Qigong (“qi” or “chi” = energy flow, “gong” = skill or achievement) is an integrated mind-body exercise and meditative practice that involves rhythmic breathing coordinated with repetition of fluid movements and calm focus on the body. A study reported in Cancer by Zhen Chen, MD, and colleagues from Fudan University Shanghai Cancer Center, China; The University of Texas MD Anderson Cancer Center, Houston; Hospital of the University of Pennsylvania, Philadelphia; and Dresden University of Technology, Germany, showed that regular qigong practice was associated with reduced depressive symptoms in Chinese women undergoing radiation therapy for breast cancer.¹ Quality-of-life benefits were particularly marked among women with higher depressive symptoms at the start of radiotherapy.

Study Details

In the study, 96 women with breast cancer stage 0 (ductal carcinoma in situ, for example) to III scheduled to receive 5 to 6 weeks of radiotherapy were randomly assigned to qigong practice (n = 49) or a wait list control group (n = 47). The qigong group was to receive five 40-minute sessions per week during radiotherapy. Symptoms of depression, fatigue, sleep disturbance, and overall quality of life were assessed by the Center for Epidemiologic Studies Depression Scale, Brief Fatigue Inventory, Pittsburgh Sleep Quality Index, and Functional Assessment of Cancer–General instruments, respectively. Cortisol rhythm was assessed using saliva samples. Outcomes were measured in the middle of radiotherapy, at the end of radiotherapy, and at 1 month (the primary outcome measure time point) and 3 months after completion of radiotherapy.

Qigong Sessions

All qigong sessions were taught by the same instructor and consisted of preparation, main, and ending exercises. Preparation exercise included relaxation through gentle breathing and meditation, synchronizing the breath with slow, shallow squatting movements, and synchronizing the breath with gentle arm movements in front of the abdomen. The main exercise consisted of participants walking in a circle, synchronizing their breathing, arm movements, and steps while focusing on the movement of their body with the goal of calming the mind, relaxing the body, and revitalizing their “life force” (qi); this activity was done first slowly and then quickly. The ending exercise consisted of breathing exercises, arm movements in front of the abdomen, and self-massage in a standing position.

There were no significant differences between the qigong and control groups at baseline with regard to age (mean, 45 and 45 years), marital status (46% and 40% married), level of education (at least some college for 55% and 50%), income, stage of disease (0 in 4% and 7%, I in 17% and 31%, II in 35% and 36%, and III in 35% and 15%), time since surgery (16.5 and 15 weeks), or number of radiotherapy fractions (25 in 78% and 78%). A difference in surgery type approached significance (mastectomy and lumpectomy in 37% and 63% vs 56.5% and 43.5%, P = .07). There were no significant differences between groups at baseline with regard to depressive symptoms, fatigue, sleep disturbance, overall quality of life, or cortisol slope.

Adherence to the qigong program was high, with 30% of women in the group attending 100% of sessions, 65% attending at least 80%, and 78% attending at least 50%; only 13% attended less than 20% of sessions.

Among all patients, there was a significant reduction in depression scores over time (P = .001); this effect was significantly moderated by treatment group (P = .05), indicating significant group differences in changes in depression over time. At 1 month after completion of radiotherapy, the qigong group had a lower adjusted mean score (10.01 vs 12.14), with the difference approaching significance (P = .09); the two groups had similar mean scores at 3 months after radiotherapy. There were no significant differences between groups with regard to fatigue, sleep disturbance, overall quality of life, or cortisol slope or awakening response.

Women with Higher Baseline Depression Scores

Significant group by time by baseline depression score interactions were observed for depressive symptoms score, fatigue score, and overall quality-of-life score. Thus, the investigators analyzed outcomes according to whether patients had high or low (mean ± 1 standard deviation) baseline depressive symptom scores. For each of these measures, there were no differences between groups when analysis was limited to patients with low baseline depression scores.

Among those with high baseline scores, women in the qigong group had marginally significantly lower depression scores during radiotherapy (least mean square 16.4 vs 23.6, P = .06) and significantly lower scores at 1 month (15.5 vs 29.1, P < .001) and 3 months (12.7 vs 26.5, P < .05) after completion of radiotherapy than the women in the control group. Similarly, among women with high baseline depression scores, those in the qigong group had significantly better fatigue scores at 1 month after radiotherapy (2.93 vs 4.19, P < .05) and significantly better overall quality-of-life scores at 1 month after radiotherapy (82.4 vs 66.3, P < .01), as well as a clinically significant difference in quality-of-life scores (defined as a difference of ≥ 7 points) at 3 months after radiotherapy (85.5 vs 78.1).

Baseline depressive symptoms did not significantly moderate group by time interactions for sleep disturbance or cortisol slope or awakening response. As noted by the investigators, the absence of differences between groups in cortisol rhythm suggests that the improvement in depressive symptoms is not explained by improved cortisol regulation.

The finding that qigong was most effective in patients with greater baseline levels of depression is consistent with results of a large meta-analysis indicating that psychosocial interventions in patients with cancer are most effective in those with higher preintervention levels of distress or depression.²

The investigators concluded that the results of the study “indicate that qigong may lead to reductions in depressive symptoms over time and may be especially useful for women who report high symptoms of depression at baseline. Studies involving a blinded design with an active control group, selecting for high levels of baseline depressive symptoms, and longer-term follow up will be necessary to examine the generalizability of our findings and to deepen our understanding of this promising therapeutic approach.” The investigators currently are conducting a three-arm trial of qigong including an active control group. ■

Disclosure: The study was supported by a National Cancer Institute grant. At the time of publication, Bob Thornton, MD, was with Merck & Co, but he was on the MD Anderson staff when the research was conducted. The authors reported no potential conflicts of interest.

References

1. Chen Z, Meng Z, Milbury K, et al: Qigong improves quality of life in women undergoing radiotherapy for breast cancer. Cancer. January 25, 2013 (early release online).

2. Schneider S, Moyer A, Knapp-Oliver S, et al: Pre-intervention distress moderates the efficacy of psychosocial treatment for cancer patients: A meta-analysis. J Behav Med 33:1-14, 2010.