Osteopathy as a complementary/alternative medicine for breast cancer: A Canadian case study and comprehensive review

Abstract

Aim: In Canada, osteopathic medicine, a well-known branch of complementary/alternative medicine, has received minimal attention for pain management within oncology. Purpose: This review reports both the existing literature and patient experience surrounding the application of osteopathy as an effective treatment for pain in breast cancer patients. Results: Both the literature and this case study support, to some degree, the benefits of osteopathy as pain management for breast cancer patients. Conclusion: Due to contradictory reported findings, more studies would be required to make firm conclusions, especially within a Canadian context. However, a lack of standardization of osteopathic procedures and collaboration between osteopaths and traditional healthcare professionals are challenges in including osteopathy as a standard service offered to breast cancer patients.

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Osteopathy as a complementary/alternative
medicine for breast cancer: a Canadian case
study and comprehensive review
Justine Fortin*,1,2 ,Ana
¨
ıs Beaupr ´
e2,3, Lunie Anne Thamar Louis4, Carol-Anne Roy5,
Michaela Ann Bourque6, Sarah Cappeliez7& Asma Fadhlaoui8,9
1Department of Psychology, Universit ´
eduQu
´
ebec `
a Montr´
eal, 100 rue Sherbrooke Ouest, H2X 3P2, Montr´
eal (QC), Canada
2ENOSI, Professional School of Osteopathy, 6830 Parc Av., H3N 1W7, Montr ´
eal (QC), Canada
3Department of Health Sciences Research, Universit ´
e Sherbrooke, J1K 0A5, Sherbrooke (QC), Canada
4Deparment of Psychology, Universit ´
e de Montr ´
eal, 90 Vincent D’Indy, H2V 2S9, Montr´
eal (QC), Canada
5Department of Psychology, Universit ´
eduQu
´
ebec en Outaouais, 283 Bd Alexandre-Tach ´
e, J8X 3X7, Gatineau (QC), Canada
6Department of Psychiatry, McGill University, 845 Rue Sherbrooke O, H3A 0G4, Montr ´
eal (QC), Canada
7No Department or Institution, Patient-partner, Montr´
eal (QC), Canada
8Faculty of Nursing, Universit ´
e de Montr ´
eal, 2900 Bd Edouard-Montpetit, H3T 1J4, Montr´
eal (QC), Canada
9Research Center of the H ˆ
opital Maisonneuve-Rosemont, 5415 Bd de l’Assomption, H1T 2M4, Montr ´
eal (QC), Canada
*Author for correspondence: justine.fortin@umontreal.ca
Aim: In Canada, osteopathic medicine, a well-known branch of complementary/alternative medicine, has
received minimal attention for pain management within oncology. Purpose: This review reports both
the existing literature and patient experience surrounding the application of osteopathy as an effective
treatment for pain in breast cancer patients. Results: Both the literature and this case study support, to
some degree, the benets of osteopathy as pain management for breast cancer patients. Conclusion:
Due to contradictory reported ndings, more studies would be required to make rm conclusions,
especially within a Canadian context. However, a lack of standardization of osteopathic procedures and
collaboration between osteopaths and traditional healthcare professionals are challenges in including
osteopathy as a standard service offered to breast cancer patients.
First draft submitted: 27 January 2022; Accepted for publication: 6 April 2022; Published online:
20 April 2022
Keywords: affective touch •mental health •oncology •osteopathic medicine •pain
Over many years, prognoses and statistics have suggested that the global impact of breast cancer and related
mortality is growing [1,2]. An estimated report predicts breast cancer as the most frequent cancer diagnosis among
Canadian women, with one in eight being diagnosed with breast cancer in their lifetime [3]. This diagnosis heralds
a hospitalization that may be colored by difficult physical [4] and psychological symptoms [5].
Pain is a common symptom that may occur during the screening phase (i.e., biopsy) [6], but more frequently
during the treatment phase and can last until survivorship, in other words, having no signs of cancer after finishing
treatment [7,8]. A growing number of breast cancer survivors are living with pain [8,9]. Since pain seems to be a
symptom found in several phases of the breast cancer experience, it is relevant to understand how it can impact
breast cancer patients’ physical and mental health.
Currently, in Canada, several interventions, including medical, pharmacological [10] or psychosocial [11],are
recommended to treat physical pain and thus reduce patients’ psychological symptoms [10]. However, recently,
increasing numbers of oncology patients are combining complementary/alternative medicine (CAM) with their
conventional therapies in Canada [12,13]. Yet, much CAM literature in oncology excludes osteopathy, a therapeutic
discipline in Canada, from their analysis, thus adding barriers to the discipline’s emergence from both a research
and clinical point of view.
This paper aims to first review the literature on cancer-related pain, CAM, and the effectiveness of osteopathic
treatment for breast cancer patients. Then, a qualitative Canadian case study is presented regarding osteopathic
treatments during the breast cancer experience. Finally, a critical review of current issues in the formal integration
of this practice into interventions for Canadian breast cancer patients is discussed from different stakeholders’
perspectives (osteopath, nurse and patient-partner).
Breast Cancer Manag. (2022) BMT63 eISSN 1758-1931
10.2217/bmt-2022-0002 C
2022 Fortin, Beaupr´
e, Thamar Louis, Roy, Bourque, Cappeliez & Fadhlaoui

Review Fortin, Beaupr ´
e, Thamar Louis et al.
Literature review: pain & actual interventions in breast cancer
Pain according to breast cancer trajectories
Pain is a well-studied symptom in oncology, which has led to the development of several theories used to define and
characterize it. Among these theories, cancer-related pain is recognized as a multidimensional phenomenon that can
be understood through five different components associated with various consequences [14]. The pain experience
includes physiological, sensory, affective, cognitive and behavioral components, resulting in heterogeneous outcomes
among patients [14]. The development of pain (including acute, subacute, chronic and persistent pain) in breast
cancer is a common clinical condition that varies according to several factors such as the disease trajectory [15,16].
From initial mammograms and breast biopsies during the screening phase, up to 76% of breast cancer patients are
experiencing pain [17]. Many patients choose to not re-attend mammogram tests because of pain [18]. Age, medical
history and menstrual cycles are among the variables that could explain the pain felt during these examinations [19].
Moreover, the mammography itself is not administered the same way for all patients, leading to different pain
outcomes [18,20]. It is understood that mammograms and breast biopsies are associated with high psychological
distress [21].
Breast cancer treatment often involves surgical interventions such as a mastectomy [22]. The literature points
toward the fact that, following surgery, 29.8% of breast cancer patients experience persistent pain [8,22].Thepost-
mastectomy pain syndrome is diagnosed when patients experience at least a moderate intensity of neuropathic pain
in one of the following site: breast, pain exacerbated by movement, armpit or arm of affected side, chest wall [23].
A prospective study demonstrated that breast cancer patients who were younger, who had more invasive surgery,
who received radiation therapy after surgery, and who felt more severe acute postoperative pain were more likely
to experience chronic pain [24]. As for breast reconstruction following mastectomy, factors associated with younger
age, bilateral reconstruction and severity of preoperative pain, anxiety and depression were associated with more
severe acute postoperative pain [25]. Post-mastectomy pain syndrome has also been shown to present similarly in
those who choose to undergo post-mastectomy cosmetic breast implant surgery [26].
Prevalence of pain during and following breast cancer treatments ranges between 27.3 and 60% [27,28].Even
following the remission phase, just under a quarter of breast cancer survivors (21.8%) experience persistent pain [27].
Risk factors like lymphedema, chemotherapy, hormone therapy and radiotherapy are shown to be associated with
chronic pain development during the treatment and survivorship phases [29].
Additionally, breast cancer-related pain literature shows that having metastatic, advanced or terminal cancer is
associated with a higher risk of experiencing pain, closely followed by patients undergoing cancer treatment [30].In
response to the high prevalence of pain in breast cancer patients, many turn to alternative treatments.
Actual interventions proposed to reduce pain in Canada
Currently, pharmacotherapy is the most prescribed treatment for pain in breast cancer patients in Canada [10].
Indeed, pharmacology follows a sequential order, modeling the analgesic scale of the World Health Organization
(WHO) [31]. Pharmacological pain treatment ranges from the prescription of non-opioid drugs such as paracetamol
or ibuprofen to the use of more powerful opioids (morphine, oxycodone) [31]. It is, therefore, possible that
neuropathic cancer pain is treated with antidepressants, gabapentinoids or other antiepileptic drugs [32].
Despite its efficacy in treating pain in breast cancer, pharmacological interventions, particularly the consumption
of opioids, can result in several side effects, such as nausea and constipation [31,32]. In short, because of the associated
side effects, it is possible that underdosing or stopping opioids may be recommended [31]; thus, potentially reducing
the effectiveness of pharmacological pain treatment. Knowing that pharmacological interventions are not always
effective in the treatment of pain in all women with breast cancer, psychosocial interventions represent a plausible
treatment alternative [33].
Interventions including cognitive-behavioral therapy (CBT) have been tested to treat pain in patients with
breast cancer (see meta-analysis [34]). Results demonstrated that 62 and 69% of breast cancer patients who received
CBT reported less pain than those in the control group. Other non-pharmacological techniques including physical
exercise seem to contribute to the reduction of treatment side effects and improving quality of life in women who
have breast cancer [35]. Also, Smoot et al. [36] have shown that low-intensity laser therapy (LLLT) is moderately
effective in reducing the pain associated with patients suffering from lymphedema due to breast cancer.
Emergence of complementary & alternative medicine in oncology
Traditional medical interventions are the most commonly offered treatments in oncology to manage cancer-related
pain; but, emerging literature shows that complementary and alternative medicine (CAM) is increasingly coveted
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Osteopathy & breast cancer: a review Review
in breast cancer [37–39]. CAM comprises various practices that are not part of standard Western medicine, such
as manipulative and body-based practices (e.g., acupuncture, homeopathy, massage therapy, spiritual healing) [40].
CAM is often used in oncology to help treat or reduce the side effects of cancer treatments (e.g., pain [41]), to treat
post-mastectomy lymphedema [42], to help address mental health [43] or even to foster patient empowerment [37].
Notably, 55% of women at high risk of breast cancer are using different types of CAM, mainly to prevent
tumor evolution [44]. A study showed that CAM is used from diagnosis to survivorship by up to 97.2% of breast
cancer patients in China [45], 69% in USA [46], 55.7% in Europe [47] and approximately 66.7% in Canada [39,48].
Factors including younger age, higher education and having health insurance are related to CAM use among these
patients [37,49].
Although a gap exists between traditional medicine and CAM, there are many positives in the complementary
use of these two types of treatments. A systematic review showed that CAM use emphasizes sleep status, life
expectancy, and quality of life [50]. Regarding cancer-related pain, systematic reviews have demonstrated that CAM
can alleviate muscle pain following mastectomy [51] and different types of pain throughout active treatment [52] and
survivorship [53].
Certainly, CAM treatments in oncology have much attention in research; however, a notable limitation in CAM
literature is the sidelining of osteopathy (e.g., [46,54]). This issue must be considered, as this discipline has also
shown to be directly effective in the treatment of pain and indirectly in the improvement of the mental health of
oncology patients [55,56].
Literature review: current knowledge on osteopathy & breast cancer
Osteopathy & breast cancer screening & diagnosis
Only one study has compared the effectiveness of cancer screening practices across different professional areas of
expertise [57]. Among the specialists studied, physician assistants and nurse practitioners were more likely than
physicians or osteopathic doctors to adhere to the guidelines for breast cancer screening [57]. However, in this
study, the osteopaths had a doctorate, which is not a prerequisite for osteopaths in countries such as Canada.
Although lacking additional support, results show that breast cancer screening is more effective in traditional
medicine (e.g., gynecologists) compared with other types of medicine [57]. No studies were found that measured
the effectiveness of osteopathic treatments for pain associated with breast cancer screening.
Osteopathy & post-surgery
Only one study was found that aimed to measure the effectiveness of osteopathy in relieving pain in breast cancer
patients’ post-surgery [58],seeTable 1. This study aimed to determine whether osteopathic treatment lasting 4
weeks, administered once a week, had a significant effect in relieving pain and improving the quality of life of
geriatric breast cancer patients (n = 23). They observed that, when combined with physiotherapy, osteopathic
manipulation had a significant effect in pain reduction between the second and third weeks of treatment but a
non-significant effect on quality of life. According to these results, osteopathic treatment in patients who have just
undergone surgery may have a positive effect in relieving pain, enforcing the importance of further studies on the
benefits of this treatment.
Osteopathy & breast cancer treatments
Five studies were included that examined osteopathic treatments during the breast cancer treatment phase, see
Table 1 [58–62]. Each of the five studies applied different osteopathic techniques, but the most common (3/5) was
the myofascial technique [58–61]. Despite this similarity between articles, this method is applied for different reasons:
the relaxation of the back and abdomen to improve back movement and abdominal pressure [58],orthereleaseof
priority diaphragms [61]. In another article, the authors prioritize myofascial therapy for the intervention group by
focusing on the upper body, pectoral, axillary, cervical, diaphragm and scars [60]. Other techniques such as dorsal
and lumbar soft tissue, rib raising, cervical spine soft tissue, suboccipital decompression [58], analgesic and muscular
techniques [59], passive mobilizations of the shoulder, stretching of pectoral muscles, scar tissue massage [60] and
visceral manipulation [62] were applied.
The effectiveness of osteopathy as a treatment for pain was examined in four studies [58–61]; however, the results
are not unanimous. In two studies, osteopathy treatments significantly relieved cancer-related pain [58,60].Inone
case study, osteopathy showed potential to reduce pain; however, further research is needed to confirm [61].Ina
fourth article, researchers did not find a reduction in pain following osteopathic treatments [59].Lagrangeet al. [62]
evaluated the effectiveness of osteopathic treatments on digestive toxicity. Results from this study showed that
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Table 1. Studies characteristics (n =5).
Study Country Objective(s) NAge (mean) Control group Cancer phase Questionnaires
administered for
pain
Reason(s) for
osteopathic
treatment use
Osteopathy
measures/techniques
employed
Number of
osteopathic
consultations
Efcacy of
osteopathic
treatments
Ref.
Arienti et al.
(2018)
Italy 1) Study the effect
of osteopathic
manipulation on
pain relief and
quality of life
improvement in
hospitalized
oncology geriatric
patients
23 76.5 years Post-surgical
cancer patients
who underwent
only
physiotherapy
treatment
Post-surgical
Treatment
NRS 1) Pain relief
2)
Improvement
of quality of
life
1) Dorsal, lumbar and
cervical spine soft
tissue
2) Rib raising
3) Back, abdominal and
sacroiliac myofascial
release
4) Suboccipital
decompression
4 (once every
week for
4 weeks)
1) Efcient for pain
relief
2) Nonefcient for
improvement in
quality of life
[58]
Chvetzoff
et al. (2019)
France 1) Examine intensity
of pain
post-mastectomy
(3-month EVA)
2) Examine pain
(EVA) at 6 and 12
months
28 50.0 years N/A Treatment Pain intensity
measured by
VAS (me an VAS
over the past
week)
1) Reduce the
intensity of
post-
mastectomy
pain syndrome
1) Analgesic techniques
(Jones technique)
2) Muscular techniques
(Mitchell technique)
3) Myofascial
techniques (functional
techniques)
5 (each spaced 2
to 3 weeks
apart)
1) Efcient for
quality of life and
depression
2) Nonconclusive
for pain
[59]
De Groef
et al. (2018)
Belgium 1) Investigate the
effect of myofascial
therapy in addition
to a standard
physical therapy
program for
treatment of
persistent arm pain
after nishing
breast cancer
treatment
50 53.3 years Receiving a
standard
physical therapy
program and
placebo therapy
Treatment 1) Pain intensity
was assessed
with the VAS
2) The McGill
pain
questionnaire
3) Pain rating
index (PRI)
1) Persistent
arm pain after
breast cancer
treatment
1) Passive mobilizations
of the shoulder to
improve passive and
active shoulder ROM
2) Stretching of
pectoral muscles to
improve muscle
exibility and passive
and active shoulder
ROM
3) Scar tissue massage
to improve exibility
of the scar(s)
4) Myofascial therapy
(active myofascial
trigger points at the
upper body and on
myofascial adhesions in
the pectoral, axillary
and cervical region,
diaphragm and scars)
20 (week 1–8
two sessions per
week, week
9–12 one session
per week)
1) Further research
should explore the
effectiveness of
myofascial therapy
in different groups
of breast cancer
survivors with
different
underlying pain
mechanisms
[60]
FEC: Fluoracil, epirubicin, cyclophosphamide; MFR: Myofascial release; N/A: Not applicable; NRS: Numeric Rating Scale; ROM: Range of motion; VAS: Visual analogue scale.
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Table 1. Studies characteristics (n =5) (cont.).
Study Country Objective(s) NAge (mean) Control group Cancer phase Questionnaires
administered for
pain
Reason(s) for
osteopathic
treatment use
Osteopathy
measures/techniques
employed
Number of
osteopathic
consultations
Efcacy of
osteopathic
treatments
Ref.
Goyal et al.
(2017)
India 1) Explore the
efcacy of
osteopathic
manipulative
treatment on
post-mastectomy
lymphedema
induced disabilities
1 55.0 years N/A Treatment VAS for pain
measurement
1) Pain in the
upper thoracic
spine, cervical
spine and
shoulder
region
1) Diaphragm’s release
namely pelvic
diaphragm, abdominal
diaphragm, thoracic
outlet release
(caudo-lateral MFR on
bilateral
supraclavicular fossa by
thumb)
2) Hyoid diaphragm
release
10 (2 sessions
per week for
5 weeks)
1) Efcient for
post-mastectomy
lymphedema
[61]
Lagrange
et al. (2019)
France 1) Determine the
impact of visceral
osteopathy on the
incidence of
nausea/vomiting,
constipation, and
overall quality of
life in women who
have undergone
surgery for breast
cancer and
undergoing
adjuvant
chemotherapy
93 57.2 years Patients who
received a
supercial/soft
tissue
manipulation
without action
on deeper chest
wall and
abdominal
structures
Treatment N/A 1) Reduce
nausea and
vomiting
occurring
during
chemotherapy
1) Recisceral
manipulation
consisting of chest wall
and diaphragm muscle
relaxation through
manual thoracic
compression
3 (during the
15 minutes after
the 3 initial
cycles of FEC
100-Taxotere
chemotherapy)
1) Nonefcient for
reducing nausea
and vomiting in
women who have
undergone surgery
for breast cancer
and undergoing
adjuvant
chemotherapy.
2) Efcient for
quality of life
[62]
FEC: Fluoracil, epirubicin, cyclophosphamide; MFR: Myofascial release; N/A: Not applicable; NRS: Numeric Rating Scale; ROM: Range of motion; VAS: Visual analogue scale.
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osteopathic treatments are not efficient in reducing the incidence of nausea/vomiting in patients operated for
breast cancer and undergoing adjuvant chemotherapy. However, breast cancer patients reported that digestive
quality of life was significantly ameliorated through osteopathic intervention.
This ambivalence is also reflected in the literature exploring the effectiveness of osteopathy on improving breast
cancer patients’ reported quality of life. In two studies, treatments did not significantly improve participants’ quality
of life [58,60]. However, the three remaining studies contradict these findings by demonstrating a reported increase
in quality of life [59,61,62]. This lack of consensus demonstrates a gap in the standardization of the application of
osteopathic techniques as, according to these results, they do not all lead to the same outcomes.
Also, the duration of patient exposure to osteopathy treatments is inconsistent (see Table 1). The most extended
treatment periods were 12 weeks with one session per week [60] or 5 weeks with two sessions per week [61]. However,
the average treatment was spread over 4 weeks, with one 45-min session per week [58] or five total sessions separated
by 2–3 weeks [59]. The shortest exposure was 15 min for only three sessions [62]. An exploration of the possible link
between treatment duration and the type of osteopathy treatments applied may best explain these discrepancies.
Osteopathy & breast cancer survivorship
We did not find any studies that reported the outcomes of osteopathic treatments on pain during the breast cancer
survivorship phase. The literature points toward the idea that manual therapy as a treatment for chronic pain is
efficient for breast cancer survivors; however, osteopathy is excluded [52].
Osteopathy in Canada
Currently, the literature on the efficacy of osteopathic treatments during the breast cancer experience has mostly
been produced in European or Asian countries. However, osteopathic practice in Canada may differ from practices
in these areas. For more than 20 years now, Canadian osteopathic communities have been asking for a legislative
regulation as this would allow a more rapid development of the clinical practice; and, as a result, foster relevant
large-scale research ventures.
As stated in the World Health Organization’s Osteopathic Education Framework, the practice of osteopathy
includes two types of pathways: type 1 for those with no prior medical training, and type 2 for health professionals
of varying backgrounds with consideration given to their initial training and prior academic credits [63].Currently,
no school teaching osteopathy in Canada can claim to be recognized by the Ministry of Education or by the
Office des professions du Qu´
ebec (OPQ). These schools are private training initiatives that present heterogeneous
programs, at variable costs, most of which involve learning of osteopathic manipulative techniques (OMT) in the
form of seminars spread over a period of 3 to 7 years [63].
Canadian qualitative case study: osteopathy & breast cancer
To present data on the impact of Canadian osteopathic treatment in breast cancer patients, a patient-partner was
invited to partake in the discussion. Her narrative summary can be found in Box 1.
Qualitative Canadian case study: narrative from a patient-partner.
I am a 44-year-old Canadian woman. My breast cancer experience begins in August 2019, when I faced unusual
breast pain. On 19 December 2019, I was diagnosed with triple-negative invasive ductal carcinoma breast cancer
with a tumor measuring ve centimeters in diameter. These characteristics correspond to an aggressive stage 2
tumor. My treatment plan began in January 2020. In mid-July 2020, I underwent a bilateral mastectomy followed by
immediate reconstruction. Since November 2021, I am in remission.
My initial motives to seek osteopathic treatments were for both physical and psychological reasons. Physically, I
went to the treatments to prevent the pain and fatigue caused by breast cancer treatments. Psychologically, I
sought to regain a feeling of well-being and ease. Following my surgeries, I experienced several symptoms
including scars, scar adhesions, stress, digestive tract issues, and abdominal pain. Personally, osteopathic treatments
reduced the various ailments during chemotherapy.
I had already consulted an osteopath several years before my breast cancer diagnosis partly to treat a head injury
sustained as a child. However, since I did not connect with the osteopath, I did not pursue treatment. During my
breast cancer experience, I sought osteopathic treatment as my own initiative. A friend who is an osteopath living
and working in Ottawa (Canada) gave me a recommendation for an osteopath in Montreal, where I am currently
living. Considering the osteopath’s scientic approach (i.e., she took the time to explain her treatment based on
advances in research instead of using an esoteric speech), I immediately felt at ease with this new osteopath even if
she was not specialized in oncology. In ’normal times’ (before the pandemic), I would meet my osteopath the day
before my chemotherapy treatment. However, I received osteopathic services somewhat more sporadically for the
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Osteopathy & breast cancer: a review Review
remainder of my breast cancer treatments due to COVID-19 connement regulations. I associate osteopathy with a
sense of well-being and relaxation. Indeed, as soon as the treatment is over, I feel pain relief and ease in my body.
Osteopathic treatments awaken a lot of things in me when I need small breaks from traditional treatments and the
overall medicalization of my body. I appreciate these alternative treatments, too, as they are associated with a form
of non-medical yet therapeutic touch.
In my opinion, osteopathy treatments in oncology should be recommended to patients as they have a global and a
targeted effect, and have clearly helped me with the side effects resulting from the chemotherapy and surgeries.
Notably, I would like to emphasize my belief in the effectiveness of traditional oncology medicine, which is why I
maintain that osteopathic treatments should not replace the traditional treatments (i.e., chemotherapy). However,
according to my experience, it is a good complementary treatment to traditional medicine that is efcient in
removing pain and increasing well-being.
Note: Our use of the rst person singular in this section is meant to reect the point of view of the patient-partner (Cappeliez) who
is also a co-author on the paper.
Her experience shows that osteopathy was effective in reducing her physical pain, but also in improving her
psychological well-being. However, she argues that these treatments cannot replace the chemotherapy she received.
We further encourage Canadian osteopathic schools to conduct more qualitative and quantitative studies within
oncology to better understand this phenomenon.
Discussion
The first objective of this study was to report studies that have measured the effectiveness of osteopathy in breast
cancer patients. The review of the literature shows that very few studies have focused on this discipline, which does
not allow clear conclusions on its effectiveness. However, among the five studies found, some are promising. Indeed,
some of them show that complementary osteopathic treatments during breast cancer treatments can either reduce
pain [58,60,61] and/or improve quality of life [59,61,62]. It is important to note that the lack of homogeneity regarding
the effectiveness of osteopathy in reducing pain in breast cancer patients should not hinder future studies to integrate
the discipline into CAM. However, more studies are needed to better understand the factors (e.g., duration of
osteopathic treatment, type of manipulation performed) that reduce pain or improve patients’ quality of life.
The second objective was to present a qualitative case study on the experience of a patient-partner who received
osteopathic treatment in Canada during her breast cancer treatment. The case study presented suggested that
complementary osteopathy treatment was efficient to reduce physical pain caused by breast cancer treatments. Plus,
this complementary treatment enhanced the patients’ well-being, since it was associated with a therapeutic touch
that defers from the medical touch. This finding is consistent with those of a review showing that therapeutic touch
can be used as a non-invasive intervention to improve the health status of cancer patients [64]. More Canadian studies
in osteopathy would allow the development of effective complementary treatments for breast cancer patients.
Clinical implications
First challenge: standardization of norms & procedures in osteopathy
The regulation of osteopathic practice and education, in addition to creation of osteopathic university-based
programs in Quebec, carries the potential to positively improve between-practitioner interactions and increase the
capacity for inter-professional education for incoming practitioners. Currently, there are no specific guidelines for
osteopaths who desire to treat pain associated with the breast cancer trajectory. Our results showed that osteopathic
treatment could be effective in reducing pain [58,61] or improving quality of life [59]; however, it may be relevant to
repeat or build on these studies’ methodology to increase success in osteopathic treatment provided in Canada. In
addition, because breast cancer patients are a more specific clinical population, it would be relevant to promote that
osteopathic practitioners working directly with this population hold a set minimum number of years of osteopathic
experience, as highlighted in the study by Arienti et al. (2018) [58], to ensure the quality of service provided.
The educational programs currently offered in Canada do not provide oncology specialization for osteopaths,
which means that clinicians are developing their skills solely on empirical experience [65]. In addition, the lack
of standardization of CAM disciplines has been shown to reinforce some health professionals’ tendencies to not
explicitly recommend these treatments to their patients [66–68]. In parallel, in the European countries in which the
studies included in this review were conducted [58–62], collaboration between medical and osteopathic teams appears
to be less of an issue, which is promising for professionals in Canada.
Standardization of osteopathic programs and further legislative regulation may offer a better understanding of
this neoplastic disease in relation to osteopathic care and foster a new understanding of mechanisms and clinical
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reasoning through funded research. Several challenges may slow down the regulation of the osteopathic profession
in Quebec, including scopes of practice, scientific evidence, and funding. A public consultation that took place in
May of 2021 in Quebec, initiated by the Minister of Higher Education and Professional Orders, gives hope that,
within a few years, a legislative osteopathic-educational framework may be in place for the province of Quebec [69].
Second challenge: collaboration between osteopaths & traditional healthcare professionals
For a long time, traditional and complementary medicines have been placed in opposite corners. For some traditional
healthcare professionals, this has reinforced and maintained a prejudice against non-traditional medicine [56].In
Canada, the oncology nurse has many roles including assessing the overall health and persistence of side effects
of curative treatments of cancer patients, pain assessment, assisting and facilitating decision-making regarding
treatment options (e.g., traditional treatments, CAM), ensuring continuity of care (during the survivorship period);
and facilitating patient navigation in the system (referring patients to the right resources: osteopath, patient-partner,
psychologist) [68,70]. The present qualitative case study indicated that health professionals in oncology do not
immediately suggest osteopathic treatments. For adverse symptoms such as pain, the recommended service is often
physiotherapy and massage therapy, which are typically covered by insurance [68]. Currently, osteopathic care is
not covered by insurance, making this service more difficult to refer for monetary reasons. Moreover, the lack of
specialization in oncology from osteopaths, attitudes of other professionals toward CAM, and variations in licensure
and certification of CAM practitioners are reasons why CAM is not being offered outright [68]. Osteopathy as a
discipline has been systemically overlooked in nursing education; thus, oncology nurses tend not to demonstrate
the proficient knowledge or understanding necessary to refer cancer patients to an osteopath, indicating a need
for the integration of osteopathic medicine into foundational nursing education [71]. Yet, since osteopaths do not
have guidelines for treating breast cancer patients, nurses are faced with the “dilemma” of referring a patient to a
resource that is not governed by laws and guidelines [68]. These laws and guidelines should be put in place so that
academic institutions can integrate osteopathy into their programs.
In our case study, the patient-partner verbalized that osteopathic treatments have greatly helped with her pain and
well-being. Since the model of health in Canada promotes the reduction of physical and psychological symptoms,
it would be relevant for medical teams to consider all interventions complementary to their care, including
osteopathy [72]. The first osteopathic principle describes the human body as a unit and considers a patient’s mind,
body and spirit throughout care. The idea that the body is a comprehensive unit is vital for providing care to
breast cancer patients [56]. This model acknowledges that the mind influences the body and the body influences
the mind [73]. Taking this into consideration, different osteopathic manipulations such as visceral mobilization,
myofascial release, positioning relaxation, light touch and osteopathic palpation can be tools for improvement of the
balance between the musculoskeletal system and psychological well-being [74] through sensorimotor stimulation [73]
with a smaller effort for the patient. However, osteopathic treatment in the context of oncology is not designed
to be an alternative to traditional oncology treatments, nevertheless it could restore the functional capacity of the
patient to improve their general well-being (physical well-being and psychological well-being) [73].
A Canadian study brought light to specific factors which promote collaboration between osteopaths and tra-
ditional healthcare professionals. These factors include gender (female), profession (family physician), general
knowledge about practice parameters, direct sources of information about osteopathy, belief in the active role
of osteopathy for pediatric conditions, community practice, personal consultation of an osteopath, and having a
professional relationship [75]. To best increase the visibility of the osteopathic discipline, it would be critical to
encourage osteopaths to collaborate with the oncological team when providing treatment to breast cancer patients.
An open and collaborative dialogue will allow a more explicit follow-up of osteopathic procedures that have been
performed.
Third challenge: lack of Canadian osteopathic research
As previously shown in this review, studies on osteopathic treatment during breast cancer are primarily of a European
or Asian context. As such, Canadian osteopathic schools should mobilize their resources to conduct more empirical
studies showing the impact of their treatments in oncology populations. The more that studies of osteopathy are
conducted in a Canadian context, outside of these traditional models, the more it will be possible to target the
osteopathic techniques that are most effective for breast cancer patients [55].
The present literature review points out a lack of consistency in the duration of osteopathic treatments in
oncology, as well as in the techniques performed. Methodological rigor should be put forward in future studies to
10.2217/bmt-2022-0002 Breast Cancer Manag. (2022) BMT63 future science group

Osteopathy & breast cancer: a review Review
encourage the standardization of osteopathic services offered to breast cancer patients. This will help ensure that
their effectiveness does not diverge in excess. Further research evaluating the effectiveness of osteopathic treatments
appears to be needed to help healthcare professionals better intervene in the management of pain in women with
breast cancer. In the same manner, we encourage research in traditional medicine to consider the addition of an
‘alternative medicine’ component in their exploratory variables of their studies. This initiative would not only lower
the barriers between disciplines, but also provide relevant data on the effectiveness or otherwise of osteopathic
treatments. Furthermore, the collaboration between osteopaths and health professionals should not be limited to
the clinic but should be put forward in health research.
Study limitations
This review is not without limitations. The case study presents the narrative of a breast cancer patient for whom
osteopathy was efficient. In this sense, narratives of breast cancer patients for whom osteopathy was not effective
should also be included to get a better representation of the effectiveness of this discipline. Furthermore, because
osteopathic practice is not standardized in Canada, it is important to note that the results obtained from the case
study are only informative for future studies.
Conclusion
In conclusion, this paper aimed to open the discussion on the inclusion of osteopathy in breast cancer patients
as an alternative and complementary treatment. The discipline seems to be heterogeneous across countries, but it
could help reduce physical pain and improve the psychological health of breast cancer patients. The first qualitative
case study about the Canadian experience of osteopathy during breast cancer treatments opens the door for further
research and collaborations. Finally, current issues regarding the formal integration of osteopathy during breast
cancer patients’ hospitalization in Canada were provided by an osteopath, a patient-partner and a nurse in oncology,
which may be interesting avenues to consider in the future.
Future perspective
We encourage future breast cancer research projects to include variables on the use of osteopathic treatment and
its effectiveness. In addition, clinically, it would be important to initiate collaborations to provide inclusive and
quality CAM treatments.
Summary points
•This review aimed to open the discussion on the inclusion of osteopathy in breast cancer patients as
complementary and alternative medicine (CAM) treatment.
•The discipline of osteopathy seems to be heterogeneous across countries, but results show that it could help
reduce physical pain and improve the psychological health of breast cancer patients.
•A total of ve (n =5) studies were found that report on the effectiveness of osteopathic treatments in breast
cancer patients. From this, it was found that the application of osteopathic techniques is not regulated; thus, not
every cancer patient will receive identical osteopathic treatment.
•This rst qualitative case study about the Canadian experience of osteopathy during breast cancer treatments
opens the door for further research and collaborations.
•Through collaborative discussion with the patient-partner, it is suggested that complementary osteopathic
treatment was, in this case, efcient in reducing physical pain caused by breast cancer treatments.
•The case study also suggested that osteopathy treatments enhanced the patient’s well-being, since it was
associated with a therapeutic touch that defers from the medical touch.
•The challenges to include osteopathy in the services offered to breast cancer patients included a lack of
standardization of norms and procedures in osteopathy, minimal collaboration between osteopaths and
traditional healthcare professionals, and lack of Canadian osteopathic research.
•Due to contradictory reported ndings, more studies would be required to make rm conclusions on the
effectiveness of osteopathy in oncological pain management, especially within a Canadian context.
Author contributions
J Fortin: Conceptualization, project administration, methodology, validation, investigation, formal analysis, writing – original draft,
supervision; A Beaupr ´
e: Validation, formal analysis, writing – original draft preparation; LA Thamar Louis & C-A Roy: Visualization,
investigation, writing – original draft; MA Bourque: Validation, writing – reviewing and editing; S Cappeliez: Validation, formal
analysis, writing – reviewing and editing; A Fadhlaoui: Resources, formal analysis, validation, writing – reviewing and editing.
future science group 10.2217/bmt-2022-0002

Review Fortin, Beaupr ´
e, Thamar Louis et al.
Acknowledgments
J Fortin thanks the Fonds de Recherche en Sant ´
eduQu
´
ebec for her scholarship award.
Financial & competing interests disclosure
The authors have no relevant afliations or nancial involvement with any organization or entity with a nancial interest in or nan-
cial conict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria,
stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
No writing assistance was utilized in the production of this manuscript.
Ethical conduct of research
The authors state that they have followed the principles outlined in the Declaration of Helsinki for all human or animal experimental
investigations. In addition, for investigations involving human subjects, informed consent has been obtained from the participants
involved.
Open access
This work is licensed under the Attribution-NonCommercial-NoDerivatives 4.0 Unported License. To view a copy of this license,
visit http://creativecommons.org/licenses/by-nc-nd/4.0/
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