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Review Article
Massage Therapy for Fatigue Management in Breast Cancer
Survivors: A Systematic Review and Descriptive Analysis of
Randomized Controlled Trials
Tao Wang , Jianxia Zhai , Xian-Liang Liu , Li-Qun Yao ,
and Jing-Yu (Benjamin) Tan
Charles Darwin University, College of Nursing and Midwifery, Brisbane Centre, 410 Ann Street, Brisbane, QLD 4000, Australia
Correspondence should be addressed to Jing-Yu (Benjamin) Tan; benjamin.tan@cdu.edu.au
Received 1 July 2021; Accepted 1 September 2021; Published 23 September 2021
Academic Editor: Ivan Luzardo-Ocampo
Copyright ©2021 Tao Wang et al. is is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Background. Fatigue is one of the most common symptoms among breast cancer survivors. Although massage therapy has been
commonly used for fatigue management, relevant evidence on the effectiveness of massage therapy for the reduction of fatigue in
breast cancer survivors is still unclear. Objective. To identify the research evidence on the effectiveness and safety of massage
therapy to manage fatigue in breast cancer survivors and summarize the characteristics of massage therapy protocols utilized for
fatigue management in breast cancer survivors. Methods. Randomized controlled trials (RCTs) using massage therapy to manage
cancer-related fatigue were searched in PubMed, Medline, Web of Science, Cochrane Library, Cumulative Index to Nursing and
Allied Health Literature (CINAHL), ScienceDirect, PsycINFO, Wan Fang Data, and China National Knowledge Infrastructure
(CNKI) from the inception of each database to March 2021. e Cochrane Back Review Group Risk of Bias Assessment Criteria
was used to assess the methodological quality of the included studies. Descriptive analysis was applied for a summary and
synthesis of the findings. e primary outcome was fatigue measured by any patient-reported questionnaires, and the secondary
outcomes were quality of life and massage-therapy-related adverse events. Results. Ten RCTs were included. Massage therapy was
found to have a positive effect on fatigue management compared with routine care/wait list control groups and sham massage.
Despite these encouraging findings, the review concluded that most of the included studies exhibited an unsatisfactory ex-
perimental design, particularly, inadequate blinding and allocation concealment. e duration and frequency of the massage
therapy interventions varied across the studies. Adverse events were reported in three included studies, with no study conducting
causality analysis. Conclusion. is systematic review provides the latest research evidence to support massage therapy as an
encouraging complementary and alternative medicine approach to managing fatigue in breast cancer survivors. More rigorously
designed, large-scale, sham-controlled RCTs are needed to further conclude the specific therapeutic effectiveness and safety issues
of massage therapy for fatigue management.
1. Introduction
Breast cancer is the world’s most prevalent cancer and is a
common risk factor that can reduce life expectancy, par-
ticularly among females [1]. Cancer-related fatigue (CRF) is
one of the most debilitating symptoms experienced by breast
cancer survivors, which is mainly caused by radiotherapy
and chemotherapy [2]. e burden of unmanaged CRF can
lead to reduction in quality of life (QoL) as it affects patients’
physical function, mood, social interaction, and cognitive
performance [3]. Cancer-related fatigue has a more
significant negative effect on QoL than other cancer-related
symptoms, such as pain, nausea, vomiting, and depression,
and it can last for months or even years after cancer
treatment [4].
Pharmaceutical agents that are commonly applied to
manage CRF consist of antidepressants, steroids, cholines-
terase inhibitors, donepezil, and stimulants [5]. However,
evidence regarding their effectiveness and safety in breast
cancer patients remains inconsistent and unclear [6].
Physical (such as high blood pressure and kidney/liver
damage) and psychological (such as restlessness and anxiety)
Hindawi
Evidence-Based Complementary and Alternative Medicine
Volume 2021, Article ID 9967574, 13 pages
https://doi.org/10.1155/2021/9967574
side effects and consequences pertaining to pharmaceutical
interventions have impelled patients to turn to comple-
mentary and alternative medicine (CAM) as supplementary
approaches to fatigue management [7]. Various CAM ap-
proaches, such as mindfulness-based interventions (e.g.,
yoga) [8], cognitive-behavioral therapy (CBT) [9], and
physical exercise [10], have been used to manage fatigue as
supplementary approaches. However, interventions such as
yoga and physical exercise are energy-consuming, which
may decrease patients’ willingness to participate [11], par-
ticularly for those with significant fatigue symptoms. Other
approaches such as CBT have a high cost and require ex-
tensive professional support, which can limit the space for
long-term symptom management. Other non-
pharmacological approaches that are less time- and energy-
consuming are worthy of further exploration to facilitate
better management of CRF in the long run.
Massage therapy has generally been considered a safe
CAM approach to managing a wide range of health prob-
lems [12–17]. ere are several types of commonly used
massage therapy techniques in clinical practice, including
Chinese massage, Japanese massage, ai massage, Swedish
massage, and reflexology. ese types of massage involve
handling muscles and stroking or rubbing the soft tissues of
the human body [18], which can modulate body functions
and cause relaxation [19–21]. Evidence has indicated that
practicing massage therapy has a beneficial impact on in-
creasing heart rate variability [22], improvement in mood
disturbance [22–24], as well as QoL [25, 26] and reducing
fatigue [22, 27] and physical discomfort [24]. Particularly,
massage therapy has a great rate of acceptance and has been
commonly applied in fatigue management among breast
cancer survivors [28].
In the past few years, a growing body of small-scale
clinical studies have been implemented to assess the effects
of massage therapy on relieving fatigue in breast cancer
patients, and some evidence has demonstrated that massage
therapy decreased CRF [22, 23, 25, 29]. In addition, three
systematic reviews/review protocols relating to massage
therapy for cancer symptom management have been pub-
lished [12, 14, 28]. However, the review by Finnegan-John
et al. [12] focused on different types of CAM interventions
for CRF management in patients with different cancer di-
agnoses, while the other two studies emphasized the effect of
massage therapy on CRF relief [14, 28]. Pan et al. [14]
generally addressed treatment-related side effects of breast
cancer rather than focusing on fatigue management, and
Wang et al. [28] study was a review protocol but without any
available review findings, and it included all types of cancer
diagnoses.
Since all the abovementioned systematic reviews/review
protocols were published three years ago, and there was no
evidence synthesis study that specifically focused on the use
of massage therapy for fatigue relief among breast cancer
survivors. It is, therefore, necessary to explore the latest
research evidence on massage for fatigue management in
breast cancer survivors by appraising more recent clinical
research evidence from published randomized controlled
trials (RCTs). is systematic review was conducted to
explore the effectiveness and safety of massage therapy for
fatigue management, as well as to summarize the charac-
teristics of massage therapy protocols for managing fatigue
in breast cancer survivors.
2. Methods
is systematic review was conducted and reported based on
the PRISMA 2020 checklist for systematic reviews.
2.1. Data Sources and Search Strategies. is systematic re-
view located studies from nine academic databases, in-
cluding PubMed, Medline, Web of Science, Cochrane
Library, Cumulative Index to Nursing and Allied Health
Literature (CINAHL), ScienceDirect, PsycINFO, Wan Fang
Data, and China National Knowledge Infrastructure (CNKI)
from the inception of each database to March 2021. MeSH
terms and keywords such as “massage,” “fatigue,” “lassi-
tude,” “weariness,” “breast neoplasms,” and “breast cancer”
were the primary search terms used for the electronic da-
tabase search. Chinese MeSH terms and keywords, including
推拿/按摩,疲劳/疲乏/癌因性疲乏/劳累, and 乳腺癌/乳
腺肿瘤, were used for the CNKI and Wan Fang Data da-
tabase search. e search strategy for PubMed is shown in
Table 1. e reference lists of the retrieved literature were
also reviewed to identify additional eligible studies.
2.2. Inclusion Criteria. Inclusion criteria were: (1) types of
studies: randomized controlled trials (RCTs) conducted in
any healthcare setting; (2) participants: adult breast cancer
survivors, regardless of cancer stage, reporting fatigue; (3)
intervention(s): massage therapy (any types of massage such
as Chinese massage, Swedish massage, Japanese massage,
ai massage, reflexology, etc.); (4) control: wait list control,
standard methods of treatment and/or care (usual care and/
or standard medication), or other comparisons (placebo or
sham control or other interventions) other than massage
therapy; and (5) primary outcome: the symptom of fatigue
measured by any patient-reported questionnaires, such as
the Brief Fatigue Inventory (BFI), the Fatigue Severity Scale
(FSS), and so on and secondary outcomes: QoL, safety
outcomes, treatment satisfaction, and cost-effectiveness
analysis. Chinese publications had to be indexed in the core
journal list for methodological quality consideration.
2.3. Study Selection and Data Extraction. Two review authors
(TW and JXZ) screened and identified eligible studies
against the selection criteria independently using literature
management software, EndNote X9. Eligible papers were
included upon agreement of the same two reviewers. Any
discrepancy in the selection and inclusion of a study was
addressed by consulting with the third (JYT) and fourth
(XLL) reviewers to determine eligibility. Data from the
included studies were extracted adopting predefined forms,
including: (1) characteristics of the included studies (e.g.,
authors, country, breast cancer stage, and study imple-
mentation); (2) description of massage therapy intervention
2Evidence-Based Complementary and Alternative Medicine
protocols (e.g., massage modalities, procedure, intervention
instructor, and timing, duration, and frequency); (3)
methodological quality assessment (e.g., randomization,
blinding, attrition, compliance, and dropouts); and (4)
therapeutic effects of massage therapy (e.g., time points of
assessment and fatigue-related outcomes). e third (JYT)
and fourth (XLL) authors were consulted if a disagreement
on data extraction emerged.
2.4. Quality Assessment of the Literature. e risk of bias and
the methodological quality of each included study were
assessed by two reviewers independently (TW and JXZ)
using the Cochrane Back Review Group Risk of Bias As-
sessment Criteria [30]. e appraisal tool includes the fol-
lowing criteria: (1) “random sequence generation,” (2)
“allocation concealment,” (3) “baseline assessment,” (4)
“blinding – participants,” (5) “blinding – care provider,” (6)
“blinding – outcome,” (7) “cointerventions,” (8) “compli-
ance,” (9) “dropouts,” (10) “timing,” (11) “selective outcome
reporting,” (12) “incomplete outcome data,” and (13) “other
bias” (e.g., inclusion/exclusion criteria, sample size,
reporting of adverse events, evaluation of therapeutic effects,
and method of statistical analysis). Either “high risk of bias,”
“unclear risk of bias,” or “low risk of bias” was adopted to
rate each item. Further consultation with the third (JYT) and
fourth (XLL) authors was conducted to settle any
disagreements.
2.5. Data Analysis. e authors initially considered per-
forming a meta-analysis using Review Manager. However,
the notable heterogeneity in terms of the intervention
protocols, comparisons, and outcome assessments made it
an inappropriate method for carrying out a meta-analysis.
Hence, narrative analysis was used to present the effects of
massage therapy on fatigue among breast cancer survivors.
In particular, narrative subgroup analysis was adopted for
different comparisons, including massage therapy versus
standard routine treatment/care or wait list control and
massage therapy versus sham interventions (i.e., light touch
and lay foot manipulation).
3. Results
Of the 257 studies identified by searching the nine databases
(n�255) and other sources (manual retrieval, n�2), 233
studies were removed after duplication checking and title
and abstract screening. Twenty-four potentially eligible
studies were located for further full-text assessment, of
which 14 studies were excluded. Ten papers were retained
for the systematic review, and the characteristics of the
included studies were extracted (see Figure 1).
3.1. Characteristics of the Included Studies. is review in-
cluded 10 studies, with 4 undertaken in the United States, 2
in Germany, and 1 each in China, Spain, Turkey, and Iran. In
total, 1,040 randomized participants were involved in the
current review, and 885 completed the studies (394 in in-
tervention groups; 495 in control groups; completion
rate �79.59%). Only 2 studies [31, 32] had more than 100
study subjects. Seven of the included RCTs reported 2 arms
to explore the effects of massage therapy by comparing
massage therapy with standard routine care/wait list control.
e remaining three RCTs [25, 26, 31] reported three arms,
with two studies [25, 31] integrating a sham control group
(light touch or lay foot manipulation).
Regarding the fatigue assessment tools, three studies
[26, 27, 31] used the Brief Fatigue Inventory (BFI), and
two studies [23, 24] adopted the Berlin Mood Ques-
tionnaire (BSF; fatigue subscale) for fatigue assessment.
One each study employed the Fatigue Severity Scale (FSS)
[33], the Chronic Fatigue Syndrome (CFS) Score [29], the
MD Anderson Symptom Inventory [32], and the Profile of
Mood States (POMS) Questionnaire (fatigue subscale)
[22]. Noteworthily, Kinkead et al. [25] used the Multi-
dimensional Fatigue Inventory (MFI) and the PROMIS
Fatigue Short Form 7a (PROMIS) to evaluate fatigue.
Mustian et al. [26] used two tools, including the BFI and
daily fatigue diaries. Similarly, Listing et al. [24] adopted
both the BSF (fatigue subscale) and the Giessen Inventory
of Complaints (GBB; fatigue subscale) for outcome as-
sessment. e characteristics of the reviewed studies are
summarised in Table 2.
Table 1: A representative search strategy (PubMed).
ID Search strategy
#1 “massage”[MeSH Terms]
#2 (((“massage”[Title/Abstract]) OR (“massage therapy”[Title/Abstract])) OR (“massage therapies”[Title/Abstract])) OR (“tuina”[Title/
Abstract])
#3 #1 OR #2
#4 (“fatigue”[MeSH Terms]) OR (lassitude[MeSH Terms])
#5 ((((((“fatigue”[Title/Abstract]) OR (lassitude[Title/Abstract])) OR (tired ∗[Title/Abstract])) OR (“weary”[Title/Abstract])) OR
(“weariness”[Title/Abstract])) OR (exhaust ∗[Title/Abstract])) OR (“lacklustre”[Title/Abstract])
#6 #4 OR #5
#7 breast neoplasms[MeSH Terms]
#8
(((((((“breast neoplasms”[Title/Abstract]) OR (“breast neoplasm”[Title/Abstract])) OR (“breast tumors”[Title/Abstract])) OR
(“breast tumor”[Title/Abstract])) OR (“breast cancer”[Title/Abstract])) OR (“breast carcinoma”[Title/Abstract])) OR (“mammary
tumor”[Title/Abstract])) OR (“mammary cancers”[Title/Abstract])
#9 #7 OR #8
#10 #3 AND #6 AND #9
Evidence-Based Complementary and Alternative Medicine 3
3.2. Massage erapy Intervention Protocols. e charac-
teristics of the massage protocols used in the included
studies are shown in Table 3, including massage modalities,
procedures, intervention instructors, timing of the inter-
ventions, and duration/frequency of the interventions. Four
massage therapy modalities were identified in the review, of
which reflexology therapy was adopted by four studies
[27, 31–33], Swedish massage therapy was adopted by four
studies [23–26], and Chinese massage therapy [29] and
myofascial therapy [24] were adopted by one each study. Of
the four studies that used reflexology therapy, one each was
performed by a trained researcher [27], a trained caregiver
[32], and certified reflexologists [31]. However, one study
did not report the qualification of the intervention instructor
[33]. Regarding the timing of the interventions, five studies
carried out their intervention after primary treatment/
chemotherapy/radiation therapy [22, 23, 25, 29, 33], while
the remaining five conducted their intervention during
chemotherapy or radiotherapy [24, 26, 27, 31, 32]. e
duration of the massage interventions ranged from three
weeks to three months. e frequency of massage therapy
differed significantly across the included studies, ranging
from 20 minutes twice/week to 45 minutes/week.
3.3. Quality Appraisal of the Included Studies. e quality
appraisal results of the included studies are demonstrated in
Table 4. Randomization was reported in all ten studies, with
seven studies detailing their random sequence generation
methods such as coin flips, computer-generated number
sequences, and random number table [22–26, 29, 31]. Re-
garding allocation concealment, only three studies reported
the use of sealed opaque envelopes [22, 25, 31]. For blinding,
only one trial [31] reported the blinding of participants and
care providers, and three trials [22, 25, 31] described the
blinding of the outcome assessors. Six studies described the
participants’ dropout rates, and only one study reported
dropouts exceeding 30% [23].
Identification of studies via databases and registers Identification of studies via other methods
Records identified from:
Databases (n=255)
PubMed (29),Web of
Science (67), Cochrane
Library (44), CINAHL
(23), PsycINFO (9),
Medline (29), Science
Direct (10), Wan Fang
Data (15), CNKI (29)
Records removed before
screening:
Duplicate records
removed (n=108)
Records screened
(n=147)
Records excluded aer
title and abstract
screening (n=125)
Reports not retrieved
(n=1)
Reports assessed for
eligibility
(n=21)
Reports excluded:
-Conference abstracts
(n=2)
-Interventions did not
meet criteria (n=3)
-Outcomes did not meet
criteria (n=1)
-Participants did not
meet criteria (n=2)
-Language issue (n=1)
-Paper from the same
study project (n=1)
-Journals did not meet
criteria (n=3)
Records identified from:
Citation search (n=2)
Reports assessed for
eligibility
(n=2)
Reports
excluded (n=0)
Studies included in
review
(n=10)
Reports of included
studies
(n=10)
Reports sought for
retrieval
(n=2)
Reports not retrieved
(n=0)
Reports sought for
retrieval
(n=22)
IdentificationScreening
Include
Figure 1: PRISMA flow diagram of the study selection. Adapted from: Page, M. J., McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann,
T. C., Mulrow, C. D. (2021). e PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ, 71, 372.
4Evidence-Based Complementary and Alternative Medicine
Table 2: Characteristics of the included studies.
Study Country Study design Cancer stage Sample size and
age Intervention Control Outcomes
S1:
[33] Iran Double-blind
RCT Stage I
Randomized: 60
Completed: 57
Intervention G:
27/30, age (yr) �
47.85 ±8.39
Control G: 30/
30, age (yr) �
50.86 ±6.5
Reflexology
therapy
Routine
treatment and
care
Fatigue: Fatigue Severity
Scale (FSS)
S2:
[29] China RCT Stages I–IV
Randomized: 98
Completed: 98
Intervention G:
49/98, age (yr) �
50.76 ±10.25
Control G: 49/
98, age (yr) �
50.31 ±10.79
Chinese
massage
therapy
Routine
treatment and
care
Fatigue: Chronic Fatigue
Syndrome (CFS)
S3:
[25] USA
Single-blind
RCT, three
groups
Stages 0–III
Randomized: 66
Completed: 56
Group A: 20/22,
age (yr) �
54.5 ±12.4
Group B: 19/22,
age (yr) �
55.6 ±9.0
Group C: 17/22,
age (yr) �
51.8 ±9.6
Group A
Swedish
massage
therapy
Group B: light
touch (LT)
Group C: wait list
control (WLC)
Fatigue:
Multidimensional
Fatigue Inventory
(MFI) + PROMIS Fatigue
Short Form 7a (PROMIS)
QoL: Quality of Life
Enjoyment and
Satisfaction
Questionnaire (Q-LES-
Q)
Safety: adverse events
S4:
[27] Turkey RCT Stages I–III
Randomized: 60
Completed: 60
Intervention G:
30/30, age (yr) �
50.93 ±11.27
Control G: 30/
30, age (yr) �
51.06 ±10.97
Reflexology
therapy
Routine
treatment and
care
Fatigue: Brief Fatigue
Inventory (BFI)
S5:
[32] USA RCT Stages III and
IV
Randomized:
256 (patient-
caregiver dyads)
Completed: 207
Intervention G:
92/128, age
(yr) �58 (mean
age)
Control G: 99/
128, age (yr) �55
(mean age)
Reflexology
therapy
Routine
treatment and
care
Fatigue: MD Anderson
Symptom Inventory
QoL: Quality of Life
Index (QLI)
S6:
[22] Spain
Single-blind,
placebo-
controlled
crossover design
Stage I–IIIa
Randomized: 20
(crossover
design)
Completed: 20
Intervention G:
20/20, age (yr) �
49.1 ±7.8
Control G: 20/
20, age (yr) �
49.1 ±7.8
Myofascial
massage
Routine
treatment and
care
Fatigue: Profile of Mood
States (POMS)
Questionnaire (fatigue
subscale)
Evidence-Based Complementary and Alternative Medicine 5
Of the ten studies, all the participants who completed the
RCTs were analyzed, but only three [25, 31, 32] reported
implementing intention-to-treat (ITT) analysis. For selective
outcome reporting, all ten of the included studies were rated as
low risk of bias. All ten studies conducted baseline assessments.
Regarding “other bias,” inclusion/exclusion criteria of the
participants, evaluation of therapeutic effects, and methods of
data analysis were clearly elaborated in all the studies. However,
only three studies [22, 25, 31] conducted a sample size cal-
culation, and three studies described adverse events pertaining
to practicing massage therapy.
3.4. Primary Outcome: Effects of Massage erapy on Fatigue.
e effects of massage therapy on fatigue management are
outlined in Table 5. Narrative analysis was conducted to
describe the effects of massage therapy on fatigue.
3.4.1. Massage erapy versus Standard Routine Treatment/
Care or Wait List Control. Eight trials compared the effects
of massage therapy with standard routine treatment/care or
wait list control. Of these eight studies, four studies
[22, 27, 29, 33] reported a statistically significant decrease in
fatigue after the intervention compared with the routine care
group (p<0.01 or p<0.05). Listing et al. [23] showed that,
in comparing the two groups, the level of fatigue was lowered
directly after the second treatment session but did not reach
statistical significance (p�0.056). is decrease in fatigue
was sustained over time and showed a statistically significant
difference in the massage group compared with the control
group at week 11 follow-up (p�0.01), and a similar result
was reported by the study of Listing et al. [24]. Wyatt et al.
[32] reported that there was a significant decrease in fatigue
in the reflexology group compared with the control group at
weeks 2 and 3 (p<0.01), but no statistically significant
differences between the intervention and control groups at
week 4 (p�0.15). Mustian et al. [26] used the BFI as the
primary fatigue measure and daily fatigue diaries as the
secondary fatigue measure. e primary analysis revealed
that the participants who received modified massage
Table 2: Continued.
Study Country Study design Cancer stage Sample size and
age Intervention Control Outcomes
S7:
[31] USA
Longitudinal,
randomized
clinical trial
Stages III and
IV, or stages I
and II with
recurrence or
metastasis
Randomized:
286
Completed: 243
Group A: 83/95,
age (yr) �
55.3 ±9.4
Group B: 83/95,
age (yr) �
54.8 ±11.2
Group C: 77/96,
age (yr) �
57.3 ±11.8
Group A:
reflexology
therapy
Group B: lay foot
manipulation
(LFM) – light
touch
Group C: routine
treatment and
care
Fatigue: Brief Fatigue
Inventory (BFI)
QoL: Functional
Assessment of Cancer
erapy – Breast (FACT-
B)
Safety: adverse events
S8:
[26] USA RCT Any stage
Randomized: 45
Completed: 43
Group A: 15/15
Group B: 13/13
Group C: 15/15
age (yr) �25.8
Group A:
modified
Swedish
massage
therapy
Group B: polarity
therapy
Group C: routine
treatment and
care
Fatigue: Brief Fatigue
Inventory (BFI)
Daily fatigue diaries (a
0–10 scale)
QoL: Functional
Assessment of Chronic
Illness erapy-Fatigue
(FACIT-F)
S9
[23] Germany RCT Any stage
Randomized: 34
Completed: 29
Intervention G:
16/17, age (yr) �
59.5 ±12.1
Control G: 13/17,
age (yr) �
59.9 ±11.5
Swedish
massage
therapy
Routine
treatment and
care
Fatigue: Berlin Mood
Questionnaire (BSF;
fatigue subscale)
S10:
[24] Germany RCT Without distant
metastases
Randomized: 115
Completed: 72
Intervention G:
44/58, age (yr) �
57.6 ±10.8
Control G: 28/
57, age (yr) �
61.4 ±10.9
Swedish
massage
therapy
Routine
treatment and
care
Fatigue:
Berlin Mood
Questionnaire (BSF;
fatigue subscale)
Giessen Inventory of
Complaints (GBB; fatigue
subscale)
Note. QoL �quality of life.
6Evidence-Based Complementary and Alternative Medicine
Table 3: Description of massage therapy interventions.
Study Massage
modality Massage procedure Intervention
instructor
Timing of
intervention
Intervention
duration Frequency Follow-
up
S1:
[33]
Reflexology
therapy
Pressing the major
reflexive points of the soles
with the thumb and index
finger in a worm-like
movement
NR After
chemotherapy 4 weeks
Twice per week,
20 min per
session
No
S2:
[29]
Chinese
massage
therapy
(1) Massaging the patient’s
Zusanli,Yongquan,
Neiguan,Guanyuan,
Baihui,Shenmen, and
temple points
(2) Massaging and beating
of acupuncture point on
the affected side of the
patient’s affected limb that
had limited mobility
Specialist
nurses After surgery 3 months
Twice per week,
around 30 min
per session
No
S3:
[25]
Swedish
massage
therapy
SMT techniques using
effleurage kneading of
underlying muscles and
tapotement
(1) Patient takes a prone
position while the
therapist performs
massage from the
shoulders to the feet
(2) Patient turns to a
supine position and the
massage therapist
continues with the
intervention from the feet
to the shoulders, and then
the head
Licensed
massage
therapists
After primary
treatment 6 weeks Weekly, 45 min
per session No
S4:
[27]
Reflexology
therapy
(1) Performing primary
relaxation techniques
(effleurage, shaking,
rotation, and stretching)
on both feet
(2) Performing reflexology
techniques on all organ
systems
Trained
researcher
During
chemotherapy
ree sessions
(one in each
chemotherapy
cycle, 21 days)
Around
30–40 min each
session
No
S5:
[32]
Reflexology
therapy
Performing nine reflexes
on the foot with thumb-
walking pressure
Trained
caregivers
During
chemotherapy,
targeted, or
hormonal therapy
4 weeks Weekly, 30 min
per session
11
weeks
S6:
[22]
Myofascial
massage
Performing pressure,
stroke, ear pull, and
frontalis bone spread skills
on the neck-shoulder area
with the Barnes approach
Physical
therapist
After coadjuvant
treatment except
hormone therapy
NR
Two occasions
separated by a
2-week interval,
40 min per
session
No
S7:
[31]
Reflexology
therapy
Stimulating the nine
essential reflexes
specifically relating to
breast cancer using
reflexology (deep thumb-
walking pressure)
Certified
reflexologists
During
chemotherapy 4 weeks Weekly, 30 min
per session No
S8:
[26]
Modified
Swedish
massage
therapy
Applying strokes,
including light moving
touch, compression, and
static holds technique
Licensed
massage
therapists
During radiation
therapy 3 weeks Weekly, 30 min
per session No
Evidence-Based Complementary and Alternative Medicine 7
demonstrated a very small increase in CRF of 0.01 points
(<1%) compared with the average increase in CRF of 0.25
points (13%) in the standard care group during weeks 1 to 3.
However, the secondary analysis indicated an inconsistent
finding, as the patients randomized to the modified massage
group (0.59 points) had a greater increase in CRF than the
standard care group (0.39 points) across all 3 weeks.
3.4.2. Massage erapy versus Sham Massage. Massage
therapy was compared with sham massage in two trials,
including light touch [25] and lay foot manipulation [31]. Of
the two studies, Wyatt et al. [31] used the same BFI tool for
fatigue assessment, while Kinkead et al. [25] applied the
PROMIS. Wyatt et al. [31] reported that there was a sta-
tistically significant reduction in fatigue severity in the
reflexology group compared with the lay foot manipulation
group (p�0.02). e study conducted by Kinkead et al.
[25]; which used the MFI tool for fatigue assessment,
revealed large standardized treatment effect sizes, showing
that Swedish massage therapy was statistically superior over
light touch across time (effect size �0.74; 95% CI �0.10 to
1.38; p<0.0001).
3.5. Secondary Outcome: Effects of Massage erapy on QoL.
Of the 10 studies, four RCTs measured and reported QoL as
an outcome. Quality of life was assessed by 4 different
questionnaires, including the Quality of Life Enjoyment and
Satisfaction Questionnaire (Q-LES-Q) [25], the Quality of
Life Index (QLI) [32], the Functional Assessment of Cancer
erapy – Breast (FACT-B) [31], and the Functional
Table 3: Continued.
Study Massage
modality Massage procedure Intervention
instructor
Timing of
intervention
Intervention
duration Frequency Follow-
up
S9:
[23]
Swedish
massage
therapy
Applying stroking,
friction, kneading skills to
the patients in a prone
position.
Muscles for massage:
compendiously neck
muscles, autochthonal
back muscles, scapulae,
trapezii, latissimi dorsi,
supraspinati, teres
majores, pectorales
majores, and so on
Licensed,
trained female
massage
therapist
After primary
treatment 5 weeks
Twice a week,
30 min per
session
11
weeks
S10:
[24]
Swedish
massage
therapy
Same as [24]
Licensed,
trained female
massage
therapist
After
chemotherapy
and/or radiation
therapy
5 weeks
Twice a week,
30 min per
session
11
weeks
Note. NR �not reported.
Table 4: Methodological quality appraisal of the included studies.
Criteria S1: [33] S2: [29] S3: [25] S4: [27] S5: [32] S6: [22] S7: [31] S8: [26] S9: [23] S10: [24]
1 Random sequence generation ⨯ ✓ ✓ ⨯ ⨯ ✓ ✓ ✓ ✓ ✓
2 Allocation concealment ? ? ✓? ? ✓ ✓ ?⨯ ⨯
3 Baseline assessment ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
4 Blinding – participants ? ? ⨯? ? ⨯ ✓ ⨯ ? ?
5 Blinding – care provider ? ? ⨯? ? ⨯ ✓ ⨯ ? ?
6 Blinding – outcome ? ? ✓? ? ✓ ✓ ⨯ ? ?
7 Cointerventions ✓ ✓ ✓ ✓ ✓ ✓ ✓ ⨯ ✓ ✓
8 Compliance ✓✓✓?✓?✓ ⨯ ✓ ✓
9 Dropouts ⨯ ✓ ✓ ?✓?✓ ✓ ✓ ⨯
10 Timing ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
11 Selective outcome reporting ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
12 Incomplete outcome data ⨯ ⨯ ✓ ?✓?✓ ⨯ ⨯ ⨯
13 Other bias
Sample size calculation ? ? ✓ ⨯ ?✓ ✓ ?⨯ ⨯
Inclusion criteria ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Exclusion criteria ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Evaluation of treatment effects ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Adverse events reporting ⨯ ⨯ ✓ ? ? ? ✓?✓?
Data analysis methods ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Note. ⨯: high risk; ✓: low risk; and ?: unclear.
8Evidence-Based Complementary and Alternative Medicine
Table 5: Effects of the massage therapy on CRF.
Study Intervention
(mean ±SE)
Control
(mean ±SE)
Assessment time
points Fatigue outcome measures Description of the effects
S1:
[33] 20.66 ±4.54 40.36 ±9.58 Postintervention
(4 weeks) Fatigue Severity Scale (FSS)
Significant difference was identified
between the intervention and
control groups (p≤0.01)
S2:
[29] 2.63 ±1.71 3.61 ±2.16 Postintervention
(3 months)
Chronic Fatigue Syndrome
(CFS)
Statistical differences were identified
between the intervention and
control groups (p<0.05)
S3:
[25] NR NR
Postintervention
(6 weeks) at visits 3 and
6 weeks
Multidimensional Fatigue
Inventory (MFI) and Fatigue
Short Form 7a (PROMIS)
Mixed model repeated measures
analysis: the Swedish massage group
showed statistically better outcomes
over the light touch and the wait list
control groups, as well as for
superiority of the light touch over
the wait list control over time
(p<0.0001)
PROMIS analysis: significant
improvement of fatigue for the
Swedish massage group and the light
touch group over 6 weeks, while
remaining the same for the wait list
control group
S4:
[27] 1.20 ±1.44 2.33 ±1.65
Postinterventions
(every chemotherapy
cycle)
Fatigue: Brief Fatigue
Inventory (BFI)
Differences were observed between
the intervention and control groups
in the onset and first, second, and
third measurements (p<0.05)
S5:
[32]
W2: 3.36 ±0.24
W3: 3.75 ±0.24
W4: 3.57 ±0.24
W2: 4.95 ±0.24
W3: 4.63 ±0.24
W4: 4.23 ±0.24
Postintervention
(4 weeks)
MD Anderson Symptom
Inventory
Significant reduction in fatigue
severity was identified in the
intervention group compared with
the control group beginning at
weeks 2 and 3 (p<0.01)
No statistically significant
differences between the two groups
were identified for the severity of
fatigue at week 4 (p�0.15)
S6:
[22] 41.3 ±4.9 43.4 ±7.0 Postintervention
Fatigue: Profile of Mood
States (POMS) Questionnaire
(fatigue subscale)
Significant reduction in disturbance
of mood and fatigue were observed
after manual therapy (p<0.001)
S7:
[31] 5.9 ±2.8
LFM G: 5.4 ±3
Control G:
6±2.8
Postintervention
(4 weeks) Brief Fatigue Inventory (BFI)
Significant reductions in fatigue
severity in the intervention group
was observed compared with the
control group (p<0.01) and the
LFM group (p�0.02)
S8:
[26]
BFI: 3.0 ±2.2
Daily fatigue
diaries: 4.5 ±2.1
BFI: Modified
Massage G:
3.6 ±2.8
Control G:
2.5 ±1.5
Daily fatigue
diaries
Polarity G:
4.5 ±2.8
Control G:
3.2 ±1.8
Postintervention
(4 weeks)
Brief Fatigue Inventory (BFI)
Daily fatigue diaries
BFI analysis: participants who
received modified massage
demonstrated a smaller increase in
fatigue assessment of 0.01 points
(<1%) compared with an average
increase in fatigue assessment of 0.25
points (13%) in the standard care
group during weeks 1 to 3
Daily fatigue diaries analysis: the
patients randomized to modified
massage had a greater increase (0.59
point) in CRF than the standard care
group (0.39 point) across all 3 weeks
Evidence-Based Complementary and Alternative Medicine 9
Assessment of Chronic Illness erapy – Fatigue (FACIT-F)
[26]. Regarding effectiveness, 2 studies reported group
differences in measures of QoL as an outcome. Kinkead et al.
[25] reported that the Q-LES-Q scores increased substan-
tially for the intervention group compared with the light
touch and wait list control group, and the results reached
statistical significance over the 6-week trial period
(p�0.0019). Mustian et al. [26] highlighted that the patients
in the Swedish massage group reported less decline in
health-related QoL than the standard care group, but no
statistical significance was found (p�0.31, p�0.09, and
p�0.64 for Week 1, Week 2, and Week 3, respectively). In
contrast, Wyatt et al. [32] and Wyatt et al. [31] reported that
no statistically significant differences were identified re-
garding QoL in the intervention group compared with the
sham control/standard care group.
3.6. Secondary Outcome: Adverse Events. Of the 10 trials, 3
[23, 25, 31] mentioned adverse events in the Results
section, of which 1 study reported no adverse effects [31].
Kinkead et al. [25] set the adverse events as safety out-
comes, and they were monitored at each therapy session,
with bruising at the venipuncture site observed in 12/39
participants and discomfort caused by hypertension from
lying on the table experienced by 2/39 subjects. Listing
et al. [23] reported that 1 participant had higher back pain
and another participant experienced an increase in blood
pressure, but those adverse events were resolved in a later
massage session. None of the 10 included studies indi-
cated causality analysis protocols for monitoring massage
therapy-related adverse events.
3.7. Satisfaction with Treatment. None of the reviewed
studies reported findings on treatment satisfaction.
3.8. Cost-Effectiveness. Cost-effectiveness analysis was not
conducted by any of the reviewed trials.
4. Discussion
Considering the relatively small number of studies analyzed
in this review and the unsatisfactory methodological quality
of some included studies, the current evidence remains
inconclusive but does support the promising role of massage
therapy in alleviating fatigue in breast cancer survivors.
Mustian et al. [6] stated that the effectiveness of massage
therapy on fatigue was related to the stage of cancer, pre-
liminary treatment status, experimental treatment delivery
method, type of control condition, employment of inten-
tion-to-treat analysis, and fatigue measurement tools.
erefore, the results should be interpreted prudently.
4.1. Summary of Primary Outcome. Although meta-analysis
was not conducted, the findings via descriptive analysis
demonstrated that massage therapy had a positive effect on
fatigue management in breast cancer survivors compared
with those who received standard routine care/wait list
control and sham massage. Consistent with the systematic
review conducted by Pan et al. [14], the current review
suggested that there was a greater alleviation of fatigue
symptoms among the breast cancer survivors who received
massage therapy compared with the control group. Re-
garding the effect of sham massage (i.e., light touch and lay
foot manipulation), the current review revealed that both
sham massage modalities demonstrated superiority over
standard care/wait list control. In particular, there was a
significant reduction in fatigue after applying lay foot ma-
nipulation, suggesting that this modality may be a beneficial
addition to adjunctive care for survivors with breast cancer
[31].
4.2. Summary of Secondary Outcomes. Regarding QoL, in-
consistent findings were revealed in this review, which was
in accordance with the review by Pan et al. [14], suggesting
that massage therapy can potentially ameliorate QoL among
cancer patients. Regarding adverse effects, one argument for
the application of massage therapy for breast cancer
Table 5: Continued.
Study Intervention
(mean ±SE)
Control
(mean ±SE)
Assessment time
points Fatigue outcome measures Description of the effects
S9
[23]
T2: 18.2 ±14.8
T3: 18.9 ±14.8
T2: 27.9 ±17.2
T3: 33.8 ±16.4
Postintervention
(5 weeks) Fatigue Severity Scale (FSS)
Improvement of tiredness nearly
reached statistical significance
immediately after intervention (T2;
p�0.056). A better improvement of
tiredness was identified at T3.
Statistically significant difference
was identified between groups at
follow-up (p�0.01).
S10:
[24] NR NR Postintervention
(5 weeks)
Giessen Inventory of
Complaints (GBB; fatigue
subscale)
Fatigue was improved at the end of
the treatment (p�0.06). Statistically
significant difference was identified
in the intervention group compared
with the control group at week 11
(p�0.048).
Note. NR �not reported.
10 Evidence-Based Complementary and Alternative Medicine
symptom management is that it has few adverse reactions
[34]. However, none of the included trials provided infor-
mation regarding precautions of any potential adverse re-
actions associated with massage therapy. ere was also no
information about causality assessments between the mas-
sage therapy interventions and the adverse events that oc-
curred in the reviewed studies. erefore, evidence
regarding the safety of massage therapy remains unclear.
Adverse effects should be noted in future studies.
is review identified that none of the reviewed trials
evaluated treatment satisfaction or conducted the cost-ef-
fective analysis. In the systematic review conducted by
Barbosa et al. [35], it was suggested that there is a positive
statistical association between treatment satisfaction and
compliance, adherence, and lower treatment burden for
different spectrums of diseases in clinical trials. Inadequate
compliance in RCTs can lead to poor quality studies and
reduce therapeutic outcomes [36]. None of the reviewed
studies adopted validated outcome measures to explore cost-
effectiveness relationships related to performing massage
therapy. A recent review has indicated that cost-effectiveness
analysis is the standard approach in health economics [37].
e benefits of health economics are uncertain without an
assessment of the cost-effectiveness of massage therapy in
RCTs [37, 38].
4.3. Intervention Protocols. Although the majority of the
included studies described the massage therapy intervention
protocols, none of the studies elaborated whether the in-
tervention protocol was developed based on current best
available evidence and the guidance of frameworks, such as
the Medical Research Council (MRC) framework for
complex interventions. In addition, there were variations in
the interventions’ modalities, the pluralism of massage
therapy, the expertise of the intervention instructors, and the
descriptions of frequency and duration in the included
studies.
Of the four intervention modalities, reflexology therapy
and Swedish massage therapy were the most frequently
utilized among the included trials. Nevertheless, considering
the relatively limited number of included studies, it was
challenging to determine the most suitable modality of
massage therapy for fatigue management. In addition, the
massage therapy was performed by various instructors,
including trained researchers, caregivers, nurses, massage
therapists, and so on, which could have had an impact on the
effect and safety of massage therapy practice. Furthermore,
variations in massage therapy duration and frequency were
also observed, which indicated that standard massage
therapy practice with evidence-based intervention compo-
nents is scant. From the descriptive analysis, it was feasible to
perform massage therapy 30 to 45 minutes/session, one to
two times per week. No consistent massage therapy protocol
has been observed with sufficient sample sizes to date.
4.4. Quality of the Evidence. is systematic review appraised
the methodological quality of the included studies using the
Cochrane Back Review Group Risk of Bias Assessment
Criteria. Of the ten included studies, only one trial blinded
the participants and care providers, and three trials blinded
the outcome assessors. e other six studies did not report
blinding information, which implies a potential detection
bias [39]. Allocation concealment was also reported in only
three studies. Clinical studies without adequate allocation
concealment and blinding design are likely to introduce a
selection bias that can produce exaggerated intervention
effects, which can impact the reliability of the trials’ findings
[40]. Similarly, ITT analysis was described in only three
trials, which may have been subject to an attrition bias [41].
4.5. Study Limitations. Although all the included trials
suggested that massage therapy generates beneficial effects,
the trials reviewed had variable quality, which may have
prohibited drawing any firm and consistent conclusions.
Besides the flaws in methodological quality, the primary
limitation of the reviewed studies was significant clinical
heterogeneity, including insufficient sample sizes, different
types of massage therapy, study comparisons, intervention
duration, and no or short follow-up periods. Regarding the
limitations of this systematic review, there was the possibility
of language bias given that only Chinese and English lit-
erature were searched and included. Although the electronic
searches were extensive and considered grey literature as
well, the review was not able to guarantee that all pertinent
studies were located. It is possible that studies with negative
findings were not published and therefore could not be
identified. Hence, publication and reporting biases may
exist.
4.6. Implications for Further Research and Practice. e re-
view findings provided preliminary research evidence to
support the use of massage therapy as a promising approach
to alleviating fatigue in breast cancer survivors in clinical
practice. Given the variations in the intervention protocols
in the analyzed studies, in future research, developing evi-
dence-based massage therapy protocols with an appropriate
modality and most favorable duration and frequency is
warranted. More well-designed multicentered RCTs with
appropriate sham massage therapy designs and adequate
sample sizes are needed to provide more robust evidence on
massage therapy for fatigue management in breast cancer
survivors. Moreover, this review highlighted some meth-
odological issues that can be further enhanced in future
studies. First, the protocols of the massage therapy, in-
cluding massage modality, intervention duration and fre-
quency, and qualifications of the instructors, should be fully
described with justifications. Second, blinding data collec-
tors and outcome assessors should be considered to reduce
the effects of patients’ expectations on the measured out-
comes. Moreover, interventions with follow-up periods
should be designed to monitor the long-term effects of
massage therapy. In addition, adverse events and the cau-
sality between massage therapy and adverse events should be
fully measured and reported. Furthermore, some valid ob-
jective measurements such as physiological sensors should
be considered in future research to provide a comprehensive
Evidence-Based Complementary and Alternative Medicine 11
assessment of fatigue. Treatment satisfaction with and cost-
effectiveness of massage therapy should also be evaluated in
future studies to identify the acceptability and feasibility of
the wide use of massage therapy in clinical practice.
5. Conclusion
is study identified a potentially favorable role of massage
therapy in reducing cancer-related fatigue in breast cancer
survivors. However, evidence on the definite effects of
massage therapy for fatigue management in breast cancer
survivors is inconclusive due to some limitations in quantity
and quality identified in the included studies. More rigor-
ously designed, sham-massage RCTs with large sample sizes
are warranted to minimize study bias and yield high-quality
and robust evidence.
Data Availability
Data that were used for analysis in this review were all
extracted from the original studies. All data relevant to the
study are included in the article.
Conflicts of Interest
All the authors declare that there are no conflicts of interest.
Authors’ Contributions
TW contributed to the conception and design of this study,
database search, data extraction, synthesis and data analysis,
and manuscript drafting; JXZ contributed to the conception
and design of this study, database search, data extraction,
synthesis and data analysis, and manuscript writing; XLL
contributed to the conception and design of this study and
manuscript revision; LQY contributed to the study design,
database search, and double-checking all the raw data; and
JYT contributed to the conception and design of this study
and manuscript revision.
Acknowledgments
is study was supported by the CDU Institute of Advanced
Studies (IAS) Rainmaker Start-Up Grant.
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