On social media or the news, we occasionally read a comment or thread about how some people with cancer are turned away from a spa or massage clinic because they checked “Cancer” on their health history form or told the therapist or receptionist that they have cancer.

It doesn’t even matter much what type of cancer the person has. A journalist in the U.K., who was diagnosed with cancer, wrote her experience in The Guardian in 2015 about the vulnerability she felt when she fills out a questionnaire that most spas make you fill out before receiving a service.

“Because spas, on the whole, are scared of people like me,” she wrote. “Most do not have therapists trained specifically in how to treat them, and the default position in most spas is to refuse many treatments — massage especially.”

Massage therapy education, in general, do not have a strong foundation in understanding many diseases and disorders that therapists may likely face at work. Since cancer affects many people from nearly all walks of life, the chances of us meeting a new client or patient with cancer can be higher than what we expect.

What you need to know about cancer and massage therapy

A common myth about cancer is that massage can somehow “spread” cancer cells to other parts of the body, as if we can manually squeegee these cells through the blood or lymph circulation into other body parts. However, this feat is highly unlikely.

Although there are about 200 different types of human cancers that exhibit different behaviors and have different properties, they have very similar characteristics that help us understand how they grow and spread. Cancers start out as tumors, but not all tumors give birth to cancer.

Benign tumors pose little risk to our health because they are localized and small. These bundles of cells are held together by the surface tension of the cells’ molecules—like how two small wet pieces of paper tend to stick together—which are separated by a fibrous capsule.

Since they are localized to local healthy tissues, surgeons can easily identify them and remove them. However, benign tumors can be a big problem if they are large enough to interfere with our daily activities, affect our social lives (e.g. huge wart on nose or forehead), or secrete too much biologically active substances like hormones.

While describing all types of cancer cells is beyond the scope of this article, different subtypes have common characteristics.

– Constitutes 90% of all human cancers
– Originates from epithelial tissues
– Affects mostly in people age 50 and older
– Examples: lung, breast, colon, prostate, ovary, stomach

– Constitutes about 1% of all human cancers
– Originates from mesodermal tissues
– Affects all ages and genders
– Examples: bone, muscle, nerves, blood, lymph nodes

– Type of sarcoma that originates in bone marrow
– Affects children and adults
– Symptoms: fatigue, lower physical exertion, breathlessness, reduced ability to clot blood, higher risk of getting infection

– Type of sarcoma that originates in lymth nodes and lymphoid organs (e.g. tonsils, spleen)
– Affects young adults (20s) and older adults (70+)
– Symptoms: Fever, enlarged lymph nodes, fatigue, unexplained weight loss, excessive night sweating

Malignant tumors are the ones that we need to be more concerned about. Not only do they multiply and proliferate in a bundle like benign tumors, they do not always stay in one place. These cells can invade surrounding tissues via the circulatory systems and set up new camps away from their original base. This spread of tumors cells is called metastasis.

We can observe the differences between normal cells and cancer cells with a microscope. The latter is usually less differentiated than normal or benign tumor cells, usually have larger nucleus and less cytoplasm space, have a distinguished-looking nucleoli, and fewer specialized structures. However, these malignant cells still retain some characteristics of normal cells, which helps oncologists identify the type of cancer.

Among normal cells, they maintain their territories by a physical membrane called the basal lamina, or basement membrane, which underlies layers of epithelial cells and distinguishes the surfaces of external and internal epithelia and the structure of blood vessels. Contrary to what some massage therapists believe, malignant cells do not “break off” and travel through the bloodstream when manual pressure is applied to the cancerous area.

Instead, malignant cells produce excessive cell-surface receptors for the proteins and polysaccharides (complex chains of carbohydrates) composing the basal laminae, such as collagens and proteoglycans. The proteins of the laminae get digested by a type of hormone secreted by most tumor cells called plasminogen activator, which chops the peptide bond of the laminae and weakens its integrity. This allows tumors cells to eventually release themselves from their cage and enter the bloodstream.

Not all tumor cells will survive the trip in the bloodstream; the odds of any tumor cells form a second breeding site is less than 1 in 10,000 cells.

Related story: [If Cancer Feeds on Lactate, Wouldn’t More Athletes Get Cancer?]

What does research say about massage and cancer?

While many cancer patients and massage therapists may testify that massage is pretty effective in alleviating symptoms of cancer, such as pain and nausea, scientific evidence in the past 20 or so years indicates short-term positive effects of such symptoms.

Two systematic reviews on massage’s effectiveness for cancer is quite mixed on the results because of the lack of consistency of the research methods and the definition of “massage,” small sample sizes, bias in reporting and sampling, variations in duration, type, and frequency of treatment, and favoring positive outcomes (publication bias).

For example, a 2008 systematic review found various randomized-controlled trials (n=10) had mixed results in improvements in anxiety, depression, and other psychological symptoms. Some trials had significant improvements while some had reported no change.

Another systematic review published in 2016 found massage therapy to have some effectiveness for alleviating pain among cancer patients, despite the evidence quality being weak.

Larger studies with almost 700 patients were recently conducted by two hospitals—Memorial Sloan Kettering Cancer Center in New York City and Abramson Cancer Center at the University of Pennsylvania—found that 93 percent of the patients who received massage therapy from a family member or significant other (who were given massage instructions from a DVD) were satisfied with the massage. The patients self-reported a larger reduction in nausea, pain, anxiety, and fatigue than a control group who did not receive massage but were read to instead.

What massage benefits are there for cancer patients?

Although the evidence for massage therapy’s effectiveness is weak due to many problems, there’s very little evidence why cancer should not receive quality massage therapy as part of their care.

While there isn’t much difference in techniques between oncology massage and a typical Swedish massage, therapists must understand the biology behind cancer and psychosocial issues that cancer patients endure. This understanding drives how the treatment is done and how to communicate with clients and patients.

While some therapists may think that massage itself has a high effect on how cancer patients feel, some research reveals that patients’ expectations, attitude, and relationship with the therapist, and how confident therapists are with their work and what they say, can also affect the patients’ outcome.

In other words, if the patients know, like, and trust the therapist, then they are more likely to perceive massage therapy as highly beneficial to help them alleviate symptoms, almost regardless of the type of massage. Thus, massage therapists should be proficient in communicating with patients, other healthcare professionals, and the patients’ family and friends, not just the hands-on work itself.

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A native of San Diego for nearly 40 years, Nick Ng is an editor of Massage & Fitness Magazine, an online publication for manual therapists and the public who want to explore the science behind touch, pain, and exercise, and how to apply that in their hands-on practice or daily lives.

An alumni from San Diego State University with a B.A. in Graphic Communications, Nick also completed his massage therapy training at International Professional School of Bodywork in San Diego in 2014.

When he is not writing or reading, you would likely find him weightlifting at the gym, salsa dancing, or exploring new areas to walk and eat around Southern California.