Effects of Therapeutic Massage on the Quality of LifeAmong Patients with Breast Cancer During Treatment

Michele Sturgeon, M.P.H., N.C.T.M.B.,1 Ruth Wetta-Hall, R.N., Ph.D., M.P.H., M.S.N.,2 Traci Hart, Ph.D.(C),2

Marge Good, R.N., M.P.H., O.C.N.,3 and Shaker Dakhil, M.D., F.A.C.P.4

Abstract

Objective: Therapeutic massage has demonstrated positive physical and emotional benefits to offset the effectsof treatments associated with breast cancer. The goal of this study was to assess the impact of therapeuticmassage on the quality of life of patients undergoing treatment for breast cancer.Design: Using a pre=post intervention assessment design, this prospective, convenience sample pilot studymeasured anxiety, pain, nausea, sleep quality, and quality of life. Treatment consisted of one 30-minute treat-ment per week for 3 consecutive weeks.Outcome measures: Instruments selected for this study were used in previous massage therapy studies tomeasure quality of life=health status and have documented validity and reliability.Results: Participants experienced a reduction in several quality of life symptom concerns after only 3 weeks ofmassage therapy. Respondents’ cumulative pre- and post-massage mean for state anxiety, sleep quality, andquality of life=functioning showed significant improvement. Among study participants, there was variability inreported episodes of nausea, vomiting, and retching; although participants reported decreased pain and distress,changes were non-significant.Conclusions: Therapeutic massage shows potential benefits for ameliorating the effects of breast cancer treat-ment by reducing side affects of chemotherapy and radiation and improving perceived quality of life and overallfunctioning.

Introduction

Breast cancer is a major public health issue in the UnitedStates and accounts for one third of newly diagnosed

cases of cancer among women.1 In 2007, new cases of in situand invasive breast cancer were estimated at 62,030 and178,480, respectively, while more than 40,000 women withbreast cancer died.2

Therapeutic massage, a general term for soft tissue ma-nipulation using touch and movement, reduces stress andanxiety while promoting relaxation.3,4 Two studies have re-ported that breast cancer patients who received massagetherapy three times per week for 5 weeks experienced a re-duction in depressed mood, anxiety, anger, and pain withcorresponding increases in vigor, dopamine and serotoninlevels, NK cell numbers, and lymphocytes.5–7 Researchers

concluded that the use of massage therapy to improve thepsychological outlooks of breast cancer patients may boostimmune response, thereby affecting their perceptions ofstress and anxiety.5 Therefore, massage therapy may bebeneficial for breast cancer patients to reduce side effects oftreatment. The purpose of this pilot study was to explorethe effect of therapeutic massage among female breast can-cer patients during radiation and=or chemotherapy treat-ment. This study differs from previous research as massagewas given during radiation and=or chemotherapy specifi-cally to Midwestern breast cancer patients. It measuredanxiety, pain, distress, sleep, nausea, vomiting, retching, andfunctional assessment of breast cancer patients. We selectedself-administered instruments used in previous studies ofmassage therapy regarding various quality of life (QoL)issues.8

1Integrative Therapies Inc., Wichita, KS.2Department of Preventive Medicine and Public Health, University of Kansas School of Medicine–Wichita, Wichita, KS.3Wichita Community Clinical Oncology Program, Wichita, KS.4Cancer Center of Kansas, Wichita, KS.

THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINEVolume 15, Number 4, 2009, pp. 373–380ª Mary Ann Liebert, Inc.DOI: 10.1089=acm.2008.0399

373

Physical and psychological impactof breast cancer treatment

Women with breast cancer are at higher risk for elevatedstress=anxiety than those without cancer.9–11 Additional con-cerns of cancer patients include psychosocial side effects,such as weight gain, depression, fatigue, low self-esteem, andlost sense of control, all of which may negatively impactperceived quality of life.

12,13

Reduced sleep may also result inincreased fatigue,13 irritability, aggressiveness,14 and de-creased pain tolerance and QoL.14

Nausea, vomiting, and retching are associated with chemo-therapy, before, during and after treatment15–20 and remainproblematic despite improved pharmacological treatment.21–24

Completing a chemotherapy regimen is positively correlatedwith breast cancer survival,25,26 but fear of nausea and vomit-ing causes 10%–15% of breast cancer patients to refuse or delaychemotherapy.27

Research indicates that coping strategies28 such as mas-sage can enhance comfort, sleep, and relaxation,9 and re-duce pain, symptom distress,29 and pain medication use.30

Therefore, complementary and alternative therapies that re-duce the side effects of breast cancer treatment protocols andimprove QoL must be investigated.

For cancer patients, massage is a common complementarytherapy that reduces stress, anxiety, pain, fatigue, nausea,and muscle tension, and improves QoL. We specifically de-signed this study to answer hypotheses for each construct:Patients undergoing therapeutic massage during breast can-cer treatment will experience (1) decreased anxiety, (2) de-creased pain, (3) decreased nausea, (4) improved quality ofsleep, and (5) improved QoL.

Materials and Methods

Using a pre=post assessment design, this prospective,convenience sample pilot study assessed the effect of thera-peutic massage among 51 female patients during breastcancer treatment. Participants completed a battery of self-administered instruments and health history onsite priorto the initiation of massage therapy and one week of post-massage therapy. The massage therapist collected andmaintained these instruments for data entry. The study in-struments were specifically designed to measure anxiety,31

pain,32 nausea,33 distress,34 sleep quality,35 and QoL36,37 andhad been used in previous breast cancer massage therapystudies (Table 1).5,7,27,29,38–44 The study was approved by theinstitutional review boards of the Via Christi Regional Med-ical Center, University of Kansas School of Medicine–Wichita,and Wichita Medical Research and Education Foundation.

Patient recruitment

Patients living within a 100-mile radius of Wichita wererecruited through physician referral; only patients with asigned physician order and informed consent participated inthe study. The investigators distributed study brochures tomedical oncologists, radiation oncologists, and other medicalstaff within the study region. Patient referral occurred atvarious stages of treatment; therefore, the timing of thetreatment interval and study enrollment was not controlled.Patients were excluded if they had contraindications to mas-sage therapy, including active skin rash, open cutaneous le-

sions, current diagnosis of venous thrombosis or symptomaticvaricosity, untreated anemia (hemoglobin< 8 mg=dL) orcurrent touch therapy (at least twice a month).

Instruments

We collected demographic data and health histories afterobtaining informed consent. Demographic data includedage, gender, ethnicity=race, education, area of residence(urban, suburban, rural=small town), profession, work sta-tus, and annual household income. Health history includedfamily history of cancer, histology, stage of cancer (primaryto reoccurrence), and types of cancer treatment (current andprevious). Researchers verified the type and stage of cancerthrough medical chart review.

QoL measures incorporate physical factors and psycho-social side effects, including stress, anxiety, weight gain,depression, fatigue, low self-esteem, and lost sense of con-trol.8,45 Instruments selected for this study were used inprevious massage therapy studies to measure QoL=healthstatus and have documented validity and reliability.

Procedures

Patients with breast cancer with a signed physician’s orderwere scheduled for an introductory assessment during whichthey completed a health history and all outcome instruments.The therapist accompanied patients to the massage room foran explanation of the massage process (draping, temperatureof room, exposure to relaxation music), and to clarify bodyareas that should be avoided during the massage (e.g., tumorsite, surgery site, peripherally inserted central catheter, ra-diation site). The massage therapist then left the room whilethe patient disrobed, re-entering only when the patient wasin a prone position on the massage table and covered witha sheet.

As is standard practice in massage therapy delivery, roomlights were dimmed and soft, soothing music was played toenhance relaxation during therapy.46,47 Swedish massagetechniques were employed for this study and adapted to eachpatient’s medical requirements, specifically to avoid pre-determined sites. The massage therapist used hypoallergenicmassage oils and therapy consisted of light, long, glidingstrokes; a relaxation and rehabilitation focused technique. Themassage began with effleurage strokes (gentle, rhythmic,gliding strokes) on the shoulders and upper back, workingcaudally to the lower spine. Then petrissage (gentle kneadingand friction) was added as the therapist moved from the backto hips, gluteal muscles, and extremities.5 In the supine po-sition, the massage therapist used effleurage and petrissageon the upper chest, neck, face, scalp, arms, hands, legs andfeet, with variation according to medical needs. Instruction onusing acupressure point P6 stimulation was taught to theclient for self-care of nausea and vomiting symptoms.48,49

After the completion of the 30-minute massage, the par-ticipant dressed. The therapist answered questions, encour-aged the participant to drink plenty of water, take a warmbath if desired, and rest as needed. The participant wasreminded of appointment times and to keep a record ofmedications and nausea=vomiting episodes. The final eval-uation, using the outcomes measures, occurred one weekafter the final massage treatment session.

374 STURGEON ET AL.

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Results

To describe the patient population, descriptive frequenciesfor categorical variables were performed, and measures ofcentral tendency for continuous variables. The hypothesisexploring the impact of therapeutic massage on individualparticipant outcomes was assessed using dependent t-tests inSPSS v.15.0. Statistical significance was confirmed for eachmeasure using an alpha level of 0.05. By calculating effect sizefor each item, researchers determined the effectiveness ofmassage treatment.

Participant characteristics

Fifty-one (51) women from the south central Kansas regionparticipated in this study: 84% were Caucasian, 60% weremarried, 49% reported some college education, 45% wereemployed full-time, and 73% lived in an urban or suburbansetting (Table 2). Participants’ mean age was 53 years. Ap-proximately two-thirds of the participants reported house-hold income above the median income ($43,802) for state ofKansas residents.52

Ductal carcinoma represented 84% of the sample, inflam-matory carcinoma represented 8%, ductal carcinoma in siturepresented 6%, and lobular carcinoma accounted for theremaining 2% (Table 3). Recurrent breast cancer (27%) andstage-two cancers (26%) dominated the stage classifications.

The majority (78%) reported using chemotherapy only, whileapproximately 61% reported currently receiving radiationtherapy or would be in the future.

Outcome measurements

Pre and post outcome measurements are reported for eachinstrument in Table 4. Researchers calculated the effect size foreach item as the correlation between the classification variableand individual scores in order to determine the effectivenessor magnitude of the treatment effect attributed to massagetherapy. Effect size measures (r2pb) for self-rated perceptionsof anxiety, pain, distress, and functionality had large correla-tion effects, ranging from 34% (FACT B Functional) to 20%(Visual Analog Pain). The large correlation effects indicate thatparticipants experienced improvements in anxiety, pain, dis-tress, and functionality largely as a result of massage therapy.The sleep scale shared variable correlation effects on thesubscales ranging from a small effect of 1% (spontaneity) to alarge effect of 36% (sleep satisfaction, quality, and distur-bance); overall the sleep scale had a moderate effect (7%).These findings suggest massage therapy had a greater impacton participants’ perceptions of their anxiety, pain, distress,and functionality and only a moderate effect on sleep.

Respondents’ cumulative pre- and post-massage mean forstate anxiety on the State and Trait Anxiety Inventory (STAI)was 38.5 and 35.4, respectively, and showed significant im-provement, t (45)¼ 2.18, p¼ 0.034. Trait anxiety cumulativepre and post massage means were 38.4 and 35.4, respectively,a significant reduction, t (45)¼ 2.20, p¼ 0.033. Post measuremeans are comparable to population norms of workingwomen. While participants reported decreased pain anddistress after massage therapy, changes were insignificant.

There was variability among study participants in re-ported episodes of nausea, vomiting, and retching (NVR).The majority of participants (86%) reported minimal or nodistress from NVR, 3 participants reported having at least 6days of NVR distress, and 4 reported < 3 days of NVR dis-tress; therefore, the results could not be analyzed.

Table 2. Participant Demographics

Area of residenceUrban 27 (53%)Suburban 10 (20%)Small town=rural 14 (27%)

Years of educationHigh school or less 6 (12%)Some college 25 (49%)College graduate 20 (39%)

Work statusEmployed full-time 23 (45%)Employed part-time 6 (12%)Unemployed 6 (12%)Retired 5 (10%)Disabled 9 (17%)Other 2 (4%)

Annual household income� $30,000 14 (28%)$30,001–$50,000 10 (20%)$50,001–$70,000 16 (31%)� $70,001 11 (21%)

Race=ethnicityCaucasian 43 (84%)African American 3 (6%)Hispanic 2 (4%)Other 3 (6%)

Age> 40 years 3 (6%)40–49 years 17 (33%)50–59 years 22 (43%)� 60 years 9 (18%)

Marital statusSingle 7 (13%)Separated=divorced 10 (19%)Widowed 4 (8%)Married 30 (60%)

Table 3. Breast Cancer Diagnoses

and Treatment Modality

HistologyDuctal carcinoma 43 (84%)Inflammatory carcinoma 4 (8%)Ductal carcinoma in situ 3 (6%)Lobular carcinoma 1 (2%)

StageI 8 (16%)IA 3 (6%)IB 1 (2%)II 13 (25%)III 5 (10%)IV 7 (14%)Recurrence 14 (27%)

Chemotherapy (Yes) 40 (78%)Radiation

None 16 (31%)To follow 12 (24%)Currently 19 (37%)Previous 4 (8%)

376 STURGEON ET AL.

The Snyder-Halpren-Verran Sleep Scale (VSH) sleep instru-ment measured eight areas of sleep quality and showed mixedresults. Time to get to sleep, soundness of sleep, and sleep sat-isfaction, quality, and disturbance showed significant changeswhen comparing pre versus post massage therapy percep-tions; however, the remaining scales were largely unchanged.The amount of time from settling down in bed until fallingasleep lasted on average 41 minutes before and 26 minutesafter massage therapy, a significant reduction, t (45)¼ 2.39,p¼ 0.02. Participants reported an overall improvement insoundness of sleep; pre-massage therapy mean score was 55,and 63 post-massage therapy, t (45)¼�2.00, p¼ 0.05. Overallsleep satisfaction, quality, and disturbance showed significantimprovement; pre- versus post mean scores were 57 and 66,respectively, t (45)¼�2.613, p¼ 0.01. The remaining fivesleep quality assessments had non significant changes.

Participant results suggested overall improvement in per-ceived functioning after massage therapy. The functionalassessment of cancer therapy, Version B (FACT-B) compositemean score increased 25 points, t (50)¼�2.217, p¼ 0.03, whilephysical well-being mean scores increased by 5.1 points,t (45)¼�2.116, p¼ 0.04. Social=family well-being concernswere enhanced on average by 4.4 points, t (49)¼�2.339,p¼ 0.02. The functional well-being mean score increased by5.6 points, t (46)¼�2.446, p¼ 0.02. Participants’ emotionalwell-being status and the item specific to breast cancer pa-tients showed no significant change from pre- to post-massagetherapy.

Discussion

The results of this prospective pilot study suggest massagetherapy performed once per week for three consecutive weeks

during breast cancer treatment had a positive influence onperceived quality of life concerns on half of the scales mea-sured, which parallels the results of other published re-search.6,7,31 In this study, self-reported pain was reduced, onaverage, 5 points on a 10-point scale. Moreover, effect sizeanalyses on pain and distress were 20% and 23%, respectively,which may be related to the influence of massage therapy. In asmall sample quasi-experimental study, Smith et al.29 re-ported improved scores for pain, sleep quality, symptomdistress, and anxiety from baseline. Although Hernandez-Reifet al.5,6 reported a marked reduction in pain, the massagetherapy protocols and pain instruments were dissimilar tothose used in this study, which may have contributed to dif-ferences in results. In addition, a portion of this study’s par-ticipants began massage therapy concurrently with radiationtreatment, which is associated with increased pain due to skinirritation.51 Because both therapies began and ended simul-taneously, reduction in pain and distress may have been dueto either massage therapy or the completion of radiationtherapy. Further research is needed to better understand therelationship between pain, distress, and quality of life.

The majority of participants in this study reported little to nogastrointestinal symptoms, an unexpected finding. Only onepatient, who had recurrent cancer, reported extreme distressassociated with NVR and five participants reported moderateNVR distress. This may be explained by many factors, such asthe use of antiemetic medications during the course of partic-ipants’ breast cancer treatment, introduction to acupressuretechniques, or adjustment to breast cancer treatment; however,researchers did not collect this information. Physicians, re-searchers, and patients should consider NVR assessment as anongoing process within breast cancer treatment.35 Additionalexploration of the effect of massage therapy on NVR is needed.

Table 4. Quality of Life Self-Ratings

Pre-intervention Post-intervention df t pEffect sizecorrelation

State and Trait Anxiety InventoryState 38.5� 11.6 35.4� 10.8 45 2.182 0.03 0.31Trait 38.4� 10.7 35.4� 9.7 45 2.202 0.03 0.31

Visual Analog Pain Scale 32.0� 25.2 27.2� 21.9 45 1.392 0.17 0.20Symptom Distress Scale 21.9� 6.5 20.6� 5.2 45 1.611 0.11 0.23Snyder-Halpren-Verran Sleep Scale

Total sleep scale score 325.9� 101.9 332.4� 87.4 45 �0.500 0.62 0.07Number of awakenings 18.5� 24.4 23.6� 28.9 45 �1.253 0.21 0.18Amount of movement 38.6� 38.6 38.1� 31.2 45 1.36 0.89 0.20Time from settling down to awakening 8.3� 9.5 6.8� 1.8 45 1.103 0.28 0.16Time from settling down to sleeping 40.8� 46.1 25.6� 20.3 45 2.393 0.02 0.33Soundness of sleep 55.1� 26.1 63.4� 26.5 45 �2.00 0.05 0.29Feeling rested upon awakening 52.8� 26.9 54.0� 27.2 45 �0.353 0.73 0.05Spontaneity of awakening 54.9� 32.2 55.1� 28.6 45 �0.072 0.94 0.01Sleep satisfaction, quality, disturbance 56.9� 23.7 65.8� 24.4 45 �2.613 0.01 0.36

Functional Assessment of CancerTherapy, Version B (FACT B)

FACT B composite score 75.0� 9.3 99.6� 78.2 50 �2.217 0.03 0.30Physical wellbeing 10.5� 6.5 15.4� 17.6 45 �2.116 0.04 0.30Social=family wellbeing 24.1� 6.2 28.5� 12.7 49 �2.339 0.02 0.32Functional wellbeing 18.3� 5.4 23.9� 14.5 46 �2.446 0.02 0.34Emotional wellbeing 7.1� 3.2 10.8� 13.9 44 �1.791 0.08 0.26Breast cancer 16.3� 4.6 21.5� 21.7 46 �1.616 0.11 0.23

Statistically significant differences are highlighted in bold. Effect size calculated from the point biserial correlation coefficient, rpb: small,0.0–0.01; medium, 0.022–0.059; large,� 0.083.

IMPACT OF THERAPEUTIC MASSAGE ON QOL IN BREAST CANCER 377

Three of the VSH subscales showed significant changesand moderate effect sizes after massage therapy, including:(1) time to fall asleep, (2) soundness of sleep and (3) sleepsatisfaction, quality, and disturbance. Smith et al., who alsoused the VSH instrument, did not report improvement onthis measure.29 Further evaluation of the influence ofmassage therapy on sleep may provide additional insightinto symptom cluster relationships and management. Otherinfluential factors for future study include medication use,side effects of chemotherapy medications, stressful life eventssuch as divorce or death of a loved one, and amelioratingfactors such as lifestyle choices (exercise and yoga).

Functional Assessment of Cancer Therapy, Version B(FACT-B) has not been used in any of the previous studies thatincorporated massage therapy protocols; this is the firstknown study to employ this measure. The FACT-B compositescore, as well as three additional sub-scores (physical, social,and functional measures) demonstrated significant improve-ment within the study timeframe and moderate effect sizes,suggesting massage therapy improves patients’ perceptionsof overall functionality during breast cancer treatment.

Limitations

The small sample size of this pilot study and lack of acontrol group for comparison were limitations related tofunding; the only funded portion of the study was paymentfor massage therapy services, and data collection and analysiswere performed as a study pilot. However, the sample size ofthis study is comparable to previous studies.5,6,10,29 Althoughpromotion for this study included all area medical and radi-ation oncologists, patients living near the treatment facilitiesdominated the sample, which may present a selection biasand restrict generalizability to breast cancer patients in Kan-sas. Self-report of symptoms may present measurement bias;however, this methodology is common among exploratorystudies. Changes in outcome measures may be associatedwith the relaxing environment in which the massage therapywas delivered; the accompanying music and soft lightingduring massage therapy is considered standard practice.48,49

Further research should explore the influence of music andsoft lighting during massage therapy.

Recommendations for future studies include massagetherapy protocols for more frequent sessions that are longerin duration, and sessions occurring throughout the courseof breast cancer treatment. Researchers measured outcomesat baseline and after three weeks; future research shouldcontinue monitoring outcomes postintervention to assesslong-term outcomes. In addition, objective assessment usingimmunological markers, such as cortisol levels, at variousstages throughout the treatment protocol would improvethe study design.

Generalizability could be strengthened with study designsthat include randomization, multiple sites, patients with asingle cancer diagnosis, treatment-specific divisions (e.g.,chemotherapy versus radiation), more frequent collection ofoutcome measures, and initiating massage therapy sessionswhen treatment begins. Finally, a record of stressful situationsoccurring during breast cancer treatment (e.g., change in so-cial support network, lymphedema, job-related stress, or di-vorce) would be valuable in explaining the influence of eventsexternal to breast cancer treatment.

Conclusions

Results of this study suggest an improvement in severalQOL measures among women undergoing breast cancertreatment after only three weeks of massage therapy. Copingsolutions, such as massage therapy, may assist women un-dergoing breast cancer treatment to better tolerate the sideaffects and improve QOL during treatment. As the survivalrates of breast cancer continue to rise, this considerationbecomes increasingly important. Sobel52 advocates strategiesthat help patients to cope with the side effects associatedwith breast cancer treatment and enhance their QOL. Thispilot study suggests therapeutic massage is a potentialstrategy to improve QOL symptom clusters for breast cancerpatients and survivors.

Acknowledgments

The Susan G. Komen Foundation, Via Christi RegionalMedical Center, and Wichita Medical Research and Educa-tion Foundation funded this research project.

Disclosure Statement

No competing financial interests exist.

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Address reprint requests to:Ruth Wetta-Hall, R.N., Ph.D., M.P.H., M.S.N.

Department of Preventive Medicine and Public HealthUniversity of Kansas School of Medicine–Wichita

1010 North KansasWichita, KS 67214-3199

E-mail: rwettaha@kumc.edu

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