Role of Yoga Across the Cancer Care Continuum: From Diagnosis Through Survivorship

Surgical Setting/Postoperative Distress

Distress surrounding surgery in patients with breast cancer can impact postoperative outcomes. Yoga interventions, including breathing exercises, regulated breathing, and yogic relaxation techniques, improved several postsurgical measures such as length of hospital stay, drain retention, and suture removal.⁷⁸ In this study, patients who practiced yoga also experienced a decrease in plasma TNF and better wound healing. Symptoms of anxiety and distress that occur preoperatively can lead to impaired immune function in addition to decreased QOL. In a study of yoga in early-stage breast cancer patients undergoing surgery, the benefit of yoga was seen not only with stress reduction but also with immune enhancement.⁴²

Yoga has been shown to help alleviate acute pain and distress in women undergoing major surgery for gynecological cancer. A regimen of 3 15-minute sessions of yoga, including awareness meditation, coordination of breath with movement, and relaxation breathing, was shown to reduce acute pain and distress in such patients in an inpatient setting.⁷⁹

Menopausal Symptoms

Breast cancer survivors have more severe menopausal symptoms compared with women without cancer.^80,81 Hot flashes cause sleep disturbances and worsen fatigue and QOL.⁸² Tamoxifen and aromatase inhibitors significantly worsen menopausal symptoms such as hot flashes.⁸¹ Carson et al conducted a study of yoga that included postures, breathing techniques, didactic presentations, and group discussions.⁸³ The yoga awareness regimen consisted of 8 weekly 120-minute group classes. Patients in the yoga arm had statistically significant improvements in the frequency, severity, and number of hot flashes. There were also improvements in arthralgia (joint pain), fatigue, sleep disturbance, vigor, and acceptance.

Arthralgia

Joint pain can be a major side effect that interferes with daily functions and activities in postmenopausal breast cancer survivors who receive aromatase inhibitor therapy.⁸⁴ Arthralgia is reported in up to 50% of patients treated with aromatase inhibitors.^84,85 It can affect functional status and lead to discontinuation of aromatase inhibitor therapy, jeopardizing clinical outcomes.⁸⁶ Yoga as a complementary therapy has been shown to improve conditions such as low back pain⁸⁷ and knee osteoarthritis⁸⁸ in patients who do not have cancer. In a single-arm pilot trial by Galantino et al, breast cancer patients with aromatase inhibitor–related joint pain were provided with twice-weekly yoga sessions for 8 weeks. There were statistically significant improvements in balance, flexibility, pain severity, and health-related QOL.⁸⁹ As noted above, improvement in arthralgia was also found in the study conducted by Carson et al.⁸³

Insomnia

Insomnia is common among cancer patients and survivors^90,91 and leads to increased fatigue and depression, decreased adherence to cancer treatments, and poor physical function and QOL.^90-92 Management of insomnia consists of pharmacologic therapies such as benzodiazepines^93,94 and nonpharmacologic options such as cognitive behavioral therapy.⁹⁵

The first study of yoga found to improve sleep quality was conducted at MD Anderson Cancer Center in lymphoma patients.⁹⁶ The effects of Tibetan yoga practices incorporating controlled breathing and visualization, mindfulness techniques, and low-impact postures were studied. Patients in the Tibetan yoga group had better subjective sleep quality, faster sleep latency, longer sleep duration, and less use of sleep medications. Mustian et al conducted a large yoga study in cancer survivors in which patients reporting chronic sleep disturbances were randomly assigned to the YOCAS program, which consisted of pranayama (breath control), 16 gentle hatha and restorative yoga postures, and meditation, or to usual care.⁹² The study reported improvements in global sleep quality, subjective sleep quality, actigraphy measures (wake after sleep onset, sleep efficiency), daytime dysfunction, and use of sleep medication after the yoga intervention compared with participants who received standard care.