Krohn, M., Listing, M., Tjahjono, G., Reisshauer, A., Peters, E., Klapp, B.F., & Rauchfuss, M. (2011). Depression, mood, stress, and Th1/Th2 immune balance in primary breast cancer patients undergoing classical massage therapy. Supportive Care in Cancer: Official Journal of the Multinational Association of Supportive Care in Cancer, 19(9), 1303–1311.

To investigate the short- and long-term effects of classical massage therapy on cytokine responses and the Th1/Th2 ratio, depression, mood, and perceived stress in patients with primary breast cancer; to evaluate the relevance of classical massage therapy in the context of oncologic care  

Authors randomized 34 women into two groups. The massage group received a 30-minute classical massage twice per week for five weeks. The control group received standard medical care only. Time points in the study were before intervention, at the end of the five-week intervention period, and at six weeks after the intervention. At these time points, participants completed several measurement instruments, and investigators took blood samples to determine cytokine concentrations and the Th1/Th2 ratio.

• The sample was composed of 29 participants.
• Mean age of patients in the massage group was 59.5 years; in the control group, 59.9 years.
• Because participants were patients with breast cancer, the assumption is that 100% of participants were female.
• The tumor size of all participants was less than or equal to T2; nodal state, less than or equal to N2. The time since disease onset was less than four years before the study. Participants had completed surgery, chemotherapy, and/or radiation therapy at least three months prior to the beginning of the study.
   

Unspecified

• Phase of care: long-term follow-up
• Clinical applications: late effects and survivorship

Randomized controlled trial

• Perceived Stress Questionnaire (PSQ), to assess the subjective experience of stressful situations on the cognitive and emotional level. Authors used a 20-item German version of the PSQ, a version consisting of four subscales: worries, tension, demands, and joy. These are rated with a four-point Likert scale and subscale values are transformed into scores 0–100. High scores correspond to high levels of stress.    
• Patient Health Questionnaire (PHQ), to screen, diagnose, and evaluate the severity of different psychiatric diseases. Depression score is derived from nine items, and the sum of the scores varies 0–27. The higher the score, the more severe the depression.    
• Berlin Mood Questionnaire, or Berliner Stimmungsfragebogen (BSF), a self-report of mood developed on the basis of the Profile of Mood States (POMS). The 30-item BSF measures six mood states and rates each on a five-point scale. Authors used BSF scales of anxious depression and elevated mood.
• BD Cytometric Bead Array (CBA) kit to measure cytokine concentrations.
   

• Authors noted no significant sociodemographic or clinical differences between participants in the massage group and those in the control group.
• At five weeks, immediately after massage, depression and anxious depression decreased significantly, compared to depression and anxious depression in the control group (p = 0.005, effect size (ES) = 1.39 in PHQ scores).
• Stress and elevated mood did not change significantly after massage therapy.
• Changes of cytokine concentrations and Th1/Th2 ratio were insignificant, although authors noted a slight shift toward Th1 in the massage group over time.

Massage therapy is an efficient treatment for reducing depression in breast cancer patients. Insignificant results concerning immunologic parameters, stress, and mood indicate that further research is needed to determine psychological and immunologic changes associated with massage therapy.

• The study had a small sample size, with fewer than 30 participants.
• The study had a risk of bias due to no attentional control condition.
• Improvement of psychometric parameters may differ with massage therapist.
• Cytokine levels may fluctuate or increase coincident with immunologic processes, such as infections or chronic diseases.
• Authors do not make clear whether, at the five-week time point, measures were taken immediately after the massage. Timing could influence results.
• Authors stated that effect size for depression was 1.39 on a 100-point scale, but they did not state how effect size was calculated.

Massage therapy may be an effective intervention to offer to patients who struggle with depression. Additional studies should evaluate the effectivenss of this intervention as well as its effect on immunologic parameters, stress, and mood.