Lorenzo Cohen, PhD
Santosshi Narayanan, MD
The ASCO Post’s Integrative Oncology series is intended to facilitate the availability of evidence-based information on integrative and complementary therapies sometimes used by patients with cancer. Increasingly, patients with cancer desire nonpharmacologic strategies for managing their symptoms. Yoga is a time-honored mind-body practice that has been shown to improve both physical and psychological well-being. In this article, Lorenzo Cohen, PhD, and Santosshi Narayanan, MD, summarize the current evidence surrounding the use of yoga in oncology settings and highlight the need for increased efforts to make yoga available to more patients with cancer.
Patients often want a more comprehensive approach to their cancer care, seeking nonpharmacologic treatments to improve symptom management or clinical outcomes and mortality. An integrative approach involves addressing the physical, psychospiritual, and social needs alongside the biomedical aspects. Mind-body treatments, such as meditation, yoga, tai chi, qigong, and music therapy, to name a few, are commonly used by patients and are also recommended by clinicians due to their overall safety and efficacy. Yoga is one such therapy that can address physical and psychological needs and promote well-being. It is a movement-based mind-body practice that focuses on synchronizing body, breath, and mind. Originating from India, it is now practiced worldwide to improve and maintain health.
Data from the National Health Interview Survey suggest significant increases in the practice of yoga and meditation in the United States, with the use of yoga increasing from 9.5% to 14.3% and meditation from 4.1% to 14.2% between 2012 and 2017.1 Nowhere is the use of yoga more prevalent than in people undergoing cancer treatment and in cancer survivors, as more and more hospitals and cancer centers offer this important treatment modality. Interest in the field of yoga and its expansion are due, in part, to the robust evidence base showing that yoga improves multiple aspects of quality of life, physiologic outcomes, and biologic processes, as well as the increased understanding of the harms of chronic stress on cancer outcomes.
Stress and Cancer
Chronic stress activates the sympathetic nervous system and multiple biologic processes, making our bodies more hospitable to cancer growth.2,3 Evidence shows that depression, independent of disease severity, is associated with increased mortality.4 Stress also negatively impacts the quality of life; it disrupts healthy sleep patterns, with sleep disturbance among the most commonly reported symptoms in patients with advanced cancer.5 Sleep impairment can cause worsening of memory, contribute to fatigue and daytime drowsiness, and result in negative biologic changes, including increased inflammation, decreased cell-mediated immunity, and alterations in energy metabolism. Chronic stress also disrupts other health behaviors, including healthy eating patterns and motivation to exercise.6,7 It is understandable and expected that patients and their spouses/caregivers would experience chronic stress at some time during the cancer care continuum. Even though the experience of chronic stress should be normalized, it is crucial for patients with cancer to manage stress in their lives to help improve their quality of life and clinical outcomes.
Jun J. Mao, MD, MSCE
Integrative Oncology is guest edited by Jun J. Mao, MD, MSCE, Laurance S. Rockefeller Chair in Integrative Medicine and Chief of Integrative Medicine Service at Memorial Sloan Kettering Cancer Center, New York.
Extensive literature now exists to support the use of mind-body practices, including guided imagery, relaxation, hypnosis, biofeedback, meditation, yoga, tai chi, and qigong, as well as expressive arts (eg, music therapy) to help reduce chronic stress.8 These modalities may help to decrease the biologic perturbations associated with chronic stress and may improve both the physical and mental health aspects before, during, and after treatment.
Yoga as a Treatment Approach—The Evidence
Extensive research now supports yoga’s benefits in improving overall health, quality of life, and physical function, as well as in reducing distress, anxiety, depression, sleep disturbance, and fatigue.9 A review of 29 clinical trials showed that low-intensity forms of yoga, specifically gentle Hatha and restorative yoga, are safe and effective for relieving sleep disruption, nausea, fatigue, pain, psychosocial distress, and musculoskeletal symptoms; they also may have a positive effect on cognitive impairment.10 In a multicenter, randomized trial involving cancer survivors with sleep disturbance, a combination Hatha/restorative yoga intervention was found to improve sleep quality.11 Research also shows that yoga’s benefits can translate into improved physiologic functioning, including better stress hormone regulation and enhanced immune function.12,13 Finally, caregivers may experience distress, and studies indicate that yoga helps their spiritual well-being, along with improving fatigue, sleep, anxiety, and depression in couple-based yoga programs.14,15
“Greater dissemination and implementation efforts are needed to make yoga available to the broader community of individuals impacted by cancer.”— Lorenzo Cohen, PhD, and Santosshi Narayanan, MD
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According to the joint Society for Integrative Oncology and ASCO guidelines for the use of integrative therapies during and after breast cancer treatment, yoga is recommended for reducing anxiety as well as for improving quality of life, mood, depressive symptoms, fatigue, and sleep.16 Similarly, the National Comprehensive Cancer Network (NCCN®) recommends patients “consider” yoga for improving some survivorship areas, such as distress, cognitive functioning, menopausal symptoms, and pain.17 Yoga is also formally listed in the NCCN Clinical Practice Guidelines in Oncology as an effective intervention for cancer-related fatigue and anticipatory nausea/vomiting.18,19
Recommendations and Future Directions
Given the strong evidence to support yoga as an adjunct modality in managing cancer-related symptoms, it is incumbent on medical systems to offer this evidence-based treatment. Ideally, yoga instruction in an oncology setting is delivered by yoga therapists, instructors who have additional training to work with medical populations, and oncology experience. At The University of Texas MD Anderson Cancer Center, yoga and other mind-body practices are offered in a group-delivery setting for our patients and their caregivers, as well as in a one-on-one setting. Due to the expansion of telemedicine during and after the COVID-19 pandemic, our center and others are offering these sessions remotely via video. Yoga has an excellent safety profile, but modifications may be needed in patients with postoperative restrictions or spinal/bone metastatic disease.
Despite an increasing evidence base and being listed on multiple symptom-control care pathways and guidelines, many patients with cancer may be unaware of yoga therapy’s benefits. Therefore, greater dissemination and implementation efforts are needed to make yoga available to the broader community of individuals impacted by cancer. With the vast array of yoga/meditation practices to choose from, the ideal program is one that patients are willing to do regularly to create calm in their lives.
DISCLOSURE: Dr. Cohen has served as a consultant to Cancer Treatment Centers of America and holds intellectual property as a coauthor of the books Anticancer Living: Transform Your Life and Health With the Mix of Six and The Principles and Practice of Yoga in Health Care. Dr. Narayanan reported no conflicts of interest.
1. U.S. Department of Health and Human Services: Use of yoga, meditation, and chiropractors among U.S. adults aged 18 and over. Available at https://www.cdc.gov/nchs/data/databriefs/db325-h.pdf. Accessed March 17, 2021.
2. Cole SW, Nagaraja AS, Lutgendorf SK, et al: Sympathetic nervous system regulation of the tumour microenvironment. Nat Rev Cancer 15:563-572, 2015.
3. Thaker PH, Han LY, Kamat AA, et al: Chronic stress promotes tumor growth and angiogenesis in a mouse model of ovarian carcinoma. Nat Med 12:939-944, 2006.
4. Cohen L, Cole SW, Sood AK, et al: Depressive symptoms and cortisol rhythmicity predict survival in patients with renal cell carcinoma: Role of inflammatory signaling. PLoS One 7:e42324, 2012.
5. Irwin MR, Olmstead R, Carroll JE: Sleep disturbance, sleep duration, and inflammation: A systematic review and meta-analysis of cohort studies and experimental sleep deprivation. Biol Psychiatry 80:40-52, 2016.
6. Stults-Kolehmainen MA, Sinha R: The effects of stress on physical activity and exercise. Sports Med 44:81-121, 2014.
7. Khaled K, Tsofliou F, Hundley V, et al: Perceived stress and diet quality in women of reproductive age: A systematic review and meta-analysis. Nutr J 19:92, 2020.
8. Chaoul A, Milbury K, Sood AK, et al: Mind-body practices in cancer care. Curr Oncol Rep 16:417, 2014.
9. Narayanan S, Francisco R, Lopez G, et al: Role of yoga across the cancer care continuum: From diagnosis through survivorship. J Clin Outcomes Manag 26:219-228, 2019.
10. Danhauer SC, Addington EL, Cohen L, et al: Yoga for symptom management in oncology: A review of the evidence base and future directions for research. Cancer 125:1979-1989, 2019.
11. Mustian KM, Sprod LK, Janelsins M, et al: Multicenter, randomized controlled trial of yoga for sleep quality among cancer survivors. J Clin Oncol 31:3233-3241, 2013.
12. Chandwani KD, Perkins G, Nagendra HR, et al: Randomized, controlled trial of yoga in women with breast cancer undergoing radiotherapy. J Clin Oncol 32:1058-1065, 2014.
13. Infante JR, Peran F, Rayo JI, et al: Levels of immune cells in transcendental meditation practitioners. Int J Yoga 7:147-151, 2014.
14. Milbury K, Mallaiah S, Mahajan A, et al: Yoga program for high-grade glioma patients undergoing radiotherapy and their family caregivers. Integr Cancer Ther 17:332-336, 2018.
15. Milbury K, Liao Z, Shannon V, et al: Dyadic yoga program for patients undergoing thoracic radiotherapy and their family caregivers: Results of a pilot randomized controlled trial. Psychooncology 28:615-621, 2019.
16. Lyman GH, Greenlee H, Bohlke K, et al: Integrative therapies during and after breast cancer treatment: ASCO endorsement of the SIO clinical practice guideline. J Clin Oncol 36:2647-2655, 2018.
17. Denlinger CS, Sanft T, Baker KS, et al: NCCN Clinical Practice Guidelines in Oncology: Survivorship. Version 3.2018. Available at https://www.nccn.org/professionals/physician_gls/pdf/survivorship.pdf. Accessed March 17, 2021.
18. Berger AM, Mooney K, Aranha O, et al: NCCN Clinical Practice Guidelines in Oncology: Cancer-Related Fatigue. Version 1.2021. Available at https://www.nccn.org/professionals/physician_gls/pdf/fatigue.pdf. Accessed March 17, 2021.
19. Ettinger DS, Berger MJ, Arnand S, et al: NCCN Clinical Practice Guidelines in Oncology: Antiemesis. Version 1.2021. Available at https://www.nccn.org/professionals/physician_gls/pdf/antiemesis.pdf. Accessed March 17, 2021.
Dr. Cohen is the Richard E. Haynes Distinguished Professor in Clinical Cancer Prevention in the Department of Palliative, Rehabilitation, and Integrative Medicine and Section Chief of Integrative Medicine at The University of Texas MD Anderson Cancer Center, Houston. Dr. Narayanan is Assistant Professor in the Department of Palliative, Rehabilitation, and Integrative Medicine, Section of Integrative Medicine at The University of Texas MD Anderson Cancer Center, Houston.