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.

• The study reported on a sample of 75 female patients.
• Mean patient age was 46 years (SD = 9.13 years) in the yoga group and 48.5 years (SD = 10.2 years) in the control group.
• All patients had breast cancer, with 73.9% having stage III disease and all having undergone mastectomy.
• Most patients (77.3%) also received three cycles of adjuvant chemotherapy, 97.8% were married, and 54.5% were premenopausal.

• Single site
• Outpatient setting
• India

Patients were undergoing the active treatment phase of care.

A randomized controlled trial design was used.

• Hospital Anxiety and Depression Scale (HADS)
• Perceived Stress Scale
• Mean cortisol levels and diurnal cortisol response

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.

• The study had a small sample size, with less than 100 participants.
• It is not clear that the control condition provided the same amount of attention to patients as that provided with the yoga intervention.
• There was no blinding, with associated risk of bias.
• Demographics show that the vast majority of patients were married, which may not be typical of other patient populations. Potential partner/family supports may have contributed to results seen.
• Cultural aspects may have impacted results seen.
• No information regarding the extent of mastectomy was provided, and there is no subgroup analysis based on surgery type, between those who did and did not have chemotherapy as well, or in association with other patient symptoms that contribute to symptoms measured 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.