Oncology Massage, Cancer Pain, and the Research Journey

Writing the massage intervention for the Integrative Medicine for Pain in Patients with Advanced Cancer Trial (IMPACT) challenged me to think about massage therapy in an entirely new way. Developing the protocol meant translating an individualized clinical practice into something that could be taught, delivered consistently across therapists, and rigorously studied. Looking back, I realize my entire career had been preparing me—not just to develop a protocol, but to rethink how massage could be studied. I share these insights so they might assist you in your clinical or research journey.

Lessons Learned from Oncology Massage

When I joined the massage therapy team at Memorial Sloan Kettering (MSK) Cancer Center’s Integrative Medicine Service in 2007, I brought with me a strong foundation in structural techniques learned from working in a physical therapy practice, as well as an understanding of chronic illness and what it means to live with disease and treatments learned from my work with people living with HIV/AIDS. Oncology massage would become the natural intersection of those two ways of thinking.

My structural approach was a particularly good fit for MSK patients with breast, head, and neck cancers. Surgery and radiation often left people with significant fibrosis, tissue restriction, and limited mobility. The more I worked with these patients, the more questions I had. Surely someone had already figured out the best structural approach to these tissues and written about it.

With access to MSK’s library, I started digging into the research. Very few studies were asking the questions that interested me most, and even fewer described treatment approaches that reflected what I found effective in practice. So I pieced together ideas from physical therapy, emerging fascia research, continuing education, and years of clinical experience, gradually developing my own approach. Working alongside one of the country’s largest hospital-based massage therapy programs, I had opportunities to develop initiatives such as a surgical observation program that gave our massage therapists firsthand insight into how cancer surgery reshapes anatomy and function. I couldn’t shake the feeling that if an oncology massage clinical trial was going to happen, it should happen here. I eventually began pitching research ideas to leadership. Getting traction, however, was another story.

The challenge wasn’t unique to MSK. Oncology massage evolved through clinical practice rather than a strong research evidence base, and early safety concerns fostered highly conservative approaches. Although the field gradually shifted toward individualized assessment and evidence-informed practice, many of those early perceptions persist. 

Massage is still often viewed primarily as a relaxation therapy rather than a clinical intervention capable of addressing symptoms and improving function. Combined with limited research funding and the inherent challenges of studying a hands-on intervention, these misconceptions left many of the questions clinicians cared about unanswered.

My clinical experience, however, told a different story. Patients relaxed with massage—that was certainly one benefit, and that mattered. Many told me they felt as though they had drawn a breath the moment they were diagnosed and had never fully exhaled. The diagnosis hijacked their nervous systems. Massage often seemed to offer that first real exhale. Their nervous systems settled, stress responses lessened, and many described feeling more like themselves again. But I was also seeing changes that extended beyond relaxation: improved shoulder motion after surgery, easier breathing, less guarded movement, more balanced tissue tension, and a renewed sense of connection to bodies that the cancer experience had left feeling unfamiliar, unpredictable, and untrustworthy. Massage was capable of something more than comfort alone—it was functioning as a clinical intervention. The challenge was that our research hadn’t yet caught up.

When Dr. Jun Mao joined as chief of integrative medicine, his commitment to expanding the department’s research program brought renewed optimism that the kind of massage studies I envisioned might finally become possible. 

Eventually, MSK’s Integrative Medicine Center received funding from Patient-Centered Outcomes Research Institute (PCORI), an organization that prioritizes research driven by patients’ voices, for what would become the IMPACT study (see "A Deeper Dive—The IMPACT" at the end of this article). The funding source made perfect sense. The questions I had been asking hadn’t come from the literature or the medical establishment—they came from years of listening to patients describe what massage did for them and how it helped them live with pain and reconnect with their bodies. The research had simply not caught up. 

Leadership tapped me to develop the massage intervention for this multicenter, pragmatic, randomized trial comparing massage and acupuncture for chronic musculoskeletal pain in people living with advanced cancer. I dove into the daunting task of answering the question that had been following me for years: How do you translate an individualized, nuanced therapeutic modality that relies on physical attunement into something that can be rigorously studied?

Developing the Protocol

The trial’s overall design was already established when I joined the project. The treatment schedule, study procedures, and research objectives were fixed. My responsibility was to develop a 30-minute massage intervention that could be delivered consistently across multiple therapists while still producing meaningful improvements in pain, fatigue, sleep, and quality of life over six months. The protocol would need to work for whatever persistent pain walked through the door in people living with advanced cancer, each with a unique combination of contraindications and clinical considerations.

One of the biggest challenges was balancing research fidelity with the flexibility needed to preserve good massage therapy. Designing the protocol wasn’t about deciding which techniques to include. It was about deciding how much variation the intervention could tolerate before it was no longer the same intervention. I wanted the protocol to standardize therapeutic goals while giving therapists flexibility in how they achieved them.

Like most experienced therapists, I had developed a clinical style shaped by continuing education in neuromuscular therapy, lymphedema management, and osteopathic manual techniques. Together, these approaches emphasized anatomy, movement, careful assessment, and looking beyond the site of pain to understand the factors contributing to it. Those principles informed the protocol, but they had to be distilled into techniques that were safe, teachable, and likely to have the greatest impact within the study’s constraints. The challenge wasn’t preserving every aspect of my clinical approach; it was identifying which elements were essential to the intervention and could be translated into a standardized protocol.

The protocol functioned more as a framework than a script. Sessions always began by helping shift the nervous system toward a more restorative state before attention turned to the painful area, but therapists adjusted their approach according to the patient’s presentation. Someone with shallow breathing or marked rib cage restriction might spend more time there, while another patient might move more quickly through those components and devote additional time elsewhere. The therapeutic goal remained constant; the path to achieving it did not.

The same philosophy carried into treatment of the painful area. Rather than prescribing a single sequence of techniques, treatment was organized around three therapeutic targets: addressing tender points, improving movement, and reducing fascial restriction. Therapists addressed each target during every session but selected from an approved menu of techniques according to their assessment and experience. 

Some techniques were intentionally straightforward so any therapist could learn them quickly, while others required additional manual therapy training or experience. For example, tender points could be addressed with intermittent compression or, for therapists with additional training, techniques such as localized fascial stretching or positional release.

The menu wasn’t intended to give therapists unlimited freedom. It established clear boundaries while allowing them to work confidently within their own expertise. Therapists could omit techniques they hadn’t mastered without omitting the therapeutic goal itself.

Treating Cancer Pain

I approached pain as a massage therapist by asking what mechanisms were contributing to it. In advanced cancer, the answer was often more than one. Although participants qualified for the study based on persistent musculoskeletal pain, many were living with pain that was far more complex than a localized musculoskeletal condition. Cancer pain is often mixed pain, arising from multiple mechanisms simultaneously, including injured tissues, irritated or damaged nerves, and changes within the nervous system that develop as pain persists. By the time many patients entered the study, we were almost certainly treating far more than muscles and joints.

This understanding shaped the protocol. If pain was being maintained by more than injured tissues alone, treatment needed to do more than focus on the painful area. Every session intentionally included time devoted to calming the nervous system, careful assessment of movement and tissue restriction, and interventions directed toward the painful area while allowing therapists to address contributing regions when clinically appropriate.

Safety Through Clinical Reasoning

Safety began before the patient ever got on the treatment table. Whenever possible, therapists reviewed the electronic health record before each session to understand the patient’s cancer diagnosis, sites of disease, recent treatments, imaging findings, and other clinical considerations that might influence treatment. For participants receiving care outside of MSK, we gathered this information from the treating team. Our intake form captured additional details about the patient’s pain, symptoms, and functional concerns, and therapists used the intake interview to clarify any remaining questions before treatment began.

The team’s motto, “No pain, no pain,” served as an anchor for the protocol’s philosophy. I wanted therapists to understand that a pain-free session, not tissue change, was the priority. Tender-point work could occasionally produce mild, transient discomfort, but it should never become painful, and effective treatment did not require using pressure that caused pain. Therapists were taught to continuously monitor for signs of bracing, changes in breathing, or protective muscle guarding, adjusting their approach before discomfort escalated.

Safety was about adapting techniques thoughtfully. Beyond a handful of nonnegotiable safety rules, such as avoiding techniques that placed significant mechanical stress on areas of active disease, therapists modified their approach based on each patient’s medical history and clinical presentation. A patient with lumbar pain and lumbar vertebral metastases might still receive fascial work through distal contact points, adjacent tissues, or modified techniques that achieved the same therapeutic intention without loading vulnerable structures.

Pacing was equally important. We emphasized gradual progression, recognizing the goal was not to accomplish everything in one session but to build trust, comfort, and therapeutic benefit over the course of treatment. In everyday practice, we don’t always know whether we’ll see a client again. In the trial, we knew there would be another session. I encouraged therapists to be patient, to resist the urge to do everything at once, and to let the patient’s response determine the pace of treatment.

Training a Team

Training proved more challenging than I expected. The first step was developing a comprehensive yet practical manual that served as pre-work for the hands-on training and an ongoing clinical resource. It reviewed essential oncology concepts, pain mechanisms, and treatment considerations while teaching therapists how to synthesize information from the electronic health record, communication with the treating team (when needed), and a detailed intake interview to guide treatment planning.

Therapists brought remarkable diversity in experience, clinical philosophy, and oncology training. Some approached treatment through anatomy and tissue mechanics, while others worked from broader therapeutic models. Some had decades of experience; others were earlier in their careers. This diversity ultimately became one of the training’s greatest strengths.

Many of the newer therapists arrived with a strong oncology massage foundation, reflecting how much the field has matured since I entered it. That evolution has been essential. Effective oncology massage requires far more than memorizing precautions and contraindications. It requires understanding anatomy, physiology, cancer treatment, and treatment-related changes to the body so therapists can make thoughtful clinical decisions. The IMPACT training built on that foundation by helping therapists apply it within a shared framework.

To support research fidelity, therapists were trained to move deliberately through each therapeutic intention rather than blending them together as we naturally do in clinical practice. Even therapists who already worked structurally were encouraged to let this treatment feel different from their usual practice. I didn’t want them falling back into the familiar choreographies we all develop over years of practice.

In a 30-minute treatment, each therapeutic intention needed to remain distinct, so adequate time was devoted to every phase. A timer app quietly signaled transitions, helping therapists maintain both pacing and treatment fidelity. What mattered wasn’t that everyone looked the same. It was that each therapeutic intention received the intended attention and was delivered consistently and safely.

Training extended beyond manual techniques. We discussed contemporary pain science, therapeutic alliance, communicating confidence without unrealistic promises, and helping patients feel they were not facing pain alone. We also emphasized active listening, reflection, and validation, recognizing that feeling understood can itself influence the pain experience.

MSK therapists completed approximately 12 hours of in-person workshop training before practicing the protocol on one another and refining their skills through observation, discussion, and feedback. All demonstrated competency and treatment fidelity before treating study participants. Therapists at collaborating sites initially received didactic training remotely, with an intensive in-person weekend planned, but the COVID-19 pandemic required us to pivot. Instead, we developed instructional videos and live remote competency assessments, allowing me to observe therapists performing the protocol and provide individualized feedback before they began treating participants.

Massage Therapists Need to be Included

Research wasn’t part of the career I imagined. As I grew as a clinician, though, I began to feel a responsibility to extend my impact beyond the treatment room. Caring for individual clients would always be at the heart of my work, but I also wanted to contribute to the evidence that could improve care for thousands more. Becoming involved in IMPACT fundamentally changed the way I think about clinical practice. It didn’t replace my instincts as a massage therapist. It sharpened them. It taught me to examine my clinical reasoning more closely, collaborate across disciplines, and appreciate how thoughtful research begins with thoughtful questions.

This work also solidified for me that massage therapists belong at the research table from the very beginning. Years of clinical practice cultivate forms of clinical reasoning and patient-centered understanding that can only fully develop through firsthand experience in the profession. We spend our days observing patterns, adapting treatments, and asking why one person responds differently than another. Those insights don’t just help implement research—they strengthen it. We should be helping shape the questions, as well as the interventions.

Research is demanding. It requires becoming comfortable with uncertainty, learning a new language, accepting criticism, and working patiently toward answers that may take years to emerge. It’s humbling and often intimidating, but I now understand those are usually the things most worth doing. I came to realize that the way massage therapists observe, adapt, and reason clinically isn’t something to leave behind when we enter research. It’s exactly what we bring with us. 

Author’s Note: I would like to acknowledge Khadijah Hewitt-Nelson, who took over as the clinical lead for the massage intervention when I transitioned into my new role as a clinical social worker and could no longer serve as the massage intervention lead for IMPACT. Together with an extraordinary team of therapists, investigators, coordinators, physicians, statisticians, and collaborators, they carried the study across the finish line. 

A Deeper Dive—The IMPACT

The Integrative Medicine for Pain in Patients with Advanced Cancer Trial (IMPACT) was a multicenter, pragmatic, randomized clinical trial involving 298 people living with advanced cancer and persistent musculoskeletal pain. Participants were randomly assigned to receive either 30-minute massage or acupuncture treatments weekly for 10 weeks, followed by monthly maintenance sessions over six months.

The study found that massage produced meaningful and sustained improvements in cancer-related pain, reducing average worst pain scores from the severe range to the mild range over the course of treatment. Participants also reported improvements in fatigue, sleep, symptoms of anxiety and depression, and overall quality of life. By the end of the study, massage produced improvements comparable to those observed with acupuncture across all these outcomes.

People living with advanced cancer are often underrepresented in clinical trials, leaving important questions about supportive care unanswered. The IMPACT helps fill that gap by demonstrating that massage therapy can meaningfully improve pain and other symptoms in this population. The findings strengthen the evidence supporting massage as part of comprehensive cancer care and expand the range of evidence-based, nonpharmacologic options available to help manage pain and improve quality of life.

These findings represent another meaningful step toward expanding both the credibility and accessibility of oncology massage. The protocol is now being disseminated through therapist training, allowing more clinicians to bring this approach into practice.