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CHEMOTHERAPY AND MASSAGE In this article I highlight some of the interviewing and decision-making processes I use when working with people in chemotherapy. I emphasize the effects of chemotherapy, the interview questions we use to target those effects, and concrete massage adjustments for some key side effects. When I work with medically complex clients, I need specific, concrete guidelines, so I've worked to provide them for other therapists as well. I hope the following information can make massage better, more tolerable, and potentially more helpful to people in chemotherapy. WHAT IS CHEMOTHERAPY? Chemotherapy is the systemic use of drugs to treat cancer by interfering with the growth of cancer cells. Many types of chemotherapy have been developed to shrink tumors or eliminate them entirely, hold off the spread, defeat cells that have already spread to secondary sites, and relieve cancer symptoms. Chemotherapy is administered on an outpatient or inpatient basis. Because it is such strong medicine, it is generally delivered in cycles of doses alternating with rest periods. Medication can be taken orally or administered intravenously by infusion. A device called an implantable access port (IAP or simply "port") can be surgically implanted under the skin, serving as a reservoir to distribute drugs into the bloodstream. The reservoir can be accessed by a needle for intravenous (IV) infusion, eliminating the need for repeated needle sticks or IVs. A common port site is the chest, as shown in Image 1. A port may also be implanted in the abdominal cavity for intraperitoneal infusion. In some cases a chemotherapy drug is introduced directly into an area of cancer in the body so that it contacts the tumor at full strength, before it is diluted in the bloodstream. A medical oncologist determines the kind of chemotherapy and the dose. Medications might be administered once every 2–4 weeks, weekly, or several times a week. Some are infused continuously over a few days. Oral pills might be taken daily, or less often. CHEMOTHERAPY SIDE EFFECTS The side effects of chemotherapy are legendary. Because chemotherapy is delivered systemically, and because the drugs are in the bloodstream, they can have strong effects on normal cells in the body and on the body's systems. General Effects. Fatigue can range from slight tiredness to profound, chronic exhaustion. Chemotherapy diminishes blood cell production by the bone marrow, an effect called myelosuppression. As a result, cytopenias occur: blood levels of one or more blood cell types (red blood cells, white blood cells, or platelets) drop. Blood cell counts are monitored closely before each chemotherapy infusion to determine whether the treatment can proceed or a rest is needed for the numbers to come back up. Bone marrow suppression produces thrombocytopenia (low platelets), which causes easy bruising or bleeding; anemia (low red blood cell counts), which causes fatigue, light-headedness, and cold intolerance; and neutropenia (low neutrophils—the white blood cells that fight bacteria), which causes a heightened vulnerability to infection. When chemotherapy affects blood cell counts, the effects can range from mild to severe, depending on how low the counts drop. Platelets can be slightly low, with no detectable effect on bruising, or they can be profoundly low, with easily bleeding gums, or even the life-threatening danger of bleeding out of major organs (hemorrhage). Neutropenia can be mild, with a slight susceptibility to infection, or severe, requiring the use of masks and gloves to avoid infecting the person. 42 massage & bodywork may/june 2011 A device called an implantable access port (IAP or simply "port") can be surgically implanted under the chest skin, serving as a reservoir to distribute drugs into the bloodstream. Drawing is from Chapter 20, Medical Conditions and Massage Therapy: A Decision Tree Approach. Courtesy of Lippincott Williams & Wilkins, 2011. Anemia can be mild, or severe enough to strain the heart as it compensates by working harder to pump the oxygen-poor blood to the tissues. Gastrointestinal effects (GI). Side effects of chemotherapy that affect the GI tract include constipation, diarrhea, nausea, and vomiting. Mouth sores, known as stomatitis or mucositis, make chewing food difficult. Loss of appetite is common with chemotherapy and can be due to changes in taste and smell, nausea, and mouth sores. Effects on the skin and hair. Hair loss is probably one of the most devastating side effects of chemotherapy, because it affects body image, and because it is the most outward sign of cancer treatment. In addition, skin changes are common, and this includes inflammation, rash, and chapping of the skin. In hand-foot syndrome, a response to some chemotherapy treatments, the feet and hands become chapped, irritated, and swollen. Toenails or fingernails may become discolored or fall off. This condition