Yoga is an ancient Eastern science that incorporates stress-reduction techniques such as regulated breathing, visual imagery, and meditation, as well as various postures. Hatha yoga is one type of yoga. Yoga has been examined as an intervention for anxiety, depression, chemotherapy-induced nausea and vomiting, hot flashes, cognitive impairment, sleep-wake disturbances, pain, and fatigue in patients with cancer. It has also been examined as an intervention for caregiver strain and burden.
Buffart, L.M., van Uffelen, J. G., Riphagen, I. I., Brug, J., van Mechelen, W., Brown, W. J., & Chinapaw, M. J. (2012). Physical and psychosocial benefits of yoga in cancer patients and survivors, a systematic review and meta-analysis of randomized controlled trials. BMC Cancer, 12, 559.
STUDY PURPOSE: Evaluate effects of yoga on physical and psychosocial symptoms
TYPE OF STUDY: Meta Analysis & Systematic Review
DATABASES USED: AMED, CINAHL, British Nursing Index, CENTRAL, EMBASE, PEDro, psycINFO, PubMed and SPORT-Discus
KEYWORDS: States detailed search profiles available on request
INCLUSION CRITERIA: RCT, adults with any cancer diagnosis, yoga intervention including physical postures, control group non exercise
EXCLUSION CRITERIA: Yoga included as part of a larger intervention such as mindfulness based stress reduction were excluded
TOTAL REFERENCES RETRIEVED : N = 1909
EVALUATION METHOD AND COMMENTS ON LITERATURE USED Study method quality evaluated using a Delphi list previously developed and tested. Low quality defined as <50% of possible total score.
FINAL NUMBER STUDIES INCLUDED; N(studies) = 13
SAMPLE RANGE ACROSS STUDIES, TOTAL PATIENTS INCLUDED IN REVIEW: Range 18-128
KEY SAMPLE CHARACTERISTICS: 12 studies involved breast cancer patients, 1 was in lymphoma
PHASE OF CARE: Multiple phases of care
Physical outcomes: Pain was evaluated in 4 studies, meta analysis of 2 of these showed a large effect size (d=-0.63, 95% CI -0.98, -0.31)
Psychosocial outcomes: Reduced anxiety (d=-0.77; 095% CI -1.08, -0.46) fatigue (d=-.051, 95% CI -0.79,-0.22) Effects on sleep disturbance were small and insignificant.
Dropout rates ranged from 0-38%
Interventions ranged from planned 6 -15 sessions. Some studies involved supervised yoga classes, and some involved home practice only. Studies involved patients in active treatment and others involved cancer survivors who had completed treatment.
Findings suggest that yoga may be helpful to reduce anxiety and fatigue in patients with cancer.
States 3 studies included participant blinding or double blinding – it is unclear how a participant would not know they were receiving a yoga intervention. Varied methods of measurement were used in the studies included – there is no description of how these were handled in meta analysis. There is no report of heterogeneity findings. Most studies were very small sample sizes. There was a wide range of drop -out rates and no information about how this was handled in analysis. Studies did not include attentional control conditions, so it is unclear how much effect was due to group support versus the actual yoga activity. No differentiation was made between group session interventions versus patients who did home practice alone after instruction.
Findings do not provide strong support for effectiveness of yoga for sleep. Findings do suggest that yoga may be helpful for patients to reduce anxiety and fatigue. Nurses can support involvement in this type of activity for patients who are interested in participating in yoga.
Cramer, H., Lange, S., Klose, P., Paul, A., & Dobos, G. (2012). Yoga for breast cancer patients and survivors: A systematic review and meta-analysis. BMC Cancer, 12, 412.
STUDY PURPOSE: To assess the evidence for effects of yoga on quality of life and psychological health in patients with breast cancer and survivors
TYPE OF STUDY: Meta analysis and systematic review
DATABASES USED: Medline, PsycINFO, EMBASE, CAMBASE, and Cochrane Library through 2/2012
KEYWORDS: Yoga, quality of life, mental health, psychological health, anxiety, depressive disorder, stress, distress, and terms for breast cancer
INCLUSION CRITERIA: Randomized controlled trial (RCT) of patients older than 18 with history of breast cancer; assess health-related quality of life (QOL) or well-being; mental, physical, function, social, or spiritual well-being; and/or psychological health
EXCLUSION CRITERIA: Studies that included yoga as part of a larger intervention, such as mindfulness-based stress-reduction, were excluded.
TOTAL REFERENCES RETRIEVED = 156
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used, and study quality was evaluated using Cochrane risk of bias criteria.
PHASE OF CARE: Multiple phases of care
Program length and intensity varied from daily interventions for one week to interventions weekly for six months. Four studies included an attention-control condition. Risk of bias was generally high. Meta-analysis showed moderate short-term effects of yoga on global health-related QOL (SMD = 0.62, p = .04). Large short-term effects were found for anxiety (SMD = -1.51, p < .01), depression (SMD = -1.59, p < .01), and distress (SMD = -0.86, p < .01). None of these effects were maintained at long-term follow-up. There was significant heterogeneity in analysis of all outcomes except for overall mental, social, and spiritual well-being. Analysis showed that significant overall effects were only seen among studies involving yoga during active anticancer treatment.
Yoga may have short-term benefit for patients for overall QOL, anxiety, depression, and general distress; however, these effects do not appear to be maintained. It appears that benefit may be mainly seen during the active treatment phase of care.
Participation in activities such as yoga during treatment may help patients with anxiety, distress, and depression and overall quality of life during active treatment. The optimum frequency and duration of this type of intervention is unclear, and variability and study limitations make showing strong support of this intervention difficult. Yoga has been shown to be safe for patients with cancer; thus, for those patients who are interested in participating in yoga, there does not appear to be any reason to avoid it. Further well-designed research in this area is warranted to continue to explore the most effective timing, duration, and approaches for yoga interventions.
Cramer, H., Lauche, R., Klose, P., Lange, S., Langhorst, J., & Dobos, G.J. (2017). Yoga for improving health-related quality of life, mental health and cancer-related symptoms in women diagnosed with breast cancer. Cochrane Database of Systematic Reviews, 1, CD010802.
STUDY PURPOSE: To assess effects of yoga on health-related quality of life, mental health, and cancer-related symptoms among women with a diagnosis of breast cancer who are receiving active treatment or have completed treatment.
TYPE OF STUDY: Systematic review
DATABASES USED: Cochrane Breast Cancer Specialised Register, MEDLINE (via PubMed), Embase, the Cochrane Central Register of Controlled Trials (2016, Issue 1), Indexing of Indian Medical Journals, World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov
YEARS INCLUDED: (Overall for all databases) did not give date range
INCLUSION CRITERIA: RCTs were eligible if they compared yoga interventions versus no therapy or versus any other active therapy in women with a diagnosis of non-metastatic or metastatic breast cancer, and if they assessed at least one of the primary outcomes on a patient-reported instrument, including depression, anxiety, fatigue, or sleep-disturbances.
EXCLUSION CRITERIA: Duplicates, not including randomized control methodology, no assessment of relevant outcomes.
TOTAL REFERENCES RETRIEVED: 432
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Blinded/duplicated two-stage screening approach to select appropriate articles; critical review and article scoring was independently done by two researchers
FINAL NUMBER STUDIES INCLUDED: 23
TOTAL PATIENTS INCLUDED IN REVIEW: 2,166
SAMPLE RANGE ACROSS STUDIES: Only RCTs included.
KEY SAMPLE CHARACTERISTICS: Sample sizes ranged from 18 to 309, with median of 74.5. Women's mean age ranged from 44 to 62.9 years, with a median of 54 years. All studies included women with non-metastatic breast cancer; one study included women with metastatic disease. Women included were at different stages in both their diagnosis and treatment. Cancer treatment type was varied.
PHASE OF CARE: Not specified or not applicable; details about each study’s participants not specified
APPLICATIONS: Elder care, palliative care
As relevant to these PEP topics, yoga primarily improved health-related quality of life, fatigue, and sleep disturbances. Evidence suggests short-term effects of yoga compared with psychosocial/education interventions on depression, anxiety, and fatigue. During active cancer treatment, yoga improved depression, anxiety, and fatigue compared with no therapy or psychosocial/educational interventions. After therapy, yoga showed effects on health-related quality of life, fatigue, and sleep disturbances. The studies were not robust enough to measure effects of yoga more than five years after diagnosis or in the metastatic breast cancer population.
Evidence supports that yoga can have benefits on health-related quality of life in patients with breast cancer, including a decrease in anxiety, depression, and fatigue. Additional research is needed to assess the effectiveness of yoga more than five years from diagnosis and in the metastatic population.
Yoga has been shown to be an evidence-based intervention which can improve health-related quality of life and symptoms, including depression, anxiety, and fatigue, in women with non-metastatic breast cancer at all stages of treatment, up to five years postdiagnosis.
D'Silva, S., Poscablo, C., Habousha, R., Kogan, M., & Kligler, B. (2012). Mind-body medicine therapies for a range of depression severity: A systematic review. Psychosomatics, 53(5), 407–423.
To perform a systematic review of evidence related to the use of mind-body therapies to address various symptoms of depression
Among studies that included patients with cancer, six studies involved yoga and one examined relaxation and guided imagery. Among the yoga studies, three showed positive results with yoga alone or in combination with other supportive therapies, two showed negative results, and the results of one were equivocal. Relaxation and guided imagery were associated with postive results. Across all studies involving various medical illnesses, 74% associated mind-body therapies with positive results.
Mind-body therapies appear to be effective in reducing symptoms of depression.
The individualized attention provided to patients via mind-body therapies may be beneficial in reducing symptoms of depression.
Danhauer, S.C., Addington, E.L., Sohl, S.J., Chaoul, A., & Cohen, L. (2017). Review of yoga therapy during cancer treatment. Supportive Care in Cancer, 25, 1357–1372.
STUDY PURPOSE: To review results of yoga trials conducted among patients during cancer treatment
TYPE OF STUDY: Systematic review
DATABASES USED: MEDLINE, CINAHL, and PsycINFO through October 2015
INCLUSION CRITERIA: Children or adults undergoing cancer treatment, intervention was yoga or a component of yoga, randomized or non-randomized study
EXCLUSION CRITERIA: Patients receiving only hormone therapy, interventions involving only meditation or yoga, delivered as part of an MBSR intervention
TOTAL REFERENCES RETRIEVED: Not reported
FINAL NUMBER OF STUDIES INCLUDED: 4 studies of children, 22 total studies–13 were RCTs
TOTAL PATIENTS INCLUDED IN REVIEW: 1,046
SAMPLE RANGE ACROSS STUDIES: 4 to 164
KEY SAMPLE CHARACTERISTICS: Varied tumor types–majority were done in women with breast cancer. Treatments include chemotherapy, radiation, surgery and combination of these
PHASE OF CARE: Active anti-tumor treatment
APPLICATIONS: Pediatrics
Doses of yoga ranged from 1 to 18 sessions and frequency ranged from every three weeks to three times per week. Some were delivered as group classes and two included caregivers. Some interventions included psychoeducation and supportive interventions. Some provided instructions and recommendations for practice at home. Attrition rates ranged from 8%-56%. Adherence to planned sessions ranged from 59%-88% and where measured, adherence to home practice ranged from 50%-80%. In non-random studies, improvements in anxiety, depression, mood, cognition, sleep, and fatigue were reported. Several RCTs reported improvement in distress, depression, anxiety, and multiple treatment-related side effects and symptoms.
Evidence suggests that yoga can be helpful to adults undergoing cancer treatment. There is insufficient evidence to draw any conclusions regarding benefit for children.
There is not a lot of strong evidence to show benefits of yoga for various symptoms for patients during cancer treatments due to individual study design limitations. Existing evidence suggests that yoga may be helpful for anxiety, depression, sleep, and cognitive impairment. Further well-designed research to explore these areas is needed. Yoga is a relatively low-risk intervention that may be helpful and could be suggested to patients who are interested and able to participate.
Galliford, M., Robinson, S., Bridge, P., & Carmichael, M. (2017). Salute to the sun: A new dawn in yoga therapy for breast cancer. Journal of Medical Radiation Sciences, 64, 232–238.
STUDY PURPOSE: To synthesize published research to assess if yoga improves physical and psychosocial quality of life in patients receiving treatment for breast cancer.
TYPE OF STUDY: Systematic review
DATABASES USED: Scopus, Medline, PubMed, Science Direct, Cochrane, ProQuest
YEARS INCLUDED: (Overall for all databases) January 2009 to July 2014
INCLUSION CRITERIA: Articles with a yoga or mindfulness-based stress reduction (MBSR) intervention that reported outcomes related to physical or psychosocial quality of life in patients with breast cancer; studies with 15 or more participants were included.
EXCLUSION CRITERIA: Articles that were duplicate, inaccessible, or with irrelevant records.
TOTAL REFERENCES RETRIEVED: 395
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Blinded/duplicated two-stage screening approach to select appropriate articles; critical review and article scoring was independently done by two researchers
FINAL NUMBER STUDIES INCLUDED: 38
TOTAL PATIENTS INCLUDED IN REVIEW: Not reported
SAMPLE RANGE ACROSS STUDIES: RCTs: 18 to 410; NRTs: 15 to 286; otherwise not noted
KEY SAMPLE CHARACTERISTICS: RCTs: average age was 58.3 years; NRTs: average age was 50.3 years; all participants in all studies were women except for nine men included in one study; all studies look at patients with breast cancer though further details were not specified (exact phase/type of treatment, etc.)
PHASE OF CARE: Not specified or not applicable; details about each study’s participants not specified
As relevant to this PEP topic: 60% (3 of 5) studies that examined anxiety supported decreased general anxiety among patients who participated in yoga therapy. The other two large studies also showed less anxiety in this population, although it was divided into state and trait anxiety. A decrease in depression and depressive symptoms was reported in all of the studies reviewed that looked at psychosocial benefits related to yoga, which supports other meta-analyses stating that adding yoga therapy to traditional breast cancer treatment can decrease depression in these patients.
Evidence supports that yoga can have benefits on both physical and psychosocial quality of life in patients with breast cancer, including a decrease in both anxiety and depression. Additional research should aim to assess long-term effects of yoga in this population.
Yoga is an evidence-based intervention that may reduce anxiety and depression in patients with cancer. Recommending yoga to patients with breast cancer undergoing active treatment may be beneficial, particularly for those with high levels of anxiety and/or depression.
Harder, H., Parlour, L., & Jenkins, V. (2012). Randomised controlled trials of yoga interventions for women with breast cancer: A systematic literature review. Supportive Care in Cancer, 20, 3055-3064.
STUDY PURPOSE: To examine physical and psychological benefits of yoga interventions in women with breast cancer
TYPE OF STUDY: Systematic Review
DATABASES USED: MEDLINE, PsychINFO, the Cochrane Library, Embase, CINAHL, AMED, Web of Science, and Scopus
KEYWORDS: Yoga, breast cancer, and breast neoplasm
INCLUSION CRITERIA: Yoga intervention; women with breast cancer; a randomized controlled trial design (RCT); the studies were original full reports; and the studies were published in peer-reviewed journals.
EXCLUSION CRITERIA: Studies that investigated complementary and alternative medicines or exercise interventions; conference abstracts
TOTAL REFERENCES RETRIEVED: Eighteen RCTs met the inclusion criteria out of 274 initial data. The 274 initial articles returned were reduced to 132 after duplicates were removed. Further reductions occurred due to multiple publications of the same data or the same outcome measures; same studies or continuation of same studies also were removed from review.
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Physiotherapy Evidence Database (PEDro Scale) was used to rate methodological quality of RCTs. It is a 10-item scoring system that evaluates internal validity (random allocation; concealment of allocation; similarity of groups at baseline; blinding of participants, therapists, and assessors; adequate follow-up and undertaking an intention-to-treat analysis) and statistical information. A total score below 4 was considered to be of “poor” methodological quality; between 4 and 5 was considered to be of “fair” quality; 6 to 8 was considered to be of “good” quality; and 9 or 10 was considered to be of “excellent” quality. Two reviewers independently rated each study.
PHASE OF CARE: Active antitumor treatment and transition phase after active treatment. Twelve studies were conducted during treatment; six were conducted post-treatment (two months to six years); two were conducted during mixed time periods during and after treatment (mean time since diagnosis or treatment = 1.7–6.5 years).
APPLICATIONS: Elder care and palliative care
This review does not specifically focus on depression and anxiety. Only studies with patients with breast cancer were included for this review. Thus, only several studies with depression or anxiety as outcome variables were included in the final review. None of the studies were found to have excellent design (e.g., small sample size and lack of long-term follow-up).
The intervention may be beneficial, yet its specific effect on depression and anxiety should be further examined. Also, the intense, duration, and practical issues (e.g., who provided the intervention, who paid the cost) should be considered. Nurses can conduct large-sample, long-term studies of the efficacy of yoga using instruments that measure change scores and calculating sufficient power to detect group differences.
Sharma, M., Haider, T., & Knowlden, A.P. (2013). Yoga as an alternative and complementary treatment for cancer: A systematic review. Journal of Alternative and Complementary Medicine, 19, 870-875.
STUDY PURPOSE: To determine the efficacy of yoga as a treatment option in cancer
TYPE OF STUDY: Systematic review
DATABASES USED: CINAHL, MEDLINE, and Alt Healthwatch
KEYWORDS: Yoga and cancer and intervention or program
INCLUSION CRITERIA: Quantitative design; measured anxiety, depression, sleep disturbance, pain, quality of life, and/or stress as an outcome; published since 2010; English language; included any form of yoga as part of or the entire treatment of cancer
EXCLUSION CRITERIA: Not quantitative design
TOTAL REFERENCES RETRIEVED: N = 135
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: No specific method of evaluating study quality is reported.
PHASE OF CARE: Multiple phases of care
APPLICATIONS: Pediatrics
Of four studies examining effect on anxiety, two showed no effect and two showed a significant positive effect. One of these was a positive effect on parents. Two studies showed a positive effect for fatigue, and one showed no effect for fatigue. There were no effects seen for depression. One study showed a positive effect for sleep, and one showed no effect for sleep. One study of 18 breast cancer survivors showed a postitive effect for fatigue immediately after the intervention. Six of the studies used a randomized controlled trial (RCT) design. Duration and dosing of the yoga intervention varied substantially across studies. All of the studies used an instructor for the duration of the intervention. Methods of measurement used varied.
Insufficient evidence exists to draw firm conclusions about yoga’s role and effect in cancer treatment.
There were few studies, and most had very small sample sizes. No information regarding the quality of the studies was included, other than general design, as this included both RCTs and quasiexperimental studies.
There is limited evidence regarding the effects of yoga as a complementary approach in cancer treatment.
Zhang, J., Yang, K.H., Tian, J.H., & Wang, C.M. (2012). Effects of yoga on psychologic function and quality of life in women with breast cancer: A meta-analysis of randomized controlled trials. Journal of Alternative and Complementary Medicine, 18, 994-1002.
STUDY PURPOSE: To evaluate the effects of yoga in women with breast cancer
TYPE OF STUDY: Meta-analysis and systematic review
DATABASES USED: PubMed, EMBASE, Cochrane Library, Chinese Biomedical Literature Database, and Chinese Digital Journals Database
KEYWORDS: Yoga or asana and breast cancer, and additional breast cancer terms
INCLUSION CRITERIA: Randomized controlled trial (RCT) comparing yoga or yoga-based intervention with a control group
EXCLUSION CRITERIA: Studies that included yoga as part of a larger intervention
TOTAL REFERENCES RETRIEVED: N = 86
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Cochrane handbook was used for evaluation of methodological quality. Randomization was unclear in all but one study, and only one study blinded investigators. Three studies did not report complete outcome data, and dropouts were substantial percentages of the sample in all studies
Anxiety was measured in two studies, and meta-analysis showed no significant effect. Depression was measured in two studies, and meta-analysis showed no significant effect of yoga on depression. Fatigue was examined in five studies with no significant effect shown in meta-analysis. Sleep was measured in two studies with no significant effect shown in meta-analysis. Overall, quality of life was the only outcome measure in which a significant effect was seen from meta-analysis (SMD = 0.27, p = .03).
Insufficient evidence exists to advocate for the use of yoga in patients with breast cancer. No significant effects were seen related to anxiety, depression, sleep disturbance, or fatigue in these patients.
A small number of studies were included, and all had methodological limitations. Yoga interventions differed and varied in frequency and duration.
Insufficient evidence exists to show a benefit of yoga for women with breast cancer. High quality research is needed to evaluate the effects of yoga for symptom management.
Amritanshu, R.R., Rao, R.M., Nagaratna, R., Veldore, V.H., Usha Rani, M.U., Gopinath, K.S., & Ajaikumar, B.S. (2017). Effect of long-term yoga practice on psychological outcomes in breast cancer survivors. Indian Journal of Palliative Care, 23, 231–236.
To evaluate differences in psychological states between breast cancer survivors who do practice yoga and those who do not
This case-control exploratory study consisted of two groups. The first was breast cancer survivors doing regular yoga (more than six months of regular yoga practice in the last year), and the second was women who had no prior yoga experience (or less than three yoga sessions in the last year). Yoga experience was self-reported by the participants, including their regular yoga schedule. No changes to their yoga practice or schedule were made by the researchers.
PHASE OF CARE: Late effects and survivorship
Case-control exploratory study
Perceived stress scale, Spielberg’s state and trait anxiety questionnaire, Beck’s depression inventory, General Health Questionnaire, WHO QOL Questionnaire-BREF
Analysis revealed significantly decreased anxiety, depression, and stress in the group that participated in yoga (p < 0.001). This group also reported better general health and overall quality of life (p < 0.001). Higher income predicted lower anxiety and depression scores, while better reported sleep quality predicted lower stress and depression scores as well.
This study supports yoga as an intervention to decrease anxiety, depression, and stress in breast cancer survivors.
Yoga is an evidence-based intervention that may reduce anxiety and depression in patients with cancer. Although this study only examined breast cancer survivors, discussing yoga as a method to decrease anxiety and depression may be an appropriate option for many patients with cancer.
Bower, J. E., Garet, D., Sternlieb, B., Ganz, P. A., Irwin, M. R., Olmstead, R., & Greendale, G. (2012). Yoga for persistent fatigue in breast cancer survivors: a randomized controlled trial. Cancer, 118, 3766–3775.
To examine, relative to a health education control, the feasibility and efficacy of an Iyengar yoga intervention for breast cancer survivors with persistent posttreatment fatigue.
Outcome assessors of the performance tasks were blinded to group assignment. The intervention was briefly but fully described, and then participants were randomly assigned to a group that received a 12-week, Iyengar-based yoga intervention or a group that received 12 weeks of a health education (control group).
The study was a randomized, controlled trial.
Relative to the control group, fatigue severity in the intervention group declined significantly (p = 0.032) from baseline to posttreatment and over the three-month follow-up. In addition, relative to the control group, the yoga group had significant (p = 0.011) increases in vigor. Both groups had positive changes in symptoms of depression and perceived stress (p < 0.05). The authors noted no significant changes in sleep or physical performance.
One adverse protocol-related event occurred: a participant with a history of back problems experienced a back spasm in yoga class. After evaluation by her physician, she returned to class.
A targeted yoga intervention led to a significant reduction in fatigue and improvement in vigor among breast cancer survivors with persistent fatigue symptoms. This conclusion should be understood in the context of the study: participants were relatively healthy and without comorbid conditions found in the general population.
This study offered minimal conclusive data in support of the intervention. Preliminary findings indicated that the yoga intervention is feasible and safe and has a positive effect on fatigue. A larger trial that includes participants with common comorbid conditions—a study more representative of the general population of women with breast cancer posttreatment—is warranted. Secondary outcomes included vigor, symptoms of depression, sleep, perceived stress, and physical performance.
Cramer, H., Pokhrel, B., Fester, C., Meier, B., Gass, F., Lauche, R., . . . Langhorst, J. (2015). A randomized controlled bicenter trial of yoga for patients with colorectal cancer. Psycho-Oncology, 25, 412–420.
To evaluate the effects of yoga on quality of life, anxiety, depression, and sleep in patients with colorectal cancer.
At week 10, the yoga group had greater decline in anxiety (p = 0.043) and depression (p = 0.038) scores, but, at week 22, there was no difference between groups. At week 10, there were no differences between groups in PSQI scores, however, at week 22, those in the yoga group had better sleep quality (p = 0.043). There was no relationship between home practice time and outcomes. Only about half attended yoga sessions, and average home practice was about one hour per week. There were no significant differences between groups in overall quality of life scores.
Yoga may be helpful to some patients to reduce sleep disturbances.
These results did not show meaningful impact of yoga on anxiety or depression. Yoga was beneficial in terms of improving sleep, although changes seen were small, and findings are limited due to study limitations. Further research in the potential role of yoga for sleep improvement is needed.
Dhruva, A., Miaskowski, C., Abrams, D., Acree, M., Cooper, B., Goodman, S., & Hecht, F. M. (2012). Yoga breathing for cancer chemotherapy-associated symptoms and quality of life: results of a pilot randomized controlled trial. Journal of Alternative and Complementary Medicine, 18, 473–479.
To assess the feasibility and effects of pranayama (regulation and expansion of breath) among patients receiving chemotherapy. To test the efficacy of pranayama in alleviating common chemotherapy-associated symptoms (fatigue, sleep disturbance, stress, anxiety, and depression) and improving quality of life (QOL). To evaluate patients' responses to the use of pranayama in alleviating common chemotherapy-associated symptoms affecting QOL.
Participants were randomized 1:1 in blocks of four. The allocation sequence was generated by the study statistician and then transferred to sealed numbered envelopes. The study staff enrolled participants and implemented the allocation sequence, which was concealed from the study staff until study assignment. Blinding of participants was impossible due to the intervention, which consisted of a 60-minute class once per week taught by yoga instructors and twice daily home practice that totaled 20 to 30 minutes per day, along with usual care during two cycles of chemotherapy. The control group received only usual care during the initial cycle of chemotherapy, and the pranayama intervention along with usual care during the second cycle of chemotherapy.
Patients were undergoing the active treatment phase of care.
The study was a randomized, controlled trial.
Sixteen of 18 participants completed all study measures: eight from the control group and eight from the treatment group. The study intervention had no adverse effects. Increased yoga practice was associated with statistically significant reductions in sleep disturbance (p = 0.04) and anxiety (p = 0.04). The mental component of QOL approached statistical significance (p = 0.05).
This was the first study of a pure pranayama intervention for patients with cancer, and it demonstrated that yoga breathing is a feasible and safe intervention for this patient population. Any increase in the yoga breathing practice correlated with improvements of chemotherapy-associated symptoms and QOL. Researchers should confirm these findings by means of a larger study.
Among patients with cancer who are undergoing chemotherapy, pranayama breathing techniques may help decrease sleep disturbance and anxiety and increase the mental component of QOL. Pranayama breathing, supplemented with reminders during and between treatments, seems to be an intervention that is feasible for this group of patients.
Kiecolt-Glaser, J.K., Bennett, J.M., Andridge, R., Peng, J., Shapiro, C.L., Malarkey, W.B., . . . Glaser, R. (2014). Yoga’s impact on inflammation, mood, and fatigue in breast cancer survivors: A randomized controlled trial. Journal of Clinical Oncology. Advance online publication.
To assess the effects of yoga on inflammation, mood, and fatigue and to test the hypothesis that yoga would decrease inflammation, depressive symptoms, and fatigue in breast cancer survivors
Women were randomly assigned to the intervention group or a wait-list control group. The intervention consisted of two 90-minute Hatha yoga sessions per week for 12 weeks delivered in a group setting. Sessions were audiotaped, and 50% were randomly assessed for differences from predetermined poses to assess fidelity of the intervention. Yoga teachers called anyone who missed a class. Home practice was encouraged, and all practice times were recorded by participants in weekly logs. Data were collected at baseline, immediately after the intervention, and after three months post-treatment.
Single-blinded, randomized, controlled trial
Patients attended a median of 79% of yoga classes and reported an average of 24.69 minutes of practice per day at home and in class over 12 weeks. Immediately after the intervention, there were no differences between the groups in fatigue; however, in the yoga group, fatigue was significantly lower at three months (Cohen’s d = -0.36, p = 0.002). Vitality in the yoga group was significantly higher immediately post-treatment and at three months (p = 0.01). There were no differences between the groups in depressive symptoms. Immediately postintervention, there were no differences between groups in cytokine levels; however, at three months, the yoga group had significantly lower cytokine levels compared to the control group (p < 0.05). Yoga participants reported improved sleep compared to patients in the control group (p = 0.03).
Yoga was associated with reduced fatigue, increased vitality, improved sleep, and reduced cytokine levels. Yoga did not appear to have an effect on depressive symptoms in this study.
The findings of this study demonstrated that yoga practice was effective in reducing fatigue and improving vitality and sleep in this patient population. Nurses can suggest that patients become involved in yoga practice as a way to manage fatigue and sleep disturbance. These findings also suggest that yoga can have an impact on subclinical inflammation, which may be a mechanism that fuels fatigue and the decline of physical function.
Kligler, B., Homel, P., Harrison, L. B., Sackett, E., Levenson, H., Kenney, J., . . . Merrell, W. (2011). Impact of the Urban Zen Initiative on patients' experience of admission to an inpatient oncology floor: a mixed-methods analysis. Journal of Alternative and Complementary Medicine, 17, 729–734.
To evaluate the impact of the Urban Zen Initiative (UZI) on quantitative and qualitative measures of the experiences of patients admitted for inpatient oncology care.
The UZI model consists of five focus points: the physical space surrounding patients, holistic nursing techniques, yoga with trained therapists, a navigator for patients, and audiovisual yoga materials at the bedside. All patients received the intervention; therefore, the investigators collected preintervention information about patients who were receiving standard care prior to the UZI intervention. Preintervention data were the basis of the control comparison. The investigators measured the outcomes immediately after admission and immediately before discharge.
Patients were undergoing the active treatment phase of care.
The study used a quasiexperimental design with historical control groups.
UZI may improve components of mood in an inpatient oncology setting. More work is needed to assess the real impact.
Providing a multifaceted healing environment, such as the UZI, within inpatient oncology settings could improve mood and perceived health status in patients with cancer. To facilitate the care process, nurses should assess patients' physical spaces; promote relaxation techniques, such as yoga breathing; and support patients.
Milbury, K., Chaoul, A., Engle, R., Liao, Z., Yang, C., Carmack, C., . . . Cohen, L. (2014). Couple-based Tibetan yoga program for lung cancer patients and their caregivers. Psycho-Oncology, 24, 117–120.
To examine the feasibility and preliminary efficacy of Tibetan yoga practice as a supportive approach for patients and caregiver dyads during radiation therapy for lung cancer
Participants had two to three weekly sessions of yoga for 45–60 minutes over five to six weeks. The program included deep breathing awareness and visualization, guided meditation, compassion-based meditation, and gentle movements coordinated with specific breathing patterns. Patients and caregivers completed study measures at baseline and at the end of the program.
Single-group, prospective pilot study
Ten of 19 consenting dyads completed the study and attended a mean of 12 sessions (range = 6–15). For patients, there was a significant increase in spiritual well-being (d = 1.12, p = .03), improvement in sleep (d = .60), and depressive symptoms (d = .52). There were small effects for anxiety. For caregivers, there were significant decreases in fatigue (d = .89, p = .03) and anxiety (d = .81, p =.04) and some reduction in sleep disturbance (d = .71, p =.08). Class attendance and home practice frequency was not associated with differences seen in symptoms for either patients or caregivers.
A couple-based yoga program was seen as feasible for patients, including those with advanced disease. Medium effect sizes were seen for depressive symptoms and sleep disturbance.
Couple-based yoga sessions were shown to be feasible, and findings suggest that this type of supportive care during radiation therapy may be beneficial in some patients and caregivers for symptoms of fatigue, anxiety, depression, and sleep disturbances. The high drop-out rate suggests that many patients may not be interested or able to participate in such a program, but for those who are interested, it may be helpful. The fact, however, that the number of sessions attended and frequency of home practice were not related to the magnitude of results seen causes one to question whether it was the yoga practice or general support and attention provided that caused effects.
Rao, R.M., Raghuram, N., Nagendra, H.R., Usharani, M.R., Gopinath, K.S., Diwakar, R.B., . . . Rao, N. (2015). Effects of an integrated yoga program on self-reported depression scores in breast cancer patients undergoing conventional treatment: A randomized controlled trial. Indian Journal of Palliative Care, 21, 174–181.
To evaluate the effects of a yoga program versus supportive care on symptoms of depression among women with breast cancer during treatment
Patients were randomized to the yoga program or a control supportive therapy program. Yoga included education, breathing exercises, meditation, and relaxation techniques with imagery. Subjects were provided with audiotapes of the practices for use at home. Home practice was monitored via telephone calls, weekly home visits, and a daily patient log. Subjects were to practice at home for at least one hour three times per week. The comparison group used supportive, expressive therapy and education provided by therapists in an unstructured approach aimed at addressing fears and concerns and improving support from others among other issues. The intervention took place over a 24-week period including the time of surgery and following adjuvant chemotherapy or radiotherapy. There were four to six study assessments, depending on the treatment, that were scheduled pre- and postsurgery and mid- and postradiation or chemotherapy. Interventions were done on an individual basis.
Single, blinded, randomized, controlled trial
Both groups reported decreased depression over time. An analysis of covariance showed a larger decrease in depression at all time points measured in the yoga group (p < 0.01). The study sample was appropriate according to the authors' power analysis. Depression scores were directly and strongly correlated (ranged from 0.49–0.77, p < 0.001) with symptom distress scores.
Yoga was shown to be beneficial in reducing symptoms of depression among women with breast cancer during the trajectory of active treatment. Depression was strongly related to symptom scores.
The findings of this study suggest that yoga is beneficial to women with breast cancer during active treatment to manage depressive symptoms. They also show that adverse symptoms were strongly related to depression, and depression was higher with more severe adverse symptoms. This points to the importance of effective symptom management as part of the overall reduction of depression.
Taso, C.J., Lin, H.S., Lin, W.L., Chen, S.M., Huang, W.T., & Chen, S.W. (2014). The effect of yoga exercise on improving depression, anxiety, and fatigue in women with breast cancer: A randomized controlled trial. The Journal of Nursing Research, 22, 155–164.
To examine the effectiveness of an eight-week yoga program on depression, anxiety, and fatigue in women undergoing adjuvant chemotherapy for breast cancer
Patients were randomized to yoga and control groups. Control group patients received usual care and maintained ordinary daily activity routines. The yoga group had 60-minute sessions including meditation and breathing exercise, yoga exercises, and a cool-down. The program was provided twice per week over eight weeks. Study measures were obtained at baseline, at week 4, at week 8, and at four weeks after the conclusion of the intervention. It is not clear if yoga sessions were provided in a group setting or what the timing was related to chemotherapy treatments.
Randomized, controlled trial
Fatigue level and its influence on daily life were lower in the experimental group after eight weeks, which was maintained at three weeks postintervention (p < .001). In the control group, the fatigue level increased after eight weeks (p < .001). In the control group, the influence of fatigue on daily life initially declined but increased from baseline after eight weeks. In those participants with higher baseline fatigue levels, in the first four weeks, benefits were fewer in the experimental group. There were no differences between groups in anxiety or depression. Participation in the yoga sessions was 90% overall.
Yoga participation was associated with improvement in fatigue and the influence of fatigue on daily activities after four weeks. Yoga had no effect on measures of anxiety or depression.
Yoga can be beneficial for patients to reduce fatigue during active treatment as shown in this study. Findings that those with higher fatigue scores did not show fatigue reduction until after four weeks suggest that patients with greater fatigue may need a longer program than others to derive full benefits. There was no apparent effect of participation in yoga sessions on anxiety or depression.
Greenlee, H., Balneaves, L.G., Carlson, L.E., Cohen, M., Deng, G., Hershman, D., . . . Society for Integrative Oncology. (2014). Clinical practice guidelines on the use of integrative therapies as supportive care in patients treated for breast cancer. Journal of the National Cancer Institute.Monographs, 2014, 346–358.
4,900 references were identified that were published between January 1, 1990 and December 31, 2013. 203 articles were included in the final review although only 174 were referenced. Grades used and reported here were A: recommended, high certainty of benefit, B: recommended, high certainty of moderate to substantial benefit, D: recommends against use, moderate to high certainty of no net benefit, and H: recommends against use, moderate to high certainty that harms outweigh benefits.
Interventions for specific symptoms that had strong recommendations for or against use were:
It appears that only specific types of interventions were included, and there are numerous types of integrative or complementary interventions that were not considered in this review. The findings considered were limited to women with breast cancer. Quality rating of evidence was not discussed individually.
These guidelines provided an evidence-based evaluation of various integrative therapies in women with breast cancer. This set of interventions is not all-inclusive; however, it does provide some guidance to clinicians and others regarding evidence strength in these areas as assessed by this specific study group.