It was a home visit and my client had advanced pancreatic cancer, metastasized to the liver. He was struggling with pain and breathing. Liver involvement had given him ascites, an accumulation of fluid in the abdomen. He also had leg swelling and difficulty breathing.

Sometimes, the goal of a session is comfort, rather than making much change. Advanced cancer and significant liver involvement meant that his body was doing all it could to cope and it wasn't for me to tip the balance. The swelling wasn't something I could alleviate, and had I done so, it might have been too much for him. I positioned him thoughtfully to ease his breathing and pain, offered some simple classical massage on his back, neck, arms and feet, and simply held his legs.

Both he and his spouse were grateful as I left and we all agreed on another session. A second session wasn't to be, as his condition worsened considerably in the following days. I read his obituary in the newspaper only a week or so later. I had looked forward to seeing him again. I was saddened at his death and especially at how bereft so many others were at losing him. At the same time, I was satisfied that I had done what I could and hopeful that I had eased the hard path for both of them, if even a little bit.

The liver is a common site of the growth of a secondary cancer. This means that cancer cells have spread or metastasized from another primary site such as the breast, GI tract, lung or ovary, or from the pancreas, as in my client's case. The tumor growth is made of the primary cancer cells, not liver cells. So for example, primary lung cancer that has spread to the liver would be considered "lung cancer with liver metastases," or more commonly, "with liver mets." This is called metastatic cancer. This was true in this client's case.

The liver can also be a site of for primary cancer, meaning it is where the cancer growth originated. Most primary liver cancers are called hepatocellular carcinoma or hepatoma. Primary liver cancer may follow cirrhosis and liver failure, which usually arising from conditions such as chronic hepatitis B or C, excessive alcohol use or other inflammatory diseases of the liver.

Regardless of whether a tumor is primary or secondary, liver function may be affected by cancer. When such a generous organ is affected, with hundreds of different jobs, cancer organ failure can be difficult and frightening. The liver metabolizes and stores nutrients, produces bile to aid with digestion and is an organ of detoxification, taking toxic substances and either converting them into something harmless or ensuring their release from the body. It is such a vital organ that we would only survive one or two days if the liver stopped functioning entirely.

Signs and Symptoms

Liver involvement can present as loss of appetite, abdominal pain, pain in the right shoulder, fever, fatigue and enlargement of the liver with possible palpable masses. The spleen may also become enlarged with liver cancer. However, these signs and symptoms may not always point to cancer and often may lead to diagnosis of other, less harmful conditions. Early diagnosis results in a better prognosis, but diagnosis can be delayed because the initial symptoms may mimic other conditions. This often leads to a poor prognosis. The five-year survival rate for a person with primary liver cancer is less than 20 percent. Complications that may present in later stages can include the ascites, as my client had, as well as esophageal varices and profound weight loss.

If the liver is the primary site of cancer, metastases to other sites most often include the lungs, the abdominal lymph nodes and bone. Because of this, some clients may present with shortness of breath or bone pain, which are signs that the liver cancer has spread.

Liver Cancer And Massage

Working with any cancer or cancer history requires a set of skills including interviewing, clinical reasoning and modifications of pressure, joint movement and other massage elements. If these and other skills were not covered in basic massage therapy training, some MTs can teach themselves the information needed, most require comprehensive training in oncology massage to do the work safely and effectively. No matter how the skills and information are gained, one responsibility we take on is to read everything we can about cancer and massage therapy, including many books and articles on the topic.

With liver involvement affecting function of the organ, massage therapy involves adjustments that address both the cancer and liver failure. Here are some of the questions we ask a client with liver involvement:

1. Where is the cancer in your body? Did it begin in the liver or somewhere else? Are there other sites of cancer in your body?
2. How does the cancer affect you? What are your signs and symptoms?
3. Are there any complications from your cancer? Any effects on bone, lungs or brain?
4. How is the cancer being treated?
5. How are the treatments affecting you?
6. How well does your liver function? Is your doctor concerned about the level of your liver functions?
7. Do any of your doctors say that you have or might have portal hypertension?
8. Do you have any swelling in your abdomen or your legs? Any swollen or congested organs?
9. Is your skin affected by your liver function? (discoloration, bruising, itching?)
10. What would be the most comfortable position for you during your massage? In what position do you normally sleep? Does your doctor advise any certain sleeping position?

No Sound Bites

Cancer is an individual experience for each client and this experience will likely change from session to session. Although the guidelines can't be reduced to a sound bite or a short list, here is a list of a few massage adjustments.

Careful supports and joint movement: By learning how the cancer affects each client, we can customize the session in terms of bolstering and joint movement. Significant weight loss calls for gentle joint movement (loss of muscle mass can make joints unstable) and special attention to bolstering and positioning to ease any discomfort of protruding bony landmarks. Pain in the shoulder or in the abdomen can be tended to with careful positioning, such as having the client side-lying on the table, with folded towels and pillows as needed to support the abdomen or the shoulder joint.

Caution and careful interviewing about pain: If there is any possible bone involvement or any bone pain present, use gentle movement and pressure to avoid the risk of pathologic fracture. Even if the source of the pain is undetermined, the therapist should treat any new and unfamiliar pain as possible bone involvement and therefore possible instability of the bone tissue. Any time pain is new, unfamiliar or has not yet been reported to the client's doctor, the massage therapist should refer the client to their physician for support.

Easing the pressure, and a gentle approach overall: As in any medical condition causing fatigue, our approach would be gentle overall, not too taxing to the body. A typical session would include:

• Lighter pressure.
• Slower speeds.
• Even rhythms.
• Possibly shorter sessions length.

As it is for any client with cancer, massage therapists avoid pressure at any and all accessible areas of cancer, whether it is primary or secondary. For a client with liver cancer, it means avoiding pressure over the area of the liver that is accessible just under the ribs, but the massage therapist should consider other sites as well, such as the abdomen, if tissues there are or might also be involved. Also, if liver function is impaired, there may be bruising and bleeding, calling for gentle pressure everywhere.

Treatments

Some types of treatment for liver involvement include cryosurgery, where surgeons use metal probes to freeze tumors while the patient is under general anesthesia. Sometimes ethanol is injected directly into tumor sites, with the intention of dehydrating and destroying the tumors. These types of treatments generally produce few side effects afterward, other than at the incision or injection sites.

However, chemoembolization is a more intensive therapy, where the blood supply to the liver tumor is blocked and medication is delivered directly into the artery that supplies the area of the tumor. This procedure can cause pain, nausea, vomiting, fever and fatigue, and these side effects can linger even after the therapy is completed.

Easing The Way

Massage may support someone with liver involvement by providing positive, safe and comforting touch. Cancer is often far along once signs and symptoms appear and a diagnosis is made. This means the initial news, prognosis and consequent path of treatment can be a shock. Such an aggressive cancer and corresponding treatments can be very hard on the body, and things may happen quickly, as they did with my client. His death followed his diagnosis by only a few short months.

Armed with the right skills, questions and hands-on sensitivity, massage may help to "even things out" and ease the way along a tough road.