A Vacation from Cancer
By Gayle MacDonald
Consider the fact that nearly half of American men and more than a third of American women will be diagnosed at some point in their life with cancer. These people receive touch therapies at the same rate as those without cancer and in the same settings—at health fairs, in chiropractic offices, through employer seated massage programs, and in spas. Spas have a unique chance to be part of peoples’ healing process during and after the rigors of cancer treatment. For Cynthia, who has children, a partner, and a business, it was a chance to focus on her own healing. For others it can be a well-earned vacation from their disease, a day just to be normal. It may be a celebration with partner or spouse, an occasion for girlfriends to laugh, mothers and daughters to be thankful, or a day to retreat inward.
The spa setting also presents a distinctive set of issues. Guests often are seen only once by a therapist, which means practitioners have less chance to develop a trusting relationship or to know the details of a person’s health history, preferences, or sensitivities. Limited time influences spa sessions as therapists strive to keep to a rigid schedule. Clients usually will receive or participate in several services a day, on top of which they also may play a round of golf, a set of tennis, or take a yoga class. This creates a greater demand on the person’s body, a demand that a cancer patient may not be able to tolerate. And, because the fees paid by spa guests are higher than in other settings, clients have a stronger sense of entitlement, sometimes feeling they should be able to dictate the session to the therapist even though their desires may be ill advised.
Each of the above factors adds a challenge when working with the person affected by cancer, whether the cancer treatment was yesterday or ten years ago. Here we will outline some of the considerations therapists must be aware of when working with the spa guest affected by cancer and offer some solutions. What must be remembered, though, is that if the right services are given with the right adjustments, people with a history of cancer need never be turned away from a day at the spa nor be affected by negative outcomes.
Special Opportunities and Responsibilities
When a person with a history of cancer lies down on your table for a massage or sits in your chair for a facial, you have a special opportunity to be part of the healing process. The chance to soften armored bodies, heal traumatized spirits, or remind people that their body can still feel pleasure is an honor. But, this heightened opportunity is also accompanied by special responsibilities, the prime responsibility being that of safety followed secondarily by comfort. In order to give safe and comfortable spa treatments, whether it is a massage, a wrap, or a facial, greater caution and knowledge is needed.
The treatments people undergo for cancer, chemotherapy, radiation, and surgery create both short- and long-term side effects, some of which will impact spa treatments. For instance, the guest who has had lymph nodes removed from or radiated in the neck, axilla, or groin, necessitates that the massage therapist be gentle in the affected quadrant, it requires the manicurist to be certain her tools are extremely sanitary or to use disposable ones, and forces the esthetician to moderate the temperature when performing wraps so as not to create redness in the affected quadrant.
A more detailed accounting of the side effects caused by cancer treatment was addressed in the article “Bodywork for Cancer Patients: The Need for a Less-Demanding Approach” in the June/July 2005 issue of Massage & Bodywork. A copy of the article can be found at: www.massageandbodywork.com /Articles/JuneJuly2005/Bodywork.html. The 2005 article focused on the concept of being less demanding with cancer patients in general. In this article, we will look at how to be less demanding specifically in the spa setting.
A Less-Demanding Approach
No one ever needs to be denied spa services, but the services may need to be adjusted to fit the guest’s energy level or other circumstances, such as the risk for lymphedema. The person who has been through cancer treatment, even a year or two in the past, may not yet realize her “new normal.” The lymphatic system may still be on overload as the body continues to cleanse. Vital organs such as heart, lungs, and liver may still be healing or in some cases may be permanently damaged from the toxicity of chemotherapy or due to scarring by radiation. Other reasons to be less demanding are listed below.
There are many reasons for spa therapists to be less demanding in their treatment of former oncology patients. Here are a few of them.
Martina, who was treated fourteen years ago for breast cancer, offers an example of the permanent side effects that can occur from cancer regimens. Her treatment included a lumpectomy, lymph node removal from the axilla, and radiation. Radiation can damage surrounding tissue, which in Martina’s case included the heart and lungs. The side effects of this are just now coming to light. Recently she consulted her doctor because of shortness of breath. An echocardiogram of her heart revealed diastolic dysfunction due to the heart being “stiff,” a result of scarring caused by radiation. Not everyone will be affected so many years out from cancer treatment, but many will, and this will require adjustments to some of their spa sessions. I want to focus on two possible side effects that can occur when spa treatments are too demanding—flu-like symptoms and lymphedema.
- Easy bruising.
- Loss of bone density (can be due to steroids, the disease process, metastatic spread to bones, radiation therapy, or certain chemotherapies).
- Pain medications.
- Peripheral neuropathy in the hands or feet.
- Risk of lymphedema.
Flu-like Symptoms. Bodywork that is too demanding for people still recovering from their cancer treatment can cause flu-like symptoms. Many touch therapies feel wonderful in the moment, but practitioners cannot gauge the level of demand just by guests’ immediate feedback. Hot rocks applied over the liver or a deep-pressure massage feel delicious while the guest is receiving them. Too often, however, the person may have such severe fatigue or nausea later in the day that they can’t get up for dinner.
One patient who had just finished chemotherapy for uterine cancer went for a spa day to mark the end of her cancer treatment. The therapist told the patient that a detoxifying session would be best to help remove the side effects of the chemotherapy. There is some logic to this line of thinking; however, it is not appropriate for the guest who is within a year of finishing treatment. Chemo in particular requires an extended period of time before detoxification should be considered. Radiation and surgery also require a significant amount of time, perhaps four to six months before detoxification should be undertaken. Nearly always, the guest who is given a detoxifying massage ends up with flu-like symptoms for days. This is what happened to the patient with uterine cancer mentioned above. She did not suffer permanent physical damage, but decided never to have massage again.
A handful of general changes can lessen the demand of spa treatments, ensuring that the guest feels restored rather than depleted:
Risk for lymphedema. Besides flu-like symptoms, another side effect to be aware of is the risk of lymphedema. Massage in any venue can trigger this condition if the client has had lymph nodes removed from or radiated in the neck, axilla, or groin. Guests in the spa setting can be at even greater risk of triggering or exacerbating existing lymphedema because of the nature of the spa experience. Not only do people receive massage during a spa day, but may also use a whirlpool or sauna, participate in sports, or work out in the gym. The combined effect of this can be to overload the lymphatic system. Unfortunately, the risk is permanent because lymph nodes are not known to regenerate. A guest can be twenty years out from breast cancer treatment that included nodal involvement and still be at risk for lymphedema. Even a ten-minute seated massage can cause this outcome. (I know this to be true because one of our hospital students triggered it in a nursing assistant.)
- Choose products that are less demanding, essential oils that are calming instead of stimulating, or exfoliants that are powdery rather than coarse.
- Focus on being nurturing rather than detoxifying. Instead of applying detoxifying herbs and then wrapping a guest in plastic material, substitute a loose wrap in warm linen with no herbs.
- Guide guests to participate in fewer or less-demanding services. The guest whose energy is still affected by cancer treatment could be guided toward a less- demanding combination of services such as a reiki session, a pedicure, and a short sauna.
- Shorten the time of application. For instance, instead of a hot rock for thirty minutes on the abdomen, a warm rock for five to ten minutes would be better.
- Slow your movements, whether for a massage, a facial, or when preparing the guest for a wrap. Slow movements are very soothing and nurturing.
- Use less heat. One way to gauge whether the heat is too much is by observing the redness of the skin. If it doesn’t immediately dissipate, the heat is too much.
- Use less pressure. For instance, when giving a massage, make contact with the superficial muscles instead of the deeper ones. For the really frail client, just make contact with the skin. It will still feel wonderful.
When working with the guest at risk for lymphedema, therapists should employ several basic practices:
- Do not redden the skin in the affected quadrant (remember the quadrant includes the limb and the front and back of the torso). This means that hot rocks, hot tubbing, and deep massage should all be avoided in the affected quadrant of the person at risk for lymphedema. Substitute less-demanding treatments that won’t redden the skin.
- Perform strokes on the affected limb only in the direction of lymphatic flow, which is toward the heart. Both massage therapists and estheticians must be mindful of this.
- When performing pedicures and manicures, use tools that are sanitary or disposable. Be mindful that cuticles do not become torn or cut during the treatment. Openings in the skin give bacteria an entrance into the body that can more easily become infected in the person whose lymphatic system is damaged.
- Work for a shorter duration in the affected quadrant, remembering this means the limb and torso. A more complete list of guidelines is given in the article, “Cancer, Radiation, and Massage: The Benefits and Cautions” and can be downloaded at www.massage therapy.com/articles/index.php/article_id/184.
Demanding vs Less Demanding
A wealth of spa services are welcoming and appropriate to former oncology patients. Steering clear of demanding services and helping clients opt for less-demanding services are key.
- Deep pressure massage.
- Detoxifying herbal, clay, or mud wraps.
- Exfoliation treatment with coarse products such as salt, cornmeal, pumice, bamboo, nut products containing the shell, and sea sand.
- Hot stone massage.
- Sauna, whirlpool, or steam room (fifteen to twenty
- Aromatherapy massage.
- Cosmetic services.
- Energy techniques (i.e., reiki).
- Exfoliation treatment with products that contain powdery ingredients such as rice bran, bentonite clay, zeolites, and sulfur.
- Facials and pedicures.
- Gentle Swedish massage.
- Sauna, whirlpool, or steam room (five to ten minutes).
- Shampoo and style.
- Vichy shower.
Selling guests on the concept of being less demanding is sometimes difficult, especially when they are paying top dollar for services. However, discussing the reasons for prudence usually will ameliorate guests’ annoyance. I have often made comments to clients such as, “Chemotherapy takes up to a year to recover from. If I gave you a heavy massage, it may only re-trigger the symptoms you had during chemo. Massage right now should soothe your body, not stir it up.” Such an explanation makes sense to people, and they are usually grateful for it.
Four Suggestions for Safer Practice
In order to create a safer experience for these vulnerable clients, four changes in spa practices should be considered. Some of these ideas go against accepted practice within present spa culture. However, I believe they can be implemented with little financial cost and after a time will cause minimal disruption to the normal flow of the facility. Implementation of all or even some of these ideas will provide greater safety for guests and will offer greater liability protection for establishments. Liability potential is real and should be enough to convince managers to train their practitioners to work safely with the medically frail.
Let’s examine these suggestions one at a time.
- Allow and encourage therapists to spend a couple of minutes asking guests specific questions about their health history.
- Help guests be aware of which services are most appropriate for them.
- Follow up within twenty-four hours.
- Establish policies that will support practitioners.
Take a Health History
Managers and guests may prefer practitioners spend their limited time engaged entirely in hands-on work, not on gathering information about a person’s health status. However, some information must be obtained from guests in order to properly adjust the session. This is true for everyone, not just the medically fragile.
A number of other factors besides time constraints contribute to the difficulty in gathering guest’s health information. Clients sometimes withhold information because they are afraid they won’t be given a massage. A therapist in one of my classes shared that when going for massage, she doesn’t admit to having Addison’s disease, a condition that affects the adrenals. “It freaks therapists out, and they are afraid to touch me,” she said. People with a history of cancer do this even more often, purposely withholding information because they fear therapists will either be nervous or turn them away. Other people with a history of cancer may legitimately forget about their treatment if it was in the distant past or they fail to mention pertinent facts because they don’t understand the relevance of them to the therapist. Asking guests specific questions will help draw out the needed health information.
Typically, therapists who work in spa settings ask a single question—“Is there anything I need to know about your health before we start the massage?” or some variation on this. The above question is usually too vague to elicit the response the therapist needs. If specific questions aren’t asked, the guest does not know what information the therapist needs. If the therapist doesn’t ask, the guest often won’t tell. And so the spa version of don’t ask, don’t tell occurs.
One spa therapist tells of a guest who, when asked if there were any medical conditions the therapist should be aware of, answered, “None.” And yet, when the practitioner settled her face down onto the table, something about the client’s body language told the therapist the client wasn’t comfortable. Three times the therapist asked the client if she was okay or would like to reposition. Not until the third inquiry did the woman tell her story of being diagnosed over a year ago with a cancerous lesion on her lower lip. For more than six weeks, five times a week, the woman had been treated with radiation to her face. In order to be sure that only the tumor was radiated, the guest’s face and head were locked onto the radiation table by a plastic mesh mask that had been conformed to her features. (This is standard practice for head and neck cancers.) However, one of the by-products of this experience for the client was claustrophobia. Being positioned prone on the massage table with her face in the cradle was triggering the claustrophobia. Once the therapist was aware of this, she was able to help the guest position in a way that was comfortable to her. This anecdote illustrates the failure of only asking, “Is there anything I need to know?”
“Time” is often given as the reason for doing an abbreviated intake. However, a handful of specific questions can be asked by the therapist relatively quickly. Or, the front desk staff could initiate the questioning process by placing the written questions on a clipboard for guests to fill out while they wait. Listed below are specific questions therapists can ask when they are pushed for time. While these questions will not paint a complete picture, they will generate sufficient information for practitioners to move ahead safely.
Brief Health History Questions for all Spa Guests
Plan an Appropriate, Nourishing Day
- Are you being treated for any medical conditions?
If so, what?
- Are you experiencing any pain? If so, where?
- Are you on any medication for inflammation or pain?
- Are you pregnant (if appropriate)?
- Do you bruise easily?
- Do you have a history of blood clots?
- Do you have any fragile bones?
- Have you had lymph nodes radiated or removed from the neck, axilla, or groin?
- How is your energy level?
A spa experience tends to be part or all of a day. Guests have the opportunity to have bodywork sessions, use of the sauna, steam room, and whirlpool, skin or hair treatments, or to just relax and rest. Choosing the right services is important to a person’s enjoyment of the occasion.
How can guests be made aware of the level of demand? A handful of places have created special menus for people needing more gentle therapies. However, the simplest way is through the general services menu. Like the menu for a Thai restaurant, which marks the dishes that are spicy, a spa menu could designate the services that are more vigorous. And just as certain dishes can be made spicy or mild, the spa menu could also indicate which treatments can be individually tailored to be nurturing rather than demanding.
Practitioners, too, can help guide guests toward services that are in the person’s best interest. Imagine someone who finished chemotherapy six months ago chose an exfoliating treatment to be followed by a clay wrap in a highly insulating blanket, not knowing it would be abrasive to the skin and potentially detoxifying. The therapist should explain the benefits of switching to a more gentle treatment and provide it rather than the original choice. When suggesting a less-vigorous service, try to explain the situation in a way that doesn’t make guests feel as if something is being taken away from them or denied them. They feel they have lost so much already as a result of the cancer diagnosis. Suggest for now, until their body returns to a higher level of energy, that a more nurturing treatment will support their healing.
Follow Up with Clients
Following up with guests isn’t usually encouraged in the spa setting. Perhaps it’s thought to be a privacy issue or managers feel it would require extra work for the staff. And yet, follow-up it is the best way for therapists to learn how their services affect recipients. In this way, they will know where they are on track and where changes need to be made.
One way to follow up is for the therapist to give the guest a 4” x 6” card to fill out the next day. The card could contain questions such as: How did you sleep last night? How was your energy the next morning? List three words that describe how you felt several hours after your treatments. Guests would turn the card in at the main reception desk or drop it in the mail.
Another more simple method is to ask guests’ permission to phone them the next day to see how they are doing. The phone call could be made by the therapist or someone from the front desk staff. I have found clients to be very appreciative of a call the next day.
Maintain Supportive Policies
Spa therapists have shared with me in continuing education classes that guests can be insistent in their demands. That, combined with therapists’ training to please the client, makes it difficult to say no, even when therapists think they should. Instituting safety policies will support therapists in adhering to safe practices. They give the practitioner something to fall back on when guests push for more.
One area, for instance, in which policies would be beneficial is in working with guests at risk for lymphedema. The policy might read: “Guests who have had lymph nodes removed from or radiated in the neck, axilla, or groin should receive services that do not cause the skin to redden.” Another helpful policy would require guests to fill out the brief intake form. These clinically-related policies would be added to existing ones on such topics as sexual misconduct, intoxication, or verbal abuse.
Working with people who have cancer is deeply satisfying. We have a chance to help them feel whole and beautiful again, to find renewed confidence in their bodies, and give them hope that there is life in spite of cancer. Encountering practitioners who touch them fully, without fear or shying away, who embrace them as they are, is the best possible therapy. By employing one simple concept we can provide safe, comfortable, nourishing sessions. That concept is do less—less heat, less scent, less pressure, less speed, less time, less stimulation. Over and over again, guests and therapists are surprised at the deep results from gentle, mindful touch.
Acknowledgements: Thanks to staff at the El Monte Sagrado Living Resort and Spa, in Taos, New Mexico, for their help with photography. Also, thanks to Anne Dillon and Thom DeVries from the Image Renewal Center at Loyola University Medical Center and Morag Currin of CoValence, Inc., in Chandler, Arizona.
Gayle MacDonald is the author of Medicine Hands: Massage Therapy for People with Cancer (Findhorn Press, 2007) and Massage for the Hospital Patient and Medically Frail Client (Lippincott Williams & Wilkins, 2005). She can be reached at firstname.lastname@example.org.
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