By Dr. Jeff Cullers, Dr. Ross Turchaninov

 

            For readers to fully understand the subject of this article we need to briefly look at the history of recent events. For years we’ve emphasized this important aspect of Oncology Massage – that therapists should not recommend or work on clients NEWLY DIAGNOSED with cancer while they are waiting for oncology treatment (surgery, radiation, chemotherapy etc.) to start.     Our opinion is based on basic medical common sense and on multiple conversations with oncologists on this subject, especially when the body’s response to a massage session was explained to them. 

            In 2014 results of a very important study conducted by a group of Taiwanese physicians (Wang et al., 2014) were published. They are a group of 11 oncologists from the Department of Orthopaedics, Taipei Veterans General Hospital in Taipei, Taiwan. Readers may read the original study by clicking on this link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4013034/ 

            In this study the authors analyzed medical records of 200 patients with osteosarcoma. 104 patients received MT sessions BEFORE they knew about a cancer diagnosis while 96 patients in the control group didn’t receive MT.  

            The authors detected that  

“…the metastasis rate was higher and the survival rate was lower in patients who had osteosarcoma and who received MT treatment BEFORE (capital by J.C. and R.T.) being given a diagnosis compared with patients who didn’t receive MT.” 

            However, Dr. Wang and colleagues didn’t stop there. They actually simulated in an animal model the impact of MT (when it is not done correctly and on time) on cancer spread. The authors injected tumor cells into the tibia of animals and triggered the cancer growth. After a tumor developed, MT was applied twice a week for 7 or 15 weeks. After sacrificing the animals, the authors detected the presence of the same cancer cells (i.e., metastases) in the animals’ lungs.  

            Of course, Dr. Wang and his colleagues knew that MT should not have been performed in the area of the cancer to start with. This is not even an issue to discuss especially for the second part of this study. The focal point of the study was to examine if massage therapists while working on patients who WERE NOT diagnosed with cancer yet, although the cancer was ALREADY PRESENT, may have triggered tumor dissemination via the lymphatic or/and circulatory systems. The authors’ final conclusions of this study were that: 

“Cancer patients who suffer from the effects of cancer, when MT is given PRIOR (capitals by J.C and R.T) to a diagnosis of cancer, resulted in poor prognosis with an increase in metastasis and/or recurrence rate.” 

            The target group of the study were physicians who according to the authors should keep in mind the fact that MT when it is done in INCORRECT TIME may contribute to cancer spread. This incorrect time IS when the window between new cancer diagnosis is established and oncology treatment (surgery, chemo therapy, radiation, etc.) starts. 

            In the Journal of Massage Science issue #2, 2017 we published Part I of an article about Oncology Massage where results of this study as well as other topics were discussed. To review this article please click here:  

https://www.scienceofmassage.com/2017/05/science-of-oncology-massage-part-1/  

            In the October issue of Massage Today Tracy Walton, LMT, MS, one of the nation’s leading authorities in Oncology Massage, published her five page response and critique of our article and what is more important, her critique of Dr. Wang and his colleagues’ study. You may review her article here: 

http://www.massagetoday.com/digital/index.php?i=653&Page=30 

            In the following issue of Massage Today Tracy Walton, LMT, MS published a second part of her critique which now targets our article in JMS. To review this article please click here: 

http://www.massagetoday.com/mpacms/mt/column.php?c_id=2802

            Since two parts of the critique were published we were forced to answer them separately in Part I and Part II. 

 

Part I. Response to the Initial Critique of Dr. Wang’s Study 

            We really have three problems with this critique: a scientific problem, a clinical problem and an ethical problem. 

Scientific Problem

            Everyone is entitled to have their own private opinion about any topic, but if the opinion is expressed in a national publication by the nation’s authority on a controversial subject, and especially in regard to Oncology, some basic rules of engagement MUST be followed. Ms. Walton is a researcher in the field of Oncology Massage and no one disputes that. However, there are rules of discussion established in the scientific community among researchers.

            After Dr. Wang and his colleagues made the first statistical correlation between MT and the possible dissemination of cancer they double checked their findings with an animal study. We are perfectly aware that readers who may have limited exposure to medical research may not fully appreciate this fact, but Ms. Walton should because the combination of these two scientific tools in one clinical/experimental study when they support each other data is a bullet proof justification for the authors’ conclusions. 

            Considering that, on what basis does Ms. Walton may have RIGHT to criticize a study conducted by a group of well-respected oncologists and scientists who double check their own data? There are ONLY three ways she can do it: 

1. Ms. Walton conducted her own study and its results confirmed that Dr. Wang and his colleagues are wrong and their results are biased. As we know, the author of critique is not a trained oncologist and she participated in studies which examined if MT helped patients with an advanced form of cancer and the results of these studies confirmed that MT is a relevant treatment tool. Great – and we think she deserves a lot of credit for that, especially considering how medicine continues to look on MT!

            Dr. Wang is a well-respected physician and scientist who has published many articles on oncology topics in the world’s leading medical publications. Thus, since Ms. Walton never participated on the subject of the study conducted by Dr. Wang and colleagues, this avenue of critique is closed for her. 

2. Ms. Walton can also use world medical sources which confirmed that Dr. Wang and his colleagues’ study was biased. Let us give you an example. In 2010 Prof. Tschakovsky and colleagues published results of a study which showed that Sports Massage has no effect on recovery after strenuous exercise. This study created such large news that it ended up even on the pages of the NY Times

            We analyzed Prof. Tschakovsky’s study and found that with all good intentions the treatment protocol his team used didn’t even closely follow scientifically suggested application of Sports Massage and we showed that with scientific resources which proved our point. You may read an example of what a professionally ethical critique should look like:

https://www.scienceofmassage.com/2010/09/response-to-new-york-times-interview-with-prof-m-tschakovsky/

            To our complete disbelief after five pages of heated review, Ms. Walton used as her list of references only ours and Dr. Wang’s articles. It means that she doesn’t have ANY SCIENTIFIC data which support and justify her critique except her own opinion. 

3. Ms. Walton found that statistical analysis used in Dr. Wang’s article was incorrect. However, in the article there wasn’t any mention of incorrect statistical analysis in Dr. Wang’s study. 

            Since Ms. Walton’s critique did not fit in any of these three scenarios, it is obvious that she expressed her personal opinion which doesn’t have ANY merit in a scientific setting or discussion.  

 

Clinical Problem

            Ms. Walton was completely correct when she stated that:  

“Millions of people have been diagnosed with cancer. Many are already massage consumers. Millions of people present with musculoskeletal pain. It can be difficult to tell when mild symptoms will become serious.” 

            The author’s review really puzzled us. Did she unintentionally or intentionally miss the entire point of Dr. Wang’s study? The purpose of that study was to inform physicians and MTs that they should be very careful or even avoid MT application before the oncology treatment is established. Where in the article did she find that Dr. Wang blamed MT for the cancer spread and that therapists should recommend the client see an oncologist every time when the client comes in with lower back pain? It is very surprising to read such a misrepresentation of an excellent clinical and experimental study. 

            Also, in her review the author emphasizes the difference between the pressure level used by Tuina massage, which was examined in the original study with Oncology Massage. She advocates: 

“With standard Swedish strokes such as effleurage, petrissage, and even stationary compression, we tend to use gentler pressure levels…” 

            It is very surprising to read this statement because Tuina massage is the Taoist version of Swedish Massage used in the West. No one knows where she found strong pressure as part of Tuina Massage. 

            Here is another interesting quote: 

“Moreover, if increasing circulation is a concern, OMT (Oncology Massage Therapy) does not typically approach the level of pressure that is thought and taught to be “circulatory” in classical massage therapy. Neither do we employ, with our lighter strokes, the highly choreographed approaches of lymphatic techniques near a tumor site.” 

            We think that Ms. Walton doesn’t fully realize the general impact of MT on circulatory and lymphatic systems and their basic rules of operation. Even light massage strokes when applied on unrelated to the primary cancer parts of the body still increase pressure within the lymphatic system. Thus, if massage therapy is used BEFORE oncology treatment starts it may jeopardize client’s health and recovery.  

            Let us illustrate our point. In issue #1, 2017 of JMS we published an article, “The Power of Effleurage.” You may review entire article here:

https://www.scienceofmassage.com/2016/12/the-power-of-effleurage/

            Here is a picture of our patient with intracutaneous hematoma (accumulation of the hemolyzed or still fluid blood within the skin) developed after plastic surgery before and after very gentle superficial effleurage strokes conducted for 5 minutes ONLY along the skin surface. 

Fig. 1. Intracutaneous hematoma before (a) and after 5 min of gentle effleurage (b)

            We are using this picture in our classes to illustrate the effect even such a simple technique as effleurage has on the drainage. These two pictures are clinical evidence of how much circulatory power very superficial effleurage strokes have on lymphatic drainage and eventually on circulation. What therapists do in one part of the body makes changes throughout the entire circulatory system and this is a clinical fact Ms. Walton can’t dispute. 

            Yes, we completely agree with the author’s statement: 

“Whole modalities are not typically contraindicated in a condition. Cancer as a diagnosis does not come with blanket contraindications. Instead, knowing the possible benefits of OMT, we follow precautions based on a client’s presentation of cancer.” 

            However, the “client’s presentation of cancer” requires stopping massage treatment IN THE WINDOW between cancer diagnosis established and the beginning of oncology therapy. It seems that instead of considering data from scientific study, which Mrs. Walton is supposed to embrace, she does everything to discredit it simply on the grounds that data don’t fit into the author’s personal system of beliefs. 

 

Ethical Problem

            We would like readers to pause for a second and consider the issue we are discussing here. We are talking about patients with newly diagnosed cancer BEFORE their oncology therapy starts. In addition to the psychological shock, stress and anxiety they are going through, they are also in a grey zone between recovery and death. It is the direct responsibility of EVERYONE involved in their therapy to pull them from the grey zone and bring them into recovery.  

            Let’s us use again analogy of 1% chance of cancer metastasizing. If Dr. Wang and his team are correct in only 1% of cases, and we would like to inform readers that the real number is much higher, would readers give Oncology Massage suggested by Ms. Walton to their loved ones? We don’t think so and they would be completely correct. We simply don’t understand even the subject of discussion and disagreement here. The author doesn’t want to stop massage treatment to cancer patients even within a 2-3 week window despite that there is scientific proof that this is exactly what she MUST do! 

            We choose the first rule of medicine: “Do No Harm” as an epigraph to our original article. By denying data from Dr. Wang’ study Ms. Walton breaks the first rule of medicine and from our perspective it becomes an ethical problem.

 

Part II. Response to the Second Part of Ms. Walton’s critique

            The second part of Ms. Walton’s critique targets our article in JMS. Her critique is arranged in three arguments: 

Argument 1.

            According to our opponent we claimed that increase in circulation is a dangerous factor in cancer spread. 

            No, we did not. We claimed that increase of pressure within the lymphatic system is a dangerous factor and this pressure only secondarily affects circulation by unloading the content of the lymphatic system into the circulation. 

            Ms. Walton continues to make the same claim that: 

“First, even if increased circulation did pose a problem, in OMT (Oncology Massage Therapy by JMS), we often work more gently than the medium-to-deep, classical Swedish massage pressure considered “circulatory” in massage therapy school.” 

            We already illustrated in Fig. 1 what simple and gentle effleurage strokes the author mentioned can do to lymphatic circulation. However, we would like to additionally reinforce this point. LDM is a very gentle procedure and I think every reader including our opponent will agree that its pressure is even lighter that Swedish Massage strokes while effleurage and light compressions are an important part of LDM application.  

            In JMS issues #4, 2014 and #1-#2, 2015 we published a three-part article by John F. Mramor, LMT where the author shared with our readers the results of application of LDM on patients with terminal stage cancer who suffered from severe Ascites (accumulation of the fluid in the abdominal cavity due to the terminal stages of cancer with severe abdominal metastasizing). Here is link to Part II of his article:

http://www.scienceofmassage.com/2015/04/mld-for-ascites-symptom-management-part-ii

            By doing gentle LDM massage strokes John was able to assist the body in draining fluid from the abdominal cavity into the urinary system. The ONLY other solution for these patients was very uncomfortable abdominal taps (punctures) done by a physician in a sterile environment and active evacuation of the 4-5 liters of fluid every (!) 10-15 days. As a result of John’s treatment, the time between abdominal taps was increased to 1 sometimes 1.5 months where only 3 liters of fluid were removed. All of this greatly improved the quality of the patients’ remaining lives. This article was written under direct supervision of two physicians, Prof. M. Harrington, MD, and W. George, MD, who prescribe LDM conducted by John regularly to the patients in the hospice he works in.  

            How was John able to drain all this fluid from the abdominal cavity? He did this by increasing pressure within the entire lymphatic system and that allowed him to redirect lymph flow. This is clinical proof that Ms. Walton is completely wrong when she thinks that gentle effleurage and light compression strokes of Oncology Massage do not deeply affect lymphatic circulation the way that same gentle effleurage and light compression strokes do during LDM application.  

Argument 2.

            Here is our opponent’s quote: 

“The authors’ (Cullers, Turchaninov, by JMS) concern about boosting circulation ends when cancer treatment starts. They state that their conservative, segmented precautions should remain in place until treatment starts. Yet there is nothing magical about the beginning of cancer treatment. It may compromise a tumor’s ability to spread, but it does not throw a switch, reducing the risk of spread to zero. Cancer spreads in the absence of treatment. Cancer spreads in the presence of treatment. Cancer spreads, sometimes against the odds.” 

            Yes, our opponent is completely correct regarding the unpredictability of cancer behavior. However, we have a legitimate question:  Would Ms. Walton consider it right if her treatment additionally contributed to such unpredictability?” We think the answer to this hypothetical question is obvious.

            However, there is one very surprising aspect in his quote. It seems to us that our opponent is not familiar with the basics of oncology. The cancer cells which are going to metastasize first are always located on the periphery of the tumor, except in cases when the tumor has penetrated the blood vessel. This is why the cancer sheds off cells which are later taken by lymph flow and end up as metastasis in different organs and tissues. Cytostatic medications and radiation kills those peripherally located cells first and eventually shrinking tumor. Thus, cytostatics and radiation dramatically prevent further dissemination of metastasis due to any reason including increased pressure within the lymphatic system triggered by Oncology Massage. Our opponent is a national authority on Oncology Massage and it is simply puzzling why we need to explain such a basic oncology fact. 

            Another quote: 

“Their (Cullers and Turchaninov, by JMS) approach is not supported by current thought or practice in cancer care. If massage were truly thought to spread cancer through boosting blood or lymph, then it shouldn’t be performed at any point in an oncology patient’s life. It shouldn’t be offered after treatment starts, when cancer sometimes spreads. It shouldn’t be offered after treatment ends, when cancer could return. Nor should it be offered at end of life.” 

            During her two-part critique Ms. Walton constantly twisted information from our article. We never mentioned that MT is a contraindication for the patient with cancer. Dr. Cullers teaches Oncology classes nationally. We shared with therapists the results of the exceptional study to inform them about possible danger when Oncology Massage which by the way Ms. Walton also practices was applied in the wrong time!

            Yes, there weren’t studies which confirmed the side effects of MT on cancer patients, but now such a study exists and nobody including Ms. Walton, with all her credentials, has the RIGHT to completely disregard its result considering the situation cancer patients are in. 

            MT is a very democratic branch of medicine and generally speaking, therapists who work with clients including oncology patients bring an important spiritual component to their work. Even from this perspective our opponent is wrong because no therapist after working on cancer patient would like to go to bed with a heavy consciousness that maybe Dr. Wang is correct, and maybe Ms. Walton is wrong, since she didn’t provide ANY scientific counterargument to Dr, Wang’ study. At the end, the patient’s health is on the line and the author has two options at this point: conduct her own study and show that Dr. Wang was wrong or change her views. Any other position will be professionally irresponsible especially considering the nature of the disease.

 

            Finally, our opponent mispresented information in our article in regard to exercise and MT. We mentioned in the original article study which showed that exercise may indeed contribute to cancer cell dissemination (Cohen et. Al, 1992). Our opponent dismissed this information on the simple grounds that it is ‘old’, and she cited a newer 2017 source (Koelwyn, et al., 2017).  

            We went on line and bought access to read the cited article. Despite that the authors called their piece Opinion Article, the piece is a great example of theorization. The article links cancer recovery with regular exercise and authors provide a lot of interesting thoughts. However, they clearly mentioned that there is no proven protocol at this point for correct application of exercise in cancer patients and this issue MUST be examined in future clinical studies.  

“… clinical trials to evaluate whether exercise modulates specific tumor pathways and/or targets by using noninvasive monitoring of blood-borne materials (for example, circulating tumor DNA and circulating tumor cells) combined with a more invasive evaluation….” 

            In other words, the authors of this great opinion article are looking for actual data on how to best and safely examine the effect of exercise on cancer patients, including on “circulating tumor cells” while our opponent already has all the answers authors were looking for. 

            Anyone who reads our opponent’s critique without reading our original article will get the impression we are against exercise as well. This is a completely incorrect presentation of our article since we never disputed the necessity of active exercise because it is an irreplaceable tool for cancer patients to recover quicker. However, it needs to be done right and it seems that Koelwyn, et al., (2017) agree with that: 

“Nevertheless, it is important to stress that response to an exercise prescription is considerably heterogeneous between individual patients. Such heterogeneity has substantial ramifications for the appropriate prescription of exercise regimens to patients with cancer.” 

 

Argument 3 

            Here is our opponent quote: 

“The authors (Cullers and Turchaninov, by JMS) claim that OMT practice is based on personal opinion, lacking the necessary evidence to support it.”  

And 

“We agree that there is not much good data on either side about how to safely manipulate tissues near a tumor site at any point. On the plus side, research suggests negligible adverse reactions among oncology clients, especially when massage is provided by knowledgeable MTs.” 

             We rest our case with this statement. Within one sentence Ms. Walton both agrees that there is not ANY data to support her views except anecdotal claims and at the same time proclaims that “research suggests” without providing ANY references for such mysterious research. Simultaneously she completely denies the results of a very well done and rare study of this subject because its results don’t fit into her system of beliefs. This sort of approach to science is truly “remarkable.”  

            As we mentioned above, the presence of possible “adverse reactions” the author mentioned is now a fact which needs to be considered, especially by our opponent. This fact has nothing to do with the great role MT plays in the treatment of cancer patients. We are talking about simple adjustments to the protocol of Oncology Massage, but Ms. Walton’s position can’t let her compromise even there. 

 

            A final note. Massage therapists as well as various professional Massage Associations constantly complain that American medicine refuses to accept the clinical benefits of MT. One of the reasons for this unfortunate situation is that some massage educators use partial data or sometimes even manipulate information from scientific literature to fit into their own views and agenda. This cherry picking is so wide spread from so called ‘new’ pain science to now Oncology Massage that it will soon prohibit MT from returning into mainstream medicine where it originated and where it belongs. Until we stop choosing data which fits our sometimes erroneous views, MT will remain on the outskirts of health care. 

 

REFERENCES

Cohen, L.A., Boylan, E., Epstein M., Zang, E. Voluntary exercise and experimental mammary cancer. Adv Exp Med Biol. 1992; 322:41-59. 

Cullers J., Turchaninov R. Science Of Oncology Massage. Part I. 2017, JMS #2.

Koelwyn GJ, Quali DF, Zhang X, White R.M., Jones L.W. “Exercise-dependent regulation of the tumour microenvironment.” Nature Reviews Cancer, 2017; pp. 620–632.

Walton T. Does Massage Spreads Cancer? Massage Today, 2017, Vol.17(10), Oct.

Walton T. Could Massage Spread Cancer in the Newly Diagnosed? 2018, Massage Today, Vol. 18(1), Jan

Wang, J.Y., Wu, P.K., Chen, P.C., Yen, C.C., Hung, G.Y., Chen, C.F., Hung, S.C., Tsai, S.F., Liu, C.L., Chen, T.H., Chen, W.M. Manipulation therapy prior to diagnosis induced primary osteosarcoma metastasis–from clinical to basic research. PLoS One, 2014 May 7;9(5):e96571.  


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