By Paul Lewis RMT
The cancer patient has many time-sensitive decisions to make. This article’s objective is to enlighten RMTs, who may find themselves working with a patient facing cancer, about the patient’s experience before and while they seek massage therapy treatment.
By Paul Lewis RMT
The cancer patient has many time-sensitive decisions to make. This article’s objective is to enlighten RMTs, who may find themselves working with a patient facing cancer, about the patient’s experience before and while they seek massage therapy treatment. Here I will delve into some of the details of the disease, the testing and the choices that must be made by the patient in light of receiving a traumatic, life-changing diagnosis.
|Is it at all possible to remain immune to the psychological and emotional trauma associated with a diagnosis of cancer?|
Stages of disease
Cancer specialists use a type of cancer classification called staging to help them determine the type of treatment plan their patient requires. Another way to think of staging is as the amount of risk the tumour presents to the patient. Staging helps to give the health-care providers a base/common terminology for evaluating and comparing different treatments based on the same diagnosis.
There are various types of stages that are used to classify the state of the cancer and how far the cancer has spread. One such staging classification is TNM (tumour, node, metastasis). This classification has a scale from 0-4 and is based on three things: the size of the tumour, whether or not cancer cells are present in the lymph nodes and whether or not it has spread to other organs.
Staging can also be an indicator of whether a specific type of surgery is needed. In the case of breast cancer, staging can influence whether the patient is advised to have a quadrantectomy, which is the removal of the primary tumour; a radical mastectomy, which is the removal of the breast, skin, adipose tissue, pectoralis major and minor muscles, and ipsilateral axillary lymph nodes; an axillary lymphadenectomy, which is the removal of one or more groups of lymph nodes; or a modified radical mastectomy, which is similar to the radical mastectomy, but preserves the pectoralis major muscle.
If someone is diagnosed with cancer and the treatment plan requires a single or double mastectomy, there are options available for the patient who decides they would like to preserve the appearance of the breast area as though no change has taken place. This is known as reconstructive surgery. If the patient decides to have reconstructive surgery, the procedure can be performed at the time of mastectomy, which is called immediate reconstruction, or at a later date, which is called delayed reconstruction. Choices for reconstruction include synthetic implants; use of the patient’s own tissue, if possible; and the construction of a prosthesis, which allows the patient to completely avoiding additional surgeries. This latter option consists of having synthetic breasts designed, which are to be placed in the bra over the skin; these are available in colours to match the skin tone of the patient.
Diagnosis and urgency of treatment
The patient’s decisions and the degree of urgency will depend upon the severity of doctor’s prognosis. Physical exams, imaging (MRI, X-rays), laboratory tests (blood, tissue) and pathology tests (bioposy) are examples of some of the tests conducted to determine which stage the cancer is at. The doctor’s prognosis – and, if required, the type of surgery, and treatment plan – will be influenced by the location of the cancer, whether it is benign or metastatic, the degree to which organs are affected and the risks to the patient.
A Case Study
The following patient describes her experience with the procedure of receiving a double mastectomy followed by placement of tissue expanders and subsequent replacement of expanders with implants. As her expanders are filled to a specific capacity, she describes her experience with pain and how massage therapy played a role in supporting her through her pain.
“I was not prepared for how the pain would inhibit my movement, my ability to function and my life in general.
“On February 17, 2012, I underwent a bilateral mastectomy with immediate two-stage reconstruction (i.e., subpectoral placement of tissue expanders, which were subsequently replaced with permanent implants in July of that year).
“I awoke from surgery with two drains, one on either side. I was on a regimen of antibiotics, anti-inflammatories and painkillers the first week, and was surprised at how little pain I was experiencing. That all changed dramatically the second week, once I was off all prescription medication. It was difficult to separate the pain caused by the drains versus soft tissue pain caused by the surgery, versus pain caused by the rigid tissue expanders – all I knew was that the pain was unrelenting unless I remained absolutely motionless. I faithfully performed the range-of-motion exercises several times a day. These were not particularly painful in and of themselves – stretching often provided some relief. But I started to notice that my range of motion was becoming more and more restricted.
“The drains were removed after three weeks, which provided a degree of relief. This relief was short-lived, however, once I began tissue expansion a week later. The tissue expanders had been filled with 150 cc’s of fluid during surgery. 60 cc’s (each side) were added on a weekly basis, starting approximately four weeks post-op (mid-March). The pain increased steadily with each “fill” and after my third fill in early April (bringing me to 330 cc’s each side), I felt I could no longer function. The pain was constant – a crushing sensation above my rib cage and a tearing sensation across my chest and under my arms. I was also experiencing intermittent stabbing pain along the perimeter of the tissue expanders. It was difficult to concentrate on my work, difficult to perform household chores, difficult to drive, even difficult to do something simple like take a walk. I had to put my expansions on hold for three weeks, and hope that I would find a way to cope.
Desperate to obtain relief from the pain, I turned to the Internet looking for a massage therapist. It was very important to me to find someone with experience treating women who had undergone breast reconstruction. This was for several reasons: 1) they would be familiar with issues specific to the breast reconstruction process, 2) their understanding of the reconstruction process would ensure they would not compromise the tissue expanders, and 3) they would have seen the type of scarring and deformity that is typical of breast reconstruction, which I hoped would help me feel less self-conscious.
“Once I identified a therapist, I made a first appointment and, after an excruciating 75-minute drive to his office, which included an unscheduled stop to cry because of the pain, I received a 90-minute treatment after which I was pain free for several hours for the first time in many many weeks! Also, I appreciated the explanations I received on the various massage techniques and methods before they were applied.
“When the pain started to return, it was nowhere near as intense as it had been previously. I continued the therapeutic massage treatments every two weeks and resumed my expansions at the end of April. I had five more fills of 60 cc’s, bringing my expanders to a total of 630 cc’s (each side) by mid-May. Surprisingly, the fills became easier each time, which is the exact opposite of what I was told to expect by my plastic surgeon and the nurses at the breast centre at the hospital. Their experience had been that the discomfort typically increases as the expanders reach capacity, especially when the end volume is relatively high.
Once I was done with expansion, I still found it very beneficial to be treated every two weeks while I was waiting for surgery to replace the tissue expanders with permanent implants. Having treatments right up to two weeks before my exchange surgery ensured I remained comfortable, fully mobile and with full range of movement. Up until a few days before my exchange surgery, I was doing all the things I would normally be doing prior to my mastectomy/reconstruction – walking my two big dogs, mowing the lawn, even filling the water softener tank with 40-pound bags of salt.
“I also feel that continuing treatments right up to exchange surgery contributed to what has been an almost painless recovery.”
Seeking support and being informed
Is it at all possible to remain immune to the psychological and emotional trauma associated with a diagnosis of cancer? It is suggested that the patient not only try to inform their family and loved ones of what they are going through, but also try to join a support group. In doing so, the family/loved ones will have a better understanding of what the patient will be experiencing, and they could, in turn, provide additional support. As their massage therapist, you can be aware of local support groups and the need for family involvement, and discuss it with your patient if and when you feel it is appropriate for you to do so.
It is also important to advise patients to get all the facts about their diagnosis; the treatment protocol, including surgery; and the pros and cons of various procedures. Making decisions in light of all the facts can help to reduce some of the stresses associated with not knowing what to expect. Being in the know can also help to better prepare the patient for what is to follow.
As an RMT, I have treated quite a few post-surgical mastectomy patients with varying levels of Post-Mastectomy Pain Syndrome (PMPS). Many of the clients have reiterated that they wished they had known more about the surgical procedure – in turn they could have known what to expect and the pros and cons of the various procedures that had been available to them. I truly believe that understanding the procedures and what to expect post-surgery can help the patient prepare emotionally and intellectually, and may reduce some of the anxiety associated with the unknown.
SOURCES USED TO PREPARE THIS ARTICLE
- Porth, Carole Mattson. Pathophysiology: Concepts of Altered Health States, 7th Edition. Lippincott Williams & Wilkins, 2005.
- Lange, Vladimir, M.D. Be a Survivor: Your Guide to Breast Cancer Treatment. Los Angeles, CA: Lange Productions, 1999.
- National Cancer Institute http://www.cancer.gov/cancertopics/factsheet/detection/staging
- Post-Mastectomy Pain Syndrome. The Magnitude of the Problem: Revista Brasileira de Anestesiologia,Vol. 59, No 3, Maio-Junho, 2009.
- A Prospective Model of Care for Breast Cancer Rehabilitation: Postoperative and Postreconstructive Issues: Published online April 6, 2012, in Wiley Online Library (wileyonlinelibrary.com).
- Curtis, Debra. Breast Massage. Toronto, ON: Curties-Overzet Publications, 1998.
- Snyder, Goodman. Differential Diagnosis for Physical Therapies. St. Louis, Missouri: Saunders Elsevier, 2007.
Paul Lewis is an international presenter, massage therapist, and certified yoga and fitness instructor who travels and treats patients around the world. For more information, visit www.paullewis.ca .