Transcript Is Best Supportive Care Really Best Supportive Care?

Integrative Oncology &
Oncology Massage
Gabriel Lopez, MD
Assistant Professor, Integrative Medicine Program
Department of Palliative, Rehabilitation and Integrative Medicine
Section of Integrative Medicine
August 22, 2015
Objectives
• Introduction to Integrative Medicine &
Oncology Massage
• Evidence Based review of massage in
symptom management
• Discuss our Integrative Medicine model for
inclusion of massage in cancer care
Case
63 year old man with progressive,
metastatic prostate cancer.
He experiences some relief with opioid medications for
painful bone metastases and has also received radiation
to specific sites of disease.
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He is worried about his disease progressing
He would like to avoid taking more medications for pain or anxiety
He has benefitted from massage in the past but has heard it is not safe for
cancer patients. He is fearful massage will spread his cancer even more.
Pre- Massage Symptom Scores (score 0 to 10, 10 is worst):
Pain
6
Anxiety 8
Fatigue 5
Depression
7
Financial distress 2
Spiritual pain
4
Distress
Integrative Medicine in the Media
Myth versus Reality
Massage will spread my
cancer…
Why?
(1) Improve quality of life and prolong life
(2) Boost the immune system
(3) Relieve symptoms
(4) Hope after conventional treatment fails
(5) Aid conventional medical treatment
(6) Recommendation from family or friend
(7) “Might help, can’t hurt”
Why?
Molassiotis Annals of Onc 2005; Richardson JCO 2000
Complementary and Alternative
Medicine (CAM)
Definition
A group of diverse medical and health care
systems, practices, and products that are not
presently considered to be part of conventional
medicine.
* NCCAM prior to December 2014
NCCIM & Massage
• Numerous systematic reviews and clinical studies have
suggested that at least for the short term, massage therapy for
cancer patients may reduce pain, promote relaxation, and
boost mood.
• The National Cancer Institute urges massage therapists to take
specific precautions with cancer patients and avoid massaging:
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Open wounds, bruises, or areas with skin breakdown
Directly over the tumor site
Areas with a blood clot in a vein
Sensitive areas following radiation therapy.
https://nccih.nih.gov/health/massage/massageintroduction.htm
NCCIM
Complementary Health
Approach Categories
Natural Products
Mind and Body Medicine
Other Complementary Practices
Examples
Herbal medicines
Vitamins
Minerals
Probiotics
Meditation
Yoga
Acupuncture
Qi gong
Tai chi
Massage
Spinal manipulation
 Chiropractic
 Osteopathic
 Physical therapy
Energy Therapies (Magnet therapy, Reiki, Healing touch)
Movement Therapies (Feldenkrais method)
Whole medical systems
 Ayurvedic medicine
 Traditional Chinese Medicine
 Homeopathy
 Naturopathy
Difference Between Alternative,
Complementary, and Integrative
• Alternative medicine is used in place of
conventional medicine.
• Complementary medicine is used together with
conventional medicine.
• Integrative medicine is …
Difference Between Alternative,
Complementary, and Integrative
• Alternative medicine is used in place of
conventional medicine.
• Complementary medicine is used together with
conventional medicine.
• Integrative medicine is used together with
conventional medicine in a deliberate manner
that is personalized, evidence-based, and safe.
Prevalence of CAM/CIM Use
• General population 38%
• Cancer patients up to 64%
• MD Anderson Cancer Center survey
Movement/physical therapies Massage, Chiropractor, Exercise, Yoga, Qigong/Tai-chi
Richardson et al. JCO 2000
Oncology Massage Therapy
What is Oncology Massage?
• Oncology massage is the modification of existing massage
therapy techniques in order to safely work with
complications of cancer and cancer treatment.
• Anyone who has ever received cancer treatment, from those
in active treatment to those in recovery or survivorship, as
well as those at the end of life, are best served by a
massage therapist who has received special training in
oncology massage.
From www.s4om.org
Massage Precautions
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Solid tumor
Bone metastasis
Radiation site
Incision site
Limb swelling
Lymphedema risk
Blood clot
Blood counts
(platelets, INR, neutrophils)
• Neuropathy
• Medications
(anticoagulants)
• Medical devices
(chemoport, ostomy, IV)
Massage in Supp Cancer Care 2012
Massage
Pressure levels
Level 1: slight skin
movement
Level 2: slight movement
superficial adipose and
muscle
Level 3: slight movement
medium layer adipose,
muscle, & blood vessels
Level 4: move deep layers to
fascia, move adjacent joints
Level 5: move deepest
layers, engage bone
Medical Conditions and Massage Therapy: A Decision Tree Approach ,Tracy Walton
Objectives
• Introduction to Integrative Medicine &
Oncology Massage
• Evidence Based review of massage in
symptom management
• Discuss our Integrative Medicine model for
inclusion of massage in cancer care
Massage impact on multiple
symptoms
• Population:
– 1290 cancer patients, 3609 massage encounters over 3 years
– 74% inpatient, 26% outpatient
• Study design:
– single center, outpatient or inpatient setting
• Intervention:
– Outpatient massage approx 60 minutes or inpatient massage approx
20 minutes
– Massage type? Standard (Swedish), light touch, foot
– By whom? Licensed massage therapist
• Methods:
– Recorded symptoms with pre- and post symptom report cards
~50% reduction symptom scores
Benefit persists
• Subset of patients
receiving outpatient
massage
– Time course of
treatment effect to 48
hours
Massage for Pain and Mood
The REST Study
(reducing end-of-life symptoms with touch)
REST Study: Pain & Mood
Population: 380 adults with advanced cancer experiencing moderate-to-severe pain
(pain ≥ 4, 0-10 scale); 90% in hospice
Study design: National, Multi-site, randomized, single-blinded clinical trial
Intervention: Six (30-min) massage sessions over 2 weeks.
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Massage Therapy (MT) – experimental group
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Simple touch (ST) – control group
By Whom? Licensed massage therapist, > 6 months cancer patient experience
Primary Outcome Measures: Decreased pain 
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Immediate: memorial pain assessment card (MPAC)
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Sustained : brief pain inventory (BPI)
Secondary Outcome Measures:
1.
Immediate change in mood (MPAC scale)
2.
Improved quality of life (McGill QOL)
3.
Decreased physical symptom distress (MSAS-Physical)
4.
Decreased emotional symptom distress (MSAS-Psych)
5.
Less total analgesic medication use.
Kutner 2008
Memorial Pain Assessment
Card (MPAC)
Massage vs. Simple Touch:
Immediate Beneficial Effect
Immediate
Measures
MPAC Pain*
MPAC
Mood*
Change
Massage
-1.87
1.58
Change
p value
Simple Touch
-0.97
<0.0001
0.97
<0.0001
* Significant difference between massage and simple touch for
immediate measures of pain and mood
• No significant difference between massage and simple touch groups
for other measures
ww.massagetherapyfoundation.org/pdf/.../SmithMTF92609.ppt
Kutner 2008
Massage for
Anxiety/Depression
Massage for
Anxiety/Depression
Massage for
Anxiety/Depression
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Population:
• 288 adults with clinical anxiety and/or depression, prognosis > 3 months recruited from
four cancer centers and one hospice
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Study design:
• National (United Kingdom), Multi-site, randomized, single-blinded clinical trial
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Intervention: 4 weeks, two groups
• Group 1: Weekly 1 hour aromatherapy massage sessions
• Group 2: Usual care
By Whom? 12 therapists
Primary Outcome Measure:
• Change in clinical anxiety and/or depression at 10 weeks
Secondary Outcome Measures: At 6 and 10 weeks 
• Change in clinical anxiety and/or depression at 6 weeks
• Change in self reported anxiety
• Change in self reported depression
• Change in self-reported symptoms (QOL, etc.)
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Wilkinson JCO 2007
Massage for Anxiety/Depression:
Results
• 43% of patients with advanced cancer; 55% with breast cancer
• 124 of the 144 (86%) patients in each group completing at least two of the
four sessions.
Wilkinson JCO 2007
Massage for Anxiety/Depression:
Results
• At 6 weeks: clinical anxiety/depression and self reported
anxiety improved in aromatherapy versus usual care
• At 10 weeks (primary outcome): only self reported
anxiety significantly improved
Wilkinson JCO 2007
Massage in Cancer Symptom
Management: Summary
• Improves symptoms including
– Pain
– Mood
• Anxiety
• Depression
• Single massage: symptomatic benefit may
persist ≥ 48 hours
• Series of massages: benefit for anxiety may
persist up to 10 weeks post-treatment
• More research is needed to understand
mechanism of massage effect
Objectives
• Introduction to Integrative Medicine &
Oncology Massage
• Evidence Based review of massage in
symptom management
• Discuss our Integrative Medicine model for
inclusion of massage in cancer care
The Integrative Medicine Program at
MD Anderson Cancer Center
• Clinical Delivery
• Research
• Education
Clinical Delivery:
Integrative Medicine Center Philosophy
“The Integrative Medicine Center
aims to work collaboratively with
the oncology team to build a
comprehensive and integrative
care plan that is personalized,
evidence-based, and safe with
the goal of improving clinical
outcomes.”
Integrative Medicine Center Model
“the physician’s basic professional knowledge and
skills must span the social, psychological, and
biological, for his decisions and actions on the
patient’s behalf involve all three.”
Physical
Health
PsychoSpiritual
Social
Integrative Medicine Center Model
● Integrative Oncology Consultation
● Nutrition
Physical
● Exercise
● Rehabilitation
●Chemotherapy
● Surgery
● Radiation
● Pharmacy
● Acupuncture
● Massage
Optimal Health &
Healing
= Improved Clinical
Outcomes
● Smoking
Cessation
● Psychology
● Psychiatry
● Rest/Sleep
Psycho-Spiritual
● Chaplaincy
● Meditation
●Yoga
●Environmental
Exposures
Social
● Patient
Advocacy
● Social Work
● Family/Friends
● Support Groups
● Tai Chi ● Music Therapy ● Education
Integrative Oncology
Physician Consultation
• Educate
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Integrative Medicine
Herbs/Supplements
Nutrition
Exercise
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Acupuncture
Oncology Massage
Music Therapy
Meditation
• Provide personalized therapeutic recommendations
• Outpatient and Inpatient setting
• Interdisciplinary Approach
– Regular team meetings to discuss patients in inpatient and
outpatient setting
• Communication with the primary team
Integrative Medicine, when?
Continuum of Cancer Care
Surgery
Diagnosis
Radiation
Chemotherapy
Prevention
Prevention
Recurrence / Metastasis
Active
Treatment
Active
Treatment
Survivors
Meditation
Music Therapy
Massage
Acupuncture
Oncology Massage Therapy
Discuss how it may help
with:
• Mood Disturbance
• Anxiety
• Depression
• Pain
Where & how is oncology
massage available?
• Inpatients
– Treatment in hospital room.
• Physician order needed
• Integrative Medicine inpatient consultation service providing
acupuncture, music therapy, psychology, oncology massage
• For patient only
• Outpatients
– Treatment in our clinical center: 30 or 60 minutes
• Patients must obtain a physician's order before scheduling an
oncology massage treatment.
• Also available to caregivers
– Relaxation Chair massage: 10 min
• No physician order needed
• Free for patients and caregivers, supported by philanthropy
Assessment
tool
ESAS
• We ask massage
participants about
their symptoms
– Participants
complete a preand postmassage
questionnaire
– Responses
collected as part of
a database
Global Symptom Distress:
Before and After 10 minute Brief Relaxation
Massage
*
Global Symptom Distress Score
*
* P < 0.0001
Massage Clinical Trials
www.mdanderson.org/integrativemed
11th Annual Conference
Provides licensed acupuncturists and massage therapists with an overview of
evidence-based practice in cancer care. Topics of recent research findings,
recommendations for treating common side-effects, ethical issues, safety issues and
case presentations are presented.
Massage Therapy
Acupuncture
• Modern Acupuncture
• TCM Research
• Ethics
• Dietary Recommendations for GI Side Effects of
Cancer Treatment
• Acupuncture for Symptom Management in Cancer
Patients
• Acupuncture Safety Guidelines: Precautions and
Contraindications
• Case Presentations
• Quality/Safety/Interaction Issues – Herbs are
Drugs!
• Huachansu and Other Studies of Chinese Herbs
in Cancer Care
• Acupuncture and Healthcare Reform
• Overview of Recent Research: Oncology Massage
• Panel of People with Cancer
• Oncology Massage Safety Guidelines: Precautions &
Contraindications
• Medicines & Massage
• Chemotherapy-Induced Peripheral Neuropathy
• Dermatology Issues in People with Cancer
• Five Levels of Touch
• Understanding Head, Neck & Upper Extremity
Lymphedema
• Massage Modifications for Lymphedema Risk
• Standards of Practice & Admin Considerations
• Case Presentations
• Oncology Massage Treatment Planning
• Practicum: Standardized Patients
Case
63 year old man with progressive,
metastatic prostate cancer.
He experiences some relief with opioid medications for
painful bone metastases and has also received radiation
to specific sites of disease.
•
•
•
He is worried about his disease progressing
He would like to avoid taking more medications for pain or anxiety
He has benefitted from massage in the past but has heard it is not safe for
cancer patients. He is fearful massage will spread his cancer even more.
Pre- & Post- Massage scores (score 0 to 10, 10 is worst):
Pain
62
Anxiety 8  4
Fatigue 5  3
Depression
74
Financial distress 2  2
Spiritual Pain
42
Decrease
Symptom
Distress
Massage & Cancer Care:
Take Aways
• Integrative approach: Safe and Evidencebased
– Importance of recognizing unique needs of
individuals affected by cancer
– Seek opportunities to learn & build your
confidence
• Use a team based approach
– Create connections with oncology programs in
your community, build trust
• Track outcomes
– Show others the value in what you do
Our Team
Lorenzo Cohen
Richard Lee
Peiying Yang
Alejandro Chaoul
Kay Garcia
Amy Spelman
Jane Williams
Stephanie Maxson
Roma Polanska
Kira Taniguchi
Curtiss Beinhorn
Sat-Siri Sumler
Mary Jo Cox
Ingrid Moeller
Michael Richardson
Jill Flury
Sanober Ajani
Catherine Powers-James
Kathrin Milbury
Michael Spano
Donna Capps
Sarah Prinsloo
Qi Wei
Rosalinda Engle
Smitha Mallaiah
Charles Mikeska
Stephanie Gabel
Robin Haddad
Marilyn Kenebrew
Jibin Ding
Lin Tan
Yan Jiang
Tejal Patel
Taylor Austin
Andrew Cusimano
Anne Marie Alcala
Patrea Rhea
Edrea Gonzales
Xanthia Baptiste-Gordon
Tanier Williams
Yong Pan
Carol Eddy
Susan Underwood
Yousra Hashmi
Kathryn Moss
Eduardo Bruera
Natalie Schuren
Patrick Hwu
Wendy Austin
Thank you!