Pathophysiology
- Cancer cells exhibit uncontrolled replication, loss of contact inhibition, ability to promote angiogenesis, and resistance to apoptosis
- Carcinoma: Malignant tumor originating in epithelial cells (skin or visceral organ linings). The most common type
- Sarcoma: Malignant tumor originating in connective or muscle tissue (bone, cartilage, fat, blood vessels)
- Hematologic cancers: Cancers of the blood and lymph — leukemia (bone marrow), lymphoma (lymphatic cells), myeloma (plasma cells)
- Metastasis: Spread from a primary site to secondary sites via the circulatory system, lymphatic system, direct contact, or peritoneal fluid
- The sentinel node (closest to the primary tumor) is the most likely site for early metastasis. Its biopsy status determines whether cancer remains localized
- TNM staging: T = tumor size/extent (T1-T4). N = regional lymph node involvement (N0-N3). M = distant metastasis (M0-M1)
Signs and Symptoms
Hallmark Indicators
- Unexplained weight loss (>10 lbs in 2 weeks), unwarranted fatigue not relieved by rest, persistent fever
- Sores that do not heal. Changes in warts or moles (ABCDE rule: Asymmetry, irregular Border, variegated Color, Diameter >6 mm, Evolving)
- Enlarged, firm, nontender, and fixed lymph nodes (malignant nodes are typically immobile, unlike mobile, tender infectious nodes)
- Deep, aching bone pain that worsens at night and is unrelated to activity or injury
- Persistent change in bowel or bladder habits (lasting >10 days) or blood in stool/urine
- Shortness of breath or persistent hoarseness during activity
Red Flags and Rule-Outs
- Undiagnosed persistent lump or sore: Absolute contraindication. Requires immediate medical referral
- Fixed, firm, nontender lymph node: Distinguishes malignant adenopathy from reactive infectious nodes (mobile, tender)
- Deep bone pain worse at night, unrelated to injury: Suggests primary bone cancer or metastatic bone disease
- Unexplained weight loss + fatigue + fever: Constitutional signs indicating systemic malignancy
- Non-healing sore with ABCDE features: Skin cancer — immediate dermatology referral
- Active cancer diagnosis = DVT risk factor: Wells criteria automatically scores +1 for active cancer. Screen for unilateral leg swelling, warmth, and tenderness before deep or compressive work
MT Considerations
- Safety principle: Massage does not spread cancer. Decisions are based on the client's clinical presentation, not the diagnosis alone
- Goal: Supportive care to alleviate pain, anxiety, nausea, fatigue, depression, insomnia, and constipation
- Absolute contraindication: Undiagnosed cancer. Any persistent unexplained lump requires immediate medical referral
- Local contraindications: Active tumor sites, recent surgical or radiation areas, undiagnosed skin lesions, medical devices (ports, catheters, stomas)
- Surgery: Avoid locally over unhealed wounds. Accommodate ports, catheters, and stomas. Scar tissue work may improve ROM once healed (see mastectomy)
- Radiation: Local contraindication during and immediately after treatment. May cause chronic tissue fibrosis. Never blur ink markings. Clients on radioactive iodine must be in isolation (see radiation-therapy)
- Chemotherapy: Severe immunosuppression (therapist must not carry active pathogens). Thrombocytopenia increases bruising/bleeding risk. Neuropathy requires pressure modification. Time sessions around drug excretion rates (see chemotherapy)
- Bone fragility: Cancers commonly metastasize to bones (breast, thyroid, kidney, lung, prostate), creating pathologic fracture risk. Rigorous massage is contraindicated over affected areas
- DVT risk: Active cancer is a major DVT risk factor. Screen using Wells criteria before compressive lower extremity work
- Analgesic masking: Strong pain medications mask pain, increasing risk of accidental overtreatment. Use conservative pressure
- Cancer-related fatigue: Affects 70-100% of patients during treatment. Not relieved by rest. Sessions should be shorter and less demanding
- Lymphedema: Surgery or radiation damaging lymph nodes causes protein-rich fluid accumulation. Affected limbs require conservative massage or specialized MLD
- Immunotherapy: Clients on checkpoint inhibitors (pembrolizumab/Keytruda, nivolumab/Opdivo) may have immune-mediated skin reactions, fatigue, and neuropathy. These drugs activate (not suppress) the immune system — the concern is inflammation, not immunosuppression. Avoid massage over active skin rashes. For targeted therapies (imatinib/Gleevec), watch for edema and hand-foot syndrome
CMTO Exam Relevance
- Undiagnosed cancer is an absolute contraindication. Persistent unexplained lump or sore requires immediate referral
- Know the ABCDE mnemonic and the "Ugly Duckling" principle for skin assessment
- Distinguish cancerous lymph nodes (fixed, firm, nontender) from infectious nodes (mobile, tender)
- Red flag: deep bone pain worse at night, not related to activity or injury
- Cancer treatment side effects (surgery, radiation, chemotherapy) each carry distinct massage precautions
- Active cancer = automatic +1 point on Wells DVT criteria
Key Takeaways
- Cancer is a group of 100+ disorders involving uncontrolled cell replication. Massage is safe and effective supportive care when adjusted for clinical presentation
- Undiagnosed cancer is an absolute contraindication. Therapists must recognize red flags (ABCDE rule, fixed lymph nodes, night bone pain, unexplained weight loss)
- Treatment side effects (surgery, radiation, chemotherapy, immunotherapy) each carry specific precautions including immunosuppression, tissue fragility, bone metastasis, and DVT risk
- The sentinel node is the most likely site for early metastasis. Its biopsy status determines extent of surgical resection
- Massage decisions are driven by the client's current clinical presentation and treatment status, not the cancer diagnosis alone