Ethics (Mine), Massage Therapy, and Cancer Spread

A debate was recently revived around the possibility of massage therapy spreading cancer. I encourage all oncology massage therapists, massage therapy instructors, and interested parties to catch up on that conversation. Links are at the bottom of this post.

The conversation recently took a disagreeable turn when my judgment and professional ethics were challenged. It’s a serious accusation, deserving a serious response. This post is my serious response.

For those who have missed it, our dispute has focused on the role of a single massage study. We disagree about how to use it, and I’ve been faulted for questioning it. Here is an open letter to the two authors who cited the research, then used that research to mount a challenge to the practice of oncology massage therapy.

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Dr. Turchaninov and Dr. Cullers, the foundation of your argument is that I am attacking a “bulletproof” study from a respected group of oncologists, and in doing so I’ve succumbed to personal opinion and bias.

And yet…

The quality of the Wang et al. (2014) study on massage in bone cancer is not, in and of itself, the foundation of my position.

(I do think it is far from “bulletproof,” and I don’t think the investigators’ credentials carry your argument for you when they have left out so much critical information, but I already stated that and I’ll just leave that there.)

My position: You have misinterpreted the study findings.

You are trying to take a study of a certain time point (massage given pre-cancer-diagnosis, nothing known about cancer) and apply it to a different time point (massage post-cancer-diagnosis, lots known about cancer). You are using this to justify your guideline, that all massage therapy should be stopped after diagnosis, then resumed after cancer treatment starts, in order to avoid spreading cancer during that window.

One medical director has already looked at Wang’s work and the  poor cancer outcomes following pre-diagnosis manipulative therapy. That physician observed that it is entirely different from the work of oncology massage therapists, post-diagnosis.

The difference?

Pre-diagnosis, MTs are pressing away, with various levels of skill, trying to relieve pain that does not have a cause that they can relieve.

Post-diagnosis, oncology massage therapists (OMTs) swing into action with specific interview and hands-on skills that avoid direct pressure on tumor sites. They have the benefit of images and other test results that pinpoint location of masses, symptoms, and complications. Pre-diagnosis, no information. Post-diagnosis, rafts of information. We use that information to work with them safely.

This difference is significant, and you haven’t addressed it.

Moreover, you extrapolate from that osteosarcoma study, saying your prohibition must also apply to all other cancers. Many other primary tumors are deeper and much less accessible to our hands. It is problematic to apply this clinical scenario across the board to all cancer cases.

Your misinterpretation of the study is a serious concern, and it’s been echoed by others.

As of this writing, you have not responded to this concern.

(For those of you just tuning in, a full account of the conversation is available from the links at the end of this post. Here, I highlight a few points.)

The Wang et al. (2014) study, the center of this conversation, has two parts.

In the mouse study, they point to direct pressure at a tumor site being a harmful thing. I agree. I have never advocated for that kind of focused pressure on a tumor site.

The second part is the human study of cancer outcomes. They looked at people who received massage before they knew they had osteosarcoma. In this, the Wang et al. study may have implications for better basic massage therapy education, including referral skills and interviewing clients about pain before working with them. I already noted that, too.

But to withhold oncology massage therapy entirely? Based on this two-part study? That is overreach.

Here is an analogy.

It is not perfect, but it helps illustrate what is going on here:

Within days of receiving her new bunk bed, my child tumbled off the top bunk and broke her arm. It healed quickly, but of course we reinforced a rule: no standing or playing on the top bunk. We enforce the rule with all visitors playing in her room. This is a measured, appropriate guideline for a bunk bed.

An overreach would be to ban standing on or playing on all beds: single beds, trundles, with and without box springs or frames, and even mattresses on the floor.

These overbearing solutions are sometimes tempting, but they do not necessarily make a safer or livable world. No standing on the mattress on the floor. Or avoid a whole city because of a single dangerous traffic circle. These are extreme measures.

You are suggesting something just as extreme.

Using the Wang study—which is aimed at pre-diagnosis—to forbid all massage therapy for people who are between diagnosis and the beginning of treatment is an excessive guideline.

Despite what you imply about it, the Wang et al. study never reports anything about the post-diagnosis period; they do not state a guideline for post-diagnosis. They talk about direct massage of tumor sites in mice. And although it is not easy to tell from their human reporting, a quick look at previous research suggests they are talking about clumsy attempts at manipulative therapy for pain relief, right on the areas of pain, swelling, and tumor. The study subjects were human patients whose real problem was undiagnosed bone cancer, not excess muscle tension.

If there is a real link between manipulative therapy and later cancer outcomes, then it remains a massage therapy problem—how to address pain, how to ask about it, when excess muscle tension contributes to it, looking at the cause, ferreting out the possibility of bone cancer, and referring clients appropriately instead of treating them inappropriately. Massage therapy educators: Standards for handling this should be addressed in basic massage therapy education.

This is not an oncology massage therapy problem.

This point is really important. You are arguing about a problem in the field of massage therapy, not a problem in oncology massage therapy.

Moreover, your misinterpretation and misapplication of this study has been pointed out numerous times, here, here, and here.

Yet you have offered only a few leaps of logic in trying to make the Wang study fit an entirely different clinical situation than the one it describes. To the problems raised by Wang, you propose an overzealous fix. Your solution has been challenged because it affects large swaths of people, not just those in the window between diagnosis and treatment.

When pressed on your logic, you merely double down on the Wang study, claiming it as a “proof” and “scientifically a done deal.” You throw shade on the ethics of one daring to question it.

That would be me.

Wang et al. is not the focus of my challenge. Instead: your use of Wang et al. is a serious problem, and as of this writing, you have not addressed that. You continue to throw out obstructions and distortions. You continue to insist that I produce a counter-study, when you haven’t even adequately defended yours or its poor reporting. You try to shift the burden onto me to provide research to counter your misinterpretation.

Then you change the subject. You focus outrage at my ethics and professional judgment and it sounds impressive and righteous.  You repost this repeatedly, where your followers can also question my judgment, my ego, and the motives of “people like me.” Perhaps I’m just trying too hard to sell courses. It clouds the judgment, right?

After all, this is social media in the year 2018. Everyone has a sound bite and a snap judgment. We don’t need anything more to form an opinion of character, nor do we have to consider each point carefully ourselves before we pile on.

But at the end of the day?

While you and I argue, lymph moves. Blood flows. Quietly, all day long, it moves in everyone, diagnosed or not. And yet you continue to harp on some pivotal role in cancer spread, as though we should slow it down somehow and order every patient to lie quietly on the couch until their cancer treatment starts. With that reasoning, we should probably disallow blood pressure readings, saunas, scary movies, body lotion applications, and position changes, as well. Wait until treatment starts. Only then will it be safe to to move, and to move fluid again.

Your inordinate focus on lymph and blood flow as the prime contributors in cancer spread returns us to the dark ages when we didn’t have a clue about how metastasis actually worked. As Gayle MacDonald has aptly and repeatedly pointed out, we didn’t understand how a complex set of circumstances including genetics, tissue affinity, and microenvironment had to line up in order for cancer to metastasize.

Those dark ages prevented people from getting massage therapy when they really could have used it.

People need MT while they’re waiting for cancer treatment

This is an enormously stressful time for patients. It is not a good time to withhold massage therapy, waiting until cancer treatment starts.

To support your point, you cite a case where Cullers did just that, turned away a very sick patient, in a story that is supposed to sound principled.

I believe your good intentions at the time, yet the growing number of oncology massage therapists worldwide have already figured out how to support that patient with thoughtful, careful massage therapy. They’ve collaborated with nurses and physicians because they agree that symptom relief is possible and that metastasis is more complex than simple fluid flow. They know that the patient’s blood and lymph are already moving, and that their own role in that is minuscule.

And although you’ve vilified it, we offer up again our “exercise argument” to your concern: If blood and lymph movement were primary factors in cancer spread, oncologists would prohibit exercise in people diagnosed with cancer. They would send people to bed, not to the gym. They would limit the actions of skeletal muscle on vessels.

This is emphatically not the case.

Exercise and movement typically are encouraged in cancer care.

In response to my line of reasoning here, you venture out onto the fringe even more. You question whether oncologists the world over should be recommending pre-treatment exercise. You take on the common, growing practice of “prehabilitation,” exercise programs to strengthen patients for treatment.

This is important. You act as though the question of whether movement and exercise will spread cancer is still an open question. You act as though you alone have information that thousands of oncologists, PTs, nurses, OTs, and exercise scientists have somehow missed.

I don’t think you intend to sound arrogant there? But it sounds that way, for sure.

You even misinterpret an opinion paper I offered on exercise and cancer by Koelwyn et al. In that paper, the authors’  overwhelming emphasis is on understanding the tumor-suppressing effects of exercise. Yet you picked out a couple of tiny, more circumspect sentences about the need to better understand effects of exercise on different patients. You used them to support your own position, that exercise/fluid flow could contribute to cancer spread. You cast aside the thrust of the Koelwyn article in the other direction, and amplified only a single sentence, then somehow accused me of cherry-picking information.

Listen to the data, don’t sensationalize it

People with cancer will be better served when you stop fitting evidence and ideas to your worldview. Science works the other way around, to shake our beliefs and help us formulate a more accurate worldview. Let the data speak and really listen. Mind the gaps. I have joined you in this inquiry, but you have gone in a different direction with the answers.

Your academic and clinical credentials have been pointed out by followers, but the way you have conducted yourselves so far flouts some of the basic standards of academic debate.

Instead, when your data are challenged, you become more shrill. You continue to pummel me with exclamation points and all-caps and the Wang et al. study. You continue to recycle arguments, then copy/paste them into social media group after social media group. You are trying to prevail with volume rather than substance. Now you’re questioning my character. That always gets people’s attention.

To the untrained eye, your arguments seem more scientific than they are.

You point to a research paper. You use the word, “proof.” These all appear under the umbrella of your Journal, and readers might not recognize that self-publishing your views in your own journal does not subject them to the same rigor as submitting them to another journal and a blind peer review by other scholars. Self-publishing shifts the review process from a formal pre-publication review by other experts, to informal post-publication on social media, for all of us to feed on. There, readers may or may not notice the missing pieces, or the logic leaps that don’t add up.

As a result, some readers may actually come to believe oncology massage therapy (and, by extension, exercise therapy), is endangering patients the world over, cancer center by cancer center, hospital after hospital, hundreds and hundreds of thousands of patients served.

By reviving the old massage-spreads-cancer debate, you’ve created undue alarm. Following your reasoning, massage therapists could be deterred, not only from massage during a specific window, but also from working with wider swaths of the population. As Gayle MacDonald points out, this has broad implications.

We’re not making up standards on our own

You have singled me out because of my writing, but your argument is with the entire workforce in oncology massage therapy. Oncology massage therapists have already taken care of your safety concerns. Not by dreaming them up in isolation, but by partnering with countless nurses, physicians, and legal departments at hospitals to develop protocols. We have had their supervision, standards, and input in place for more than 20 years. We have taken great care to develop tools. We have lines of interview questions, assessment skills, referral skills, and hands-on modifications.

We have done so for clients who are post-diagnosis, in treatment, post-treatment, and beyond. In partnership with hospital staff around the world, we’ve made sure the care is cautious and compassionate.

We’ve done that so that we can help more people, and not have to turn people away.

Unfortunately your analysis would turn back the clock, and turn people away.

Calling all cancer centers

You have pledged to contact cancer centers one by one to “correct” their oncology massage therapy practice. On this crusade, you will likely be dismissed more often than not. Not because we have already brainwashed hospital administrators about oncology massage therapy. (In fact, massage therapists do not have a super-successful record of brainwashing hospital administrators.)

Instead, your points will be dismissed because all your audience has to do is take a quick look at the research, and at Wang’s previous research, to see immediately how you are using a scant amount of data in error.

I know you want your alarm to help, not to hurt, but it backfires. As MacDonald points out, you cast doubt on the safety of massage therapy for many different populations. You’re compounding fear about massage therapy. There is already enough nervousness about working with clients with cancer.

Ethics and Argument

You’ve lobbed serious accusations my way, and you probably need to revisit your language there. You’ve tried to paint my opposition as a self-interest problem. An ethics problem.

More generally, your views are compromised by a bombastic approach. At times you are strident and impatient. This does a disservice to the many thoughtful teachings and writing you offer. You lose people when you depart from civil, scientific discourse.

Alarmism can be damaging.

Who does it hurt the most?

Not me.

I am confident my ethics are sturdy, so I’m not concerned about that.

I’m  concerned about the patients turned away under your rigid rule.

Patients are hurt the most. Newly diagnosed patients, especially: They often feel isolated during a frightening time. They need all the symptom relief and stress relief that we can humbly offer.

They have a right to receive our care.

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Readers:

If you have read this far, I hope you will take a look back at the various installments in this conversation. Listen and come to your own conclusions. Contribute to the conversation on blog posts and on social media.

We’ve had 20+ years of active oncology massage. Now, the fear that massage could spread cancer has re-emerged, fanned by Turchaninov and Cullers.

We need to air any concerns and put them to rest again, once and for all.

Please read, share, and participate.

Here are the articles, columns, and pivotal posts so far:

• Turchaninov & Cullers initial articles, raising their concern about massage post-cancer-diagnosis and pre-treatment, and citing Wang et al. article (2014), focused on massage prior to cancer diagnosis:

Turchaninov and Cullers Part 1

Turchaninov and Cullers Part 2

• My initial response, focused on the Wang et al. paper, “Does Massage Spread Cancer? An Update”
• Turchaninov and Cullers’ response
• My second response, “Could Massage Spread Cancer in the Newly Diagnosed?”  focused on Turchaninov and Cullers’ reasoning and interpretation of the Wang et al. article
• Turchaninov and Cullers’ response:
• Laura Allen weighs in on her blog, with comments from Turchaninov
• Gayle MacDonald’s post
• Wang et al. (2014) paper. Wang, J.Y., Wu, P.K., Chen, P.C., Yen, C.C., Hung, G.Y., Chen, C.F., Hung, S.C., Tsai, S.F., Liu, C.L., Chen, T.H., Chen, W.M. Manipulation therapy prior to diagnosis induced primary osteosarcoma metastasis–from clinical to basic research. PLoS One, 2014 May 7;9(5):e96571.