When cancer is diagnosed, many fears can arise in the mind of the patient. What will happen to my body, my family, my career? Can I stand the pain? Will I survive? Foreboding thoughts of disfigurement, difficulty in daily functioning and physical discomfort come to the forefront. Pain can be a constant reminder of the ravaging, internal monster cells hell-bent on bodily destruction. And frequently pain and anxiety reinforce each other, leading to chronic distress. Although pharmacologic pain treatments are standard, they don’t always provide the relief needed. And many care centers have yet to establish an effective means of assessing the patient’s true experience of pain. For many patients, “pain is a ‘vital sign’...and often is more relevant to their care than pulse or blood pressure.”1
Surveys conducted over the past few years highlight the need for more diligent and effective treatment for cancer patients suffering from pain and anxiety. A study by Bernabei et al of more than 13,000 elderly cancer patients found 4,003 reported daily pain. The survey, published in JAMA (June 17, 1998) indicated that not only is cancer pain prevalent, it is also undertreated in older and minority patients.2 C. S. Cleeland pointed out in an editorial in the same issue, “Patients with pain are also less able to commit to fighting their disease.”3 Lesage and Portenoy suggest undertreatment of pain, as noted in recent surveys, can be due to several factors: “Physicians may not be adequately educated about pain control or they may be more focused on control of the disease than on control of pain and other symptoms; patients may be reluctant to report their pain; and both physicians and patients may be reluctant to use morphine and other opioids for pain control because they fear addiction, which is extremely rare in people with cancer.”4
Left untreated or inadequately controlled, cancer pain can have a significant impact on emotional function. The patient may develop feelings of isolation, depression and anxiety if their pain is not given validation. If pain persists, it can have a negative influence on relationships and most importantly, healing.5 Severity of pain has been shown to be an important factor in patients’ assessment of their quality of life.
After studying 216 patients with metastatic cancer, the Pain Research Group at University of Texas M.D. Anderson Cancer Center in Houston concluded in its 1999 report, “Increasing severity of pain was associated with health-related functioning, even when an estimate of disease severity was taken into account.”6
A recently published study in the British Journal of Oncology revealed that symptoms of stress, anxiety and depression are often overlooked by physicians. In a survey of 2,300 cancer patients, researchers noted doctors were detecting these symptoms in only about one-fourth of the cases in which they occurred. The authors recommended appropriate intervention, “...whether this be medication, taking treatments or alternative or complementary therapies — as soon as they first need it.”7
Thus the problem of dealing with pain and accompanying emotional stress presents a conundrum for both medical staff and cancer patients alike — one which cannot be solved with a set medication schedule, but demands consideration of a holistic care approach and the individualization of treatment.
A Personal Perspective
According to Margo McCaffrey, pain management expert and co-author of Pain: Clinical Manual, “Pain is whatever the experiencing person says it is, and exists whenever he says it does.”8 Pain is subjective, expressing itself individually through the psychological and physical make-up of each person. Belief systems — spiritual, cultural and religious — as well as states of anxiety and depression also affect the patient’s experience of pain.9 Although not everyone with cancer will experience pain, approximately 30 percent to 50 percent of those undergoing tumor treatment and 70 percent to 90 percent of those with advanced disease will have to contend with episodic or chronic pain during their illness.10 Cancer pain can result not only from the disease itself, but also from medical procedures, whether dispensed for diagnosis, cure or monitoring physical status. As many as half to two-thirds of those with well-controlled chronic pain can experience a “breakthrough” of acute pain.11
Alternatives — Simple, Effective, Non-invasive
Cancer patients, their families and nursing staff have been increasingly turning to complementary and alternative treatments as an adjunctive aide.12 Although empirical evidence of effectiveness of these interventions is limited, there has been a slow, steady stream of successful studies using massage and various relaxation techniques to address chronic pain and anxiety in cancer and other disorders. In a pilot study, Weinrich and Weinrich (1990) reported significant pain decrease following a 10-minute massage administered to male cancer patients. Within a hospice setting, male and female patients demonstrated improvement with a three-minute back massage (Meek 1993). Ferrell-Torry and Glick (1992) also reported positive results in cancer patients receiving a 30-minute massage.13
More recently, researchers have turned to the foot as a receptor for massage aimed at relieving cancer pain and anxiety. In a study published in 2000, foot reflexology was described as a successful nonpharmacologic adjunct in the control of these symptoms. Basing their proposal on the foundation of previous research, a team at East Carolina University, N.C., found that patients with breast and lung cancer experienced a significant decrease in anxiety, and pain relief was expressed in one of three measures in breast cancer subjects.14 An Australian study published within months of the reflexology article also showed foot massage to decrease perception of pain and nausea and increase relaxation in hospitalized cancer patients.15 Both studies emphasized the adaptability of their approach to home and nursing care, noting the techniques could be easily learned by caretakers or self-administered by the patient.16,17
Foot massage for good health dates back to ancient Far Eastern, Egyptian and Native American cultures. While the “good old” foot rub is still very much alive today, a more refined and specifically medicinal form has found a place in alternative treatment. Reflexology began its evolution in the early 1900s with William H. Fitzgerald’s development of zone therapy. Fitzgerald noted that pressure applied at various points produced an analgesic effect on corresponding body parts.18 Eunice Ingham refined the technique, identifying sensitive “reflex points” by mapping out parts of the body on specifically defined areas of the foot. Ingham’s approach expanded the treatment beyond its singular use for pain, noting other therapeutic benefits could be achieved as well.19
When the N.C. research team set out to study reflexology for cancer patients, they noted while a variety of nonpharmacologic treatments had been tested in cancer studies, none of those reported had included reflexology. A 1991 study by Ferrell et al showed a decrease in cancer pain, following foot massage and reflexology, had been noted to reduce anxiety in a study on premenstrual symptoms (Oleson and Flocco, 1993).20 Using the Original Ingham Method, the N.C. team developed a “quasi-experimental, pre/post, crossover trial with patients serving as their own control.”21 This approach entailed having one group of patients first serve as control, the other as intervention and then allowing a minimum of 48 hours to lapse before alternating the patients’ assigned groups. The sample group of 23 patients (majority female) with breast or lung cancer were recruited from an inpatient oncology unit. Of the 13 with breast cancer, 10 had metasticized; there were five cases of metasteses in the remaining 10 with lung cancer. Researchers excluded cases involving recent surgery, radiation to the site of pain, those reporting no anxiety and those potentially experiencing acute rather than chronic pain. A medical consultation was required by oncologists prior to treatment of patients with symptoms of deep vein thrombosis. In cases of lower limb circulatory problems, those areas of the foot associated with the diseased body part were avoided during reflexology.22
At the beginning and end of each 30-minute session, relaxation techniques were administered to the foot and ankle area for 10 minutes. Reflexing of areas corresponding to pain and cancer sites accounted for 15 minutes of the session with a five-minute reflexing of the entire foot to ensure coverage of all body areas. Those patients reporting no pain at the time of their intervention session were administered reflexing on points corresponding to the location of their cancer. Researchers noted, “The specific areas reflexed for breast cancer and lung cancer, (i.e., the balls of the feet and on top of the feet over the balls) are identical.”23
Results of the study were based on measurements of anxiety and pain as quantified by a visual analog scale (VAS) and the Short-Form McGill Pain Questionnaire (SF-MPQ). Although all patients experienced pain at times during their hospitalization, it was not always present at the time of measurement. In the breast cancer group, the 11 subjects reporting pain had a significant decrease following reflexology as measured by the SF-MPQ. Because only two lung cancer patients reported pain during measurements, researchers noted “results from this group could not be calculated.” Significant decrease in anxiety was noted for both types of subjects with the greatest decrease in lung cancer patients, the majority of which were male.24
In light of the fact that 61 percent of the subjects reported pain during the study despite pharmacologic management for their symptoms, the success of the reflexology intervention to ease pain and decrease anxiety validates this approach as an effective and viable adjunctive treatment. The study team suggested, “Replication with a larger sample of a single cancer type is necessary to limit the type of pain.” In addition, they recommend comparison studies with other complementary and alternative therapies such as massage, healing touch and relaxation response.25
As noted previously, within the same year of publication of the N.C. study, a team of Australian researchers reported their findings on the use of foot massage as a complementary therapy to relieve pain and nausea in cancer patients. The mixed-gender sample group of 87 patients represented a wide range of cancer types. Although the intervention was limited (two sessions, 10 minutes each, and a third control session), results showed a significant positive effect on perception of pain, nausea and relaxation as measured with a VAS. Based on their findings, the authors recommended implementation of this approach by nurses and family members.26
Whether reflexology or a simple foot massage, these caring interventions have proven to be of great benefit to cancer patients, not only relieving the uncomfortable symptoms of their illness but also meeting a basic need for human touch.