Chapter Eighteen

However, in a telephone interview, Layman told me that he had found to his frustration that he was not able to replicate the study. One problem with the exercise studies on animals, he pointed out, was that virtually all of them force the animals to exercise, and that may cause the exercise to be a stress on the organism rather than a source of health promotion. One researcher, he said, has tried allowing experimental animals to exercise voluntarily and found some protective effect against cancer in animals that choose to exercise a lot, but this raises the question whether the protective effect is from the exercise itself or from factors that predispose the animal to high levels of exercise.2

In human studies, some of the most important work has been done by Rose E. Frisch of Harvard. Frisch and colleagues surveyed 5,398 women ages 21 to 82.3 According to a summary in Oncology Times, they found that “in every age group, the non-athletes had a higher life-time occurrence of cancers of the reproductive system, which covered cancers of the uterus, ovary, cervix, and vagina. The non-athletes had 2.5 times the risk of the athletes.”4

The risk of breast cancer for nonathletes was approximately twice the risk that athletes faced. The study was carefully controlled for confounding variables including family history of cancer, age at menarche, number of pregnancies, age at first pregnancy, use of oral contraceptives, use of estrogen during menopause, leanness, smoking history, and current diet. Frisch also found that exercise during the college years was far more protective against cancer than exercise initiated by nonathletes in later life, although exercise initiated later did have some effect. Of nonathletes who exercised later in life, 50% had a reduced risk of cancer. Oncology Times reported:

Dr. Frisch …postulates reasons for the lower risk in former athletes. First, the athletes may have made less estrogen because they were leaner and had less adipose tissue, which converts androgen to estrogen. A decrease in estrogen, which causes breast and reproductive tissue to divide, would result in less tumor cell division. Secondly, the estrogen athletes made may have been less potent. It has been previously shown that the leaner one is, the more one’s estrogen metabolism produces a less potent estrogen, which does not let uterine and breast cells divide.5

That vigorous exercise reduces body levels of the highly active form of estrogen was confirmed in a study by Rachel Snow, a graduate student working with Frisch, who measured body fluids of athletes and nonathletes. She found that girls and women with anorexia and an irregular menstrual cycle develop an excess of the inactive form of estrogen. An Olympic gold medal figure skater, Tenley Albright, later became a specialist in female disorders and took part in Frisch and Snow’s research. Albright reported that in view of recent findings, an athlete’s irregular menstrual cycle should be considered an “appropriate response” by the body that would disappear when a less active life was resumed.6

Frisch also found that hard exercise is often associated with the delay of the onset of menstruation. She believes this may be protective against breast and reproductive system cancers. In fact, she postulates that the higher the total number of ovulatory periods in a woman’s lifetime, the greater her susceptibility to cancer may be. She noted that 100 years ago menarche typically took place at 15 1/2 years of age. It is now, in general, 3 years earlier, but remains 151/2 for girls who exercise hard. “I don’t think there is anything great about menarche at twelve-and-one-half,” she said.7

In another study, Frisch found that cancers of the digestive system, thyroid, lung, and other sites, as well as the hematopoietic cancers (lymphoma, leukemia, myeloma, and Hodgkin’s disease), were also lower for the college athletes. Interestingly, the prevalence rates of malignant melanomas and skin cancers did not differ significantly between the two groups.8

Further evidence of the protective benefits of exercise in later life was found by Lawrence Garfinkel and Steven D. Stellman of the Department of Epidemiology and Statistics of the American Cancer Society. In a study published in 1988, they reported that “exercise is inversely related to mortality in males and females in both smokers and non-smokers.” But the detailed findings were more intriguing: while people who did not exercise had markedly higher cancer mortality levels–and the drop in mortality was substantial for those who described their exercise pattern as “slight” or “moderate”–there was an increase in cancer among male and female smokers who described their exercise as “heavy.” In addition, female nonsmokers who exercised “moderately” enjoyed no gain in cancer protection compared with women who exercised “slightly,” whereas those who exercised “heavily” did show an increase in cancer risk. Male nonsmokers, by contrast, had some additional gain in cancer protection as they moved from slight to moderate exercise, and a very small amount more as they moved to heavy exercise. These correlations, while fascinating, were too small to achieve significance statistically. The elevated risk for cancer associated with intense exercise referred specifically to lung, colorectal, and pancreatic cancers–not, interestingly, to breast or reproductive system cancers.9

But the evidence does not all point in the same direction. Ralph S. Paffenbarger of Stanford University Medical School found in another extensive retrospective review of the effects of physical activity (participation in college sports) on students that the active male students, while considerably less likely than inactive students to develop rectal cancer, were considerably more likely than inactive classmates to develop prostate cancer. He also did not find in his sample the protective effects of athletics for breast cancer that Frisch had reported–in fact he found none of the protective effects for women’s cancers that Frisch had reported in her sample.10

Thus we find that the picture is complex when we link exercise and cancer. It is striking that the greatest protective effect of exercise against cancer may be associated with concomitant protective factors. Exercise helps men and women–smokers and nonsmokers–but it helps the nonsmokers more and it helps most if done in moderation.

So exercise may work by many complex and varied pathways in either lowering or increasing cancer risk. Its association with leanness, which is protective against cancer, has been noted, as has its effect on estrogen, ovulation, and other factors related to female breast and reproductive cancers. Another protective pathway by which exercise may modulate the development of cancer is through its effect on depression. In a number of studies, exercise has been shown to have an antidepressive effect, and depression is a common precursor and concomitant factor in cancer. Moderate exercise can have a powerful protective effect against depression, which in turn may work through complex mind-body pathways to help prevent or modulate the development of a cancer.

Some researchers have hypothesized that at high exercise levels the body may experience an increase in free radicals and peroxide production in the body, which might account for the increase in cancer in some animal studies and the increase (albeit statistically nonsignificant in the previously cited study) in humans, particularly in smokers.

Still another interesting perspective on cancer and physical activity comes from Ron E. LaPorte, Associate Professor of Epidemiology at the School of Public Health at the University of Pittsburgh. LaPorte believes physical activity rather than exercise may be the important protective factor against cancer. As Oncology Times reported, LaPorte believes “there is …some evidence …that increased physical activity alters bowel transit time. Decreased transit time might be related to reduced colon cancer risk, said Dr. LaPorte, because there is less time for carcinogens to be produced. He also cited evidence for decreased cancer risk related to physical activity via increased thermal effects, and increased concentrations of vitamin A.”11

One very striking gap in the literature on exercise and cancer is that there are no studies that I have been able to find assessing the effect of exercise on an existing cancer–only cancer prevention. Indirect evidence, however, shows the benefits of physical activity for people with cancer. The line of reasoning is that enhanced functional status or performance status is a predictor of better outcomes in some cancers, and “functional status” is a synonym for capacity to be physically active. Similarly, most oncologists regard a person who is in good physical shape as potentially more resilient to treatment.

The absence of studies of the effects of exercise on survival in people with cancer is as striking as the paucity of psychological and nutritional cancer survival studies. It reflects the same astounding medical assumption that what we eat, think, feel, and do while we have cancer can have no possible effects on the outcome of established disease, and therefore that the subject is not worth studying.

Massage

In the weeklong retreats we offer for cancer patients through the Commonweal Cancer Help Program, we have found that the three hourlong massages each participant receives are among the most treasured forms of nurturance and relaxation that the program provides. We try to schedule the most anxious participants for the first massage appointments because the effect is often transformative. Participants whose skin color when they arrive is almost gray from chemotherapy often get pinker skin after one or two massage appointments. Areas of chronic pain and tension are often eased or fully relieved.

For many participants, the massage at Commonweal is the first they have ever had. And for many, the only touch they have experienced from health professionals during their illness has been associated with painful or, at best, neutral diagnostic or treatment procedures. Many participants have not shown their bodies and scars to anyone since they began cancer treatment. The experience of having a scarred body treated with love and compassion by a truly caring masseuse can be a profound one. (We select women as massage therapists, incidentally, because the large majority of participants are women.)

The sparse clinical literature on massage for cancer is mixed, but largely positive. The occasional concern, which is a legitimate one, is that massage might possibly help the cancer spread because it increases circulation. Based on this concern, some massage clinics have a policy of not providing massage for cancer patients, and a few texts recommend against massage for people with cancer on this basis. On the other hand, increased circulation and deep relaxation could well have protective benefits. The primary nursing literature supports massage for cancer patients.

Our own rule of thumb at Commonweal is to use gentle massage techniques and especially to avoid any form of deep massage in areas of known cancer activity. We also avoid pressure around bone metastases, and we avoid any form of massage that stimulates lymphatic movement in cancers that are in the lymph system. We also avoid pressure massage in leukemias because of the special characteristics of leukemic cells.

In the literature on massage for cancer patients, a number of nursing studies show that slow-stroke back massage enhances relaxation or the feeling of general well-being. For example, an article by K. Warren in Nursing Times recommends slow-stroke back massage, along with distraction, guided imagery, progressive muscle relaxation, systemic desensitization, hypnosis, and dietary adjustments, to help patients with chemotherapy-induced nausea and vomiting.12 In the same journal, S. Sims reports a pilot study with six breast cancer patients undergoing radiotherapy for whom back massage resulted in fewer symptoms, more tranquility and vitality, and less tension and tiredness.13 L.A. Barbour, in a descriptive study in Oncology Nursing Forum, found that patients use an array of nonanalgesic methods to control pain that include heat, deep breathing, massage, and exercise.14 B.Z. Dobbs in Nursing Mirror reports that reflexology was helpful to advanced cancer patients both in comforting them and controlling pain.15 Reflexology involves massage of the hands and feet based on the theory that pressure points there correspond to different parts of the body, including the internal organs.

In physical therapy, massage is frequently a necessary part of the management of lymphedema, in which the protein-rich fluids of the lymph system accumulate in tissue after breast surgery or radiotherapy. One key to the treatment of lymphedema is to spot it and treat it early, since prolonged presence of lymphedema in the tissue can break down the structure of the tissue so that it loses the elasticity necessary to squeeze out lymphatic accumulations. At Sir Michael Sobell House in London, which specializes in the treatment of lymphedema, diuretics are no longer used (they reduced edema at the expense of dehydration). Instead, massage combined with a variety of sleeves and stockings is used to control the movement of lymphatic swelling.16

Therapeutic Touch

The implications of Therapeutic Touch for medicine and science are–if the scientific studies of its efficacy are valid–truly awesome. Something is happening in these studies, if they are correct, that medicine should attend to and science cannot yet account for.

Therapeutic Touch is a modern version of the ancient practice of laying on of hands. Many of our ancestors–in antiquity and throughout the Middle Ages–believed that touch had a magical quality for healing, particularly if it were administered by a holy man or healer. Today, the laying on of hands is being revived in much of its original method in many churches. Therapeutic Touch, however, is a new and systematic protocol for healing with the hands, originated by Dora Kunz, a famous healer, and Dolores Krieger, Professor of Nursing at New York University. According to Krieger, although it had its historical origins in the laying on of hands, Therapeutic Touch takes its theoretical basis both from modern physics (which “posits that energy fields are the basic units of all matter …that the human being extends beyond what we perceive as a physical boundary and is, through energy, interconnected with everything in the environment”) and from the Eastern theories of qi and prana, the Chinese and Indian concepts of the life energy. Says Krieger

Eastern literature states that a healthy person has an overabundance of “Prana” or “Qi” …and that an ill person has a deficit. Indeed, having a deficit of Prana is the Eastern definition of illness. Prana or Qi can be transferred from a healthy person to an ill one if–and this is very important–the healer has the conscious intent to do so. This transfer of energy will help the ill person to buttress his own energy system in the service of self-healing.17

Krieger believes that anyone can learn therapeutic touch: “It’s a natural potential in all human beings and this potential can be developed.”17

There are three major phases in the procedure: the first is centering–a short period in which the therapist enters a meditative state of awareness so that she washes away all the “busy-ness” of her own thoughts and becomes acutely open to any input from her client. Second, the therapist then “listens passively” with her hands as she scans the client’s body a few inches above the skin, and “tunes in” to any disturbances in the energy field around the body. She is searching for temperature changes or other energy differences as clues to underlying energy imbalances. This is called assessing. In the third phase, with her hands still above the client’s skin, the therapist “unruffles” or smoothes out the energy field surrounding the body and begins to concentrate on areas where she has sensed accumulated tension. She helps redirect the energy flow so that it is no longer congested and begins to move smoothly through the body. This is known as rebalancing.

Normally, the whole process takes no longer than 15 to 20 minutes and should not be drawn out, lest the client (in the vocabulary of Therapeutic Touch) receive too much energy and become irritable. “The basis of Therapeutic Touch,” says Krieger, “lies in intelligently directing healing energy through the healer to the healee.”18

Therapeutic Touch is now widely used by nurses in many major medical centers, hospices, and in home care throughout this country and abroad, albeit not without resistance from conservative physicians. Scientific studies of its effectiveness have been made by Krieger and many others, including Janet F. Quinn, R.N., Ph.D., Associate Professor at the Center for Human Caring at the University of Colorado School of Nursing, and Theresa Connell Meehan, R.N., Ph.D., Associate Director of Nursing for Research at New York University Medical Center. To date, research has shown that Therapeutic Touch is effective in reducing acute pain in postoperative patients; in relieving pain in general; in helping the body’s basic metabolism (by increasing hemoglobin values); in decreasing anxiety in hospitalized cardiovascular patients; in reducing behavioral stress in premature infants; and in decreasing headache pain in adults. In several other studies, by contrast, Therapeutic Touch produced no significant effects.19

In an innovative and well-designed study by Daniel Wirth, M.S., J.D., president of Healing Sciences International in Orinda, California, small experimental wounds were administered to the arms of college students, who then placed their arms through a special armhole in a wall and were randomized into a group that received Therapeutic Touch and a group that did not. The group receiving Therapeutic Touch experienced significantly faster wound healing.20 Wirth and his colleagues obtained similar results in a subsequent replication of the original study.21

Obviously, Therapeutic Touch makes assumptions about the nature of reality that are not universally shared in our culture. But these assumptions have a history that goes back far beyond the beginnings of the great traditions of medicine. Every year, millions of Americans use laying on of hands in religious healing services. What is different about Therapeutic Touch is that it is employed systematically by nurses and researchers in a nonsectarian manner and that a strong effort has been made to develop systematic research on its effectiveness. Whatever the merits of its theory, Therapeutic Touch has been demonstrated in careful research to have efficacy in physical and psychological healing. Says Krieger, “Like acupuncture, the workings of Therapeutic Touch have not yet been adequately explained within the postulates of Western science. We know acupuncture works–and therein lies its value. But we have yet to understand just how it works from the Western scientific view. We have begun the scientific study but we still need more research.”22

There is a very small literature on Therapeutic Touch in regard to cancer. M.L. Raucheisen at the Veterans Administration Medical Center in Washington, D.C., describes the use of Therapeutic Touch for relief of a “multitude of symptoms,” including nausea and pain. She also describes its effectiveness in enhancing relaxation and quality and duration of sleep.23 Cathleen Fanslow, R.N., M.A., a hospice nurse in New York and teacher of Therapeutic Touch, uses it extensively to relieve pain in cancer patients and to give dying patients the relaxation and reassurance to let go and die.

Using Therapeutic Touch or the simple laying on of hands with participants in the Commonweal Cancer Help Program, we have the participants work with each other, so that each participant has the opportunity to give a healing experience to someone, as well as to receive it. For the vast majority of participants, the experience of both giving and receiving some form of simple touch with intent to heal is a profoundly positive one. It often induces deep feelings of mental, emotional, and spiritual healing, and sometimes has significant effects on physical symptoms as well. Many participants say that they enjoy the giving of Therapeutic Touch more than receiving it. This is perhaps not surprising, given that Cancer Help Program participants consist in large part of women with breast cancer who often say that excessive giving and difficulty in receiving have been issues all their lives.

Chiropractic

Chiropractors are much more likely than physicians to be interested in unconventional health-promoting approaches to cancer. They are often familiar with a range of nutritional and physical supportive treatments for cancer, some possibly beneficial and some possibly harmful. The greatest harm that can take place with a chiropractor occasionally occurs when a cancer patient goes to the chiropractor with back or neck pain caused by an undiagnosed spinal metastasis. In such a case, a physical manipulation of the neck or spine could cause further damage or a break in the compromised vertebrae. Sophisticated chiropractors are well aware of this danger. W.D. Defoyd, a chiropractor, writes:

Metastatic disease of the lumbar spine is a relatively common but catastrophic cause of low back pain. Because of an increasing role as primary care providers for back pain patients, it is essential that chiropractors keep this possibility in mind. Careful consideration of the patient’s history, physical and laboratory findings, and the use of imaging procedures are helpful in establishing a correct diagnosis in those cases where metastasis is suspected.24

Historically, physicians have been hostile to chiropractors–and many still are today–since they often see patients who have done poorly with chiropractors, just as chiropractors often see patients who have done poorly with physicians. A typical warning comes from P. Shvartzman and A. Abelson at Ben Gurion Hospital in Israel:

Back pain often causes patients great despair, and they expect the primary care physician or orthopedic surgeon to provide a quick, simple solution. Rest and analgesia are the most commonly prescribed treatments, and muscle relaxants, heat, traction, and physiotherapy are also used. If these treatments do not help, the patient may search for relief through faith healing, acupuncture, chiropractic treatment, or other nonconventional forms of treatment. Although chiropractic treatment is a popular alternative, its long-term effect is questionable and the medical literature contains numerous reports of patients whose condition has worsened as a result of it. Physicians should be aware of the dangers of chiropractic treatment, particularly in patients with severe spondylitic [inflammation of the vertebrae] changes, osteoporosis, fractures, [and] tumors.25

While the dangers to patients suffering from cancer who visit poorly informed chiropractors are real, physicians historically have grossly underestimated the relief and help that many patients experience from chiropractors, osteopaths, and other physical manipulators skilled in structural work.

As an example of the constructive use of chiropractic, imagine a woman with a primary breast cancer and no metastases who also has a history of spinal problems. She goes through conventional therapy but wants to take whatever measures she can to enhance her general health in order to lower the risk of recurrence. She visits a chiropractor who points out that the region of the spine connected by nerves to the breast is out of alignment, and also that other misalignments in her spine keep her from breathing deeply and effectively, lowering her capacity to oxygenate her blood fully. He recommends a short course of chiropractic adjustment (she has been warned against chiropractors who believe you should come back for an endless and expensive series of treatments, and is fortunate enough to find a like-minded practitioner). He also recommends gentle yoga and moderate exercise as ways to reinforce correct spinal alignment. Finally, he suggests a low fat diet and basic nutritional supplementation. She finds that the manipulations do, indeed, correct long-standing areas of pain in her back; that she is able to stand more erect and with less fatigue; and that her breathing is improved. This consultation certainly improved her basic health and quality of life. It may have been helpful to her in reducing the risk of recurrence of the cancer.

An example of successful collaboration between a chiropractor and an oncologist is recounted by S.E. Downs, who provided chiropractic treatment for a woman with bronchogenic carcinoma who was experiencing muscle spasms and pain in the neck, axilla, and ribs. His x-ray film showed a lesion in the lung and he referred the woman for conventional treatment of her cancer. While she was being treated for the cancer, Downs says, “a significant reduction in the pain experienced by the patient was achieved with spinal manipulative therapy.”26

In summary, chiropractors, like physicians and, indeed, like all health care practitioners, are a mixed lot. There are excellent ones and there are poorly trained or negligent ones. But many cancer patients find that chiropractors represent one group of licensed health professionals with a broad general interest in supportive health promotion for people facing chronic or degenerative illnesses such as cancer. It is not insignificant, moreover, that many forms of health insurance reimburse for chiropractic treatment.

References

1 R.A. Yedinak, D.K. Layman, and J.A. Milner, “Influences of Dietary Fat and Exercise on DMBA-Induced Mammary Tumors.” Meeting abstract, Federation Proceedings, 46(3):436 (1987).

2 D.K. Layman, personal communication with the author, 1991.

3 Rose E. Frisch et al., “Lower Prevalence of Breast Cancer and Cancers of the Reproductive System Among Former College Athletes Compared to Non-Athletes,” British Journal of Cancer 52(6):885-91 (1985).

4 Sarah Tilyou, “Exercise May Reduce Risk of Certain Cancers,” Oncology Times, 15 August 1987.

5 Ibid.

6 The New York Times, 16 February 1988.

7 Ibid.

8 R.E. Frisch et al., “Lower Prevalence of Non-Reproductive System Cancers Among Former College Athletes,” Medicine and Science in Sports and Exercise 21(3):250-3 (1989).

9 Lawrence Garfinkel and Steven D. Stellman, “Mortality by Relative Weight and Exercise,” Cancer 62:1844-50 (1988).

10 Robert S. Paffenbarger, “Physical Activity and Incidence of Cancer in Diverse Populations: A Preliminary Report,” American Journal of Clinical Nutrition 45:312-7 (1987).

11 Tilyou, Oncology Times.

12 K. Warren, “Will I Be Sick, Nurse?” Nursing Times 84(12):53-4 (1988).

13 S. Sims, “Slow Stroke Back Massage for Cancer Patients,” Nursing Times 82(47):47-50 (1986).

14 L.A. Barbour, “Nonanalgesic Methods of Pain Control Used by Cancer Patients,” Oncology Nursing Forum 13(6):56-60 (1986).

15 B.Z. Dobbs, “Oncology Nursing 6: Alternative Health Approaches,” Nursing Mirror 160(9):41-2 (1985).

16 C. Badger, “The Swollen Limb,” Nursing Times 82(31):40-1 (1986).

17 Therapeutic Touch–A New Skill From an Ancient Practice, a half-hour videotape produced by Harriet Harvey for the Hospital Satellite Network and the American Journal of Nursing Company, 1985.

18 Ibid.

19 Ibid. See also, Janet F. Quinn, “Building a Body of Knowledge: Research on Therapeutic Touch 1974-88,” monograph, table 1. Prepared for publication in Journal of Holistic Nursing Spring, 1988.

20 Daniel P. Wirth, “The Effect of Non-Contact Therapeutic Touch on Healing Rate of Full Thickness Dermal Wounds,” Subtle Energies 1(1), Winter 1990.

21 Daniel P. Wirth, Joseph T. Richardson, and William R. Eidelman, “Full Thickness Dermal Wounds Treated with Noncontact Therapeutic Touch.” Unpublished manuscript, 1991.

22 Therapeutic Touch–A New Skill From an Ancient Practice, videotape produced by Harriet Harvey.

23 M.L. Raucheisen, “Symptom Relief with the Use of Non-Invasive Techniques,” Oncology Nursing Forum 12(2 Supplement):94 (1985).

24 W.D. Defoyd, “The Use of Imaging Procedures in the Diagnosis of Metastatic Disease of the Lumbar Spine,” Journal of Manipulative and Physiological Therapeutics 13(3):161-4 (1990).

25 P. Shvartzman and A. Abelson, “Complications of Chiropractic Treatment for Back Pain,” Postgraduate Medicine 83(7):57-8, 61 (1988).