occult and convenient theories of tissue predispositions and specific "immunity" of organs". At a very general level, however, what does she appear to be talking about? Remember this point--she'll clarify it later in her discussion.
Where does she use Occam's Razor in her argument here, and why?
The importance of vascular embolism in the spread of tumors has long held an unchallenged position in instances in which the pulmonary veins were known to be grossly involved and the arterial circulation in that way obviously open to a supply of tumor cells. A valuable contribution on this phase of the subject was made when M. B. Schmidt showed that not infrequently the tumor cells readily pass the pulmonary capillaries and are deposited elsewhere before macroscopic growth appears in the lung. In a study of forty-one cases of primary abdominal carcinomata without extensive gross metastases, the lungs of fifteen were found to contain microscopic arterial emboli of tumor cells, showing that once the cells gain entrance to the blood stream they may reach any portion of the body and are not necessarily always retained or destroyed within the lungs. This may, however, be their fate, for Schmidt found many small thrombosed vessels with degenerating tumor cells entangled in the clot. These phenomena have been duplicated experimentally by Takahashi and by Iwasaki, both of whom injected tumor cells into the blood stream of animals. Both these authors have well shown that although embolic cells are frequently treated as foreign bodies and phagocyted, many, on the contrary, survive the adverse conditions, and invade and replace the vascular endothelium or undergo mitosis even before they become implanted on the vessel wall.
What does she mean by "the pulmonary veins were known to be grossly involved and the arterial circulation in that way obviously open to a supply of tumor cells"? Describe the relationship between pulmonary veins and arterial circulation that she is referring to.
What is M.B. Schmidt's valuable contribution on the subject, and why is it so valuable?
What did Takahashi and Iwasaki show, and what does it mean?
Notice the unusual term "phagocyted"; it means the same thing as "phagocytosed", which is the term you see more often nowadays, as in this example from Wikipedia:
Phagocytosis (from Ancient Greek φαγεῖν (phagein) , meaning "to devour", κύτος, (kytos) , meaning "cell", and -osis, meaning "process") is the cellular process of engulfing solid particles by the cell membrane to form an internal phagosome by phagocytes and protists...Bacteria, dead tissue cells, and small mineral particles are all examples of objects that may be phagocytosed.
For purely physical reasons, however, we must suppose that cells of small size accomplish this more readily than do larger ones, and experience shows that the large spindle and giant cells, or those distended with mucus as many from the gastro-intestinal tumors are, do not find their way through the pulmonary capillaries except in small numbers. Whether or not the ameboid motion of the cells is a factor in facilitating this is not known. That such motion exists was shown by Carmalt in 1872 and later by Lambert and Haynes.
What are two possible physical explanations that could account for smaller cells establishing metastases beyond the lungs more successfully than larger cells do?
The localization and growth of embolic tumor cells within the dilated capillaries of the bone-marrow have been explained as due to the physiological hyperaemia which is practically constant in that situation. Slowing of the blood current and adhesion of the tumor cells to the endothelium seems to produce circumstances favorable to the growth of such emboli.
Is she saying that bone marrow is particularly susceptible to metastasis from tumors that originated elsewhere in the body? Why or why not?
Lymphatic embolism, either direct or retrograde, has also been unquestionably a frequent and important means of tumor dissemination; but the status of lymphatic permeation, although very convincingly demonstrated by Handley in certain cases, is perhaps a less constant phenomenon than he at first believed.
Notice the British spelling of "tumour", and beware the typo in "pulmonary"--this image was probably created by a non-native English speaker, but is factually correct with regard to the referent, although they misspelled the term.
Tell me what we're looking at here--what structures and processes do you see?
The process, as Handley described it, consists in the proliferation of tumor cells which, having gained access to the superficial lymphatics in the proximity of the tumor, continue to grow within them and to extend through their branches, often appearing in the skin, where they form cutaneous nodules. Secondarily, there often occurs an inflammatory fibrosis and obliteration of portions of the lymph-channel, a process analogous to the thrombosis which is common in invaded vascular channels. Handley studied especially breast carcinomata and melanomata--two of the tumors which most frequently exhibit regional cutaneous recurrences and extensions; and it is on the basis of his evidence that one may perhaps regard some of the recurrences in surgical scars as accidental occurrences due to the proliferation of tumor cells present in the lymphatics prior to the incision, though possibly accelerated in growth by the increased vascularity of the wound area. Probably, however, a majority of the local recurrences are due to a mechanical transplantation from an infected to a non-infected field.
What metastases do breast cancer and melanoma frequently exhibit?
What is the connection between metastasis and surgical scars?
What are 2 possible mechanisms for their occurrence?
Notice the use of "infected" to refer to cancer cells here.
FIG. 1.-Metastasis of breast carcinoma in pectoralis muscle following massage in man.
What different kinds of cells and other material physical things do you see there?
What indicates that you are looking at muscle cells?
What, particularly, indicates the pectoralis muscle?
In the case of the melanomata this mechanical transfer by operation is not a completely adequate explanation, for the nodules are often found far from the region of the incision, and, indeed, are frequently seen in unoperated cases, giving a striking illustration of the fact that tumor cells, especially those of moderate size, have the capacity to invade the cutaneous lymphatics for long distances and to spread against the direction of flow of the lymph. When the vessel is large, as in the abdominal trunks, permeation would not be expected to occur, and it is probable that extensive backward spread of tumor cells is due to a combination of several processes. Vogel has described two such cases, one a carcinoma of the gall-bladder, which extended into the left kidney hilus [RST: This is an old name; it means the same thing as "hilum"] and there perfectly outlined the perivascular lymphatics of that region; the other a pancreatic carcinoma which extended directly along the mesenteric and aortic trunks into these nodes.
What are two explanations that Knox provides for why surgery is not the only thing that accounts for metastasis?
Vogel described two cases where the spread was far away, and it travelled retrograde to the direction of lymphatic flow.
In what direction did the gall bladder tumor have to travel to reach the hilum of the kidney?
How far did it have to travel?
What did it have to pass through to get there?
Where have we seen a hilum of an organ before in this discussion? What do they have in common with each other?
It is well known also that oesophageal carcinomata are prone to spread longitudinally along the lymphatics of the submucosa and that small secondary nodules often appear considerably below and separated from the oldest portion of the tumor by uninvolved mucosa. It used to be the fashion to describe these as implantation growths, but this view is now generally abandoned. Zahn has even described one situated as high as the tracheal bifurcation, but associated with three small carcinomatous nodules beneath the mucosa on the gastric side of the cardia. This occurred also in an oesophageal carcinoma with tracheal fistula (St. Luke's Hospital, No. 1309), the secondary nodule being 4 cm. from the main mass of the neoplasm. The mechanism of the formation of these multiple nodules, as well as of multiple papillary gastric carcinomata, has not been shown to be necessarily a process of permeation, although theoretically this would readily explain their occurrence.
"Oesophageal" is an older, Latin/Greek-based, spelling for "esophageal".
Why does the esophagus have carcinomata?
If you're a tumor cell, how far away is 4 cm in proportion to your size?
At the time Knox wrote this, did they know the mechanism by which these secondary metatastic tumors got away from the primary tumors?
On the other hand, emboli are, no doubt, prevented from growing by the mechanical activity of muscles and muscular organs. Metastases are singularly rare in the cardiac muscle, being practically never seen except in the case of extremely vascular tumors with scanty stroma from which the loosened cells spread and overwhelm the whole arterial circulation with countless emboli. The aortic valves must also act to deflect emboli from the mouths of the coronary arteries. Benecke, studying the invasion of the walls of vessels from carcinomatous thrombi, believed that the infrequency of metastasis in the muscular coat was due to the physiological tonus of the muscle. This is a reasonable conclusion, and the principle holds good for striated muscle as well. Metastases into the latter are extremely rare, due in part to the contractility of the fibres, a condition which offers considerable resistance. The fact that lymphatics are lacking within striated muscle bundles is certainly not the reason for the rarity of metastases, for if the emboli were lymphatic, not vascular, and if the motion did not play so large a part in preventing their growth, they should be present in tendons where lymphatics are very numerous. Direct permeation of both striated and unstriated muscle is, however, frequently seen, showing that the soil is not unsuitable provided the cells once gain access to the tissue.
What protects muscles, and muscular organs like the heart, against metastasis?
Does this protection always work perfectly?
How do we know that it's not just the lack of lymphatic vessels in skeletal muscle that protects them?
Normal peritoneum has been shown by Jones and Rous to possess a high resistance to the implantation of tumor cells, but when it was injured by a mechanical irritant, tumor growth was at once made possible. This offers an explanation for the frequently observed fact that carcinoma of the stomach often metastasizes into the ovary, producing the so-called Krukenberg tumor of the latter organ, without any intermediary deposits on the peritoneal surface. That such deposits will eventually occur in late stages of carcinomatosis is, of course, well known, but it is probable that the constant motion of the opposed serous surfaces is an important factor in destroying whatever cells may find their way to it. It has long been recognized that it is the gelatinous carcinomata of the ovary, stomach, and intestine that are most widely distributed in the abdominal cavity. This is, of course, as would be expected, for the bulk and consistency of the mucus make it in a sense a foreign body and must keep the cells in contact with the peritoneum and also irritate it, and so indirectly facilitate adhesion and ultimate vascularization, whereas a few free cells would be more likely to be destroyed.
Is peritoneal tissue normally relatively vulnerable or relatively resistant to metastasis?
What is a proposed mechanism that could account for that tendency?
What can change that tendency?
Post-operative human results have occasionally shown the remarkable persistence which cells from malignant tumors may exhibit. During the quiescent period the cells are probably most frequently inactive in the lymph-nodes, occasionally for as long as ten to twenty years. Late recurrences usually appear first in the nodes to which drainage was directed, and if the morphology of the tumor is that of the primary growth there can be no question that these are really late recurrences from previous metastatically deposited cells. For example, small groups of living cells from a gastric carcinoma have been observed by Rohdenburg in the liver and omentum ten years after the operation on the primary tumor, with a clinical cure. Such a case may be the result, like many of the very late cutaneous recurrences from breast tumors, of slow permeation along the efferents of a node or even from a small group of cells for years quiescent in the tissue spaces.
How long after a tumor is removed can a recurrence or metastasis happen?
How can it do that, since the tumor was removed?
How can they tell it was a recurrence of the old cancer, rather than the development of a brand-new different cancer?
A spindle-cell sarcoma has occasionally recurred after a very long period. A tumor of this type, originating in the cervical fascia, has been seen by the writer recurring as a mass the size of a walnut twelve years after the first operation, the patient being free from symptoms during the greater part of the period. Such a phenomenon is difficult to explain, since only rarely does this type of sarcoma metastasize into the lymphnodes, and there form a focus for new growth. As this recurrence was in the centre of a large skin graft made at the first operation, it seems more probable that it was a recurrence in situ of very slowly growing cells situated in the deep fascia below the graft.
What happened in this case?
Was it what you would usually expect?
How does Knox explain it?
Other rare and late metastases which give no hint as to the mechanism of their localization and long course are cited by Schmidt and Goldmann, who observed a cerebral metastasis four years after a rectal carcinoma with no local or lymphatic return. Schmidt believes that such tumors are derived from latent intravascular cell groups in the pulmonary vessels. Another still more remarkable observation is that of Crouzon, who described a cerebral metastasis eighteen to twenty years after operation on a bilateral breast carcinoma. Gathmann and Schmidt have each observed cases in which four years after operation on similar tumors, with apparent cure, widespread skeletal metastases appeared. In such a case a general emboli distribution of cells by the blood into the capillaries of the myeloid canals must have occurred fairly early, and the growth processes have been very slow.
What happened in these cases?
Why are they so surprising?
How does Knox explain these events?
The frequency of skeletal metastases is so much greater than can possibly be demonstrated by clinical or röntgenological means until a very advanced stage that the high percentage of such growths is not often appreciated. Although the vascularity of the marrow is great, the stroma reaction may be here as marked as elsewhere and the metastasis of a scirrhous breast carcinoma be only a sclerotic nodule of the same appearance as the primary growth. When the bones are noticeably eroded or spontaneous fractures occur the process is far advanced and statistics drawn from such cases only give misleading data as to the frequency of the process.
"Röntgenological" is an old-fashioned word for "x-ray", because in 1895 the German physicist Wilhem Röntgen was the first person to discover x-rays in nature.
Is the skeleton particularly resistant to metastasis?
What does that translate to in clinical observations?
This view of the localization of metastases has not, however, been universally accepted, and many convenient hypotheses have had to give way to the increasing weight of pathological and experimental evidence. The theory of the specific adaptation of some tissues, as the liver, for neoplastic cells, and the relative immunity of others, as the brain, has been prevalent in the literature for many years. Virchow stated that organs in which carcinoma is never primary do not serve as a site for metastases. Recent observation has shown these conclusions to be wholly incorrect, as the brain is the site of secondary metastatic carcinomatous deposits in at least 0.3 per cent. of all autopsies (Krasting). Adherents to this theory point out, however, that some types of tumors have distinctly greater capacity to metastasize into certain organs than others, since not all tumor cells readily grow within the bones, but others very commonly do so, as those of the breast, thyroid, adrenal and ovary. Von Recklinghausen even advanced the idea that breast and prostatic carcinomata were apt to form metastases in similar regions because they were in a sense analogous organs, each being a part of the genital system. Bamberger and Paltauf believed that there was some specific organ susceptibility, and offer as evidence the fact that not only the small-cell carcinomata of the prostate metastasized to the bones, but the large-cell medullary carcinomata of the gland behaved in the same way.
Remember earlier, when she mentioned "occult and convenient theories of tissue predispositions and specific "immunity" of organs"?
What are some of those theories?
Rudolph Carl Virchow is called the "father of modern pathology", because of all the discoveries and knowledge contributions he made. Was he correct about metastasis sites? Why or why not?
When it comes to the concepts and terms of a big name, versus material physical referents, which do we believe, and why?
What is the other choice of belief called? Is it a logical fallacy?
The spleen also has been called "immune" to metastases by various writers because gross tumors in it are not especially frequent and microscopic ones often escape detection; but late stages of breast carcinoma are not infrequently accompanied by palpable enlargement of that organ due to a diffuse carcinomatosis, while E. E. Goldmann demonstrated that animal tumors inoculated into the spleen grow as readily there as elsewhere. While the vascularity of the organ exposes it to numerous emboli, yet as it possesses no efferent lymphatics and is in practically constant motion, embolic cells can not proliferate within it with as much facility as in some other organs. The great vascularity of the adrenals, as well as their protected position and absence of intrinsic motion, provides a suitable location for the secondary growths so often found in them. It is possible that the wide vascular sinuses of the pituitary, which resemble those in the adrenal, facilitate the location of metastatic tumors in this organ as well.
Again, this is an example of the "occult and convenient theories of tissue predispositions and specific "immunity" of organs" she referred to earlier.
Is the spleen immune to metastases? What does the evidence say?
How about the immunity or vulnerability of the adrenal glands and the pituitary? What might explain their situations?
External mechanical influences have for some years been recognized as an important factor in dealing with any malignant tumor. Gerster, in 1885, discussed the apparent breakdown of the forces which keep a malignant tumor for a time localized, and believed them to be largely mechanical. He pointed out the need, for example, of high amputation, not alone for the purpose of obtaining an uninfected field, but in order that the neoplasm itself should be free from manipulations, and so facilitate cellular dissemination. This writer further compared the results of malignant tumor massage to that which is sometimes effected by massaging a sprained joint--a process which certainly disseminates inflammatory exudate rapidly and widely. The effect of pressure, rubbing, or active massage on the tumor has been frequently observed in human beings as the result of osteopathic or massage treatment of malignant tumors, and many examples have been seen in recent years of wide dissemination of a primary growth very effectively accomplished by this procedure.
What were the two reasons Gerster advocated amputation in the case of cancer?
What is the analogy he drew with massage?
Does the evidence back up that analogy?
Such an instance has recently occurred at St. Luke's Hospital, and furnishes one of the rare instances in which extensive gross metastatic invasion of muscle could be observed. The patient stated that massage treatment had been regularly employed for some time previous to admission. When the breast tumor was examined there was found a fairly extensive area of eczema overlying a large very hard tumor which was fixed to the pectoralis fascia. Small white tumor nodules were scattered widely throughout the muscles, even invading the individual fibres. (See Fig. 1.)
What was unusual about this patient's case?
Does the evidence back up Knox's claim that massage accomplished this metastasis?
While, therefore, much interesting and important information has thus been obtained by clinical, operative, and post-mortem studies, the number of cases is too small to enable final conclusions to be drawn.
Is this consistent with everything that Knox said earlier?
The determination of the weight of a factor in producing metastases can not be judged from single experiences on man, as it is impossible to eliminate conflicting conditions. Only by the use of a homogeneous material in which the size of the cells, their histological and biological qualities, and the vascularity of the surrounding tissue, etc., are practically constant can valid conclusions be drawn, and this elimination of variables is possible to obtain only by the use of animal tumors of a long transplanted strain, so that the morphological and biological characters are well known. The possibility of obtaining by inoculation in a single day more tumors than any one surgeon observes in a lifetime of active practice also eliminates the occurrence of errors due to random sampling affecting the result--a condition never possible in human material. For example, following the discussion produced by the publication from the Crocker Fund of a paper on the results of the incision of tumors, many surgeons brought forward individual instances which they thought were of value in proving the danger of diagnostic incision, not realizing that from a statistical aspect a single instance is of no value. Even from a basis of reasoning, so remote from the complexities of mathematics as what is ordinarily termed common sense, many of those who cited these single instances were unable to deny on cross examination that pre-operative manipulation by the patient, or that dragging or pressure on the tumor during the operation might have equally well caused the evident dispersal of tumor particles, as evinced by the subsequent course of events.
What is she saying here about individual observations? About confounds?
It was not until Tyzzer, in 1913, demonstrated that gentle massage of a transplanted carcinoma in a mouse greatly increased the number of metastases observed in the lung that definite evidence was brought forward to substantiate these occasional clinical observations. The number of Tyzzer's experiments was small, and he obtained results with only one tumor, a highly malignant neoplasm of the Japanese waltzing mouse. With the Ehrlich mouse tumor No. 11 and the Jensen rat sarcoma he was unable to obtain metastases artificially by massage of the implanted tumors. Rous states that his experiments in massaging rats with adenocarcinoma resulted in the death of all the animals, but did not cause more than the ordinary number of metastases.
What did Tyzzer's and Rous' studies demonstrate? Were they definitive?
Several recent clinical experiences of the writer in which after the removal of a very small primary tumor of the breast by perfect surgical technic (no involvement of the axillary nodes being present), the patient died of generalized carcinoma in a short period thereafter, pointed to the desirability of further extension of Tyzzer's experimental results. We will say, in passing, that in one of these human tumors which had been somewhat vigorously palpated by a number of physicians, a small hemorrhagic area was found in the middle of the growth, and in the vessels surrounding the tumor numerous emboli of cancer cells were present.
What is the clinical relevance of Tyzzer's and Rous' studies?
What did the physical evidence show in one case?
What does this table tell us?
A considerable variety of transplantable carcinomata or sarcomata of the mouse and rat were used for the experiment. Some of these tumors under normal conditions, especially the spindle-cell sarcomata, do not produce spontaneous metastases in the animals in any number. Others, especially the carcinomata, are apt to metastasize early.
What were they comparing in this experiment? What is the internal validity likely to be?
The following tumor strains were employed: Crocker Fund mouse carcinomata, Nos. 5, 11, and 48, the Borrel mouse carcinoma, the Ehrlich mouse carcinoma and the Flexner rat carcinoma; Crocker Fund mouse sarcomata Nos. 7 and 180, and the Ehrlich mouse sarcoma.
The method employed was as follows, with the exception of the two series described separately below: The animals were inoculated subcutaneously in the inguinal or axillary region with a tumor particle weighing about 0.003 gm. When the tumor reached a diameter of approximately 5 mm. it was gently massaged for half a minute every other day for about two weeks. The tumor was then removed by operation to prevent further metastasis, in order to obviate the difficulty of having to decide whether embolic masses in the vessels of the lung were really growing tumor particles, or only recently deposited emboli which might ultimately die without giving rise to a tumor nodule. In the final results only those masses are considered as true metastases in which the vessel wall was invaded, a separate column giving the number of instances in which emboli were found in the lumen of the pulmonary vessels.
What were they studying in this experiment? What did the method provide?
In one series, mouse carcinoma No. 11, the experiment was repeated, and the technic was varied as follows: The tumor was massaged vigorously for one minute on each of two consecutive days. After the second massage treatment all tumors, both controls and those which had been manipulated, were excised and the animals all killed twenty-seven days later. (No. 11, Series II.)
In order to check the results a third series of mice were inoculated two years after the first lot with the Crocker Fund mouse sarcoma No. 180. The mice were all of the same breed, and the conditions were kept as nearly as possible the same as in the preceding experiments. This time the mice were inoculated in the right axillary region, and as soon as the tumors were easily palpable the massage was begun on one-half of the mice, the others being reserved for controls. As before, the massage was carried out for thirty seconds on alternate days for about two weeks. The tumors were then very large, and many of the mice died at this time. In those surviving the tumors involved the thoracic wall too extensively to make removal feasible, so the aninmals were, therefore, allowed to die and then were autopsied. The results of this experiment are recorded as No. 180, Series II.
What does the variation in the method mean for the validity of the study?
In all the series the lungs were carefully removed, distended through the trachea with 4 per cent. formaldehyde, and hardened, and six sections from each animal were examined. Much difficulty was experienced in determining microscopically whether a mass of cells in a vessel should be considered as a true metastasis or merely an embolus. When emboli cease to be capable of forming a tumor we do not know. Careful morphological studies have been made by Takihashi and others to determine the early degenerative and proliferative changes which occur in emboli of tumor cells, but the two processes are frequently coincident, and, as many groups showed no evidence of either process even after being in the vessels many days, we cannot be too cautious in deciding whether a death point has been reached. Such emboli were found, for example, in specimens 9515, 6363, 6359, thirty-two, twenty-seven, and twenty-six days after removal of the primary tumor and no local recurrence at the site of inoculation had taken place from which such emboli could have been derived. Presumably such cells are dead; hence these groups have been called emboli, not metastases. In one sense, however, they are just as important as a growing lung tumor in showing that emboli of cancer cells can be set free in the blood stream by massaging a tumor, and any embolus in its early stage carries the potentiality of metastasis formation.
What is the meaning of the different kinds of things they found in the animal's lungs?
What do they tell us about massaging a tumor?
How meaningful is that for the kind of massage that we would do for someone living with cancer?
Only six sections of the lungs were studied, for it was found after a few complete sets of serial sections had been examined that the gain in number of emboli or small tumors discovered was unimportant.
This means that the distribution of emboli and small tumors was relatively uniform throughout the lungs they studied, and they were able to work with a smaller data set than they had originally thought they would need.
The tabulated records of the experiments are self-explanatory and need no further elucidation.
No, I disagree. Remember, a lot of the statistical tests that we presently use to interpret studies were being developed at about the same time as Knox wrote this article.
While I don't fault her for not using something that she didn't have access to in her time, it remains true that without those tools to interpret her results with, we necessarily have to consider them weaker than we would similar results that had stood up to robust statistical testing.
The point of these tests is to make sure that we are, in reality, seeing what we think we see. Without the assurance provided by those tests, such as tests of statistical significance, confidence level, and the like, we just cannot consider these results as explanatory and self-evident as she considers them.
Examination of the chart (Fig. 2) shows that, in general, with nine tumor strains, there was a more or less distinct increase after massage in the number of embolic particles in the lungs, the increase varying from 1 to 37 per cent.
FIG. 2.-Chart showing percentage of emboli (hatched areas) and of metastases (solid areas), and their relative numbers in controls and massaged animals. In each case the column at the right represents the massaged animals, that at the left, the controls.
Tell me, what does this bar mean?
What does this one mean?
What does this one mean?
What does this one mean?
What does this one mean?
Can you find any cases where the control animals had more emboli or metastases than the study animals did? How does Knox explain these unexpected results?
The actual percentages can be considered of little importance, and it is even surprising to find that the tendency is so general. With the carcinomata the results are in many cases unequivocal; for example, the Ehrlich carcinoma, at the time showing no regression and 75 per cent. of takes, in other words, in its positive phase, formed more than twice as many metastases after massage as without it. A similar condition obtained with the Borrel carcinoma, at that time spontaneously regressing in 50 per cent. of inoculations, but still showing numerous metastases after massage. The ratio is probably artificially high as the number of control animals which survived was very small.
"The actual percentages can be considered of little importance"? Well, no; they are vitally important to the question we are trying to answer.
You can see here a cultural shift in how science used to be interpreted from how it now is.
The emboli are found in both lymph-and blood-vessels, frequently in both locations in the same lung. The perivascular space can frequently be seen filled with cells from which the parenchyma is invaded, but the primary process is evidently in the vessels, as it is seen in all stages within them. The lymphatic system of the mouse being developed to a much less extent than in man, it may also be expected to show relatively less tumor involvement. One reason for this may very probably be, as is pointed out by Murray, that the lymphatics are so delicate and quickly obscured by an inflammatory reaction that metastatic particles apparently freely growing in the tissues may have originated from an embolus either in a lymph-vessel or the nodal capsule. In these studies, however, there is seldom room for doubt that the emboli are vascular in the great majority of cases. Multiple emboli nearly filling both large and small vessels of a lobe are occasionally found, in the controls as well as in the massaged animals, but cell groups are much more frequent in the treated ones.
The illustration (Fig. 3) is from a massaged animal which died twenty-four days after inoculation. Both proliferation and degeneration are seen, and most of the stages described by Takahashi may be found in some area.
FIG. 3.-Multiple emboli of tumor cells in pulmonary vessels of a massaged mouse tumor.
Which things in this slide are the vessels? Which are the emboli?
How can you tell the difference?
Fig. 4 (No. 18363) and Fig. 5. (No. 18319) each show a small embolus which is certainly undergoing dissolution, as the surrounding lung is well preserved, but the tumor cells stain poorly. The outlines of cell walls and the nuclear membrane are indistinct, and the cytoplasm granular.
FIG. 4.-Degenerative changes in cells of a tumor embolus in pulmonary vessels.
Can you see the embolus clearly?
What is different about the pulmonary vessel the tumor embolus is in, compared to the other blood vessels in this slide?
FIG. 5.-Embolus of tumor cells in pulmonary vessel. Embolic cells are undergoing early degenerative changes. The lung tissue is well preserved.
What is the meaning of her explanation here?
On the other hand, occasionally even small emboli may be seen in which the actively invasive tendency of the tumor cells is plainly demonstrated.
Fig. 6 (No. 18322) shows a small embolus which has apparently lifted up the endothelium from the vessel wall and so given itself a fibrous surface upon which to obtain a footing.
FIG. 6.--Endothelium of vessel containing embolic tumor cells stripped from wall. Early stage of attempt to localize.
Tell me, what do you see here?
What do you see here?
What looks to you like an "attempt to localize"?
Another phase of apparently successful implantation is shown in Fig. 7 (No. 18343), where a number of well preserved tumor cells are growing in direct continuity with the endothelium.
FIG. 7.--Later stage in implantation of embolic tumor cells. A few have replaced the endothelium.
What do you see here? Where do you think the emboli have replaced the endothelium?
Figs. 8 and 9 show two small pulmonary emboli from a case of carcinoma of the stomach in a human being. In Fig. 8 there is no adhesion of the embolus to the endothelium, although nearly a third of the mass is made up of mucus produced by the epithelial cells;
FIG. 8.--Small embolus from case of carcinoma of stomach in man, showing invasion of pulmonary vessels. Nuclei surround a central mass of mucus.
Where do you see the vessel here? The nuclei? The mucus?
in Fig. 9 one cell only appears to have invaded the endothelium.
FIG. 9.--Beginning adhesion of tumor cells to endothelium in pulmonary capillary from case of carcinoma of stomach in man.
What structures and processes do you see here?
Another lung furnishes a picture of a more advanced stage of invasion, Fig. 10 (No. 18384). The endothelium can no longer be distinguished, as practically the whole circumference of the muscularis is lined with the tumor cells, and the lumen is almost filled with a carcinomatous embolus in which early degenerative or thrombotic changes have occurred [sic]. Similiar parietal thrombi were examined by Schiedat throughout their length and were found to extend for some distance along the surface of the wall and eventually to break through it.
FIG. 10.-Embolic tumor cells replacing endothelium of pulmonary vessel.
What do you see happening here?
The same process is illustrated in Fig. 11(a) where a large vascular sinus is shown containing many embolic cells from a bone sarcoma in man. The nuclei already show pycnosis, swelling, agglutination by fibrin, and are being surrounded by polymorphonuclear and lymphocytic cells. In (b) is another large blood-vessel from the same tumor with a giant cell among the red blood-cells. This, although of the "endothelial" type and not itself likely to invade other tissues, is of interest in showing that all types of cells may gain access to the blood stream.
FIG. 11.--(a) Embolus from bone sarcoma in man. Cells are of several types and illustrate early degenerative changes and phagocytosis. (b) Giant cell in blood-vessel in bone sarcoma.
That most of the small vascular emboli are derived from larger ones in the main vessel, and not from primary lymphatic involvement, is seen from such an extensive embolus as appears in Fig. 12 (No. 18343), a fairly frequent picture. A very large mass is found in one of the main pulmonary veins and many of its cells are degenerating, the nuclei are pycnotic, and some of the cells have been phagocyted.
FIG. 12--Larger tumor embolus in pulmonary artery.
Figure 13 shows a smaller group of cells surrounded by a thrombotic mass containing many polymorphonuclears, as would be expected in such a situation.
FIG. 13.-Polymorphonuclear cells surrounding a few embolic tumor cells; probably an early stage of thrombus formation.
It may only occasionally be seen that the cells break into the lymphatics and there grow freely, but it is shown in Fig. 14(No. 18307).
FIG. 14--Large embolus of tumor cells in perivascular lymph space; probably an extension from a vascular thrombus.
Not infrequently, as in tissues from human beings with tumors, multiple emboli are found in the vessels which may be densely crowded with cells, most of them small, and though hyperchromatic only with difficulty to be distinguished from lymphocytes--in fact, to make a differential diagnosis is very hazardous in spite of the absence of inflammation elsewhere in the section (Fig. 15).
FIG. 15.--Multiple emboli of small cells in pulmonary vessels, possibly tumor cells, but resembling lymphocytes.
Inspection of Table III shows that among the controls metastases and emboli were coincident only four times in twenty-one animals, or in 19 per cent., while among the massaged this occurred nine times in twenty-five animals, or in 36 per cent. of the cases. The average duration of life was the same in each case. There seems little doubt but that the massage has effected a wider distribution of the tumor even though it is impossible to decide in all the cases just what the ultimate fate of the scattered cells may be, whether they will die or succeed in establishing themselves in the vessel wall.
Crocker Fund No. 180
Total number metastases in controls = 23
Total number emboli in controls = 24
Total number metastases in massaged = 41
Total number emboli in massaged = 38
On the whole, the polyhedral-cell sarcomata (Crocker Fund No. 180 and Ehrlich mouse sarcoma) seemed just as apt to produce metastases as the carcinomata. In the spindle-cell tumors, metastases are apt to be scanty. This may be explained upon mechanical grounds, from the fact that the cells of most fibro-or spindle-cell sarcomata are more definitely intermingled with and attached to the surrounding connective tissue than in the case of the free-lying cells of the carcinomata. This sustains the view that anatomical relationships of the cells are important in determining metastases.
It would be incorrect, however, to assume that the mechanical factor is of so great importance in determining the ultimate production of a growing tumor as distinct from an embolus as the biological characteristics of the tumor itself. Examination of the chart shows that the correlation between the percentages of total metastases in controls and massaged animals is negative, that is, that those tumors which metastasize spontaneously in a high percentage do not show as great an increase after massage as do those in which spontaneous metastasis is low. For example, the Crocker Fund carcinoma No. 5 shows a smaller increase in its percentage of metastases than does the Flexner rat carcinoma. The same is true of the Ehrlich sarcoma, a strain in which Haaland also found a high percentage of spontaneous metastases; in fact, this writer reports approximately the same percentage of metastases in the twenty-three mice which he observed (60 per cent.) as were seen in the twenty-six animals used in this experiment (58 per cent.).
What is she claiming in her discussion here?
In these freely metastasizing highly vascular tumors the organism is evidently flooded with emboli before manipulation, and hence many tumor cells may be found in the pulmonary capillaries at all times. Less difference, therefore, can be detected following the massage.
What is the effect of massage in these cases, and why?
There can be no question under these circumstances that concomitant immunity has any influence on the prevention of appearance or growth of the metastases.
Is it clear what she means here?
1. Study of human material in many ways suggests, but does not finally prove, the importance of massage as a means of inducing metastasis of tumor cells. In animals, on the contrary, very gentle massage for a total period of from two to five minutes, distributed over a number of days, has been shown to set free numerous particles of tumor which form emboli in the lungs.
Is this the correct approach to take in studying the question?
Does the study show what she states that it shows?
2. Such emboli produce metastatic tumors in a variable proportion of instances, depending upon the growth activities of the tumor. Tumors which take in low percentages when implanted in the subcutaneous connective tissues give much fewer metastases than those of high virulence.
Is this consistent with what you would expect to see?
3. Carcinomata and also sarcomata of the loose polyhedral-cell type are easily generalized, but sarcomata of the compact spindle-cell variety are not influenced.
How do we know this from the information in her article?
4. The importance of avoiding diagnostic or operative manipulation of a tumor in man is obvious.
I agree it's a good idea in general. Does the evidence show that it's as obvious as Knox says it is?
No, it cannot. Massage of a solid tumor site should be avoided, but there is more to a person than a tumor site.
An old myth warned that massage could, by raising general circulation, promote metastasis since tumor cells travel through blood and lymph channels. We now recognize that movement and exercise raise circulation much more than a brief massage can, and that routine increases in circulation occur many times daily in response to metabolic demands of our tissues. In fact, physical activity usually is encouraged in people with cancer; there is no reason to discourage massage or some form of skilled touch. Massage is practiced widely at the Dana-Farber Cancer Institute, Memorial Sloan-Kettering, and growing numbers of hospitals around the country. Metastasis is not a concern; instead, patients and researchers report countless benefits.
Bamberger and Paltauf: Wein klin. Wchnschr., 1899, vol. xii, p. 1100.
Benecke: Beitr. z. path. Anat. u. z. allg Path., 1890, vol. vii, p. 95.
Carmalt: Virchow's Arch. f. path. Anat., 1872, vol. lv, p. 481.
Crouzon: Bull. et mém. Soc. méd. d. hôp. de Par., 1920, vol. xlvi, p. 500.
Ernst: Beitr. z. Path. Anat., 1905, Supp., vol. vii, p. 29.
Ewing: Neoplastic Diseases, Philadelphia, 1920.
Gathmann: Ein Fall von allgeimeinen Karzinome des Knochensystems, Leipzig, 1902.
Gerster: New York M. J., 1885, vol. xli, p. 233.
Goldmann: Bruns Beitr. z. klin. Chir, 1897, vol. xviii, p 595.
Goldmann: Bruns Beitr. z. klin. Chir., 1911, vol. cxxii, p. 1.
Haaland: Berl. klin. Wchnschr., 1906, vol. xxxiv, p. 1126.
Handley: Arch. Radiol. and Electroth., 1919, vol. xxiv, p. 137.
Handley: Cancer of the Breast and Its Operative Treatment. London, 1906.
Handley: Lancet, 1907, vol. i, p. 927.
Iwasaki: J. Path. and Bacteriol., 1915-16, vol. xx, p. 85.
Jones and Rous: J. Exper. M., 1914, vol xx, p. 404.
Krasting: Ztschr. f. Krebsforsch., 1906, vol. iv, p. 315.
Lambert and Haynes: J. A. M. A., 1911, vol. vi, p. 791.
Murray: Seventh Scientific Report, Imperial Cancer Research Fund, London, 1921, p. 63.
Poirier et Charpy: Traite D'Anatomie Humaine, Paris, 1909, Tome II.
Rohdenburg: Proc. New York Path. Soc., 1920, n. s., vol. xx, p. 141.
Rous: J. A. M. A., 1913, vol. lx, p. 2021.
Sabin: The Harvey Lectures, 1915-16, Series xi, p. 124.
Schiedat: Ueber den Untergang maligner Geschwulstmetastasen in der Lung, Leber, und Lymphdrusen, Inaug.-Diss., Königsberg, 1908.
Schmidt: Die Verbreitungswege der Karzinome und die Beziehung generalisirter Sarkome zu den leukämischen Neubildungen, Jena, 1903.
Takahashi: J. Path. and Bacteriol., 1915-16, vol. xx, p. 1.
Tyzzer: J. M. Res., 1913, vol. xxiii, p. 309.
Van Raamsdonk: Nederlandsch Tijdschrift v. Geneeskunde, 1921, vol. i, p. 3355.
Virchow: Die Krankhaften Geschwulste, Band 2. Berlin, 1864-5.
Vogel: Virchow's Arch. f. path. Anat., 1891, vol. cxxv, p. 495.
Von Recklinghausen: Virchow's Arch. f. path. Anat., 1885, vol. c, p. 503.
Wood: J. A. M. A., 1919, vol. lxxiii, p. 764.
Zahn: Virchow's Arch. f. path. Anat., 1899, vol. cxvii, p. 30.
What have we learned from this discussion?
At the beginning of this post, I asked you the following questions:
Where did the idea that massage promotes metastasis, and therefore, we shouldn't offer massage to patients living with cancer, come from?
What is the current best practices recommendation for massaging someone with a history of cancer, and on what basis is that best practices recommendation formed?
Why is the idea that we shouldn't massage someone with a history of cancer, because it might promote metastasis, so persistent in the face of what we actually know?
Have your answers to them changed over the course of this discussion? If they have changed, then in what way have they done so?
What else did you learn during this discussion? Can you explain it to someone else now?
How relevant is this discussion to what we practice as MTs?
In medicine, a fistula (/ˈfɪstjʊlə/; pl. fistulas (/ˈfɪstjʊləz/), or fistulae (/ˈfɪstjʊli/ or /ˈfɪstjʊlaɪ/)) is an abnormal connection or passageway between two epithelium-lined organs or vessels that normally do not connect.
A highly malignant epithelial tumour with a fulminant [quick, intense, and severe] clinical course, bizarre histologic appearance and poor prognosis [predicted outcome]; it is most common in the lung and thyroid, but is well-described in the endometrium, breast and elsewhere.
From Ancient Greek ὑπέρ (huper, “over”) + αἷμα (haima, “blood”).
excess of blood in a body part.
Wiktionary "lymphocyte", accessed 29 December 2012
A lymphocyte is a type of white blood cell in the vertebrate immune system.
Under the microscope, lymphocytes can be divided into large lymphocytes and small lymphocytes. Large granular lymphocytes include natural killer cells (NK cells). Small lymphocytes consist of T cells and B cells.
A Krukenberg tumor refers to a malignancy in the ovary that metastasized from a primary site, classically the gastrointestinal tract, although it can arise in other tissues such as the breast. Gastric adenocarcinoma, especially at the pylorus, is the most common source. Krukenberg tumors are often (over 80%) found in both ovaries, consistent with its metastatic nature...
There has been debate over the exact mechanism of metastasis of the tumor cells from the stomach, appendix or colon to the ovaries. Classically it was thought that direct seeding across the abdominal cavity accounted for the spread of this tumor, but spread by way of the lymphatic is considered more likely.
Latin, from Ancient Greek μέλας (melas, “black, dark”) and -oma (“disease, morbidity”).
melanoma (plural melanomas or melanomata)
(oncology, pathology) A dark-pigmented, usually malignant tumor arising from a melanocyte and occurring most commonly in the skin.
Wiktionary "metastasis", accessed 27 December 2012
From Late Latin, from Ancient Greek μετάστασις (metastasis, “removal, change”), from μεθίστημι (methistemi, “to remove, to change”)
metastasis (plural metastases)
(medicine) The transference of a bodily function or disease to another part of the body, specifically the development of a secondary area of disease remote from the original site, as with some cancers.
Latin permeātus, participle of permeāre, meaning to pass through.
permeate (third-person singular simple present permeates, present participle permeating, simple past and past participle permeated)
To pass through the pores or interstices of; to penetrate and pass through without causing rupture or displacement; -- applied especially to fluids which pass through substances of loose texture; as, water permeates sand.
Phagocytosis (from Ancient Greek φαγεῖν (phagein) , meaning "to devour", κύτος, (kytos) , meaning "cell", and -osis, meaning "process") is the cellular process of engulfing solid particles by the cell membrane to form an internal phagosome by phagocytes and protists...Bacteria, dead tissue cells, and small mineral particles are all examples of objects that may be phagocytosed.
Pyknosis (from Greek pyknono meaning "to thicken up, to close or to condense"), or karyopyknosis, is the irreversible condensation of chromatin in the nucleus of a cell undergoing necrosis or apoptosis. It is followed by karyorrhexis, or fragmentation of the nucleus.
Granulocytes are a category of white blood cells characterized by the presence of granules in their cytoplasm. They are also called polymorphonuclear leukocytes (PMN or PML) because of the varying shapes of the nucleus, which is usually lobed into three segments. In common parlance, the term polymorphonuclear leukocyte often refers specifically to neutrophil granulocytes, the most abundant of the granulocytes. Granulocytes or PMN are released from the bone marrow by the regulatory complement proteins.
serous (comparative more serous, superlative most serous)
(medicine) Containing, secreting, or resembling serum; watery; a fluid or discharge that is pale yellow and transparent, usually representing something of a benign nature. (This contrasts with the term sanguine, which means blood-tinged and usually harmful.)
Spindle cell sarcoma is a type of connective tissue cancer in which the cells are spindle-shaped when examined under a microscope. The tumors generally begin in layers of connective tissue such as that under the skin, between muscles, and surrounding organs, and will generally start as a small lump with inflammation that grows...Spindle cell sarcoma can develop for a variety of reasons, including genetic predisposition but it also may be caused by a combination of other factors including injury and inflammation in patients that are already thought to be predisposed to such tumors. Spindle cells are a naturally occurring part of the body's response to injury. In response to an injury, infection, or other immune response the connective tissues will begin dividing to heal the affected area, and if the tissue is predisposed to spindle cell cancer the high cellular turnover may result in a few becoming cancerous and forming a tumor.
What anatomical system (or systems, depending on how you count them) do we and other complex animals (like dogs, cats, bears, elephants, and tigers) use for movement?
Easy question straight out of Anatomy 101, right? But did you ever think about how organisms or organism parts that don't have muscles and bones are still able to solve the challenge of moving from one place to another?
Amoeboid movement is a crawling-like type of movement accomplished by protrusion of cytoplasm of the cell involving the formation of pseudopodia. The cytoplasm slides and forms a pseudopodium in front to move the cell forward. This type of movement has been linked to changes in action potential; the exact mechanism is still unknown. This type of movement is observed in amoeboids, slime molds and some protozoans, as well as some cells in humans such as leukocytes. Sarcomas, or cancers arising from connective tissue cells, are particularly adept at amoeboid movement, thus leading to their high rate of metastasis.
While several hypotheses have been proposed to explain the mechanism of amoeboid movement, the exact mechanism is still unknown.
What it comes down to, then, is that sarcomas and other cells use a method of movement very similar to the amoeba (or ameba: a one-celled animal-like microscopic organism) you see in this video:
As the definitions mentioned, in the video, you saw the cytoplasm slide to stick out (protrude) in the direction the amoeba moved.
Like the amoebas, individual cells in multi-cellular organisms (like us) can also move in a very similar way. Watch how nimbly responsive the human neutrophils (white blood cells) in this video are to the presence of a chemical attractant (this response is called chemotaxis):
As the Wikipedia definition mentioned, the ability of sarcomas to move in this way--although not yet fully explained--is thought to be a factor in their ability to metastasize aggressively.
The esophagus (oesophagus, commonly known as the gullet) is an organ in vertebrates which consists of a muscular tube through which food passes from the pharynx to the stomach. During swallowing, food passes from the mouth through the pharynx into the esophagus and travels via peristalsis to the stomach. The word esophagus is derived from the Latin œsophagus, which derives from the Greek word oisophagos, lit. "entrance for eating."...
The layers of the oesophagus are as follows:
nonkeratinized stratified squamous epithelium: is rapidly turned over, and serves a protective effect due to the high volume transit of food, saliva and mucus.
lamina propria: sparse.
muscularis mucosae: smooth muscle
submucosa: Contains the mucous secreting glands (esophageal glands), and connective structures termed papillae.
muscularis externa (or "muscularis propria"): composition varies in different parts of the esophagus, to correspond with the conscious control over swallowing in the upper portions and the autonomic control in the lower portions:
Occam's razor (also written as Ockham's razor, Latin lex parsimoniae) is the law of parsimony, economy, or succinctness. It is a principle stating that among competing hypotheses, the one that makes the fewest assumptions should be selected.
Parenchyma is the bulk of a substance. In animals, a parenchyma comprises the functional parts of an organ and in plants parenchyma is the ground tissue of nonwoody structures.
The term parenchyma is New Latin, f. Greek παρέγχυμα - parenkhuma, "visceral flesh", f. παρεγχεῖν - parenkhein, "to pour in" f. para-, "beside" + en-, "in" + khein, "to pour".
The parenchyma are the functional parts of an organ in the body. This is in contrast to the stroma, which refers to the structural tissue of organs, namely, the connective tissues.
In cancer, the parenchyma refers to the actual mutant cells of the single lineage, whereas the stroma is the surrounding connective tissue and associated cells that support it.
Early in development the mammalian embryo has three distinct layers: ectoderm (external layer), endoderm (internal layer) and in between those two layers the middle layer or mesoderm. The parenchyma of most organs is of ectodermal (brain, skin) or endodermal origin (lungs, gastrointestinal tract, liver, pancreas). The parenchyma of a few organs (spleen, kidneys, heart) is of mesodermal origin. The stroma of all organs is of mesodermal origin.
The peritoneum (pron.: /ˌpɛrɨtənˈiəm/) is the serous membrane that forms the lining of the abdominal cavity or the coelom—it covers most of the intra-abdominal (or coelomic) organs—in amniotes and some invertebrates (annelids, for instance). It is composed of a layer of mesothelium supported by a thin layer of connective tissue. The peritoneum both supports the abdominal organs and serves as a conduit for their blood and lymph vessels and nerves.
The abdominal cavity (the space bounded by the vertebrae, abdominal muscles, diaphragm and pelvic floor) should not be confused with the intraperitoneal space (located within the abdominal cavity, but wrapped in peritoneum). The structures within the intraperitoneal space are called "intraperitoneal" (e.g. the stomach), the structures in the abdominal cavity that are located behind the intraperitoneal space are called "retroperitoneal" (e.g. the kidneys), and those structures below the intraperitoneal space are called "subperitoneal" or "infraperitoneal" (e.g. the bladder).
I can't really say much about the article itself until I get to the University later this week, and can get behind the paywall, but the abstract certainly served its purpose--it alerted me that this is a potentially interesting and very useful article, and that I should go to the effort to get the entire article and read it.
Massage therapists encounter skin on a daily basis and have a unique opportunity to recognize potential skin cancers. The purpose of this study was to describe the skin cancer education provided to massage therapists and to assess their comfort regarding identification and communication of suspicious lesions. An observational retrospective survey study was conducted at the 2010 American Massage Therapy Association Meeting. Sixty percent reported receiving skin cancer education during and 25% reported receiving skin cancer education after training. Massage therapists who examine their own skin are more likely to be comfortable with recognizing a suspicious lesion and are more likely to examine their client's skin. Greater number of clients treated per year and greater frequency of client skin examinations were predictors of increased comfort level with recognizing a suspicious lesion. Massage therapists are more comfortable discussing than identifying a potential skin cancer. Massage therapists may be able to serve an important role in the early detection of skin cancer.
Once again, we have an invitation to up our game, to commit to the shared body of knowledge of the client-centered healthcare team, and to contribute in a specific way to that team and to the client's well-being.
What are some concrete steps we could take--individually, through our organizations, both ways, or some other way--that would demonstrate that we are serious about wanting massage to become a healthcare profession, and to take steps toward accepting that invitation?
Is this something that we really want to do? What are the risks and benefits of doing so?
The images above show the 3 classic types of skin cancer. Reading from left to right, what are the names of the skin cancers in the photographs?
Reading from left to right, do the types of cancer you see in the images get more common or less common in occurrence in the general larger population?
Reading from left to right, do the types of cancer you see in the images get more deadly or less deadly?
If you saw a skin lesion on a client during a session, and the lesion looked exactly like one of the types of cancer you see in the images, what words would you choose to talk to the client about what you saw?
A 34-year-old woman carrying a BRCA1 gene and a significant family history was diagnosed with T1c, N1 breast cancer. The tumor was estrogen receptor, progesterone receptor, and HER-2/Neu negative. The patient received dose-dense chemotherapy with Adriamycin and Cytoxan followed by Taxol, and left breast irradiation. Later, a bilateral S-GAP flap reconstruction with right prophylactic mastectomy and left mastectomy were performed. During her treatment, the patient had an integrative medicine consultation and was seen by a team of health care providers specializing in integrative therapies, including integrative nutrition, therapeutic massage, acupuncture, and yoga. Each modality contributed unique benefit in her care that led to a satisfactory outcome for the patient. A detailed discussion regarding her care from each modality is presented. The case elucidates the need for integrative approaches for cancer patients in a conventional medical setting.
DK a 34-year-old female physical therapist first presented to her obstetrician/gynecologist in November 2004 for evaluation of her increased risk of breast and ovarian cancer. Her risk was deemed high based on her mother’s diagnosis at age 54 with fairly rapidly progressive and drug resistant ovarian cancer, which led then to her subsequent death.
This part of the patient's history is pretty straightforward.
In addition, DK carried the BRCA1 gene and had an aunt and 2 of her 3 sisters who also were carriers. The aunt was diagnosed with breast cancer at the age of 50 and is alive with the disease. It is unclear whether a maternal great aunt had either ovarian or uterine cancer.
Here, we get into shorthand that can be confusing for non-specialists who don't have the same implicit knowledge.
Everyone carries the BRCA1 gene. What the author means to say here is that DK and her aunt and sisters carried a particular mutation of the BRCA1 gene, and that particular mutation is linked to high rates of cancer (including breast cancer and ovarian cancer)--so much so that people sometimes get preventive mastectomies or hysterectomies to avoid getting the cancers associated with that mutation of the gene.
Review of DK’s history is fairly unremarkable. Her periods began at age 13 and had been regular from 24 to 34 while she was on oral contraceptive therapy (OCT). She discontinued OCT in April of 2004 in anticipation of marriage in August 2005 and plans for early conception. At that time she began having irregular periods with mild to moderate cramps. Sexually active, she had normal pap smears since her initial one at age 18. She carried out breast self-examinations regularly. Her review of systems had been generally negative with a stable weight of 115 lbs with good nutrition and regular exercise routines. Her only notable past medical history was surgery on her jaw in 1993.
This is all pretty straightforward.
Her initial examination in November 2004 was normal and at that time she was found to carry the BRCA1 gene.
They shorthanded it again, but after our previous discussion, you should understand what they mean to say she carries.
She had her first cancer screening including a pelvic ultrasound which was normal and a CA 125 in the normal range. It was recommended that she continue to have a pelvic ultrasound and CA 125 drawn every 6 months.
CA 125 is a protein in the blood that is used as a blood marker in testing for ovarian cancer. It is useful for that purpose, because it often occurs at elevated levels in women with ovarian cancer, but since other conditions--some of them harmless--can cause the protein levels in the blood to be elevated, it is not a perfect test.
Although elevated CA 125 can point to ovarian cancer, you can also have elevated CA 125 levels without having ovarian cancer.
As a BRCA1 heterozygote, DK was followed in the Dana-Farber Cancer Institute (DFCI ) high risk clinic.
We have two copies of each gene in most of the cells of our bodies, one each from our mother and our father.
If the two copies of the gene are the same, that's called being a homozygote--for example, if we get an X chromosome from our mother, and another X chromosome from our father, then we are homozygotes with XX chromosomes, and we're female.
If we get an X chromosome from our mother, and a Y chromosome from our father, then we are heterozygotes with XY chromosomes, and we're male.
BRCA1 heterozygote means that DK had two different kinds of the same BRCA gene from her mother and father, presumably one copy with the bad mutation, and one normal copy.
She had her first child, a son, in May 2006 and the birth was complicated by a C section infection. She intended to breast feed, but experienced breast pain. In October of 2006, 5 weeks after her son’s birth, she noted a mass in the upper outer aspect of the left breast which did not resolve with massage.
Not the kind of massage MTs perform, by the way--we never try to just massage a suspicious lump away.
An ultrasound of the breast showed a suspicious lesion in the lateral aspect and an ultra sound guided core biopsy showed a grade 3 invasive ductal carcinoma without lymphovascular invasion.
Carcinoma is a kind of cancer that originates in epithelial cells, such as the ones that line the milk ducts of the breast.
Grade 3 means that the cells visible under the microscope are very distorted. Breast Cancer Canada explains in more detail:
Grade 1. Well Differentiated, or low grade
Grade 2. Moderately differentiated, or intermediate grade
Grade 3. Poorly differentiated, or high grade
Note that overall grades are also described as 'highly differentiated, moderately differentiated, and poorly differentiated. Sometimes these terms may be confusing. A cell that has enough functioning normal DNA to form a specific type of tissue, and behave like that tissue, is "differentiated". A cell that has so many mutations, that it forms hideously distorted tissues, is poorly-differentiated. A higher cancer grading corrsponds to more poorly-differentiated cells and cellular structures.--http://www.breast-cancer.ca/staging/infiltratingductalcarcinoma-grading.htm accessed 22 August 2012
The fact that it has not yet invaded the lymph or vascular systems around it means that they caught it before it had a chance to spread significantly to the regions around the lump.
The tumor was estrogen receptor, progesterone receptor, and Her 2-Nu negative, often referred to as a triple negative breast cancer.
This refers to receptors in the cancer cells. If the cells have receptors for these hormones, then hormonal therapy can be used to treat the cancer, since the receptors are there for the hormonal therapy to bind to.
Triple-negative cancers don't have any of those receptors, so hormonal therapy won't work, and these cancers are especially aggressive.
One of the bits of implicit knowledge that cancer specialists reading this have, but that has not been said here, is that--although we cannot say anything for sure about DK's specific prognosis--the fact that she has a triple-negative breast cancer means that she is in a population that responds to chemotherapy more poorly than the population with other kinds of breast cancer does, and that the prognosis for DK's group's 5-year survival is worse than for populations with other types of breast cancer.
However, there is evidence that if they do make it through that difficult 5-year window, then survival rates long-term are similar to those of populations with other forms of breast cancer.
On lymph node biopsy, one of 4 nodes showed a 0.5 millimeter micrometastis.
Although not yet widespread, the metastasis of the tumor has begun.
A PET CT was performed which showed intense tracer uptake within the primary tumor in the left breast. There were other areas in the left breast adjacent to the primary tumor where there was a lower grade tracer uptake consistent with inflammatory changes.
Positron emission tomography (PET) is an imaging technique that shows metabolic activity in a living organism. Intense tracer uptake in the primary tumor means that that tumor is quite metabolically active, and other areas in the left breast where the metabolic activity indicates that inflammation is taking place.
There was also minimal uptake seen in the left axillary nodes and no FDG evidence of distant disease. The resected breast specimen measured 5.4 by 4.3 by 1.7 centimeters.
Very little or no metabolic activity was observed by PET in the lymph nodes or spread to more distant sites.
5.4 by 4.3 by 1.7 centimeters is about 2 inches by 1-3/4 inches by 2/3 inches in size.
The final pathology report came back as triple negative invasive ductal carcinoma poorly differentiated (modified beam-richardson grade II/III) measuring at least 0.6 centimeters in size with no lymphovascular invasion. In addition, there was also ductal carcinoma in situ, solid type (high nuclear grade), without necrosis or calcifications.
Ductal carcinoma in situ means the cancer is in its original place--in the site where it began, the epithelial tissue of the milk ducts.
You can see necrosis (traumatic cell death) and calcifications (calcium deposits, which can indicate sites of trauma or inflammation) in the previous microphotograph of cancer cells.
Her course of treatment after the initial lumpectomy and sentinel node biopsy would include chemotherapy and then breast and nodal irradiation followed by bilateral mastectomy.
First, they would take out the lump, and some additional lymph nodes that serve as watchguards (sentinels) to indicate whether or not the cancer has spread to the lymphatic system yet.
Next, they would administer chemotherapy.
Third, they would administer radiation therapy.
Finally, they remove both her breasts.
This sounds drastic, and, compared with the treatment for most breast cancers, it is.
The reason they got so aggressive with DK's treatment is her BRCA1 mutation. Not everyone with that mutation gets breast cancer--but if they do, then the cancer is so dangerously aggressive that it can get ahead of more moderate treatments very fast.
BRCA1 mutation-associated cancers are so likely to happen, and are so dangerous, that many women choose to have preventive mastectomies, hysterectomies, and oopherectomies (removal of ovaries) before any signs of cancer ever show up.
Their risk-benefit analysis is that the cancer, if it ever should occur, will be so bad that it is worth running the risk of taking out perfectly healthy organs that may never get sick, in order to get the guarantee that they will not develop cancer.
DK's family history of her mother's early death from ovarian cancer, and her aunt living with breast cancer, reinforce her risk, and were factors in this treatment decision.
She was staged as a T1C, N1 breast cancer.
Grading, which we talked about previously, sounds similar to staging, so it's easy to confuse the two, but they're not the same thing. Grading talks about the form of the cancer itself (the size of the nuclei, or how well or poorly differentiated the cells are); staging refers to how far it's spread at a particular time.
The TNM system is one of the most widely used staging systems. This system has been accepted by the International Union Against Cancer (UICC) and the American Joint Committee on Cancer (AJCC). Most medical facilities use the TNM system as their main method for cancer reporting. PDQ®, NCI’s comprehensive cancer information database, also uses the TNM system.
The TNM system is based on the extent of the tumor (T), the extent of spread to the lymph nodes (N), and the presence of distant metastasis (M). A number is added to each letter to indicate the size or extent of the primary tumor and the extent of cancer spread.
Primary Tumor (T)
TX Primary tumor cannot be evaluated
T0 No evidence of primary tumor
Tis Carcinoma in situ (CIS; abnormal cells are present but have not spread to neighboring tissue; although not cancer, CIS may become cancer and is sometimes called preinvasive cancer)
T1, T2, T3, T4 Size and/or extent of the primary tumor
Regional Lymph Nodes (N)
NX Regional lymph nodes cannot be evaluated
N0 No regional lymph node involvement
N1, N2, N3 Involvement of regional lymph nodes (number of lymph nodes and/or extent of spread)
Distant Metastasis (M)
MX Distant metastasis cannot be evaluated
M0 No distant metastasis
M1 Distant metastasis is present
So DK's T1C N1 was toward the lower end of the scale in spread, which is better than a more widespread tumor would be.
She did undergo dose-dense Adriamycin/Cytoxan followed by Taxol, then left breast irradiation, and in November 2007 underwent a bilateral S-GAP flap reconstruction with right prophylactic mastectomy and left mastectomy by a reconstructive surgeon. The pathology of the mastectomy specimens was normal. According to her medical providers at the time, she tolerated treatment well with the exception of some mucocitis during chemotherapy, She returned to work as a physical therapist.
Adriamycin, cytoxan, and taxol are all chemotherapy drugs.
The treatment plan followed the sequence previously outlined.
You might wonder why, if they're going to remove her breasts anyway, why put her through chemo and radiation first?
The reason is they're trying to fight a very aggressive cancer on all fronts, and to prevent spread by any means necessary. The fact that the pathology of the mastectomy specimens was normal indicates that they succeeded in that goal--because they took out a lot of healthy tissue that was not infiltrated by the cancer, that means they probably succeeded in getting all of the cancer that was surrounded by that tissue.
Mucocitis: they misspelled "mucositis", from mucosa (mucus membrane) + -itis (inflammation). Mucositis is a condition that is often a side effect of cancer treatment--the lining of the throat and esophagus become inflamed, and eating becomes painful and unappealing.
If you think back to the first day of the first anatomy class you took, what was the very first thing taught in it?
Probably the four tissue types:
As you learned, they're qualitatively very different from each other--they originate and grow in different ways, and they carry out very different jobs.
One of the characteristics of the epithelial tissue in the digestive tract is that it is fast-growing. Since radiation and chemotherapy have the most powerful effects on fast-growing cells, that means that the digestive tract mucosa is especially vulnerable to the side effects of those treatments (the same for hair, by the way, which is why many cancer patients undergoing chemotherapy or radiation lose their hair).
That's pretty much it for the highly technical part of the excerpt I'm presenting here; the rest of it should be fairly easy to read, so I'll see you again on the other side.
DK began to discuss with her physician the timing for her to get pregnant again; how long to wait after chemotherapy, when the risk of recurrence is maximal, whether pregnancy can affect the risk for recurrence, and other questions. It was suggested that she wait 2.5 years after the completion of active treatment. She continued to be followed by her primary oncologist and radiation therapist.
During the course of her therapy, she was seen in consultation by several members of the Leonard P. Zakim Center for Integrative Therapies at Dana-Farber Cancer Institute including a nutritionist, an integrative oncologist, a massage therapist, a Lebed Method instructor, and an acupuncturist. All sessions were held on-site in the cancer hospital and the medical clearance for each therapy was obtained from the primary oncologist. All clinical notes were documented in the patient’s electronic medical record and communication back to the primary oncologist happened as needed.
At the time she had the integrative medicine and nutrition consults, she was receiving her 3rd cycle of Taxol therapy just before her radiation therapy. She was interested in knowing more about nutrition and cancer, and specifically about management of her hot flashes and the use of dietary supplements. She expressed a great deal of anxiety in terms of ending chemotherapy treatment and was very interested in healthy behaviors for cancer survivorship. Her comment was “I want everything I put into my mouth to be the right thing.” Her diet consisted of 3 meals a day and sometimes snacks. Her symptomatology included frequent hot flashes and constipation alongside some bone and muscle pain and some muscle twitching. She continued to be physically active, but less so during the radiation and chemotherapy. She often tried to do some cardiac exercises and weight training but this was limited due to the fatigue she related to the chemotherapy and radiation therapy. She had many questions for both the nutritionist and the integrative oncologist about ginseng and sage supplements.
Her integrative medicine/oncology consult was held shortly thereafter which reinforced the nutritional advice, emphasized the use of the Vitamin D, fish oil and a phytonutrient rich diet. The importance of physical activity was also emphasized. It was revealed that DK had been a high caliber tennis player while at college.
One of the issues brought forth during this consultation was the anxiety of trying to care for her son during radiation therapy while continuing to care for herself. It became obvious during this interview that there was a great deal of anxiety and stress dealing with the breast cancer and raising a child. Various types of integrative therapies were discussed with DK. She expressed a significant interest in acupuncture and other mechanisms of reducing anxiety and stress. In addition, it was suggested that DK find some of her own time separate from demands of her work and her childcare could interfere with. A social worker became involved and facilitated some new arrangements for childcare. She was taught the relaxation response, encouraged to practice the breathing technique daily for 30 minutes. In addition, acupuncture was discussed and she was referred for an acupuncture consultation.
DK also elected to receive massage therapy to help with her left arm discomfort. Massage for her left arm discomfort had a noted marked improvement in her range of motion. She also had been having constant left shoulder discomfort which she wanted addressed as well. She received light to moderate pressure slow speeds general massage techniques She also received regulated neuromuscular techniques (NMT), myofascial release techniques (MFR), manual lymphatic drainage techniques (MLD) and basic acupressure techniques (BA) as called for during her sessions.
She felt that the massage made her feel good and it was suggested that she continue this integrative care treatment with massage, acupuncture, and yoga. She also exercised by participating in the Lebed Method movement classes held at DFCI for her upper extremity lymphedema prevention. With massage, she noted significant improvement after the session and continued to have therapeutic massage every two to three weeks. She increased her physical activity, including the new addition of yoga. Overall, the massage, yoga, Lebed classes, and her physical therapy helped with cording, muscle tension after surgery and radiation and with general relaxation.
Through all of the interventions, DK continued to rehabilitate and feel well. She increased her exercise and was better able to balance her work life and her family life, taking good care of her son.
She started acupuncture during her radiation therapy and continued this for several months afterwards. She received a total of 12 acupuncture treatments and the results were a decreasing back pain and a decreasing in the intensity of the hot flashes. She started her massage therapy at the end of her radiation therapy and continued for 14 massage visits which resulted in improvements in her muscle aches, pains and anxiety. Presently, she continues to feel well with diminishing hot flashes, increasing energy, a balanced diet, and regular, daily exercise.
All massage sessions and techniques at the Zakim Center are modified for the oncology population to ensure a safe and effective treatment for our patients, at different stages of their diagnosis, illness and recovery. DK had very specific reasons for using massage therapy as an integrative modality. One was the physical issue of tension and discomfort manifesting as a deep pain in her left shoulder blade area, rated 3 out of 10. Second was the emotional issue, manifesting as anxiety.
In designing the treatment plan to address these issues, DK and the massage therapist discussed the following:
The possible multi-factorial issues surrounding her discomfort (postural changes, surgery, radiation, overuse and possibly emotional factors).
Laboratory results-scans to rule out structural issues or bone involvement.
The need for integrative care and inclusion of self care for more long term results.
Understanding that the resolution (temporary vs. permanent) of the anxiety symptom may depend on what is going on with her diagnosis and coping after treatment as well as other factors.
Combination of techniques to address the symptoms and modifications that may be needed.
In DKs situation the following techniques were used:
General massage techniques (MT); effleurage and petrissage to the full body were administered for warm up and integration. Addressing the entire body surface area with light to moderate pressure and slow, rhythmic techniques was a good way to elicit the relaxation response and calm the body back down after doing the focus sessions.
Regulated neuromuscular techniques (NMT) were chosen to address the increased muscle tension on the shoulders and upper back erectors for more focused work and trigger point release.
Manual lymphatic drainage (MLD) techniques were incorporated into the session. Although DK was not at a high risk for lymphedema, the decision to incorporate MLD was more for preventive and proactive purposes after focus work in consideration of the load on the tissues brought about by recent radiation therapy. MLD was also useful in addressing the “cording”, and the techniques in themselves provide a relaxing rhythm.
Myofascial techniques (MFR) were later used for help with tightness after radiation therapy. These also included some light pin and stretch work and muscle energy techniques.
Good intention holds and/or basic acupressure points (BA) were used as transition or termination techniques as a slow way to ease the body back from the massage session.
The combination of these techniques seemed to work very well for DK, with immediate response in addressing both the anxiety and shoulder discomfort. DK always reported feeling very relaxed after her sessions. Complete resolution of the deep left shoulder blade discomfort was achieved after the 3rd visit.
During the subsequent sessions, we had to address any recurring or additional discomfort or sequelae that came up. This included tightness at the area of radiation, pectoral tightness, decrease range of motion of the left shoulder and “cording”. Techniques were added or the combination of the above mentioned techniques modified to address this. General MT was always used to continue to address her need for relaxation.
DK continued to use massage as part of her integrative care with PT, OT, and swimming and yoga for self care throughout recovery and healing.
The last time DK was seen at the Zakim Center, she scheduled a massage to coincide with her oncology check up. A year and 4 months after she first engaged in integrative therapies, she reported feeling well and is now balancing and enjoying her work and family life.
Cancer patients often request support from integrative therapies in addition to their conventional cancer therapy. The evidence-based integrative therapies presented here demonstrated many advantages in being offered through a team approach at this comprehensive cancer center. It is important for cancer patients to be able to speak with and receive guidance from their medical team about integrative therapies so that the best of all available therapies can be safely and effectively offered as part of the patient’s care plan. Future work in integrative oncology should focus on improving clinical effectiveness, enhancing financial sustainability, maintaining high safety standards, and improving communication so that all patients and clinicians are aware of the benefits that integrative therapies can provide during the cancer journey.
Although case reports can't tell anything about cause and effect, there is a lot here about DK's experience that deserves further investigation.
Massage has good evidence supporting its use for treating pain and anxiety, both of which she experienced as she learned she had aggressive breast cancer, that she had a mutation that gave her an excellent chance of having the cancer recur in future, and that going through and adapting to a very disfiguring treatment actually made sense in light of her BRCA1 status.
The Summary identifies areas where further investigation and increased clarity around the use of massage in cancer treatment would be very valuable:
clinical effectiveness: does massage for cancer care do what people claim it does? How does it do so? What are the best matches between client needs and availability/access to massage?
enhancing financial sustainability: can massage demonstrate outcomes that justify its reimbursement as part of healthcare plans? What would it take to do so?
maintaining high safety standards: we're past the day (I hope!) where, out of fear, we totally contraindicated massage for people living with cancer--but what real, validated, client-centered knowledge about safety is needed to fill that vacuum? and
improving communication: what can we teach our clients to expect? What do our clients need for us to hear from them? How does all this fit into the larger picture?
This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Here, I'd like to express my profound appreciation to Ackerman and her team for choosing a form of licensing that promotes open access to her text, and the learning that results from our being able to go through the text together.
Background. No in-depth qualitative research exists about the effects of therapeutic massage with children hospitalized to undergo hematopoietic cell transplantation (HCT). The objective of this study is to describe parent caregivers’ experience of the effects of massage/acupressure for their children undergoing HCT. Methods. We conducted a qualitative analysis of open-ended interviews with 15 parents of children in the intervention arm of a massage/acupressure trial. Children received both practitioner and parent provided massage/acupressure. Results. Parents reported that their child experienced relief from pain and nausea, relaxation, and greater ease falling asleep. They also reported increased caregiver competence and closeness with their child as a result of learning and performing massage/acupressure. Parents supported a semistandardized massage protocol. Conclusion. Massage/acupressure may support symptom relief and promote relaxation and sleep among pediatric HCT patients if administered with attention to individual patients’ needs and hospital routines and may relieve stress among parents, improve caregiver competence, and enhance the sense of connection between parent and child.
Questions for you
From the abstract, does the study sound reasonable and plausible to you? Why or why not?
Based on what we've read so far--just the abstract--would you recommend massage to someone whose child was undergoing this procedure?
Therapeutic massage, a term that encompasses a wide variety of techniques of touch and tissue manipulation, has deep roots in the world’s oldest medical practices, including both traditional Chinese medicine and Western medicine. In the late 19th century, a rift between massage and Western medical practice grew with the rise of scientific medicine, and physicians relinquished massage as a routine clinical practice. By the second half of the 20th century, massage had become professionalized and was increasingly associated with the alternative medicine movement .
 R. N. Calvert, The History of Massage: An Illustrated Survey from Around the World, Healing Arts Press, Rochester, NY, USA, 2002.
More recently, a growing body of scientific literature on therapeutic massage—bolstered by its widespread popular use—has led to the reintroduction of various forms of massage as an adjunct to biomedical therapies. This shift is situated in growing popular and scientific interest in nonpharmacologic approaches to symptom management .
Research on therapeutic massage has shown benefits in managing adult and pediatric patients’ distress related to cancer and cancer treatment [3–7], and hematopoietic cell transplantation (HCT) [8, 9], although results are not consistent . Acupressure massage has shown benefits for chemotherapy-related nausea [8, 11, 12], anxiety , and fatigue [8, 14]. In addition, performing massage on a family member with cancer has been shown to reduce anxiety and fatigue [9, 15] among caregivers, and to increase their sense of well being and confidence in managing their family member’s symptoms [16–18].
"Survival rates for children 100 days after their transplant was 97.8 percent in 2006, improved from 95 percent in 2005 and 85 percent in 2004. Survival rates for children one year after their transplant are equally encouraging, going from 75 percent in 2004 up to 82 percent in 2005."
In other words, of 100 children who received a transplant at SCCA, then 100 days after the transplant:
in 2004, 85 of them would still be alive;
in 2005, 95 of them would still be alive;
in 2006, almost 98 of them would still be alive.
Of 100 children who received a transplant at SCCA, then 1 year after the transplant:
in 2004, 75 of them would still be alive;
in 2005, 82 of them would still be alive.
This means that we've gotten better at finding ways to support the survival after the transplant. However, these children are very ill, and the fact that they are getting such a drastic treatment in the first place means that their situation is desperate--this kind of transplant is done only as a last resort to try to interrupt a fatal illness by wiping out the child's immune system and starting over.
Survival rates are getting better, but overall, this is a field where there are many who miss out on a happy ending to the story. This chart shows the percentage of survival at 6-month milestones for 5 years after bone marrow provided by an unrelated donor (allogeneic transplant) for children with acute lymphoblastic leukemia.
The three different colored lines trace the survival over the period from 1999-2008 of three different populations of children with different disease statuses.
Questions for you
According to the chart, if 100 children received an allogeneic bone marrow transplant during their first complete remission from their disease, how many of those children would you expect to be alive in 2 years? In 5 years?
According to the chart, if 100 children received an allogeneic bone marrow transplant in an advanced disease status, how many of those children would you expect to be alive in 2 years? In 5 years?
From the chart, what would you say is the most dangerous time post-transplant for these children?
How can you tell whether a particular child who receives a transplant in advanced disease is going to be one of the 30% who are still alive in 5 years?
My point in presenting these figures is not to destroy all hope in you, but rather to present a realistic picture of what the people in this situation are facing, so that you can decide if this is a population that you might want to work with.
There is absolutely no shame in finding this too difficult to work with; it is only natural, when faced with the fundamental unfairness of these children and their families' necessity to cope with this situation. There is no point in working in a situation that makes you miserable and depressed; there are so many people in the world who need massage that you can certainly find other populations of clients where you can make a real difference, without being shattered emotionally as a result.
If you do decide that this is a population that you want to work with, you will probably find that parents are unlikely to discuss their child's prognosis with you.
Children may or may not ask questions; of course, as healthcare practitioners, our discussing their diagnosis and prognosis with them is totally out of scope and unethical for us. That doesn't stop children from being curious, of course, so you may have to find diplomatic ways to deal with their questions or conversation that neither violate medical ethics, nor your own values.
Depending on their age, they may know more or less about what awaits them, and as individuals, they will react in different ways to that partial knowledge.
Questions for you
Take a moment to reflect on what the children and the parents in this situation must be going through. Think of how you would need to present yourself to be supportive in such a difficult situation, with so much often going unsaid, yet always present below the surface. Knowing yourself better than anyone else can, do you think this would be the right practice situation for you?
What are some ways you could prepare yourself in advance to be supportive of these children and their families?
What kind of support and self-care systems would you want to cultivate for yourself, so that you can work effectively in this situation? What would they look like, and how would you draw on them?
To date, most studies on therapeutic massage have measured predefined patient outcomes, usually medical and psychological symptoms. This growing body of research can be complemented by more in-depth investigations of patients’ and caregivers’ lived experiences of receiving and performing massage. Qualitative research has demonstrated, for example, that massage practices contribute to improvements in patient-caregiver relations  and to the “meaningful relief ” of suffering among cancer patients .
Questions for you
What do you understand by the term "suffering"?
In what ways, if any, is suffering different from pain?
Do you think that massage addresses suffering as well as, or in the same ways as, it addresses pain?
To what degree can we have access to another person's lived experiences? What mediates our understanding of it?
To what degree does lived experience reflect the material physical universe? What mediates their connection?
Through open-ended interviews and close attention to the perceptions and interactions of participants, clinicians, and researchers, qualitative methods can examine aspects of massage practices that may go undetected by quantitative methods. This study focuses primarily on the perceptions and experiences of parent caregivers of pediatric HCT patients at an academic hospital. Parents living with and caring for a pediatric HCT patient typically spend weeks and even months in an isolated hospital room with filtered air and limited access to visitors. Parents are neither patient nor clinician; they are witness to their child’s pain, suffering and confinement, as well as healing and resilience.
Why does the hospital staff confine the child receiving HCT to an isolated hospital room with filtered air and limited access to visitors?
What effects might that confinement have on a child? On the parent witnessing it?
What does resilience mean in this context, and can you think of some examples of what it might look like?
This study is one component of a mixed-method, randomized controlled pilot study introducing a combined Swedish and acupressure massage intervention in a pediatric HCT hospital unit. The overall aim of the pilot study was to assess whether conducting a study of such an intervention is feasible in the HCT unit, whether massage/acupressure alleviates patients’ and parent-caregivers’ distress and discomfort associated with HCT and accompanying chemotherapy, and to explore the effects of caregivers’ experiences performing massage. Quantitativeoutcome measures of this feasibility study are reported separately . The study described here examined caregivers’ experiences learning to perform massage for their child and observing their child receive massage from a professional massage practitioner.
Building on recent, more quantitatively oriented research assessing the effects of massage for pediatric HCT patients [6, 9], this study offers important new findings through the most in-depth, descriptive analysis to date of parent and practitioner-provided massage for children undergoing HCT.
What is particularly important about this research, and why is it noteworthy?
What does that translate to in human terms?
The massage intervention provided (1) practical, hands on training for parents to provide massage/acupressure for their child; (2) professional practitioner-performed massages and acupressure treatments for children undergoing HCT. Professional massage practitioners provided up to three massages/acupressure sessions per week to the children during their entire hospital stay (days of hospitalization: median 37, range 23–110).
Questions for you
What was the longest that any child in this study stayed in the hospital?
What was the shortest that any child stayed in the hospital?
What information does "days of hospitalization: median 37" give you?
They demonstrated massage/acupressure techniques to the parents for additional parent-provided massages for approximately ten minutes whenever the parent was present and amenable to it and provided a detailed handout with locations of and indications for specific acupressure points. The massage practitioners received training in several sessions with the research team (EAL, WEM) and received additional consultation from Traditional Chinese Medicine practitioners at the academic medical center. The massage intervention was a semistandardized integration of Swedish massage (gentle to moderately firm strokes, light pressure, holding touch to the back, shoulder girdle, hands, and legs) and acupressure based on traditional Chinese medicine using points on the feet, lower legs, wrist, and chest that are commonly used for nausea, pain and distress (9 points: PC6, ST36, LI4, LV3, BL62, KI6, SP6, HE7, CV17) . Massage practitioners had more than ten years of experience each with Swedish massage and acupressure in a hospital setting.
 P. Deadman, M. Al-Khafaji, and K. Baker, A Manual of Acupuncture, Journal of Chinese Medicine Publications, Hove, UK, 2007.
Variations in pressure, strokes, and massaged body areas were permitted within the frame of the intervention manual according to the child’s needs and response. Symptom specific acupressure points were selected according to patient needs and the massage protocol instructions. Foot massage (Swedish and acupressure) was routinely given for relaxation.
In what follows, we will use the shorter term “massage” for the combination of Swedish massage elements, including foot massage, with acupressure as it was applied in this study.
Massage duration was typically 10 to 30 minutes. Children wore hospital gowns during massage. Massage practitioners produced written reports on the type and duration of each massage, their impression of the child’s response to the massage, and how they adapted their technique to accommodate this response.
This is where "Supplementary material", containing this data from the massage practitioners, and appropriately de-identified to protect the identity of the children, would have been an absolutely awesome resource to include with this paper.
One of the grand challenges facing massage students is learning how to adapt the basic massage protocol that they are taught to the varying needs of different clients who present themselves in real-life practice.
These written reports would be an excellent example of how practicing massage practitioners carry out that task--what they take into account, how they implement it, and how they change their approach if something doesn't quite work out as originally planned.
Questions for you
Given what you know about how massage protocols tend to be standardized in research studies, in order to avoid confounds, can you find three areas in which there seems to be a rather unusually large amount of variation in this study?
Why would the researchers not be more concerned about the possibility of confounds in this approach?
What does this mean for other massage research studies?
We decided to interview parents and massage practitioners exclusively in order to reduce the burden of research participation on the children. Data collection was restricted to the intervention arm using interviews with parents after hospital discharge, detailed hand-written notes by massage practitioners about each massage session, and interviews with two massage practitioners.
Semistructured interviews with twelve mothers and three fathers were conducted by telephone approximately one week after hospital discharge. Each interview lasted approximately 30 minutes. Semistructured interviews with two massage practitioners were conducted by phone and lasted approximately 45 minutes. Interviews were conducted by two authors (ED and SA) who were not directly involved with the study intervention or the medical and nursing care on the unit. Practitioner interviews asked massage practitioners open-ended questions about their experiences performing massage for study participants, and their impressions of the children’s experiences receiving massage and parents’ experiences performing massage. The questions asked in the parent interviews were as follows.
“Can you tell us in a few words how it was for you to learn some massage and to massage your child?”
“What was the best thing about the massage experience for you?”
“Was it possible for you to give massages?”
(If yes:) “How did that go for you and your child?”
(If no:) “What was the biggest barrier for giving a massage?”
“What was the best thing for you when you were giving your child a massage?”
“What do you think was the best thing about the massage experience for your child?”
“Was it the same with the practitioner and with you?”
“What do you think was the hardest thing about the massage experience for your child?”
“What was the hardest thing about the massage experience for you?”
“What was the hardest thing about the massage study?”
Questions for you
Before reading any further to see their answers, think about these questions that the interviewers asked. What do you think might be some of the best, worst, and hardest things about massaging their children that these parents might have encountered?
English-speaking children, 5 to 18 years of age, and their parents were invited to participate in the randomized controlled trial (RCT) as they were consecutively admitted to the transplant unit over a twelve month period (November 2008 to December 2009, patient characteristics in Table 1; additional details in ). Participation in the RCT was offered to child and parent during their preadmission consenting visit with a nurse manager and attending physician. No children over age 5 were excluded. Twenty-three children and their parents (rooming in with the child in the same hospital room) signed informed consent, enrolled and were randomized 2 : 1 to intervention versus control. The RCT was registered with clinicaltrials.gov NCT00843180. The qualitative study reported here included 15 of the 16 parents in the intervention arm. No payment was offered to participants in this group. Both the RCT and the qualitative study were approved by the university’s Human Subjects Review boards.
Were there exactly as many children in the control group as there were receiving massage?
Why did the researchers feel it necessary to mention that no payment was offered to participants?
What steps did the researchers take to ensure that the study was up to the best-practices ethical standards of biomedical research?
Children under age twelve signed assent forms, children twelve years and older signed consent forms, and parents signed consent for their own participation and their children under age 18. Seven child-parent dyads were assigned to the control arm, sixteen child-parent dyads to the intervention. One child subsequently declined all massages. The remaining 15 dyads are the subjects of this qualitative study (Table 1): eight were mother-son or father-daughter and seven were mother-daughter or father-son.
Questions for you
Do you think there might be any differences in the children's perceptions between massage from the same-sex parent, compared to massage from the opposite-sex parent?
Knowing that we don't know for sure, and are only speculating, what are some reasons why one of the children in the treatment arm might have declined all massages?
Were the telephone interviewers blinded as to whether the people they talked to were in the treatment arm or the control arm of the study?
From the context, what seems to be the difference between "assent" and "consent" to treatment?
Children in the intervention arm underwent autologous or allogeneic HCT for treatment of malignancies and other diseases listed in Table 1.
An allogeneic (ἄλλος/allos,"other" + γενεά/geneá,"generation, descent" ==> "different descent") transplant means that the bone marrow comes from someone else. An identical twin is ideal (or almost so) for this purpose; however, very few people have an identical twin who can donate marrow to them. Siblings are often a partial match, even if they're not twins; if there are no siblings that are a reasonably good match, then the search for an unrelated donor begins.
Questions for you
What are some of the advantages of autologous transplant over allogeneic transplant?
Why wouldn't they always do autologous instead of allogenic transplants for those reasons?
Participants remained on the unit in their individual hospital rooms, behind double doors with high-level infection precautions.
Questions for you
Why were the patients behind double doors with high-level infection precautions?
Massage group participants received 8.5 professional massages (median) during their hospitalization, at an average of 1.6 massages per week.
Questions for you
What information does "received 8.5 professional massages (median)" give you?
Table 1: Patient characteristics.
Questions for you
What does Table 1 tell you?
How many children participated in the treatment artm of the study?
If the age range was 5-18, and the mean age was 11.3, what does that tell you?
Are the study participants representative of the general population of children by sex?
Are the study participants representative of the general population of children by ethnicity?
How many of the children have cancer?
How many of the children can expect to be on immunosuppressive medication for the rest of their lives?
Qualitative data analysis was conducted collaboratively by three of the authors (SA, EAL, WEM). The interpretive process was iterative and multistaged and included coding and thematic development [23, 24]. Data included transcripts of audio-recorded interviews, massage practitioners’ written reports on massage sessions and study activities. First, interview recordings were listened to, and interview transcripts and massage therapists’ report cards were read repeatedly, in order to form an overall impression of participants’ and practitioners’ experiences. Recurrent themes and patterns were identified in the data—particularly in terms of massage’s effects on patients’ and caretakers’ experiences at the intersection of cognitive, affective, and physical states. Descriptive categories, or codes, were then developed for each emerging theme, and data fragments were systematically assigned codes. After the data were organized by code, key concepts were reworked through further discussion and analysis. This process included linking data extracts back to their original narrative context and conceptually situating ambivalent and contradictory statements.
 N. K. Denzin and Y. S. Lincoln, The Sage Handbook of Qualitative Research, Sage Publications, Thousand Oaks, Calif, USA, 3rd edition, 2005.
 A. J. Coffey and P. A. Atkinson, Making Sense of Qualitative Data: Complementary Research Strategies, Sage Publications, Thousand Oaks, Calif, USA, 1996.
Questions for you
What steps did the interviewers take to ensure that they accurately recorded the information provided by the parents?
How did the interviewers analyze the parents' information?
What did they do with information that appeared ambivalent or contradictory?
Three major themes were developed: (1) perceived benefits of massage for patients; (2) massage’s effects on parents and family dynamics; and (3) impact of the timing and duration of massage therapy over the period of hospitalization. Each theme, along with related subthemes and examples, is described below. The voices of participants (parents of patients), massage practitioners, and researchers are included; their words are reported verbatim, revealing differing levels of English fluency among participants.
Quotes are identified as follows:
P = parent of pediatric HCT patient,
R = research assistant/interviewer,
M = massage practitioner.
4. Parent-Perceived Benefits of Massage for Patients
Without exception, parents said that massage brought relief, comfort, and even pleasure to their children, although the effectiveness of massage in relieving specific treatment related symptoms was variable among patients. The particular strength of the massage intervention appeared to be in promoting pleasurable sensations and a state of relaxation, with many children dozing off near the end of massage sessions. Most parents reported that their child looked forward to massages performed by parents and/or practitioners, and several parents continued to perform massage on their child after completion of the study. According to a massage practitioner, nurses on the transplant floor also described children’s eagerness for the massage visits.
Questions for you
All of these reports are indirect reports of the children's experiences with massage. Why did the researchers not ask the children directly about how massage affected them, and what they felt about it?
Claims in this section
I've started the first claim in this section:
What other claims do the researchers report in this section?
4.1. Symptom Relief.
Parent caregivers reported that massage—performed by the professional massage therapist and/or a parent—provided relief from or support with symptoms, including nausea, pain, and inflammation.
(P6) We still use the pressure points. She loves the foot pressure points for the pain. She enjoys it.
(P17) I think it was very beneficial to have massage during the time when he was in a lot of pain and
very uncomfortable. It was a good distraction and comforting.
(P1) It was amazing, especially with the nausea points. It worked.
(P20) Even though she’s got headache or even though she’s got vomiting, she wanted to have massage.
(P21) When he had the joint inflammation, they were able to relieve–to help him through that.
However, according to parents, not all patients found consistent symptom relief through massage.
(P6) For pain it did not work as well, but the nausea—it really did, at times, alleviate all the nauseous feeling.
(P17) I cannot say that, you know, when I press on a certain area that it really made it [nausea] go away.
4.2. Positive Feelings, Relaxation, and Sleep.
Although relief from acute physical symptoms was reported by parents to be variable among patients, massage was uniformly associated with relaxation, comfort, positive physical sensation, and greater ease falling asleep. Whereas physical contact is often associated with uncomfortable treatments and procedures for children on the transplant unit, massage offered more pleasurable, calming sensations, which was seen by the massage providers as a way for children to “be in their bodies” instead of dissociating from them. A massage practitioner reported, for example, that a patient told her he felt like he was “floating on air” after massage.
(P12) [Massage] make her more comfortable. At least make her have a better sleep.
(P7) The best thing about the whole experience was knowing that it helped him to relax.
(P14) Best thing is that it was making him relax, feel calm, and then he went to sleep.
(P21) He was really in a lot of pain, and for him to fall asleep during that 15 to 20 minutes was amazing. . . so that’s–I took pictures [laughs].
(M) Some of the kids were trying not to be in their bodies because the whole thing was so unpleasant. The massage was a way for them to be in their bodies in a way that was pleasurable.
4.3. Special Treatment.
Parent caregivers often experienced massage as a practice situated outside of the transplant unit’s routine activities, and as a kind of nonmedical therapy—or gift—that attended to the patient as a complex, feeling person, in contrast to the biomedical emphasis on treating disease as an entity belonging to the body and distinct from the person.
(P21) It really is one of the few things outside of medicine that I saw work. You know, right before your eyes you can see the results.
(P20) I learned that giving a massage to my daughter was kind of changing atmosphere. It made more comfortable and safe. . .that was not the kind of giving medicine, but giving a kind of touch. There is big difference between medicine and massage.
(P13) When the therapist came in. . .she [the daughter] was getting the royal treatment. . . It was a person that was bringing peace to her versus an injection or taking blood from her. [The massage therapist] was not taking from her, but giving. . .I think it’s just good for their soul. . .
4.4. A Heightened Sense of Control.
Hospital patients are subject to frequent and unannounced invasions of their privacy and bodies, and they often experience a sense of loss of control. This may be particularly true of pediatric patients, for whom cooperative decision making is limited. Massage sessions offered through this study, in contrast, took place only with patients’ consent. Participation gave patients the opportunity to say “yes” or “no” and to shape the course of therapy, in a context in which their control over their environment and bodies is greatly diminished.
(P12) Sometimes she do not want anybody to bother her. . .and I’m not bother her. . .only when she want it [massage] and she needs it.
(P22) Sometimes she did not want to be touched, so I would just leave her alone.
(M) Massage is the one thing in the hospital regimen that is voluntary, where the kids have the power to say “no.” It is the one time where how they feel is the most important thing. I think this made them feel empowered.
4.5. Tailoring the Massage Protocol.
Not only were patients able to choose whether to undergo a massage when a session was offered to them, at each session the patient was asked by the massage practitioner to describe in detail how he or she was feeling. Following a semistandardized protocol with specific instructions on how to choose acupressure points, practitioners would tailor the massage based on the patient’s self-reported key symptoms, making adjustments throughout the session according to the patients’ response. This process of tailoring within a given frame of techniques and specific acupressure points was described as essential to massage’s efficacy by practitioners. Although parents were not asked directly about adapting massage techniques to their child’s current physical and emotional state, their use of this approach was implicit in interview narratives.
(M) Mom said they’d used the P6 point when she was feeling nausea earlier in the day and it had helped. Mom said she wished she would move around more so I showed them some gentle stretches she could do in bed knees pulled up to belly and knees going to either side. . . so she could do ST36 point herself.
(M) I think it is really important. . .that the massage therapist be able to determine what the patient needs at the moment because their needs do change.
(P4) On last Sunday when he feel his body ached, so I just rub him. Most of the time he do not feel like getting massage.
5. Massage’s Effects on Parents and Family Dynamics
5.1. Performing Massage Improved Parents’ Confidence as Caregivers.
Most parents reported that they were able to learn massage techniques, and that they performed massage for their child intermittently or regularly—particularly parents of younger patients. Feelings of helplessness and anxiety are common among parents with hospitalized children, and parents expressed satisfaction and pride at being able to offer comfort and symptom relief to their children.
(P21) It was great. It was one of the few things I could do to help him through everything he was going through.
(P23) It felt good because I was able to put her at peace, relax, help her to go to sleep, help her with the pain.
(P13) For me it was, as a parent, taking control of her pain and just providing the peace that she needs. So just creating an environment of peace that you normally do not find in a hospital. . .I was reassuring her that. . .it was going to be all right.
5.2. The Social Effects of Massage.
Parents reported that performing massage contributed to a heightened sense of intimacy and connection with their child.
(P10) When I give her massage, I just feel closer to her. I feel we’re like one.
(P13) When you massage someone, you’re touching them, and you’re loving them at the same time. . .it gives you the desire to love your child, to touch them, to let them know that you are there for them.
(R) What was the best thing for you when you were giving your child a massage?
(P3) Well, that bond that occurs between two people when there’s comforting happening.
(P22) To be able to talk to her and touch her at the same time, and just talk about how she was feeling.
At least two parents, however, reported that they did not readily learn or perform massage for their child, either due to the parent’s perceived lack of competence or a missed opportunity for instruction in massage because she welcomed the opportunity for respite outside the hospital room when the massage practitioner arrived.
(P6) It helped when the massage therapist would show me and do it on my child, and then I would do it with her there. After she left, I kind of forgot where those [pressure points] were.
(M) She seemed amenable to learning the points and doing massage, but in practice she wasn’t often there when I came. . . Some of the parents used the time when I came as respite time to leave the room.
Indeed, practitioner-provided massage offered parents a respite from caretaking and worry about their child, particularly since individual massage therapists became known and trusted by patients and parents over the course of the intervention. The knowledge that their children were experiencing comfort or pleasure provided stress relief for the parent and an opportunity to relax and take a break from the confines of the hospital room.
(P4) Sometime when she’s give him massage, I was like out for a walk. Sometime when the therapist come in, I was like tired and fall asleep and nap.
(P7) It was actually relaxing. Knowing that it was helping him to relax, then it also helps me to relax.
(M) It gave the kids a sense of nurturing when their parents were absent or too overwhelmed or exhausted to provide physical touch.
Although most parents reported feeling closer to their child as a result of learning and performing massage, it is important to note that parent-child or broader social dynamics can also be a barrier to massage as a beneficial practice for children undergoing HCT. For example, one child mentioned to the professional massage practitioner that she preferred the professional massage to her father’s massage, but felt uncomfortable communicating this to her father. Once this was revealed, the massage practitioner was able to help the father to improve his technique. Also, two teenage boys in this study declined to receive massage from parents or massage practitioners (all women), which may suggest possible discomfort with touch or embarrassment of female touch.
6. Impact of Timing of Massage and Length of Hospitalization
The timing of massage treatments was an important factor in parents’ perception of the efficacy and desirability of massage. The concept of timing includes how a massage session fit into a patient’s daily schedule, and whether massage was perceived as more or less beneficial at particular phases of an individual’s journey through the transplant process. In addition, participants who remained hospitalized—and therefore enrolled in the study—for a longer period of time often moved from initial skepticism to becoming strong advocates for massage.
6.1. Fitting Massage into the Daily Clinical Routine.
Patients on the unit follow a busy schedule of tests and treatments, and the degree to which massage was welcomed by patients and their parents was contingent on how well it was coordinated with clinical routines and family visits. Massage practitioners were attuned to these scheduling issues, and often tried to schedule their visits to the unit during the late afternoon lull in clinical activity.
(R) What was the hardest thing about the massage study?
(P2) Scheduling. . .when they were ready, [my daughter] wasn’t ready sometimes, or when [she] was ready, they were far away.
(P12) . . .it’s evening, it’s nighttime, so they’re [massage practitioners] all gone. I would like to call them back [laughs].
One parent felt that she had to “stand guard” at her child’s hospital room door so that her massage would not be interrupted by hospital staff.
(P13) . . .[the practitioner] coming in was very important to her. . .and that’s when I had to step in and say, ”She’s getting a massage”. . .I had to be the keeper of the door.
6.2. Massage during Periods of Acute Symptoms.
During periods of acute discomfort or nausea, generally during the first week after chemotherapy, children varied in their response to massage, and some did not want it.
(P6) I think the hardest thing was just being open to it when she really felt miserable.
(P17) . . .As he got more sick and was feeling worse, he wasn’t able to have the massage therapist come in. . .So I would say at the beginning it’s nice, and maybe at the end as they’re getting back into normal life again, it’s good. But there in the middle of the transplant, it’s not so necessary.
(R) And what was the biggest barrier for giving a massage?
(P2) Basically, I do not know, if she’s in deep pain or if she’s not in the mood or she’s sick and tired of the whole situation, you know?
Several parents, however, reported that massage was particularly beneficial for their child during periods of acute discomfort.
(P12) I remember one day she said she hardly to sleep. The whole body is miserable and tired. And I have a really gentle massage for her, but it help.
(P4) It’s only whenever he feels nauseous and, yeah, vomiting, then he agree he want to have physical therapy [massage].Most of all, he’s always like not agree with the physical therapies.
6.3. Length of Participation in the Study and Being “Won Over”.
Most parents in the study were new to massage. Some were immediately convinced of the potential benefit of massage while others were initially doubtful about whether massage could be helpful for their child. However, through the course of the study most parents came to value massage as an important component of the healing process.
(P21) Well, it’s just something that he never really experienced before and was hesitant about in the beginning. But once they started, he looked forward to it every night that it was available.
(P13) . . . You tend to be in the hospital and you do not want extra people coming into your room. But once [the practitioner] came in and we realized the benefits that she was getting from it, J. welcome her in. . .
Questions for you
Based on their methodology and their results, does it seem to you that this study was well-planned and well-carried out?
Did it do a good job of studying what it claimed to study?
Of all the reports of the children's experiences reported in this section, which ones resonated with you the most? Why is that?
HCT has resulted in improved survival rates among children with certain cancers, immune deficiency syndromes, or bone marrow failure, but it can be an agonizing ordeal for patients and their families. Indeed, in 1998 bone marrow transplantation was described as “the most devastating treatment that the human body could be subjected to” .
Medical advances in intervening years have resulted in a less punishing regimen, but transplantation still remains arduous and disruptive of the lives of patients and their caregivers. This study contributes to a growing body of research suggesting that massage can help alleviate the distress associated with HCT among both patients and their family caregivers. The qualitative methods employed by this study reveal outcomes that were undetected—and undetectable—by the broader study’s quantitative design, including several that have not yet been reported in the literature. New findings include reported benefits for patients in promoting sleep and providing symptom relief; benefits for parents in an increased sense of competence and respite from caregiving; and increased closeness between parent and child and a demonstrated willingness by parents to perform massage on their child
According to parent caregivers, massage provided varying degrees of relief from pain, nausea, and other symptoms associated with HCT for most, but not all, participants. Nearly all parents reported that massage sessions facilitated a general state of comfort, relaxation, and pleasure for their child. These findings are consistent with a study that reported reduced pain and increased relaxation among pediatric cancer patients who received massage , and with the results of a study suggesting that massage for cancer patients promotes positive feelings, relaxation, and a sense of being special and cared for .Whether these benefits are sustained over time is an important question for future research, given the longterm suffering among survivors of childhood cancer and family caregivers described in numerous studies [27–31].
How does this fit into the larger picture of what we know about massage?
Does it make sense?
What possibilities for future investigation does this study highlight?
Massage helped children fall asleep. This finding is notable because HCT patients often find sleep elusive in the midst of chronic pain, nausea, and discomfort, yet sleep is rarely mentioned in the literature on massage and symptom management. Moreover, the promotion of comfort and sleep–states not easily reduced to dualistic conceptions of mind or body–suggest that the positive effects of massage are not physical or affective, but rather both simultaneously. This result is in line with previous research reporting that massage alleviates physical symptoms while also addressing the “existential suffering” associated with cancer and cancer treatments and improving patients’ “quality of life” [20, 32, 33].
Why is sleep improvement such an important finding?
Why do the authors refer to "dualism" here? What do you think their point is? Do you think they succeeded in making their point?
What do the authors mean by "existential suffering"? What does it mean for the children in the study? How does existential suffering relate to a cancer diagnosis? How do children at different stages of biological, physiological, and psychosocial development process and express existential suffering?
It should not be assumed, however, that massage is relaxing and pleasurable for all patients at all times. As demonstrated by our results, patients’ request for, and response to, massage varied widely throughout the different stages of HCT, with some patients declining massage during periods of acute pain and nausea, and others requesting massage at precisely these times. Massage enabled children undergoing HCT to become coagents in the therapeutic process, and most children embraced this agency without reserve—electing massage only when it suited them. While most children appeared to appreciate parent massage, one child felt unable to decline her father’s massages when she did not want them. Individual patients’ needs, and the specific ways in which family dynamics mediate these needs, should be carefully determined and addressed in any pediatric massage intervention so as to avoid coercion and the perception among patients that massage is obligatory.
Questions for you
What is the importance of the children's choice whether or not to have a massage?
For the child who did not want her father to massage her, is there anything in our scope of practice and ethics that we could do to improve the situation?
This study suggests that it is important to adapt a semistandardized massage protocol to the immediate, and always mutable, sensations and perceptions of individual patients; when it offers respite from long periods of tedium and inactivity; and when it does not interfere with treatment schedules and hospital routines. This is not to suggest that a carefully constructed protocol with clear instructions on acupressure and massage techniques for typical HCT-related symptoms is not important. However, a massage protocol that does not allow for flexibility within a semistandardized frame runs counter to the study’s findings and may undermine some of massage’s reported benefits.
Questions for you
When might a more flexible protocol be appropriate in a study like this?
When might a more standardized protocol be appropriate?
Parents in this study were, for the most part, amenable to learning massage techniques that they could perform for their child, and the resulting interactions tended to have a positive effect on parent-child relations and to mitigate parents’ and patients’ suffering. These findings are in alignment with a nascent body of research suggesting that learning to perform massage for a family member can alleviate caregivers’ anxiety and feelings of helplessness [16, 17], and that caregiver-provided massage for chronically ill family members increases a sense of intimacy and connection between the provider and recipient of massage . More broadly, these results offer support for an understanding of disease and healing as social and material processes that extend beyond the individual, physical body .
 N. Scheper-Hughes and M. Lock, “The mindful body: a prolegomenon to future work in medical anthropology,” Medical Anthropology Quarterly, vol. 1, no. 1, pp. 6–41, 1987.
Moreover, providing parents with a means of actively participating in their child’s treatment and recuperation—and children with a sense of control over their bodies—may represent a shift in what one of the study’s massage practitioners described as a hospital culture in which “the professionals are taking care of the children and the parents try not to get in the way.” Parents felt comforted and strengthened when they were able to alleviate their child’s suffering through massage. What are the broader implications, then, of parents playing a more active role in supportive care? Future research on massage and its increasing inclusion in biomedical treatment regimes could help elucidate these processes.
Questions for you
How would you answer Ackerman et al's question: What are the broader implications, then, of parents playing a more active role in supportive care?
The success of parent-provided massage was dependent not only on parents’ desire to help their child, but on the nature of the interaction between patient, parent, and massage practitioner, and on the development of trust and recognition within this triad. Massage is an inherently social practice, and for most of the children participating in the study, who was touching them was as important as which massage techniques were used. For example, in addition to the two teenage boys who decided not to enroll in the study, some older children, particularly boys, declined massage from their parent and/or from a massage practitioner (who were all women). These children’s reluctance emerged postintervention in conversations between researchers and massage practitioners, rather than in interviews with participants, so the causes have not been explored in depth. In a study on massage for children with cancer, Post-White et al. reported no gender differences in response to massage, but 8 boys (over 30 percent of enrolled participants) failed to complete the study . It is clear that more research is needed to examine how factors such as the child’s age, sex, and ethnicity mediate the perception and experience of massage.
Why might older boys (including adolescents) be reluctant to receive massages from women?
Is there anything within our training, scope of practice, and ethics that could help us address this situation?
The researchers refer to how the "age, sex, and ethnicity mediate the perception and experience of massage"--what do they mean by that, and how could we study it?
The limitations of this investigation are primarily related to it being a small pilot study without data from direct interviews with patients. There are also limitations in the study’s data collection methods. First, conducting interviews by telephone limited the interviewer’s ability to establish rapport with participants. In addition, scheduling the interviews after parents and children returned home from the hospital meant that participants’ perspectives were restricted to recall. Future research would be enriched by a series of in-depth, inperson interviews with both caregivers and patients over the course of treatment.
Questions for you
What effect might these limitations have had on the study?
The researchers made a deliberate decision not to interview the children in this study in order not to add to the children's treatment burden. How could they avoid this problem in future research if they decide to interview patients over the course of treatment?
While parent reports indicate that massage may offer some short-term symptom relief, and that teaching massage to a parent may increase her or his sense of self-efficacy in managing a child’s symptoms, longer-term benefits for both symptom relief and parent-child relationships were beyond the scope of this study. Questions that could be explored in more detail in follow-up studies include whether massage mitigates long-term, posttreatment suffering associated with HCT among both patients and caregivers, including posttraumatic stress. If massage/acupressure can provide relief from symptoms and even provide pleasurable feelings, it may reduce parental feelings of helplessness in the face of their child’s pain and discomfort, a key symptomof posttraumatic stress.  Future research could also investigate the extent to which massage influences children’s perceptions of their bodies  as they struggle with chronic disease and prolonged, invasive treatments for these diseases.
 American Psychiatric Association, Task Force on DSM-IV: DSM-IV Sourcebook, American Psychiatric Association,Washington, DC, USA, 1994.
Did the idea of posttraumatic stress as a consequence of treatment for cancer surprise you? Why or why not?
This study suggests that parent- and practitioner-provided massage may reduce suffering associated with HCT among pediatric patients and their parent caregivers. According to parent caregivers, massage relieved symptoms associated with HCT, and promoted sleep, relaxation, and comfort for their child. The data suggest that massage also may enhance the experience of intimacy and connection between children and parents; offer relief from prolonged periods of social isolation, boredom, and anxiety that characterize life for families in the pediatric HCT unit; and enable both patients and parents to play a more active role in managing symptoms. As a simultaneously physical and social practice, massage as applied in the context of this study’s hospital setting is a therapy whose effectiveness among children requires family support, practitioner flexibility, coordination with clinical routines, and affinity among those who perform and receive it.
Questions for you
Will the information in this article make any difference in how you practice massage? What kinds of difference might it make?
Based on reading the entire article, would you recommend massage to someone whose child was undergoing this procedure?
If you knew someone who wanted to try this for their child, but who was hesitant about approaching the child's medical team with the suggestion, what terms would you couch the claims in to communicate with the medical team with honesty and integrity?
How certain is this evidence? How do you know that?
What else did you get from the article that we haven't yet discussed?
The authors thank the children and parents who took part in this study; the Community Foundation Sonoma County, Santa Rosa, California, that sponsored the study; massage practitioners Paula Koepke and Jnani Chapman; research assistant Viranjini Gopisetty; nurses on the children’s hospital transplant unit with Trish Murphy and Sara Okane as nurse coordinators. The sponsor of the study was not involved in study design, or in the collection, analysis, interpretation, or presentation of the information. The authors have no financial or personal relationships with any individuals, organizations, or companies that might be perceived to bias the work.
 R. N. Calvert, The History of Massage: An Illustrated Survey from Around the World, Healing Arts Press, Rochester, NY, USA, 2002.
Jim, a patient with prostate cancer, simply never slept. He would close his eyes for 15 to 20 minutes, then get up and pace or smoke for a couple of hours. This continued for several nights until one of his nurses convinced him to try massage. The nurse massage therapist took him to the massage room, performed a gentle massage, and sent him back to his unit. He promptly went to bed and slept through until the next morning, nearly missing a 7:30 AM radiation therapy appointment. As one nurse said, "We kept going in to make sure he was still alive. He had never slept like that."
Hollings Cancer Center, and Division of Biostatistics and Epidemiology, Department of Medicine, College of Medicine, Medical University of South Carolina, Charleston, SC 29425, USA. email@example.com
Chemotherapy-induced peripheral neuropathy (CIPN) is a common, miserable, potentially severe, and often dose-limiting side effect of several first and second-line anti-cancer agents with little in the way of effective, acceptable treatment. Although mechanisms of damage differ, manual therapy (therapeutic massage) has effectively reduced symptoms and improved quality of life in patients with diabetic peripheral neuropathy.
Here, we describe application of manual therapy (techniques of effleurage and petrissage) to the extremities in a patient with grade 2 CIPN subsequent to prior treatment with docetaxel and cisplatin for stage III esophageal adenocarcinoma. Superficial cutaneous temperature was monitored using infrared thermistry as proxy for microvascular blood flow.
By the end of the course of manual therapy without any change in medications, CIPN symptoms were greatly reduced to grade 1, with corresponding improvement in quality of life. Improvements in superficial temperature were observed in fingers and toes.
Manual therapy was associated with almost complete resolution of the tingling and numbness and pain of CIPN in this patient. Concurrently increased superficial temperature suggests improvements in CIPN symptoms may have involved changes in blood circulation. To our knowledge, this is the first report of using manual therapy for amelioration of CIPN.
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