March 2005: Acupuncture and Touch Therapies

Complementary therapies for all stages?

Question from Jo: Can complementary therapies be used for all types and stages of breast cancer?

Answers —Tracy Walton, L.M.T., M.S.: Massage therapy, when it's practiced skillfully and with care, attention, and sensitivity to the stages of cancer, can absolutely be used. It can be very helpful, whether it's someone in survivorship, during diagnosis, or in the middle of treatment.

Beth DuPree, M.D., F.A.C.S.: In my practice, complementary therapies are used for all types and all stages of breast cancer. My hope is that through education of my peers and colleagues, other physicians will adopt complementary therapies, as well, to aid in the healing process at any time during the treatment of breast cancer. I have actively referred patients for complementary therapies for the past five years, and I myself have been trained in the Japanese art of energy healing called Reiki.

Mary Ellen Scheckenbach, M.Ac.: The first thing to know is that there are many, many complementary modalities. Most of them focus on the person, as opposed to just the disease or the problem. For the person during diagnosis, during treatment, after treatment, and until the end of life, these modalities are always appropriate and can assist in different ways as the person makes the journey through illness.

Acupuncture and treating the spirit?

Question from Eileen: Mary Ellen, do you treat the spirit in your acupuncture treatments? And if so, what do you find is often needed, and what points do you find yourself frequently using to deal with the emotional aspects of having cancer?

Answer —Mary Ellen Scheckenbach, M.Ac.: That is a very large question! Many forms of acupuncture treatments treat the spirit. Much of the acupuncture from China comes from the period when Mao was in power. In America, much of that has been maintained or rejuvenated from certain teachers who come to this country. Traditionally in Chinese medicine, the spirit is always treated, because it is the finest level of our being, and therefore the most important in many respects.

When treating at the spirit level, what is often needed is to evoke, in Chinese terms, the five spirits, which are hope, compassion, service, forgiveness, and courage. All of these things are vitally important to be active in the journey through a significant illness. Which points are treated is entirely dependent on the constitution of the person and how the person presents each day or at a treatment. So theoretically, you could use any point.

How long until complementary therapies work?

Question from Joan: How long will it take for these therapies to take effect? And how will I know they are working?

Answers —Beth DuPree, M.D., F.A.C.S.: Many patients feel the effects of complementary therapies during the sessions themselves. As Mary Ellen stated before, there are so many types of complementary therapies that the individual results will depend upon the actual therapies being performed. Patients have told me of their experiences when receiving Reiki massage, reflexology, acupuncture, etc., that they felt a very profound transformation. I believe this to be the beginning of their healing process. Knowing whether or not they're working is something the individual themselves would only be able to gauge in the feeling that this process invokes.

Tracy Walton, L.M.T., M.S.: I agree with everything Beth said. My clients tell me that they do feel effects during the massage sessions and soon afterwards. I think if you sleep well that night and deeply, and feel some ease in anxiety and an increase in well-being, you know that massage therapy has had an effect and in some way met you where you are on your journey. Clients tell me they feel really fully seen and felt and heard during this very important time in their lives by their massage therapist. If you're seeking a long term reduction in muscle tension, that may take several sessions to manifest.

Beth DuPree, M.D., F.A.C.S.: Regardless of what therapy someone is receiving, I believe the initial connection with the human spirit of the therapist or physician is a very profound experience when it takes place. That can sometimes, in and of itself, initiate this process.

Mary Ellen Scheckenbach, M.Ac.: From a very practical standpoint, acupuncture is often used to treat symptoms associated with chemotherapy and radiation. Although the side effects of chemotherapy are not eliminated, hopefully, they are greatly reduced. Hopefully the recovery time after individual chemotherapy sessions and after the courses of radiation and chemotherapy is quick. I like it best when my patients say to me, "I'm not sure why I did acupuncture, because I never really felt that bad!"

Tracy Walton, L.M.T., M.S.: Reiki, which can involve hands-on touch, is a really potent therapy for people during cancer treatment. I heard one story of a person who chose to have a Reiki practitioner with her during her chemotherapy infusions. She swore by the ability of the Reiki and the practitioner to get her through that time with a minimum of side effects. Another person who chose to have energy therapies later in the day after her infusion felt it made the difference between her tolerating chemotherapy enough to continue working at her job and not being able to do that.

Complementary therapies for advanced cancer?

Question from Susie: If someone has tried every medical treatment for advanced cancer, is it too late to move onto complementary treatments?

Answer —Beth DuPree, M.D., F.A.C.S.: It is never too late to move on to complementary therapies. For some of my patients that may have been closed or uninterested in them previously, they may become the greatest fans of complementary modalities when faced with their mortality. I have had profound effects with several patients in Stage IV breast cancer when I have referred them to my acupuncturist, and I know in my heart that their therapies with the acupuncturist are making the greatest change in their physical bodies and their spirit. I truly believe that when we are able to get to a point where we marry Western medicine and Eastern medicine, not only can we treat the physical body, but we will truly be treating the spirit, and the healing process will be accelerated and profoundly affected. So the answer is that it is never too late.

Paying for complementary treatments?

Question from Lanie M.: How can I pay for complementary treatments? Does insurance cover any of them?

Answer —Beth DuPree, M.D., F.A.C.S.: From state to state and from insurance carrier to insurance carrier, there are many different policies regarding complementary therapies. I know that in Pennsylvania, when a massage therapist is working for a chiropractor, many therapies can be covered. But this again would have to be checked on an individual basis. Hopefully in the future, the medical community as a whole will recognize the importance of these therapies and we will be able to affect globally their coverage by insurance companies.

How does acupuncture work?

Question from Bairboak: How does acupuncture work, specifically, and how many sessions would a Stage II breast cancer need?

Answer —Mary Ellen Scheckenbach, M.Ac.: No one knows how acupuncture works. The Chinese have spent the last two thousand years trying to figure out how to make it work, because it treats so many different conditions and functions of the body. Scientists have been unable to determine a mechanism of action. I frequently treat people during their conventional treatments of chemotherapy and radiation. I will treat weekly or bi-weekly through the course of treatment, and sometimes afterwards, but that is more rare unless the person has a special request.

Can acupuncture move chemo?

Question from Grazzinik: Is there any concern about the moving properties of acupuncture actually moving the chemo from the target area?

Answers —Beth DuPree, M.D., F.A.C.S.: I have no concerns about the moving properties of acupuncture. I feel that the acupuncture enhances the effects of the chemotherapy as it is treating the entire mind, body, and spirit of the person receiving it. The chemotherapy, on the other hand, is targeting the cancer that has grown in this physical being; and therefore, they can work in concert with one another.

Mary Ellen Scheckenbach, M.Ac.: The magnitude of the intervention of chemotherapy is so many times greater than the intervention of the acupuncture that there appears to be no evidence of a decrease in effect.

Best touch therapy for fatigue?

Question from Beneteau: What is the best type of acupuncture or touch therapies to combat post chemo and radiation fatigue?

Answers —Beth DuPree, M.D., F.A.C.S.: Again, the best modality of treatment is often dependent upon the person receiving the treatment. I am a firm believer that so many complementary therapies will be able to work on combating the chemo and radiation fatigue. The exact therapy that is best I do not believe could ever be determined, as this is very user-dependent.

What works best for one patient may not work for another. My recommendation would be to talk to either your physician or someone from your support network in your area. If they can make a recommendation of what worked for them or other patients, that's a good starting point. You can always be open to trying a new form of therapy to get back to that safe place and a normal energy level.

Tracy Walton, L.M.T., M.S.: Because different people tolerate radiation and chemotherapy differently, I would echo that there are no one or two kinds of massage or touch therapies that are best. However, I will say that modalities that involve strong pressure are usually contraindicated for people going through chemo and radiation. They can be, in and of themselves, fatiguing. This is a time when massage therapy should support the body and help it integrate the therapies, rather than place additional demands on it. This is why it's important to seek a massage practitioner who is trained and skilled with people going through cancer treatment so that they recognize and apply those adjustments in their work with people. The body needs its resources for healing at that time and managing the treatment, so massage should not place any additional demands on the resources.

Mary Ellen Scheckenbach, M.Ac.: I'd like to reemphasize Tracy's point about being a practitioner who is well trained and skilled, because although many kinds of acupuncture could potentially treat the fatigue, it will be most effective done by someone who can do a good Chinese medicine diagnostic workup, which would attempt to understand the person's constitution and the particular effects that radiation and chemotherapy have exerted on that person.

Complementary therapies physically change the body?

Question from JS: Is there evidence that these therapies actually make changes in the physical body - or is what happens to you just a placebo effect from feeling like people are taking care of you?

Answers —Beth DuPree, M.D., F.A.C.S.: Although I do not have a prospective randomized double blinded trial to support my knowledge in this field, I have 20 years experience as a surgeon to know that these changes are taking place in the physical body. The term, "placebo effect," is one that I often think may be synonymous with the body's own ability to heal. When the human body is so totally connected with one's mind and spirit, the healing process can and is accelerated. The exact cause of why this happens to me is not as great a concern as the fact that this is actually happening. When my patients receive chemotherapy and radiation and simultaneously are receiving some form of complementary therapy such as Reiki or acupuncture, I do not know that it is important to give one credit over the other. I feel the effects of both are so profound that I am just in awe of their abilities to be able to work in concert with one another.

Tracy Walton, L.M.T., M.S.: The way to establish the role of the placebo effect vs. the effect of the complementary therapies is to do good rigorous study. The gold standard of that is the randomized controlled clinical trial.

In massage therapy, we are seeing a growth in interest in these kinds of studies. Specifically, one study looked at 230 patients and compared effects of massage, Healing Touch, caring presence, and just standard care, and found that massage reduced the pain and use of analgesics (pain killers) as well as anxiety. In addition, a meta-analysis which collects groups of studies together suggested that there was at least some short-term psychological benefit of massage for people with cancer. So we're on our way in establishing these things even more firmly.

Mary Ellen Scheckenbach, M.Ac.: In acupuncture research, there is a significant body of study on physical changes in blood chemistry and changes on MRI resulting from acupuncture treatment. The issue of placebo with acupuncture has mostly been discounted due to the phenomenon of veterinary acupuncture. The placebo effect is obviously very complicated.

The documentation for physical changes from "being taken care of" exists. There is some preliminary evidence that endorphins, (natural painkillers produced by the brain), which are somewhat released during well-being experiences, have some cancer cell-killing effects. It's probably wise for us to consider care-taking from a loved one or a healthcare practitioner as integral for healing. The relationship with a complementary medicine practitioner is often very significant and important, and probably carries some effects into overall healing.

Beth DuPree, M.D., F.A.C.S.: My favorite quote to my patients is, "The energy that I share with you in our relationship is equally, if not more, important than the scalpel I will use to physically remove the cancer from your body."

Mary Ellen Scheckenbach, M.Ac.: The word "energy" has now come up. What we learned in about sixth grade is that the atom is 99 percent space. We are made of atoms, which means that the physical reality of our being is space. In that space, there exists energy. Probably, that energy is organized in ways we don't understand yet. Probably, it becomes disorganized in some way in disease. Many of these modalities are not treating the body at the level of the biochemistry. They are probably treating at the physics level of the body. Again, we don't know exactly how, and we're in a very large process of learning how to make these interventions significant in the direction of health and well-being.

Tracy Walton, L.M.T., M.S.: Could you distinguish further between the physics level and the biochemistry level?

Mary Ellen Scheckenbach, M.Ac.: The biochemistry level is the level of matter, material—cells, tissue, organ systems. The physics level is the 99 percent space that we, in fact, are. It's hard to speak of it because it is not our everyday reality, but thanks to Einstein, we know.

Taking complementary therapies together?

Question from Paultan: Why is it that when you have a conventional treatment like chemo or radiation, you have one at a time, but you can have massage, meditation, acupuncture, music therapy, etc. all at the same time?

Answers —Beth DuPree, M.D., F.A.C.S.: Because God is good to us! Chemotherapy and radiation are staggered by days and weeks in order to allow our normal cells to recover while the chemotherapy works to destroy the cancer cells. Our bodies need time to come back to their normal state between the therapies, as our goal is to destroy cancer cells while maintaining normal function within the rest of the physical body.

Tracy Walton, L.M.T., M.S.: Many of these complementary therapies work wonderfully together and enhance each other. At the same time, it's good to consider sequencing complementary therapies appropriately and asking each of your practitioners how they'd like you to time these therapies.

One example is that it may be best to have an acupuncture session and let it settle in the body, rather than follow it with a massage therapy session later that day. There may be other examples as well.

Mary Ellen Scheckenbach, M.Ac.: When using multiple energy modalities such as acupuncture, Reiki, shiatsu, etc., it is important to have adequate space between them as Tracy mentioned. I usually ask people not to have another energetic intervention for about 72 hours. In general, I ask people not to do too much. The theory, right or wrong, behind these medicines is that they are inputting corrective information into the body. Too many in too short a time period can be confusing, because the body needs to sort out each input.

Sometimes when there is an attempt by an energy medicine to regulate a function, there can be a period when it appears there is an exacerbation, (symptoms flare up) and this process of "clearing out" of the function needs to run its course before another input is entered. I always ask people if they want to do multiple modalities to listen very carefully to their bodies and to follow the response that they're getting to not do too much.

Acupuncture after lymph node removal?

Question from Becca: Is it ok to get acupuncture needles in the arm of someone whose lymph nodes have been removed if there are no symptoms of lymphedema? I have heard that the needles are so fine and sterile that there is no risk, but others advise against it.

Answers —Beth DuPree, M.D., F.A.C.S.: If someone has had a complete axillary node dissection, then any invasion into the affected arm can increase the risk of developing lymphedema. If someone has had a sentinel node biopsy alone, the risk is far less than with a complete axillary node dissection. My personal recommendation for my patients would be to avoid needles in that arm and discuss with their acupuncturist what alternative forms of energy therapy they could perform with the affected extremity. The acupuncturist who works with my patients chooses to use tuning forks and sound, but this may vary from therapist to therapist and should be discussed prior to the treatment.

Mary Ellen Scheckenbach, M.Ac.: I agree 100 percent with Dr. Dupree, and I personally have done treatments on the affected arm with no ill effects. However, again, I do agree with Dr Dupree.

Massage while undergoing radiation?

Question from Heather: I am a breast cancer patient who is ready to begin radiation therapy. Can I do massage therapy while undergoing radiation?

Answer —Tracy Walton, L.M.T., M.S.: Yes, you can begin or continue massage therapy throughout your radiation therapy. The massage therapist needs to follow all precautions, including not massaging directly on the radiation field with pressure. They also need to ask where your radiation markings are, and avoid rubbing at them. This depends on what kind of markings they are. Different radiation therapists use different tools for marking. On the other hand, you may find that if they rest their hands gently on the field through the towel draping you and do some gentle energy work, or even "cooling energy" into that area, that this helps reduce irritation in the area. The therapist also needs to honor any lymph node removal by not massaging the affected arm and the upper trunk with any significant pressure.

Massage spreads breast cancer cells?

Question from Tweeti: Does massage contribute to the spread of breast cancer cells to the lymph nodes?

Answer —Tracy Walton, L.M.T., M.S.: Unfortunately, it is a common myth that massage therapy, by increasing overall circulation, could contribute to the metastasis or spread of cancer. This myth has finally been questioned, thought through, and overturned in the literature in the last ten years or so.

It has been overturned for two reasons. The first is that it's not clear that massage therapy has a very significant circulatory effect. Instead, its effect may be more mediated by neuroendocrine and other responses. Secondly, and most compelling reason the myth has been overturned, is that people in cancer treatment are rarely restricted from exercise unless there is some medical risk of bone fracture, etc.

Exercise and hot showers would confer the same, if not greater, risks than massage therapy if it were true that circulation is the only thing causing metastasis. But in fact, metastasis is a very complex process. One person in one of my classes summarized the argument against that old myth in just two words—Lance Armstrong. In fact, exercise is encouraged where possible for people with cancer for its health-promoting effects, and it much profoundly more circulatory than any hour-long session of massage therapy.

Tell oncologist about massages?

Question from Jennifer: Should I tell my oncologist that I'm getting a therapeutic massage once a week? I think he'd just laugh at me or tell me I shouldn't do it. How do I start this conversation?

Answers —Beth DuPree, M.D., F.A.C.S.: As a physician, I feel that my relationship with my patients is one of the most sacred relationships that exist. As such, in order to completely treat someone, there need to be open lines of communication at all times. I feel you should share with your oncologist that you are receiving massage therapy, and if the response that he/she is not one that you feel is completely supportive of what you are doing, understand that he/she may be in a different place in their spiritual development, and this is not a negative judgment against your choices.

I feel the patient should be quite open with any therapy that they are receiving, as well as any herbal supplements, vitamins, or antioxidants that are being taken concurrently with treatment. I encourage my patients to seek therapies apart from what we offer in standard "Western medicine." And my hope is that some day all patients will be asked by their physicians, "What complementary therapies are you taking that enhance your care that I can share with my other patients, as you seem to be doing so well."

Mary Ellen Scheckenbach, M.Ac.: If a patient is actively discouraged from pursuing these modalities, what would you advise the patient to do?

Beth DuPree, M.D., F.A.C.S.: Just as I would tell one of my patients if they were diagnosed or recommended to have a certain type of treatment, I would say to get a second opinion about whether or not that treatment is appropriate for them. I would also ask my physician why they would advise against a healing modality. My goal is not to destroy an existing relationship between a doctor and a patient, but know that being able to communicate your needs and the ability for the physician to communicate their needs are equally important in the doctor/patient relationship.

Risks of massage after surgery?

Question from Gerry: What are the risks with massage therapy after surgery for breast cancer? I am eight months post surgery, and taking tamoxifen.

Answers —Tracy Walton, L.M.T., M.S.: As with any medication you're on, it's good to talk with the massage therapist about any interactions between massage, medication, and your condition, and it's another reason to visit a massage therapist trained in this area. The massage therapist should be able to develop direct, focused questions for your physician about your medication and massage therapy. Tamoxifen carries with it a slight increase in risk of deep vein thrombosis, or blood clots. The elevated risk is very slight, but if you have other risk factors for DVT, your massage therapist needs to consider that with your physician before, for example, they use pressure on your legs where DVT is most likely to form.

Beth DuPree, M.D., F.A.C.S.: I regularly refer my patients to the holistic center at my hospital for massage therapy after surgery or radiation, even with taking tamoxifen, as I feel the benefits to the patient far outweigh the risks.

Finding a safe practitioner?

Question from Paula: I'm nervous about doing either massage or acupuncture because I don't know anyone who does it. How do I find a safe practitioner who understands not just the therapy but also knows breast cancer?

Answers —Mary Ellen Scheckenbach, M.Ac.: With regard to acupuncture, most states in the United States license acupuncturists, so the first step would be to find someone licensed in your area. The second step would be to call the person and have a conversation about his/her training and experience in this area. Obviously, the more training someone has, the more likely you'll get effective treatment. There are websites where one can find a qualified acupuncturist. In states with no law, the person should be certified by the NCCAOM. (National Certification Commission for Acupuncture and Oriental Medicine.)

Tracy Walton, L.M.T., M.S.: Massage therapists are regulated differently state to state. However, you should see a massage therapist who is nationally certified - NCTMB (National Certification Board for Therapeutic Massage and Bodywork). In addition, ask them if they've had advanced training in work with people with cancer. Ask them what kinds of adjustments they make in their work for clients with cancer. And finally, a number of us teach training around the country and can be found on the web and maintain databases of our trainees. Memorial Sloan-Kettering does training, and Gayle MacDonald, Cheryl Chapman, and I all train significant numbers of massage therapists each year. Hopefully, one of us could locate someone in your area if you choose to call us.

Beth DuPree, M.D., F.A.C.S.: If you live outside of the United States, my best advice would be to inquire with a national cancer or breast cancer organization for a referral to a therapist in your country.

Timing of acupuncture around treatments?

Question from Sally: When should patients have their acupuncture appointments while going through chemo and/or radiation? Should they have it just before the chemo/radiation, just after, or on the day of treatment?

Answer —Mary Ellen Scheckenbach, M.Ac.: I generally like to see patients one to days before chemotherapy, and as soon as one is well enough afterwards (after 10 days of chemo if it is, for example, a 3-week schedule).

This can vary from practitioner to practitioner. During radiation, weekly is usually fine. I would like to add that during radiation therapy, I will use a technique called Colorpuncture, which is non-laser light shone through crystals of different colors to treat radiation burns for redness.

Touch therapy for pre-cancers?

Question from Karlee: Can touch therapy and acupuncture be effective treatments for pre-cancerous conditions (e.g., DCIS) rather than radiation following lumpectomy or mastectomy?

Answers —Beth DuPree, M.D., F.A.C.S.: I'd like to make the point that the therapies we are discussing are termed "complementary," and not "alternative." They are used in concert with conventional radiation and chemo, and not in place of.

Mary Ellen Scheckenbach, M.Ac.: If the condition is truly pre-cancerous and no Western conventional treatment is prescribed yet, frequently these conditions can be slowed at least with oriental medicine—acupuncture and herbs.

Acupuncture with tuning forks?

Question from Barb: Can you explain the form of acupuncture that does not require needles, but uses tuning forks instead? And how effective is this form?

Answers —Mary Ellen Scheckenbach, M.Ac.: There are several new modalities which use acupuncture theory or acupuncture points, but not the traditional acupuncture tool of needles. These can involve sound and light therapies. They work on a similar principle and are probably as effective insofar as they are a complex and advanced modality. Some are in their infancy, and some are more developed. We shall see.

Beth DuPree, M.D., F.A.C.S.: Having experienced traditional acupuncture with very tiny needles, I was quite amazed when my acupuncturist began using sounds in the form of tuning forks, Tibetan singing bowls, and gongs of varying frequencies in order to deliver an acupuncture treatment. My patients, as well, who had a fear of needles or who had felt that the treatment of their cancer had already used all of the needles that they cared to see were quite pleased to see that seeing an acupuncturist did not mean an absolute beginning of more needles. I will be very interested to experience Colorpuncture in my near future, as I use crystals within my office and my practice in order to change the energy patterns throughout the physical space of my practice, and knowing the very powerful nature these crystals possess makes Colorpuncture a very intriguing therapy, which I will experience myself very soon. I'm coming to see you Mary Ellen!