Massage Therapy for Symptom Control: Outcome Study at a Major Cancer Center
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244 Journal of Pain and Symptom Management Vol. 28 No. 3 September 2004
Original Article
Massage Therapy for Symptom Control:
Outcome Study at a Major Cancer Center
Barrie R. Cassileth, PhD and Andrew J. Vickers, PhD
Integrative Medicine Service (B.R.C., A.J.V.) and Biostatistics Service (A.J.V.), Memorial
Sloan-Kettering Cancer Center, New York, New York, USA
Abstract
Massage is increasingly applied to relieve symptoms in patients with cancer. This practice
is supported by evidence from small randomized trials. No study has examined massage
therapy outcome in a large group of patients. At Memorial Sloan-Kettering Cancer Center,
patients report symptom severity pre- and post-massage therapy using 0–10 rating scales of
pain, fatigue, stress/anxiety, nausea, depression and “other.” Changes in symptom scores
and the modifying effects of patient status (in- or outpatient) and type of massage were
analyzed. Over a three-year period, 1,290 patients were treated. Symptom scores were
reduced by approximately 50%, even for patients reporting high baseline scores.
Outpatients improved about 10% more than inpatients. Benefits persisted, with
outpatients experiencing no return toward baseline scores throughout the duration of 48-
hour follow-up. These data indicate that massage therapy is associated with substantive
improvement in cancer patients’ symptom scores. J Pain Symptom Manage
2004;28:244–249. 쑖 2004 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc.
All rights reserved.
Key Words
Massage, cancer, pain, anxiety, depression, nausea, fatigue, clinical trials
Introduction similar results, plus major dysfunctions as they
developed and when they themselves became
In the 1940s, Rene A. Spitz learned that
mothers.3 His major work, “Touching: The
foundling home infants, well fed and warm
but not held or touched, tended to wither away Human Significance of the Skin,”4 clarified a
and die. Of 91 such babies he observed, 27 died major message: tactile stimulation is essential
in their first year of life, followed by seven to normal development and even to survival.
more in their second year; in other homes, up The use of human touch as an intervention
to 90 percent died in early infancy. Babies who against pain and other problems has great
survived in the institutions were classified as appeal. If effective, it could provide a non-inva-
hopeless.1,2 Harlow’s studies of monkeys that sive, inexpensive adjunct to the management
had been removed from their mothers showed of pain and other symptoms experienced by
patients with major chronic illnesses. Data
from related, difficult to control clinical circum-
Address reprint requests to: Barrie R. Cassileth, PhD, stances are promising. Massage therapy, de-
Memorial Sloan-Kettering Cancer Center, 1275 York fined as manipulation of soft tissue areas of
Avenue, H13, New York, NY 10021, USA. the body, is offered in clinical settings to assist
Accepted for publication: December 23, 2003. relaxation, facilitate sleep, and relieve muscular
쑖 2004 U.S. Cancer Pain Relief Committee 0885-3924/04/$–see front matter
Published by Elsevier Inc. All rights reserved. doi:10.1016/j.jpainsymman.2003.12.016Vol. 28 No. 3 September 2004 Massage for Cancer-Related Symptoms 245
aches and pains.5 It is increasingly used for Three variations of massage therapy are avail-
symptom relief in patients with cancer. Approxi- able to patients at MSKCC: standard (“Swed-
mately 20% of U.S. cancer patients seek mas- ish”) massage,5 light touch massage, and foot
sage therapy,6,7 and approximately 70% of U.K. massage. A specific type of massage is requested
hospices offer it.8 Massage is included in treat- for almost all referrals. Patients receive the re-
ment guidelines such as those of the National quested type of massage approximately three
Comprehensive Cancer Network, which recom- times out of four. The majority of the remaining
mends consideration of massage for refractory cases are requests for regular massage in which
cancer pain.9 either light touch or foot massage was given,
Research supports such recommendations. typically because the practitioner felt that a
Several trials suggest that massage can reduce weak or late-stage patient could not tolerate
pain in cancer patients at varying stages of dis- a regular massage or because the patient was
ease.10,11 In the largest study to date, 87 hospital- too ill to move into a comfortable position to
ized cancer patients were randomized to receive standard massage therapy.
massage therapy or to control on a crossover Massage sessions average 20 minutes in
basis. Pain and anxiety scores fell by approxi- length for inpatients and 60 minutes for outpa-
mately 40% during massage compared with tients. Before and 5–15 minutes after massage
little or no change during control sessions.12 therapy, patients are given a 5 ⫻ 8 inch card
Massage therapy was superior to control against with numerical rating scales for common symp-
anxiety, nausea, fatigue and general well-being toms: pain, fatigue, stress/anxiety, nausea, de-
in a randomized study of patients awaiting bone pression, and “other.” Patients rate each on a
marrow transplantation.13 0 (“Not at all bothersome”) to 10 (“Extremely
Massage has been available systematically at bothersome”) scale.
Memorial Sloan-Kettering Cancer Center Data from symptom cards for massage ther-
(MSKCC) since establishment of the Integrative apy from April, 2000, when use of the rating
Medicine Service in 1999. Twelve licensed mas- scales was initiated, to March, 2003 were ana-
sage therapists treat inpatients and also provide lyzed. Combinations of interventions, such as
massage therapy at our outpatient facility. Pa- massage and a simultaneous relaxation therapy,
tients who receive integrative medicine ther- were excluded. Comparisons between different
apies record symptom scores before and after types of massage or symptoms were conducted
treatment as a routine part of clinical manage- by ANCOVA of the presenting symptom, with
ment. To avoid bias, staff not associated with baseline score as a covariate. The presenting
the evaluation, rather than therapists, provide symptom was defined as that with the highest
cards on which patients complete symptom baseline score. If more than one symptom was
rating scales. These cards are placed privately scored equally high, the presenting symptom
by patients in a closed box. Only research staff was chosen in the following priority order: pain,
work with the completed cards. Data from these depression, anxiety, nausea, fatigue, other. The
scores, reported here, shed important light on main analyses concern the initial episode of
the management of common and often refrac- care. This ensures that each patient is included
tory symptoms experienced by patients with in the analysis only once. Analyses were con-
cancer. ducted by AV using Stata 7 statistical software
(Stata Corp., College Station, Texas).
Ethical approval for this retrospective review
Methods of clinical data was given by the MSKCC IRB.
Patients at MSKCC may self-refer to massage
therapy or may be referred by a health profes-
sional responsible for their care. About 50% of
inpatient referrals come from MSKCC nurses; Results
self- and family referrals account for a further Cards were returned for 3,609 episodes of
20% and 10%, respectively. Physicians and care; post-therapy data were available for 3,359
other health professionals account for the re- (93%). Of these, 2,465 (73%) involved care of
maining approximately 20%. Outpatient mas- an MSKCC patient, with smaller numbers for
sage therapy is self-referred. cancer patients from other hospitals (94, 3%),246 Cassileth and Vickers Vol. 28 No. 3 September 2004
Table 1 the data for each symptom includes a significant
Types of Massage Therapy Received number of zero or near zero scores. A patient
Inpatients Outpatients Total presenting with depression, for example, may
Therapy n (%) n (%) n (%)
have reported no pain or nausea. For such
Massage 316 (33) 244 (74) 560 (43) a patient, no improvement in pain and nausea
Light touch 69 (7) 21 (6) 90 (7)
massage
would be possible, thus diluting the apparent
Foot massage 536 (56) 49 (15) 585 (45) effects of treatment on these symptoms at the
More than 40 (4) 15 (5) 55 (4) group level.
one therapy
Total 961 (74) 329 (26) 1290 (100)
Accordingly, Table 3 includes only data for
symptoms rated four or higher at baseline, the
traditional threshold for considering a symp-
tom of at least “moderate” severity. The strong-
family members (78, 2%), staff (345, 10%) and
est effects were seen for anxiety and the smallest
members of the public (377, 11%). Data re-
changes for fatigue, although a 43% reduction
ported below reflect the initial episode of
in fatigue is clinically relevant. There was no
care for the 1,290 different MSKCC patients
evidence of an attenuation of effect at high
who provided post-treatment data.
baseline scores. For example, an approximate
As indicated in Table 1, the most commonly
45% improvement in pain scores was seen even
administered touch therapies were standard
(Swedish) massage or foot massage, with far in the 244 patients with baseline scores of
fewer patients receiving light touch massage. seven or above, and in the case of anxiety, im-
Fifty-five patients received more than one type of provements were always close to 60%, regard-
touch therapy during the same session, i.e., less of baseline score.
some foot massage and some Swedish mas- After adjusting for baseline score, outpatients
sage during a single session. Foot massage reported symptom scores 0.56 points lower
was predominantly used for inpatients; stan- (95% C.I. 0.27, 0.85; P ⫽ 0.0002) than inpa-
dard and light touch massage was more equally tients, equivalent to an approximate 10%
balanced between in- and outpatients. The most greater improvement. Effects by type of mas-
common presenting symptom was anxiety (397, sage are shown in Table 4. Adjusting for in- or
31%), followed by pain (366, 28%) and fatigue outpatient and baseline score, patients receiv-
(312, 24%). Fewer than 10% of patients ing Swedish and light touch massage had supe-
reported greatest distress from depression, rior outcomes to those receiving foot massage
nausea or another symptom. (0.32 points; 95% C.I. 0.03, 0.60 P ⫽ 0.03). Pa-
The immediate effects of massage therapy tients receiving Swedish or light touch massage
on symptoms are shown in Table 2. Although had an average 58% improvement in severity of
major improvements in symptom scores are ap- their presenting symptom compared to a 50%
parent—severity of the presenting symptom was improvement in patients receiving foot mas-
reduced by a mean of 54% (95% C.I. 52%, sage. There was no significant difference be-
56%)—Table 2 may actually underestimate tween Swedish and light touch massage (0.41
massage effects. Patients did not necessarily ex- points better response for light touch; 95% C.I.
perience high levels of all symptoms. Therefore, ⫺0.11, 0.13; P ⫽ 0.12).
Table 2
Improvements in Symptom Scores Following Massage Therapy
Symptom n Baseline Post-treatment Change Improvement
a
Presenting 1290 6.6 (2.5) 3.2 (2.7) 3.4 (2.6) 54.1% (34.1)
Pain 1284 3.6 (2.9) 1.9 (2.2) 1.7 (2) 40.2% (40.9)
Fatigue 1263 4.7 (2.9) 2.7 (2.7) 2.1 (2.2) 40.7% (39.1)
Anxiety 1273 4.6 (3.1) 1.8 (2.2) 2.8 (2.5) 52.2% (39.5)
Nausea 1255 1.4 (2.4) 0.7 (1.6) 0.7 (1.6) 21.2% (38.3)
Depression 1254 2.4 (2.8) 1.2 (2) 1.2 (1.9) 30.6% (41.0)
Other 105 6.5 (2.5) 3.4 (2.8) 3.1 (2.8) 46.6% (36.9)
Figures are given as mean (standard deviation).
a
Defined as the symptom with the highest score at baseline.Vol. 28 No. 3 September 2004 Massage for Cancer-Related Symptoms 247
Table 3
Improvements in Symptom Scores After Massage Therapy
Symptom n Baseline Post-treatment Change Improvement
a
Presenting 1131 7.3 (1.9) 3.5 (2.7) 3.7 (2.6) 52.0% (33)
Pain 625 6.1 (1.8) 3.3 (2.3) 2.9 (2.2) 47.8% (32.2)
Fatigue 819 6.6 (1.8) 3.8 (2.6) 2.8 (2.4) 42.9% (35.4)
Anxiety 786 6.7 (1.9) 2.7 (2.3) 4 (2.4) 59.9% (30.2)
Nausea 222 6 (1.9) 3 (2.5) 3.1 (2.4) 51.4% (37.4)
Depression 378 6.2 (1.9) 3.2 (2.5) 3 (2.3) 48.9% (35.7)
Other 94 7.1 (2) 3.7 (2.8) 3.4 (2.8) 48.3% (35.5)
Data include only baseline scores of four or higher. Figures are given as mean (standard deviation).
a
Defined as the symptom with the highest score at baseline.
Similar effects appear for additional massage ably representative of the whole sample. As
therapy interventions. Percent improvement in shown in Table 5, the effects of touch therapy
presenting symptoms for episodes two to five for inpatients did not persist in the longer term.
for the same individuals are, respectively: 53% Two to five hours after treatment, scores were
(n ⫽ 450; 95% C.I. 50%, 56%); 58% (n ⫽ 203; approximately 0.5 points higher than immedi-
95% C.I. 54%, 63%); 56% (n ⫽ 118; 95% C.I. ately after treatment. This suggests that inpa-
49%, 62%) and 61% (n ⫽ 73, 95% C.I. 53%, tient severity scores returned to baseline within
69%). Indeed, in a general linear model ad- a day or so.
justed for baseline score and clustered by pa- The effects of massage therapy lasted longer
tient, the coefficient for each treatment was for outpatients. Indeed, there is no evidence that
negative and statistically significant (P ⫽ 0.001), symptom scores regress toward baseline values
suggesting that the effects of massage therapy (Fig. 1). There was no difference between types of
probably increase for each additional treatment. massage therapy concerning the time course
We attempted to follow about one in four of symptom improvement.
patients (83 outpatients and 247 inpatients)
for up to two days to obtain data in addition to
their immediate post-treatment scores. Inpa-
tients and outpatients were assessed typically Discussion
two to five hours after treatment; outpatients This is the largest study of massage for cancer
were additionally assessed approximately 24 patients yet reported. Such studies typically
and 48 hours after treatment. Data were ob- note sample sizes of six,14 2315 and 54.13 We
tained from 74 outpatients (89%) and 237 inpa- found no study of massage therapy with a
tients (96%). These patients versus those we sample size greater than 100. This may reflect
did not attempt to follow beyond 48 hours that massage therapy services have been avail-
received similar therapies: 43%, 53%, 9% vs. able only rarely until recently, at major cancer
48%, 47%, 8% received regular, foot or light centers. Our first conclusion, therefore, is that
massage, respectively. The two groups also had implementation of a high volume massage ther-
comparable immediate responses to therapy apy service is feasible at a major cancer center.
(53% vs. 54% improvement, P ⫽ 0.6) and simi- Major, clinically relevant, immediate im-
lar proportions of inpatients (78% v. 73%). provements in symptom scores were reported
Baseline scores were slightly lower in patients following massage therapy. Given the observa-
followed longer (6.3 vs. 6.7), suggesting that tional nature of this study, we cannot make con-
patients followed beyond 48 hours were reason- clusions about the cause of this effect. However,
Table 4
Differences in Effect by Type of Massage Therapy
Type of massage n Baseline Post-treatment Change Improvement
Swedish 550 6.7 (2.5) 3.1 (2.7) 3.1 (2.7) 57% (32)
Light touch 88 6.7 (2.5) 2.7 (2.7) 2.7 (2.7) 62% (35)
Foot 574 6.5 (2.5) 3.4 (2.8) 3.4 (2.8) 50% (36)
Figures are given as mean (standard deviation).248 Cassileth and Vickers Vol. 28 No. 3 September 2004
Table 5 than do our outpatients. The relationship be-
Symptom Scores for Longer-Term Follow-Up tween the length of massage treatment and
Outpatients the size and duration of effects is worthy of
Baseline n ⫽ 74: 5.8 (2.2)
Post-treatment n ⫽ 73: 2.7 (2.1) further research.
Later same day n ⫽ 53: 2.9 (2.3) We found that Swedish and light touch mas-
Next day n ⫽ 49: 2.7 (2.2) sage were superior to foot massage, even after
Two-day follow-up n ⫽ 38: 2.6 (2.4)
controlling for baseline severity and location of
Inpatients treatment. It may be that the effects of touch to
Baseline n ⫽ 237: 6.2 (2.4)
Post-treatment n ⫽ 237: 3.1 (2.7) the body are more profound than touch given
Later same day n ⫽ 237: 3.7 (2.9) only to the feet. However, it is also possible that
Figures are given as mean (standard deviation). the apparently lesser effects of foot massage
reflect a case mix inadequately captured by
baseline symptom scores. For example, weak or
cachectic patients often receive massage just to
it is notable that the size of the effects found the feet rather than the whole body. Set against
are highly similar to those reported in prior such an explanation is that such patients also
randomized trials of massage therapy in receive light touch massage.
cancer patients. For example, Grealish et al. In conclusion, massage therapies apparently
reported that pain and anxiety scores improved lead to large, immediate improvements in
during treatment from approximately 2.5 to 1.5 symptoms scores in cancer patients, even those
(40%) and from 5.4 to 3.2 (41%), respectively, with very high baseline scores indicating sub-
with no change in controls.12 The comparable stantial levels of pain, anxiety, or other symp-
figures reported by Stephenson et al. are 2.9 to toms. Outpatients experienced persisting
1.4 (53%) and 4.7 to 2.4 (50%), again, with benefit across the total of 48 hours studied. We
marginal change in controls (15). This suggests plan a prospective controlled trial for longer
that the results reported in randomized trials periods of time to determine the duration of
can be achieved in the clinical setting. effect. Meanwhile, it is clear that massage therapy
The effects of massage were smaller and less achieves major reductions in cancer patients’
persistent for inpatients. There are two possible pain, fatigue, nausea, anxiety and depression.
explanations. First, inpatients are more subject Massage therapy appears to be an uncommonly
to intervening events than are outpatients. They non-invasive and inexpensive means of symp-
may undergo procedures or have medication tom control for patients with serious chronic
changed. Inpatients also tend to receive shorter illness. It is non-invasive, inexpensive, comfort-
massage treatments in less comfortable settings ing, free of side effects and greatly appreciated
by recipients. This non-randomized study sug-
gests that it is also markedly effective.
Acknowledgments
Anne Seidler collated and entered the data
for this article. The authors also thank the
MSKCC massage therapists, headed by Wendy
Miner, LMT and the staff of the MSKCC Bend-
heim Integrative Medicine Center.
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