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.
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.
Banerjee, B., Vadiraj, H.S., Ram, A., Rao, R., Jayapal, M., Gopinath, K.S., . . . Hande, M.P. (2007). Effects of an integrated yoga program in modulating psychosocial stress and radiation-induced genotoxic stress in breast cancer patients undergoing radiotherapy. Integrative Cancer Therapies, 6, 242–250.
The yoga intervention was a 90-minute, six-week course taught by expert yoga trainers. The course included meditative practices, various postures, guided imagery of cancer cells, positive thought provocation, chanting of various sounds according to the respective patient’s religious beliefs, awareness practices, deep relaxation, and soothing sound vibrations. Control group patients were given supportive counseling and advised to take light exercise.
Three centers in India
A randomized controlled trial design was used.
There was significant decrease in anxiety levels in the yoga intervention group (repeated measures ANCOVA, p < 0.001). Yoga intervention decreased anxiety in women with breast cancer receiving radiation therapy.
Cohen, L., Warneke, C., Foulacli, R.T., Rodriguez, M.A., & Chaoul-Reich, A. (2004). Psychological adjustment and sleep quality in a randomized trial of the effects of a Tibetan yoga intervention in patients with lymphoma. Cancer, 100, 2253–2260.
Yoga intervention was a seven-week Tibetan yoga (TY) program provided to patients with lymphoma who were undergoing active treatment or who had concluded treatments within the past 12 months. The TY intervention consisted of stress-reduction techniques, including:
TY classes were conducted by an experienced TY instructor. After each class, participants were given an audiotape that walked them through all of the techniques. They were encouraged to practice the techniques at least once per day.
Patient characteristics used for group assignment were the type of cancer (Hodgkin or non-Hodgkin lymphoma), the status of treatment (active treatment or completed), gender, age, and baseline state anxiety scores. The allocation process was concealed from investigators. Patients were randomized and notified of their group assignment by telephone. Three separate cohorts of patients were assigned to either the TY group (n = 20) or the wait group (n = 19). The wait group was offered the program three months after the last follow-up assessment was completed. (One participant dropped out of study before attending any classes; therefore, 19 were evaluated.)
Measures were taken at baseline, one week, one month, and three months after the last session.
The study reported on 39 patients with lymphoma.
A randomized controlled trial design was used.
There were no statistical differences between groups on the measures of psychological adjustment (intrusion or avoidance, state anxiety and depression) and fatigue. However, the TY program reduced patients’ sleep disturbances (p < 0.004).
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.
Gregoire, C., Bragard, I., Jerusalem, G., Etienne, A.M., Coucke, P., Dupuis, G., . . . Faymonville, M.E. (2017). Group interventions to reduce emotional distress and fatigue in breast cancer patients: A 9-month follow-up pragmatic trial. British Journal of Cancer, 117, 1442–1449.
To determine the long-term (nine months) effectiveness of three different group interventions compared to usual care for patients with breast cancer
Participants were allowed to select one of three groups to receive either cognitive behavioral therapy, yoga, and self-hypnosis. People who declined to participate were in a control group. Measurements were taken T0 through T3 to include before and after the short-term interventions, at month 3, and at month 9 follow-up.
PHASE OF CARE: Multiple phases of care
Three group intervention self-selection; testing at T0, T1, T2 (month 3), T3 (month 9)
Demographics; medical history; Hospital Anxiety Depression Scale (anxiety and depression emotional distress); Quality of Life 30-item questionnaire (fatigue); Insomnia Severity Index (sleep quality)
Only results from baseline (T0) and the month 9 follow-up (T3) were reported using MANOVA with repeated analysis and post-hoc analysis.
Post-hoc comparisons of time T0-T1: hypnosis group showed significant decreases in anxiety (p = 0.000), depression (p = 0.004), and fatigue (p = 0.045). Yoga group showed significant decrease in anxiety (p = 0.01).
Post-hoc comparisons of time at T3: hypnosis group showed decreases in anxiety (p = 0.000), depression (p = 0.000), and fatigue (p = 0.002); yoga group showed decrease in anxiety (p = 0.024).
Self-hypnosis led to improvements in anxiety, depression, and fatigue. Anxiety improved in the yoga group. There were no improvements in the CBT or control groups.
Two of the three interventions may be helpful in reducing anxiety, depression, or fatigue when measured at nine months. Self-hypnosis may help patients improve emotional distress such as depression and anxiety, and may also reduce fatigue; yoga may also help improve anxiety. Larger samples and longer follow-up studies are needed.
Lundt, A., & Jentschke, E. (2019). Long-term changes of symptoms of anxiety, depression, and fatigue in cancer patients 6 months after the end of yoga therapy. Integrative Cancer Therapies, 18, 1534735418822096.
To examine the long-term changes of anxiety, depression, and fatigue in patients with cancer six months after a yoga intervention
Gentle hatha yoga provided to the participants in small groups under supervision and guidance. 60 minutes once a week for 8 weeks total. Participants also received a CD and a printed manual to motivate training at home.
PHASE OF CARE: Active anti-tumor treatment
Prospective observational one group pre-/post-test design
Self-reported Generalized Anxiety Disorder Scale (GAD-7) to measure anxiety, Patient Health Questionnaire (PHQ-2) to measure depression, European Organization for Research and Treatment of Cancer QOL (EORTC) Questionnaire-Fatigue scale to measure fatigue
There was a statistically significant reduction in the anxiety, depression, and fatigue levels after six months from the baseline. A small time effect on anxiety (SES = 0.22, CI [-0.3, 0.47]) and fatigue (SES = 0.27, CI [-0.11, 0.13]) indicating slight nonsignificant increase of symptoms. No time effect found in terms of depression (SES = 0.01, CI = [-0.11, 0.13]).
Although the study shows reduction in outcomes, studies with larger sample sizes with better study designs (i.e., RCT) are needed to confirm the findings.
Yoga appears to have some benefit in reducing the symptoms of anxiety, depression, and fatigue, and the benefits may be lasting. Additional research with randomized studies will be important to confirm these results.
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, M.R., Raghuram, N., Nagendra, H.R., Gopinath, K.S., Srinath, B.S., Diwakar, R.B., . . . Varambally, S. (2009). Anxiolytic effects of a yoga program in early breast cancer patients undergoing conventional treatment: A randomized controlled trial. Complementary Therapies in Medicine, 17(1), 1–8.
To compare effects of a 24-week yoga program with those of a supportive therapy control intervention in patients with early breast cancer
Prior to surgery, patients were assessed and randomly assigned to the yoga program intervention or control condition. All patients received 50 cGy of radiation therapy over six weeks and were prescribed six cycles of standard chemotherapy with the same schedule. Patients in both groups received alpraxolam 0.5 mg once daily for one week following chemotherapy for the first one to two chemotherapy cycles. Patients in the yoga group had four in-person sessions during the perioperative period and were to undergo three in-person sessions per week for six weeks during radiotherapy treatment, with self-practice on the remaining days. During chemotherapy, patients had in-person sessions during visits (one per 21 days) and in-person sessions with a trainer every 10 days. The instructor monitored self-practice through telephone calls and house visits. The control intervention was brief supportive therapy with education, including 15-minute counseling sessions every 10 days during treatment by a social worker. All patients were asked to maintain daily diaries of symptoms, medication, and diet intake, and for those in the yoga group, their frequency and duration of yoga practice.
Patients were undergoing the active treatment phase of care.
A randomized controlled trial design was used.
Sixty-one percent of patients initially randomized dropped out of the study. Approximately half of these patients decided to leave the study after initial surgery, and the rest of the dropouts were removed from the study because they did not end up receiving the same expected adjuvant treatment sequence. Anxiety declined over time in all patients, and overall ANOVA did not show a significant group and time effect. Post hoc analysis showed that the yoga group had significantly lower anxiety immediately postsurgery and midway through radiation therapy (p < 0.05) and midway through chemotherapy (p < 0.001). Analysis of overall symptom distress showed a significant effect of the yoga group over time for reduction in symptom distress (p = 0.001). Post hoc testing showed a significant decrease in trait anxiety in the yoga group compared to controls at several time points in the study (p < 0.01). The effect size for state anxiety was 0.33. Anxiety and symptom distress were strongly correlated at all phases of treatment, with r ranging from 0.49 to 0.73 (p < 0.05).
Anxiety decreased over time in all patients. The yoga intervention was associated with a significantly greater reduction in anxiety at several time points in the treatment schedule, immediately following surgery, midway through radiation therapy, and midway through chemotherapy.
Yoga as provided in this study, with individual instructor-directed sessions and patient self-guided practice expectations, had a mild effect in reducing anxiety over time during various phases of cancer treatment. Guided sessions were done at scheduled visits for treatment, suggesting that this can be a practical way to facilitate patient participation. Patients may find yoga helpful to reduce stress and anxiety.
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.
Ülger, O., & Yagli, N.V. (2010). Effects of yoga on the quality of life in cancer patients. Complementary Therapies in Clinical Practice, 16, 60–63.
To investigate the effects of yoga on patients with breast cancer to help them cope with the treatment process and reduce social isolation
Patients were given eight sessions of classical yoga twice a week in a physical therapy department. Each session lasted one hour, including warm up and breathing exercises, asanas, relaxation, and medication. Study data were collected before and after treatment. All sessions were taught by one yoga physiotherapist, and all assessments were done by another yoga teacher.
Patients were undergoing the transition phase of care after initial treatment.
A prospective trial with a pre/post-test design was used.
State and trait anxiety significantly declined from baseline after the yoga intervention (p = 0.001). All NHP parameters improved after the yoga sessions, including energy level, pain, sleep, emotional level, social adaptation, and physical skills.
Participation in yoga sessions was associated with reduced anxiety and improved quality-of-life scores after initial cancer treatment in these patients with breast cancer.
Findings suggest that yoga may be helpful for patients with cancer to reduce stress and improve overall fitness and ability to relax.
Vadiraja, H.S., Raghavendra, R.M., Nagarathna, R., Nagendra, H.R., Rekha, M., Vanitha, N., . . . Kumar, V. (2009). Effects of a yoga program on cortisol rhythm and mood states in early breast cancer patients undergoing adjuvant radiotherapy: A randomized controlled trial. Integrative Cancer Therapies, 8, 37–46.
To compare effects of an integrated yoga intervention with those of a brief supportive intervention on salivary cortisol levels and mood in patients with early breast cancer undergoing adjuvant radiotherapy
Patients were randomly assigned to a six-week yoga intervention or a control group. The yoga intervention included a set of asanas (postures), breathing exercises, meditation, and yogic relaxation techniques with imagery. Individual hour-long sessions were to be attended at least three times per week for six weeks during radiation treatments. These were administered by a trained yoga therapist. The control intervention was brief supportive therapy with education that was routinely offered to all patients. Control patients and caretakers underwent counseling sessions for 15 minutes every 10 days with a social worker as well. Study data were collected at baseline and at the end of the study period. Patients were asked to provide saliva samples three times per day for three consecutive days before and after radiotherapy. Specific procedures for saliva collection, storage, and immunoassay were followed.
Patients were undergoing the active treatment phase of care.
A randomized controlled trial design was used.
There were no significant effects of the yoga intervention on cortisol results overall; however, the mean pooled diurnal cortisol and 6 am cortisol levels were lower in the yoga group (p < 0.05). There were significant declines in anxiety levels in both groups. ANCOVA showed a significant decrease in reported anxiety in the yoga group compared to controls (p < 0.001). Depression declined in both groups over time. ANCOVA showed a significant decrease in reported depression in the yoga group compared to controls (p = 0.002). There was a significant decrease in perceived stress in the yoga group (p < 0.001), but not in the control group. Effect sizes seen were 0.31 for anxiety and depression scores and 0.36 for perceived stress.
Results suggest decreases in anxiety, depression, perceived stress, and 6 am and pooled mean cortisol levels with the yoga intervention used here.
Findings show that anxiety and depressive symptoms decline over time among patients in active treatment with adjuvant radiation therapy in women with breast cancer. Participation in stress reduction interventions, such as yoga, may augment this decline. Changes in cortisol findings seen here with yoga suggest that effects may be attributed to stress reduction, rather than attention, social support, and education alone. Further research in this area is warranted to determine efficacy of yoga in other patient groups, and association with other patient symptoms and problems associated with anxiety and depression.