Research Highlights

Massage and Cancer: Supporting Patients and Caregivers

A massage can be a relaxing treat after stressful events, or a nice quick rehabilitation for sore or tight muscles. It can also be a hands-on therapy that provides supportive care for cancer patients and their caregivers, relieving more than just stress and tight muscles. Massage can help reduce pain, fatigue, nausea, and other symptoms often suffered by cancer patients and survivors. The benefits are not exclusive to massage recipients — those giving the massage can also feel greater levels of confidence in their ability to help their loved one cope with cancer.

William Collinge, Ph.D., M.P.H., LCSW, is the owner of Collinge and Associates, an independent research and consulting organization funded by research grants from the NIH and other sources. He also runs a private practice focused on cancer survivorship located in Eugene, Oregon.

Dr. Collinge’s work was funded by the Small Business Innovations Research (SBIR) Grant mechanism (R43/R44). SBIR grants are awarded to domestic, for-profit, small businesses to conduct innovative research and development that has potential for commercialization and public benefit. Dr. Collinge was awarded an SBIR grant* to study how touch and massage, used as supportive care and guided by a multimedia instructional program, could affect patient symptoms and side effects, patient quality of life, and caregiver attitudes toward touch as a form of caregiving. Collinge and Associates created the DVD used in the multimedia instruction program titled, Touch, Caring and Cancer: Simple Instruction for Family and Friends. The goal of the DVD was to allow family members to become part of a treatment team for a cancer patient. Using massage and simple touch, both the patients and caregivers could receive benefit. The video provided 78 minutes of instruction by Collinge and two oncology massage therapy researchers and was filmed with live patientcaregiver pairs. A 70-page illustrated manual accompanies the DVD and is designed to teach caregivers techniques for relaxation, acupressure, and simple light touch. The DVD and manual are intended for use at home by patients and caregivers and are available in English, Spanish, and Chinese (Mandarin and Cantonese).

Dr. Collinge conducted a randomized controlled trial of a multi-ethnic sample of 97 adult caregiver-patient pairs. Pairs were randomized to either the treatment or control group. Pairs in the treatment group met with other subjects, viewed the instructional DVD together, and were then given a copy of the DVD plus data collection materials. The participants were encouraged to view the materials of both the DVD and manual as often as they liked and practice the techniques of their choice three times per week, with a suggested duration of 20 minutes. However, pairs were told that as little as 5 minutes could be beneficial.

The control group acted as an attention control which required caregivers to read to the patients at least three times per week with a suggested duration of 20 minutes, but were told as little as 5 minutes would be beneficial. Reading material could be of any type of literature of the patient’s choice. Control group participants were allowed to join the intervention after 4 weeks and all subjects were followed for another 16 weeks.

Both the treatment and control groups were to report on session effects for one session each week as they related to the pre-and post-session severity levels for pain, fatigue, stress/anxiety, nausea, and depression, and an optional other category. The caregivers in each group also filled out surveys to assess their stress levels and feelings towards caregiving. Results showed significant reductions for all symptoms after both the treatment and control group activities. Pain reduced 18% in the control group and 34% in the massage treatment group. Fatigue was reduced 20% vs. 32% (reading vs. massage); stress/anxiety, 28% vs. 44%; nausea, 12% vs. 29%; depression 22% vs. 31%; and other symptoms 17% vs. 42%. Massage was shown to be significantly superior to reading for stress/anxiety, pain, fatigue, and other symptoms. Both groups of caregivers had significant increases over the 4 weeks in satisfaction with their ability to help their partners feel better, and they had reduced concern about causing distress. Results have been published in Journal of the Society for Integrative Oncology**, Seminars in Oncology Nursing***, and another article about the research is currently under review.

Dr. Collinge notes that he wanted to pursue this area of research because he “saw a need for caregivers to be able to offer something tangible to benefit the well-being of their loved ones with cancer. Caregivers experience distress from a perceived inability to reduce suffering in a loved one. This intervention benefits the patient, makes caregiving more satisfying for the giver, and strengthens the quality of their relationship, all at the same time.” He was pleased with the results because “informal caregivers using the techniques were able to achieve results approaching those of professionals. Caregivers can easily learn safe and simple techniques from a very low-cost multimedia intervention. Patients can experience the benefits of touch and massage far more frequently than they would ever be able to if relying on professionals. This has huge potential for overcoming disparities in palliative care for low-income and underserved populations.”

This study is currently being adapted for use in Vietnam. “The Vietnamese version is being used at National Cancer Hospital in Hanoi to train caregivers. We are collecting data from sample families in Hanoi, and it will be interesting to see how the program might help meet palliative care needs in an underresourced country like Vietnam,” notes Dr. Collinge.

In summary, this research shows that supportive care at home can offer benefits to both patients and caregivers at relatively low cost and effort. Caregivers’ self-efficacy about their caregiving can be increased and patients can see improvements in their quality of life.

Connie Dresser, RDPH, LN, Program Director for Dr. Collinge’s grant, noted that the project was significant because “the study results indicate there is a good possibility that similar outcomes could be achieved by caregivers of patients with other chronic diseases or depression. Today, technology has completely taken over how we live and the art of tangible communication (such as face-to-face and writing) has decreased from the previous norms. Dr. Collinge’s work offers a meaningful and healthy way of reengaging with family, friends, and patients.”

Dr. Collinge is also busy working on a current R43 grant**** from NCI titled “Palliative care provider online education in evidence-based complementary therapies.” This current research aims to develop the first online continuing education program for palliative care personnel who teach evidence-based applications of complementary therapies in the palliative care setting. Dr. Collinge stresses that palliative care is one of the most rapidly expanding sectors in health care and complementary therapies offer significant benefits for reducing suffering and improving quality of life. However, there are currently no systematic educational offerings to help health care professionals learn how to use complementary therapies with diverse patient groups in the palliative care setting. Through the R43 grant, Dr. Collinge is working to create an interactive website delivering educational curricula to health care professionals about complementary therapies and palliative care. This is a large undertaking that will consist of multiple reviews of the literature, working with a team of professionals in palliative care, and creating and reviewing course content and the best methods of delivery.

Dr. Collinge notes that he wanted to do this work because “complementary therapies are underutilized in palliative care environments. They have a lot to offer in terms of comfort and symptom reduction, but practitioners need help making evidence-based decisions. We aim to help them sort through the strengths and limitations of complementary therapies in palliative care.”

Compound Found in Green Tea May Help Improve Pancreatic Cancer Treatments

Pancreatic cancers tend to be very aggressive, with a very small percentage of patients surviving 5 years after diagnosis. Results of a new, NCI-supported* study suggest there may be a new weapon in the fight against pancreatic cancer — one found in a very popular beverage. Epigallocathechin gallate (EGCG) is a component in green tea that has anti-tumor activity in the laboratory. Numerous studies, in a number of different cancer types, have shown that EGCG may decrease tumor cell growth, increase apoptosis (programmed cell death), and prevent formation of new blood vessels around tumor cells.

In the current study**, researchers investigated the effects of EGCG on pancreatic cells. Treatment of pancreatic cells with EGCG resulted in decreased cell migration and increased apoptosis. The researchers also treated cells with a combination of EGCG and gemcitabine, a chemotherapy drug used by pancreatic cancer patients. The results indicated that while EGCG and gemcitabine alone were effective in increasing cell death and apoptosis, the effects were greater when the two agents were used in combination. EGCG also enhanced the effects of CP690550, an immunosuppressant drug that has been shown to have anticancer activity.

While the exact mechanisms of EGCG’s actions on pancreatic cancer cells are unknown, results of this study suggest that EGCG may be interfering with a protein — STAT3 — involved with cancer progression. STAT3 is a member of the signal transduction and activators of transcription (STAT) family of proteins, which are important for normal cell growth. When STAT3 is activated, a number of genes necessary for tumor cell growth and survival are turned on. In this study, treatment of pancreatic cancer cells with EGCG resulted in lower levels of STAT3 in the cells. In addition, levels of certain genes that are turned on in cancer and controlled by STAT3 were inhibited following EGCG treatment.

While this initial study used an in vitro model only, the authors noted that their results “provide a new application method, in which the use of EGCG can enhance the therapeutic effects of anticancer drugs while possibly reducing their side effects.”

To read more about this study, go to http://www.ncbi.nlm.nih.gov/pubmed/22348037.

A New Report Offers Review of Research on Exercise in Cancer Survivors

An increasing amount of research suggests that exercise may help cancer patients feel better during treatment. But what about when the chemo and radiation are finally over — does exercise help or hinder survival? A systematic review* by Rachel Ballard-Barbash (Associate Director of the Applied Research Program in the Division of Cancer Control and Population Sciences at NCI) and her colleagues, published in the Journal of the National Cancer Institute, examined recent studies that investigated the effects of physical activity on mortality and/or cancer biomarkers in cancer survivors.

The majority of studies included in this review were published after 2009 and focused on breast cancer survivors. Other types of cancers included in the review were colorectal, prostate, ovarian, and brain.

Almost all of the breast cancer studies reviewed indicated that physical activity (before or after breast cancer diagnosis) may be related with greater survival. In addition, about half of the breast cancer studies suggested a dose-response effect — greater amounts of exercise were associated with larger decreases in mortality risk. There were also a number of studies that revealed physical activity may increase survival in colorectal cancer survivors. There was not enough evidence in the reviewed studies to support a relationship between physical activity and mortality risk for survivors of other types of cancer.

This review also identified studies that reported links between physical activity and biomarkers in cancer survivors. Among breast cancer survivors, results of randomized controlled trials have suggested that physical activity may result in beneficial changes in circulating insulin levels and insulinrelated pathways. Results of randomized controlled studies of survivors of other cancer types indicated that exercise may lead to beneficial changes in biomarkers related to inflammation and immunity.

Although the outcomes of physical activity seem promising, the authors of the review note there are some caveats that prevent them from making specific recommendations for cancer survivors. The studies included in this review assessed physical activity in different ways and reported various types of exercise. For example, among observational studies, the questionnaires that were used examined participants’ physical activity over various time points (exercise in the past year versus exercise in the past 6 months). Among randomized control studies, there were a variety of exercise interventions used, including aerobic exercise, walking, and strength training. In addition, more cancer types should be investigated, along with more racial and ethnic groups. The authors of this review concluded that while exercise may be safe for cancer survivors and help improve survival, “additional research is warranted before clear conclusions can be reached on the effects of physical activity on disease outcomes among many groups of cancer survivors.”

To read more about these findings, go to: http://www.ncbi.nlm.nih.gov/pubmed/22570317.