- Massage involves the manipulation of the body’s muscles and soft tissues
- Some evidence indicates that massage may, decrease pain and improve quality of life, nausea, anxiety, stress, fatigue, anger and depression in individuals diagnosed with cancer
- The methodological quality of the research published to date is however mixed
- Massage for cancer patients is generally safe
Classical/Swedish massage involves mechanical manipulation of muscles and soft tissues. Practitioners claim that massage may have several positive effects in the treatment of people suffering from cancer, including psychological improvements (e.g. reduction of anxiety and depression) or alleviation of physical symptoms associated with cancer (e.g. reduction of nausea and strengthening of the immune system). Massage has also been promoted to improve overall quality of life.
Evidence from six systematic reviews (four of which included a meta-analysis), one non-systematic review as well as an additional four controlled trials published after the systematic reviews suggests massage may improve cancer pain and that massage may be a useful supportive care intervention in both adults and children with cancer. The positive health-related quality of life outcomes reported in the studies however are not consistent across the symptoms, so no clear pattern is apparent of benefits for specific symptoms.
Overall, there is some evidence that classical/Swedish massage administered as a symptomatic treatment has benefits for cancer patients and is generally safe. It is not possible to draw firm conclusions due to mixed methodological quality of the available research. Documentation indicates that contraindications include strong forceful massage in patients suffering from haemorrhagic disorders, low platelet counts, and blood thinning medication.
Fully updated and revised in September 2016 by Helen Cooke.
Updated and revised in December 2013 by Helen Cooke.
Summary updated in January 2012 by Helen Cooke.
Summary first published in October 2010, authored by Helen Seers.
Helen Cooke, Helen Seers, CAM-Cancer Consortium. Massage (Classical/Swedish) [online document], http://cam-cancer.org/en/massage-classicalswedish. September 28, 2016.
Massage involves kneading, stroking or rubbing, and sometimes vibration, of the body’s muscle and soft tissues. Massage therapists commonly use their hands, and sometimes also their forearms, feet and elbows to treat their clients. Special rollers, water pressure or vibrating tools may also be used as part of a massage session. Lubricants such as oils and diluted essential oils are sometimes used to facilitate smoother massage and in order to avoiding skin irritation. Massage may be deep or more light/shallow.
A variety of massage therapies exist. For the purposes of this CAM summary, only classical/Swedish massage will be reviewed. The majority of research has been carried out on this type of massage.
In Swedish massage soft tissues are manipulated by the use of:
- Effleurage: light gliding strokes of the skin;
- Petrissage: lifting, pressing and kneading skin and muscles;
- Friction: rubbing of skin and muscles;
- Tapotement: rapid tapping, rhythmical movements of the skin and muscles;
- Vibration: vibration of the skin1,2.
Massage therapy is sometimes provided by nurses or physiotherapists as an adjunct to standard medical care, but usually undertaken by licensed massage practitioners. At the first massage session, patients are often asked about their diet, medical history, lifestyle and current symptoms. Most commonly, massage is given while the patient is lying on a soft table, couch or bed, covered by a clean sheet. Patients are covered by towels or sheets to help keep warm during a treatment session. The client may lie face down for half the massage and then turn over. A typical massage lasts from 30 to 60 minutes, and the number of subsequent sessions depends on the condition.
The use of massage therapy in fever, chills and paralysis dates back to 2700 BC and also appears in early Japanese, Roman, Greek, Arabic, Egyptian and Indian history1. Massage became popular in the renaissance and spread throughout Europe, but it was only in the 19th and 20th century that massage, and in particular Swedish massage, became familiar to the general public. Swedish massage, developed Swedish physician Per Henrik Ling in the early 1800s, is currently one of the most commonly used forms of massage.
Claims of efficacy/alleged indications
Massage practitioners claim that massage may have positive benefits for people with cancer, such as reduced anxiety, depression, stress, tension and insomnia; and improved self-image and quality of life. Practitioners also claim that massage can reduce pain, muscle tension, nausea, constipation, lymphodema and scarring. Massage practitioners claim that their intervention is safe and that it does not result in the spreading of cancer.
Mechanism of action
Massage is thought to bring about psychological and physiological changes which include: psychological relaxation, improvement in mood, reduction in blood pressure, increase in pain threshold, reduction in muscle tension, and improvement in blood and lymph circulation2-9. Some evidence seems to indicate changes in biological markers in the blood when tested before and after massage, including an increase in natural killer cells and lymphocytes, serotonin (5-hydroxytryptamine), and dopamine10.
Prevalence of use
Massage is a popular treatment modality across the world. A European Survey of cancer patients reported that 3.9 % of respondents used massage after their cancer diagnosis11. Use varies across the different cancers with 15-18% of breast and gynaecological cancer patients using massage after diagnosis compared with less than 10% use by people with colorectal, haematological or lung cancer12-16.
Massage is used globally for people with cancer, although legislation varies from country to country. No mandatory regulation of massage therapists although massage may also be provided by registered health professionals including nurses and physiotherapists. In the UK, massage therapists may voluntarily register with the Complementary and Natural Healthcare Council (CNHC).
Prices often range from £20 to £60 (30 to 70 Euros) for a single massage session13. Some charities offer free treatment for people with cancer.
There is evidence available from six systematic reviews, one non-systematic review, three RCTs and one non-randomised controlled trial assessing various outcomes in the supportive and palliative treatment of cancer. Two systematic reviews on cancer pain suggest that massage therapy may reduce cancer pain (especially surgery-related pain) in the short-term. In terms of other positive health-related quality of life outcomes reported in the studies, findings are not consistent, so no clear pattern is apparent of benefits for specific symptoms. Preliminary evidence also suggests massage may be a helpful supportive care intervention for children with cancer.
In all trials of massage there is a risk of bias affecting reported results, particularly if outcomes are subjective and self-reported, because it is not possible to use adequate blinding. All included reviews and clinical trials had methodological shortcomings that limit their findings.
A systematic review and meta-analysis by Boyd et al. (2016) examined the impact of massage therapy on function in cancer pain18. Sixteen studies (n= 2034) published until February 2014 were included in the review. Samueli Institute’s Systematic Rapid Evidence Assessment of Literature review process was utilised. Methodological quality was assessed using the SIGN 50 Checklist. Twelve of the studies were considered high quality and four low quality using the checklist. Results of 11 of the 14 studies indicated massage therapy to be effective for treating cancer pain, the remaining 3 studies displayed non-significant results. Three studies (n=167 cancer patients) were pooled for the meta-analysis Standardised Mean Difference (SMD) was −0.20: 95% CI, −0.99 to 0.59 compared with no treatment and −0.55 (95% CI, −1.23 to 0.14; I2 = 89.26%) compared with active comparators for a reduction of pain intensity/severity; the results are therefore not conclusive.
A systematic review by Lee et al (2015) investigated the effects of massage therapy for all types of cancer patients experiencing pain19. Nine electronic databases were searched for studies published through August 2013 in English, Chinese, and Korean. The search included a wide range of databases without language restrictions. To reduce bias caused by the use of different pain assessment scales only trials that used the Visual Analogue Scale (VAS), Brief Pain Inventory (BPI), Numeric Rating Scale (NRS) and Present Pain Inventory (PPI) were included. Methodological quality was assessed using the Physiotherapy Evidence Database (PEDro) and Cochrane risk-of-bias scales. Twelve RCTs (total sample size n=559) were included in the meta-analysis. Results indicated that massage therapy significantly reduced cancer pain (especially surgery-related pain) compared with no massage treatment or conventional care (SMD), −1.25; 95% CI, −1.63 to −0.87). No details of the type of conventional care were provided and several different types of massage were included. Among the various types of massage, foot reflexology appeared to be more effective than body or aroma massage. The review has some limitations. Possible selection bias and the small number of long-term studies included in the analysis therefore render this evidence insufficient to suggest that massage is an effective long-term care option for patients with cancer pain.
This second review by Lee et al19 demonstrated larger overall effect sizes for massage on cancer pain. Reasons for these differences might be that Lee et al searched a larger number of databases, included other types of massage (reflexology/shiatsu) and did not limit their searches to English language compared with the Boyd et al review; the reviews also used different methods for appraising the methodology of the included trials.
Palliative and supportive care – various outcomes
A Cochrane systematic review and meta-analysis by Shin et al. (2016) examined the impact of massage with or without aromatherapy for symptom relief in people with cancer20. Eight electronic databases were searched for studies published through August 2015 with no language restriction. 19 studies (n=1274) were included in the review. Meta-analysis was conducted on 5 studies. Methodological components of the trials were assessed according to the Cochrane Handbook for Systematic Reviews of Interventions. Evidence was assessed using GRADE (Grading of Recommendations Assessment, Development and Evaluation). Results for massage without aromatherapy were only given in this review. Short-term pain (Present Pain Intensity-Visual Analogue Scale) was greater for the massage group compared with the no-massage group (one RCT, n = 72, mean difference (MD) -1.60, 95% confidence interval (CI) -2.67 to -0.53).
The data for anxiety (State-Trait Anxiety Inventory-state) relief showed no significant difference in anxiety between the groups (three RCTs, n = 98, combined MD -5.36, 95% CI -16.06 to 5.34).
The subgroup analysis for anxiety demonstrated that the anxiety relief for children was greater for the massage group compared with the no-massage group (one RCT, n = 30, MD -14.70, 95% CI -19.33 to -10.07). The size of this effect was not considered clinically significant.
The review demonstrated no differences in effects of massage on depression, mood disturbance, psychological distress, nausea, fatigue, physical symptom distress, or quality of life when compared with no massage. The quality of the included trials was low, the majority of the studies were small and the results were not consistent and not reliable.
In the above-mentioned systematic review by Boyd et al (Boyd 2016) massage therapy was also found to be beneficial for treating fatigue (SMD, −1.06 (95% CI, −2.18 to 0.05; I2 = 92.81% and stress, mood and health-related quality of life (SMD, −1.24 (95% CI, −2.44 to −0.03; I2 = 93.56%) compared to active comparators. This review however provides only limited evidence for the benefits of massage as the size of the benefits are moderate.
A systematic review by Pan et al (2014) examined whether massage interventions provide any measurable benefit in breast cancer-related symptoms21. It assessed various outcomes and used a range of assessment scales such as pressure pain thresholds, the Profile of Mood State Questionnaire, Short Form-8 Health Survey, and Giessen Complaints Inventory. Three electronic databases were searched for studies published to June 2013 in English. Risk of bias of the studies was evaluated using the Cochrane standards. Eighteen RCTs (total sample size n=950) were included. The control groups varied from self-initiated support (four trials), standard healthcare (seven trials), health education classes (two trials), visit (one trial), modified massage treatment (one trial), bandaging (one trial) and self-administered support (one trial). Compared with the control group, the meta-analysis showed that patients receiving regular use of massage had significantly greater reductions in anger, pain, and fatigue. There were no significant differences in depression, anxiety, upper limb lymphedema, cortisol or health-related quality of life. Although a significant reduction in pain was reported in the results, the discussion section highlighted the fact analgesics (and anti-emetics) were used by some of the participants in the trials and this was inadequately controlled. The small number of databases searched and poor methodological quality of some of the included trials (lack of control of non-specific effects and inadequate control groups) limits the quality of this review.
Ernst (2009)22 conducted a systematic review including RCTs testing the effectiveness of classical massage on palliative and supportive care for cancer patients. Fourteen RCTs published up until November 2008 were identified. Overall results suggested that massage may help relieve pain, nausea, anxiety, fatigue, stress, anger and depression. However, due to methodological shortcomings including small sample sizes, adequate control interventions, and lack of evaluation of long-term effects the evidence was considered not to be conclusive.
Wilkinsonet al.(2006)23 conducted a systematic review which evaluated the evidence base for the effectiveness of massage (including aromatherapy) for people with cancer, particularly considering quality of life, psychological or physical problems and adverse effects. They considered any trials published up to September 2006, and included RCTs, pre-post test studies and interrupted time-series studies. A total of ten studies were identified. Results suggested that massage may reduce anxiety on a short term, and it may reduce physical symptoms in cancer patients, such as nausea and pain. Again, methodological short-comings prevent firm conclusions.
Controlled clinical trials
A large RCT (n=280) published after the above-mentioned reviews RCT assessed the effect of aromatherapy and classic massage administered in various ways (1st group inhaled aromatic oils, 2nd group classic massage only, 3rd group received massage and inhaled aromatic oils) breast cancer patients receiving chemotherapy on their symptoms and quality of life24. The control group received standard care at the chemotherapy department. A significant difference was found between the control and intervention groups in terms of quality of life scale subdomain scores for general well-being, appetite, sexual function (P < 0.001), physical symptoms and activity, and medical interaction and the overall total quality of life score averages (P < 0.05). For the quality of life scale, the overall and subdomain score averages decreased over time in the control group, whereas an increase was observed in the score averages of the intervention groups. No significant difference was determined between the all groups regarding the quality of life scale score averages for the sleep, perception, social relations, and work performance subdomains (P > 0.05). Aromatherapy massage was found to be especially effective.
An RCT examining the effect of massage therapy on the quality of sleep in breast cancer patients (n=57) reported significant differences (P < 0.001) in the mean scores of quality of sleep before and after in the intervention group, while no significant differences (P > 0.05) were observed in the mean scores of quality of sleep before and after the intervention in the control group25. Significant differences (P<0.001) were observed in the mean scores of quality of sleep after the intervention between the case and control groups. Participants received twenty minutes of massage three times a week for four weeks.
The feasibility of a massage intervention delivered over the continuum of care, as well as assessment of the immediate and cumulative effects of massage, was examined in an RCT in patients with acute myelogenous leukemia26. Participants (n=20) received fifty minutes of gentle Swedish massage three times a week for seven weeks. Massage therapy was carried out in both acute care and home settings. Significant improvements in levels of stress and health-related quality of life (P<0.001) were observed in the massage therapy group versus the usual care alone control group. The relatively small size of the study sample limits generalizability. Also, the participants were not followed up post-intervention to examine the level of symptoms following the intervention and treatment period.
Cancer in children
Hughes et al.(2008)27 evaluated massage as a supportive care intervention for children with cancer. Their non-systematic review concluded that light to medium pressure massage may help reduce pain, anxiety, depression, constipation and high blood pressure in children with cancer. Furthermore they found that massage could help support the function of the immune system during periods of immune suppression following cancer treatments such as chemotherapy. However, these conclusions cannot be considered reliable due to lack of quality assessment and inclusion of a wide range of literature indicating that the review was non-systematic.
Controlled clinical trials
A small (n=25) non-randomised controlled trial investigated the effect of massage therapy on pain and anxiety arising from intrathecal therapy or bone marrow aspiration in children with cancer28. The control group received standard care. When the pretest and posttest pain and anxiety levels of the groups were compared, no statistically significant difference was found (P > 0.05). Limitations include a small self—selected sample.
A 2016 Cochrane review20 found no trials reporting adverse events of massage with aromatherapy or massage without aromatherapy. Ernst (2003)  summarized the existing documentation on adverse effects of massage therapy. The majority of adverse effects arose from the use of exotic (non-Swedish) massage techniques and is therefore not applicable to this review. Whilst massage is not risk free, serious adverse effects are rare.
A concern that has been raised is the theory that massage of a tumour site may induce the spreading of cancer cells and development of metastasis. There is no evidence to date that therapeutic massage interventions may have such effects10, but direct pressure on a tumour site is usually discouraged in massage practice.
Strong massage may cause complications in people with haemorrhagic disorders, low platelet counts or those taking blood thinning medication (e.g. heparin or warfarin)1. Other contraindications include phlebitis, deep vein thrombosis, burns, skin infections, open wounds, bone fractures and advanced osteoporosis.
If essential oils and massage lubricants are used interactions are possible may cause allergic reactions1.
- Natural Medicines Database: Massage. Available online, accessed 26thFebruary 2016.
- Ernst E, Pittler MH, Wider B, Boddy K (2008) Oxford Handbook of Complementary Medicine. Oxford University Press, Oxford.
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- Frey Law LA, Evans S, Knudtson J, Nus S, Scholl K, Sluka KA (2008) Massage reduces pain perception and hyperalgesia in experimental muscle pain: a randomized, controlled trial. J Pain 9(8):714–721
- Coelho HF, Boddy K, Ernst E (2008) Massage therapy for the treatment of depression: a systematic review. Int J Clin Pract 62(2):325–333
- Durkin JL, Harvey A, Hughson RL, Callaghan JP (2006) The effects of lumbar massage on muscle fatigue, muscle oxygenation, low back discomfort, and driver performance during prolonged driving. Ergonomics 49(1):28–44
- Ouchi Y, Kanno T, Okada H, Yoshikawa E, Shinke T, Nagasawa S et al (2006) Changes in cerebral blood flow under the prone condition with and without massage. Neurosci Lett 407(2):131–135
- Aourell M, Skoog M, Carleson J (2005) Effects of Swedish massage on blood pressure. Complement Ther Clin Pract 11(4):242–246
- Mori H, Ohsawa H, Tanaka TH, Taniwaki E, Leisman G, Nishijo K (2004) Effect of massage on blood flow and muscle fatigue following isometric lumbar exercise. Med Sci Monit 10(5):CR173–CR17
- Corbin L. Safety and efficacy of massage therapy for patients with cancer. Cancer Control. 2005; 12(3):158-64.
- Demmer C. A survey of complementary therapy services provided by hospices. J Palliat Med. 2004; 7(4): 510-6
- Molassiotis A et al. Use of complementary and alternative medicine in cancer patients: a European survey. Annals of Oncology 2005; 16: 655-653
- Molassiotis A, Scott JA, Kearney N, Pud D, Magri M, Selvekerova S, Bruyns I, Fernadez-Ortega P, Panteli V, Margulies A, Gudmundsdottir G, Milovics L, Ozden G, Platin N, Patiraki E. Complementary and alternative medicine use in breast cancer patients in Europe. Support Care Cancer. 2006a 14(3):260-7.
- Molassiotis A, Browall M, Milovics L, Panteli V, Patiraki E, Fernandez-Ortega P. Complementary and alternative medicine use in patients with gynecological cancers in Europe. Int J Gynecol Cancer. 2006b Jan-Feb;16 Suppl 1:219-24.
- Molassiotis A, Fernandez-Ortega P, Pud D, Ozden G, Platin N, Hummerston S, Scott JA, Panteli V, Gudmundsdottir G, Selvekerova S, Patiraki E, Kearney N. Complementary and alternative medicine use in colorectal cancer patients in seven European countries. Complement Ther Med. 2005a Dec;13(4):251-7. Epub 2005 Sep 19.
- Molassiotis A, Margulies A, Fernandez-Ortega P, Pud D, Panteli V, Bruyns I, Scott JA, Gudmundsdottir G, Browall M, Madsen E, Ozden G, Magri M, Selvekerova S, Platin N, Kearney N, Patiraki E. Complementary and alternative medicine use in patients with haematological malignancies in Europe. Complement Ther Clin Pract. 2005b May;11(2):105-10.
- Molassiotis A, Panteli V, Patiraki E, Ozden G, Platin N, Madsen E, Browall M, Fernandez-Ortega P, Pud D, Margulies A. Complementary and alternative medicine use in lung cancer patients in eight European countries. Complement Ther Clin Pract. 2006c Feb;12(1):34-9. Epub 2005 Nov 14.
- Boyd C, Crawford C, Paat CF, Price A, Xenakis L, Zhang W; Evidence for Massage Therapy (EMT) Working Group. The Impact of Massage Therapy on Function in Pain Populations-A Systematic Review and Meta-Analysis of Randomized Controlled Trials: Part II, Cancer Pain Populations. Pain Med. 2016 May 10.
- Lee, S. H., J. Y. Kim, S. Yeo, S. H. Kim and S. Lim. Meta-Analysis of Massage Therapy on Cancer Pain. Integr Cancer Ther 2015 14: 297-304.
- Shin ES, Seo KH, Lee SH, Jang JE, Jung YM, Kim MJ, Yeon JY. Massage with or without aromatherapy for symptom relief in people with cancer. Cochrane Database Systematic Review. 2016 Jun 3;6:CD009873.
- Pan, Y. Q., K. H. Yang, Y. L. Wang, L. P. Zhang and H. Q. Liang (2014)
Massage interventions and treatment-related side effects of breast cancer: a systematic review and meta-analysis. International Journal of Clinical Oncology 19, 829-841
- Ernst E. Massage therapy for cancer palliation and supportive care: a systematic review of randomised clinical trials. Support Care Cancer. 2009 Apr;17(4):333-7. Epub 2009 Jan 13.
- Wilkinson S, Barnes K, Storey L. Massage for symptom relief in patients with cancer: systematic review. J Adv Nurs. 2008; 63(5):430-9.
- Ovayolu, O., U. Sevig, N. Ovayolu and A. Sevinc. The effect of aromatherapy and massage administered in different ways to women with breast cancer on their symptoms and quality of life. Int J Nurs Pract 2014 20: 408-417.
- Kashani, F. and P. Kashani. The effect of massage therapy on the quality of sleep in breast cancer patients. Iran J Nurs Midwifery Res 2014 19: 113-118.
- Taylor, A. G., A. E. Snyder, J. G. Anderson, C. J. Brown, J. J. Densmore and C. Bourguignon. Gentle Massage Improves Disease- and Treatment-Related Symptoms in Patients with Acute Myelogenous Leukemia. J Clin Trials 2014 4.
- Hughes D. Ladas E. Rooney D. Kelly K. Massage therapy as a supportive care intervention for children with cancer. Oncology Nursing Forum. 2008; 35(3):431-42.
- Celebioglu, A., A. Gurol, Z. K. Yildirim and M. Buyukavci. Effects of massage therapy on pain and anxiety arising from intrathecal therapy or one marrow aspiration in children with cancer. Int J Nurs Pract 2014.
- Ernst E. The safety of massage therapy. Rheumatology (Oxford). 2003 Sep;42(9):1101-6.