Yoga

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.

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.

• FINAL NUMBER STUDIES INCLUDED: N = 12
• TOTAL PATIENTS INCLUDED IN REVIEW: N = 742

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.

• Small overall number of studies that could be included in various meta-analyses
• High risk of bias in studies
• High heterogeneity
• Highly varied interventions
• Samples limited to patients with breast cancer

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.

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.

To perform a systematic review of evidence related to the use of mind-body therapies to address various symptoms of depression

• Databases searched were PubMed, EMBASE, CINAHL, PsycINFO, Current Contents, Web of Science, and Web of Knowledge.
• Searched keywords were MeSH terms for depression, complementary therapies, mind-body therapies, biofeedback, hypnosis, autogenic training relaxation, meditation, imagery, yoga, relaxation therapy, mindfulness, and multiple terms for yoga and tai chi.
• Studies were included if they used a validated depression-scoring system and monitored for changes over time and if the study used any type of control comparison.
• Studies were excluded if they did not last at least two weeks and if they had a sample size of more than 30 participants.

• Investigators retrieved 2,864 references.
• Authors used the Scale for Assessing Scientific Quality of Investigations, modified for use in studies of complementary and alternative medicine.

• The final number of studies analyzed was 90. Eight studies included patients with cancer.
• Across studies, the size of samples included in analysis was 30–298. In studies including patients with cancer, sample size was 38–191. The total number of patients in studies that included patients with cancer was 561.
• Studies including patients with cancer involved mainly breast cancer patients.

Among studies that included patients with cancer, six studies involved yoga and one examined relaxation and guided imagery. Among the yoga studies, three showed positive results with yoga alone or in combination with other supportive therapies, two showed negative results, and the results of one were equivocal. Relaxation and guided imagery were associated with postive results. Across all studies involving various medical illnesses, 74% associated mind-body therapies with positive results.
 

Mind-body therapies appear to be effective in reducing symptoms of depression.

• Authors eliminated studies with relatively low quality scores. How these exclusions affected the final sample is unclear.
• Most studies did not include any attentional control conditions, and authors noted that attention alone could have produced positive results. (Individualized attention is often lacking in mainstream medicine.)
• Many studies involved multiple modalities, so gauging the effect of any single intervention is difficult.
• Authors used various types of instruments to measure depression. Because the level of depression involved is unclear, one cannot tell if benefit was derived by patients with clinically relevant symptoms.

The individualized attention provided to patients via mind-body therapies may be beneficial in reducing symptoms of depression.

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.

• No quality evaluation
• Mostly low quality/high risk of bias studies
• Low sample sizes
• Varied type, frequency, and duration of interventions. Multiple limitations in study designs and high attrition rates

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.

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.

• Low sample sizes
• No meta-analysis, no table of evidence; difficult to synthesize all data accurately independently on article review

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.

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.

• FINAL NUMBER STUDIES INCLUDED: N = 18
• SAMPLE RANGE ACROSS STUDIES: The sample size range was 18–164 at baseline to 14–75 at follow-up.
• TOTAL PATIENTS INCLUDED IN REVIEW: N = 760
• KEY SAMPLE CHARACTERISTICS: The mean age (based on 10 studies adequately reporting age) was 52.7 years (mean age range = 45–62.9 years). Most studies investigated women with early or advanced stage disease; three included women with noninvasive breast cancers. Seventeen studies conducted repeated measures at a minimum of two time points (pre- and post-intervention) using an adequate baseline assessment performed before or after randomization (though not all studies reported change scores). Follow-up occurred over a range of one to six months.

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

• The most common intervention was integrated yoga (consisting of postures, breathing, and meditation) and Iyengar and Hatha yoga (71 %) given via self-practice (83%) or in-class lessons. The duration was 4 to 12 weeks (median 8 weeks).
• The primary outcome variables of the yoga intervention were (1) mood and psychosocial functioning (depression, anxiety, stress, and psychological symptom distress); (2) health-related quality of life; (3) fatigue; and (4) biological changes and physical measures (i.e., wound healing, hospital stay, TNF-alpha, immunoglobulin, nausea and vomiting, and overweight).
• Overall, all 18 studies in the review reported positive effects from the yoga interventions, with the greatest impact on global QOL scores and emotional well-being. Few in the yoga program experienced improved cancer-related fatigue. Biological measures varied, and conclusions for this outcome cannot be drawn.
• Total quality rating scores for the RCTs was a median of 6, indicating that overall the quality was “good” (range 1 to 8); one study was rated methodologically poor (score 1). Low quality was found in the description of the randomization process (i.e., concealed allocation), blinding (i.e., blinding of assessors), and reporting of adequate follow-up (i.e., > 85% of subjects).
• Adherence was a major problem of the intervention.

• Qualities measures were used to evaluate studies. Overall study quality appears to be good, and the studies relatively consistently reported that yoga may be a useful practice.  
• However, long-term and specific objective effects of yoga interventions need to be further examined. Outcome variables in this review varied across studies. Only seven studies used validated depression measures, and only two studies used a validated anxiety measure. Among them, six studies reported positive effects from the intervention on depression and/or anxiety, whereas two studies reported no effect.
• The intervention program ranged from 6 to 26 weeks with up to three sessions of yoga per week and were generally well received and safe. Yet, more safety data are required to report that yoga is not harmful and is a credible intervention compared to conventional therapies. More economical and practical information also is needed to implement yoga.

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.

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.

• FINAL NUMBER STUDIES INCLUDED: N = 13
• SAMPLE RANGE ACROSS STUDIES: 536 total
• TOTAL PATIENTS INCLUDED IN REVIEW: Range = 4-240
• KEY SAMPLE CHARACTERISTICS: Six studies involved only patients with breast cancer; two involved parents of children or adolescents with cancer.

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.

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

• FINAL NUMBER STUDIES INCLUDED: N = 6 included in meta-analysis  
• SAMPLE RANGE ACROSS STUDIES: Range = 18-164
• TOTAL PATIENTS INCLUDED IN REVIEW: N = 382
• KEY SAMPLE CHARACTERISTICS: All were women with breast cancer aged ≥ 30 years.

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.

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.

• N = 52   
• AGE: 30-65
• FEMALES: 100%
• CURRENT TREATMENT: Other
• KEY DISEASE CHARACTERISTICS: Female breast cancer survivors diagnosed with stage II or III ILC or IDC who received adjuvant chemotherapy and completed all treatment at least six months prior. 
• OTHER KEY SAMPLE CHARACTERISTICS: Patients with neutropenia, grade 3 or 4 thrombocytopenia, and other reported chronic illnesses (diabetes, arthritis, hypertension, thyroid abnormalities, obesity, or recent acute infections) were excluded. Patients who participated in other complementary or alternative treatments within the past six months were also excluded.

• SITE: Multi-site   
• SETTING TYPE: Outpatient    
• LOCATION: Participants were screened at six-month follow-up appointment at three cancer centers in Bengaluru, India.

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.

• Small sample (< 100)
• Risk of bias (no appropriate attentional control condition)
• Findings not generalizable
• Other limitations/explanation: Differences in regular yoga practices among the participants could have influenced the results as yoga schedules were not controlled for. In addition, this study only looks at yoga in breast cancer survivors and may not be generalizable to other patients with cancer.

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.

To examine, relative to a health education control, the feasibility and efficacy of an Iyengar yoga intervention for breast cancer survivors with persistent posttreatment fatigue.

Outcome assessors of the performance tasks were blinded to group assignment. The intervention was briefly but fully described, and then participants were randomly assigned to a group that received a 12-week, Iyengar-based yoga intervention or a group that received 12 weeks of a health education (control group).

• The sample was comprised of 31 women.
• Mean age was 54.4 years (standard deviation [SD] = 5.7 years) in the intervention group and 53.3 years (SD = 4 years) in the control group.
• All participants had stage 0 to II breast cancer.
• Most participants were white.
• The range of education was high school completion through graduate degree.
• Twenty-four participants were completing radiotherapy, 17 were completing chemotherapy, and 22 were receiving hormone therapy.
• In the intervention group, median time posttreatment was 1.7 years (range 0.7–4.1).
• Breast cancer survivors with posttreatment fatigue were recruited through multiple mechanisms. Inclusion and exclusion criteria were applied.
• The original enrollment target was 72 participants; researchers assumed a 20% loss to follow-up. Because of the stringent enrollment plan, the sample size was smaller than expected.
   

• Single site
• Outpatient
• University of California, Los Angeles
   

• Patients were undergoing the posttreatment phase of care.
• The study has clinical applicability for survivorship and late effects and survivorship.

The study was a randomized, controlled trial.

• Fatigue Symptom Inventory (FSI)
• Multidimensional Fatigue Symptom Inventory (MFSI), to assess vigor
• Beck Depression Inventory II (BDI-II)
• Pittsburgh Sleep Quality Index (PSQI)
• Perceived Stress Scale (PSS)
• Timed chair stands and functional reach test, to assess physical performance
• Medical Outcomes Study (MOS)
   

Relative to the control group, fatigue severity in the intervention group declined significantly (p = 0.032) from baseline to posttreatment and over the three-month follow-up. In addition, relative to the control group, the yoga group had significant (p = 0.011) increases in vigor. Both groups had positive changes in symptoms of depression and perceived stress (p < 0.05). The authors noted no significant changes in sleep or physical performance. 

One adverse protocol-related event occurred:  a participant with a history of back problems experienced a back spasm in yoga class. After evaluation by her physician, she returned to class.

A targeted yoga intervention led to a significant reduction in fatigue and improvement in vigor among breast cancer survivors with persistent fatigue symptoms. This conclusion should be understood in the context of the study:  participants were relatively healthy and without comorbid conditions found in the general population.

• The study had a small sample size, with less than 100 participants.
• Some participants had been living with cancer for more than five years, which was longer than most in the study had been living with cancer.
• Because of the context of the study, researchers were unable to use a double-blind design.
• The study included multiple conditions.
• The results were not generalizable.

This study offered minimal conclusive data in support of the intervention. Preliminary findings indicated that the yoga intervention is feasible and safe and has a positive effect on fatigue. A larger trial that includes participants with common comorbid conditions—a study more representative of the general population of women with breast cancer posttreatment—is warranted. Secondary outcomes included vigor, symptoms of depression, sleep, perceived stress, and physical performance.

To evaluate the effects of yoga on quality of life, anxiety, depression, and sleep in patients with colorectal cancer.

• N = 44  
• MEAN AGE = 68.26 years (range = 40-87)
• MALES: 61.1%, FEMALES: 38.9%
• KEY DISEASE CHARACTERISTICS: All had colorectal cancer and were an average of 23 months since surgery
• OTHER KEY SAMPLE CHARACTERISTICS: The majority of patients were retired and were married

• SITE: Multi-site  
• SETTING TYPE: Outpatient    
• LOCATION: Germany

• PHASE OF CARE: Late effects and survivorship

• Randomized, controlled trial

• Functional Assessment of Cancer Therapy (FACT) colorectal and fatigue scales
• Hospital Anxiety and Depression Scale (HADS)
• Pittsburgh Sleep Quality Index (PSQI)

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.

• Small sample (less than 100)
• Baseline sample/group differences of import
• Risk of bias (no blinding)
• Risk of bias (no appropriate attentional control condition)
• Measurement validity/reliability questionable
• Subject withdrawals of 10% or greater 
• Other limitations/explanation: More than 20% were lost to follow up. Baseline anxiety and depression scores were very low, so it is not likely that reduction would be seen due to floor effects, and those reductions seen have questionable clinical relevance.

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.

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.

• The sample was comprised of 16 patients.
• Mean age was 56 years (standard deviation [SD] = 11.9 years) in the control group and 52.4 years (SD = 14.6 years) in the treatment group.
• The treatment group was 75% female and 25% male; the control group was 100% female.
• Patients were receiving intravenous chemotherapy for cancer (50% of participants had breast cancer, 50% had some other type of cancer).
• Patients were included in the study if they had a visual analog scale (VAS) score for fatigue of at least 4 out of 10 and a Karnofsky Performance Status (KPS) of 60 or higher.
• Patients were excluded from the study if they participated in ongoing yoga practice; had severe chronic obstructive pulmonary disease (COPD), class III or IV heart failure, child class C cirrhosis, or end-stage renal disease; or had received more than three prior chemotherapy regimens.
• The sample was 62.5% white, and 7 out of 16 were employed.

• Single site
• Outpatient
• University medical center

Patients were undergoing the active treatment phase of care.

The study was a randomized, controlled trial.

• Participants kept a daily diary in which they recorded the amount of time spent practicing pranayama.
• At baseline, between the first and second cycle, and at the end of the study, the investigators took measures according to these instruments:
  • Piper Fatigue Scale (PFS)
  • General Sleep Disturbance Scale (GSDS)
  • Hospital Anxiety and Depression Scale (HADS)
  • Perceived Stress Scale (PSS)
  • Short Form 12 (SF-12 v1), to measure QOL.

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.

• The study had a small sample size, with less than 30 participants.
• The study had risks of bias due to lack of an attentional control and due to selection bias:  those who would elect to participate in a study of this kind may be more likely than others to benefit from it. In addition, the study included self-reported outcomes.

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.

To assess the effects of yoga on inflammation, mood, and fatigue and to test the hypothesis that yoga would decrease inflammation, depressive symptoms, and fatigue in breast cancer survivors

Women were randomly assigned to the intervention group or a wait-list control group. The intervention consisted of two 90-minute Hatha yoga sessions per week for 12 weeks delivered in a group setting. Sessions were audiotaped, and 50% were randomly assessed for differences from predetermined poses to assess fidelity of the intervention. Yoga teachers called anyone who missed a class. Home practice was encouraged, and all practice times were recorded by participants in weekly logs. Data were collected at baseline, immediately after the intervention, and after three months post-treatment.

• N = 186 (completed initial data), 181 (finally included)
• MEAN AGE = 51.6 years (SD = 9.2 years)
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: Breast cancer survivors who had completed cancer treatment within the past three years and were at least two months post-treatment intervention (other than tamoxifen or aromatase inhibitors)
• OTHER KEY SAMPLE CHARACTERISTICS: Those who already completed five hours or more of vigorous physical activity per week were excluded. Those with any prior yoga practice for more than three months were excluded. The majority of participants were college graduates, were employed full or part time, and were married. The average time since treatment was 10.9 months (SD = 7.9 months).

• SITE: Single-site
• SETTING TYPE: Outpatient
• LOCATION: Ohio, United States

• PHASE OF CARE: Late effects and survivorship

Single-blinded, randomized, controlled trial

• Multidimensional Fatigue Symptom Inventory Short Form (MFSI-SF)
• Short Form (SF-36)
• Center for Epidemiological Studies Depression Scale (CES-D)
• Pittsburgh Sleep Quality Index (PSQI)
• Fasting blood samples for proinflammatory cytokines

Patients attended a median of 79% of yoga classes and reported an average of 24.69 minutes of practice per day at home and in class over 12 weeks. Immediately after the intervention, there were no differences between the groups in fatigue; however, in the yoga group, fatigue was significantly lower at three months (Cohen’s d = -0.36, p = 0.002). Vitality in the yoga group was significantly higher immediately post-treatment and at three months (p = 0.01). There were no differences between the groups in depressive symptoms. Immediately postintervention, there were no differences between groups in cytokine levels; however, at three months, the yoga group had significantly lower cytokine levels compared to the control group (p < 0.05). Yoga participants reported improved sleep compared to patients in the control group (p = 0.03).

Yoga was associated with reduced fatigue, increased vitality, improved sleep, and reduced cytokine levels. Yoga did not appear to have an effect on depressive symptoms in this study.

• Baseline sample/group differences of import
• Risk of bias (no appropriate attentional control condition)
• Risk of bias (sample characteristics)
• Other limitations/explanation: The sample included only women who were highly educated and had higher income levels.

The findings of this study demonstrated that yoga practice was effective in reducing fatigue and improving vitality and sleep in this patient population. Nurses can suggest that patients become involved in yoga practice as a way to manage fatigue and sleep disturbance. These findings also suggest that yoga can have an impact on subclinical inflammation, which may be a mechanism that fuels fatigue and the decline of physical function.

To evaluate the impact of the Urban Zen Initiative (UZI) on quantitative and qualitative measures of the experiences of patients admitted for inpatient oncology care.

The UZI model consists of five focus points:  the physical space surrounding patients, holistic nursing techniques, yoga with trained therapists, a navigator for patients, and audiovisual yoga materials at the bedside. All patients received the intervention; therefore, the investigators collected preintervention information about patients who were receiving standard care prior to the UZI intervention. Preintervention data were the basis of the control comparison. The investigators measured the outcomes immediately after admission and immediately before discharge. 

• The sample was comprised of 163 patients.
• Mean age preintervention was 52.9 years (standard deviation [SD] = 17.3 years). Mean age in the UZI group was 54.4 years (SD = 14.6 years).
• The preintervention group was comprised of 55% males and 45% females. The UZI group was comprised of 49% males and 51% females.
• The investigators did not specify the key disease characteristics.
• Patients were included if they
  • Were admitted to a specific inpatient oncology unit
  • Had a Karnofsky Performance Status (KPS) score greater than 60
  • Had a life expectancy longer than six months
  • Were able to speak English.

• Single site
• Inpatient
• Beth Israel Deaconess Medical Center, New York City

Patients were undergoing the active treatment phase of care.

The study used a quasiexperimental design with historical control groups.

• Profile of Mood States–Brief Form (POMS-BF)    
• EuroQol EQ-5D
• Semistructured qualitative interview
   

• The investigators noted no significant admission or discharge changes based on POMS scores.
• The investigators reported significant changes between groups in regard to tension (p = 0.009), depression (p = 0.03), vigor (p = 0.001), fatigue (p = 0.03), and total mood disturbance (p = 0.008). The scores indicated positive associations with UZI.
• Mobility was significantly different (p = 0.03) between the groups, according to the EQ-5D scores. The EQ-5D demonstrated no significant group-based changes in pain, anxiety, or health state.
• Thirty-three patients participated in qualitative data collection and indicated that the experience included fear and the need for information, caring, and connection. Responses also described the impact of the physical environment on patients' experiences, as well as the impact of yoga on patients' experiences of symptoms. Some patients stated they believed that what they had learned from the UZI could be useful in the future.

UZI may improve components of mood in an inpatient oncology setting. More work is needed to assess the real impact.

• The study had a risk of bias due to lacking an appropriate historical control group.
• Knowing which part of the intervention had the greatest effect was difficult because the UZI has many components.
• Whether the finding of significant pre- and post-UZI differences was based on initial POMS scores or \"change scores\" is unclear. Based on change scores, no intergroup differences existed.  

Providing a multifaceted healing environment, such as the UZI, within inpatient oncology settings could improve mood and perceived health status in patients with cancer. To facilitate the care process, nurses should assess patients' physical spaces; promote relaxation techniques, such as yoga breathing; and support patients.

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.

• N = 10 dyads  
• MEAN AGE = 71.22 years (patients, range = 61–82 years); 68.77 years (caregivers, range = 61–78 years)
• MALES: Patients 50%; caregivers 10%, FEMALES: Patients 50%; caregivers 90%
• KEY DISEASE CHARACTERISTICS: All patients had lung cancer and were receiving radiation therapy. 50% had stage IIIb disease. Average time since diagnosis was 2.88 months, range 1.13–5.97 months.
• OTHER KEY SAMPLE CHARACTERISTICS: Slightly greater than 50% of participants had some college level or higher education, 80% were white, and 75% had incomes greater than $50,000 per year.

• SITE: Single-site    
• SETTING TYPE: Outpatient  
• LOCATION: Texas

• PHASE OF CARE: Active antitumor treatment
• APPLICATIONS: Elder care  

Single-group, prospective pilot study

• Center for Epidemiologic Studies Depression Scale (CES-D)
• Anxiety dimension of the Brief Symptom Inventory (BSI)
• Pittsburgh Sleep Quality Index (PSQI)
• Brief Fatigue Inventory (BFI)
• Medical Outcomes Study Short-Form Health Survey (SF 36)
• Functional Assessment of Cancer Therapy Spiritual Well Being Scale (FACT-Sp)
• Finding meaning in cancer scale

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.

• Small sample (< 30)
• Risk of bias (no control group)
• Subject withdrawals ≥ 10%

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.

To evaluate the effects of a yoga program versus supportive care on symptoms of depression among women with breast cancer during treatment

Patients were randomized to the yoga program or a control supportive therapy program. Yoga included education, breathing exercises, meditation, and relaxation techniques with imagery. Subjects were provided with audiotapes of the practices for use at home. Home practice was monitored via telephone calls, weekly home visits, and a daily patient log. Subjects were to practice at home for at least one hour three times per week. The comparison group used supportive, expressive therapy and education provided by therapists in an unstructured approach aimed at addressing fears and concerns and improving support from others among other issues. The intervention took place over a 24-week period including the time of surgery and following adjuvant chemotherapy or radiotherapy. There were four to six study assessments, depending on the treatment, that were scheduled pre- and postsurgery and mid- and postradiation or chemotherapy. Interventions were done on an individual basis.

• N = 69
• AGE: Not provided
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: 87% of participants had grade 3 breast cancer.

• SITE: Single site  
• SETTING TYPE: Outpatient  
• LOCATION: India

• PHASE OF CARE: Active antitumor treatment

Single, blinded, randomized, controlled trial

• Beck Depression Inventory (BDI)
• Symptom checklist

Both groups reported decreased depression over time. An analysis of covariance showed a larger decrease in depression at all time points measured in the yoga group (p < 0.01). The study sample was appropriate according to the authors' power analysis. Depression scores were directly and strongly correlated (ranged from 0.49–0.77, p < 0.001) with symptom distress scores.

Yoga was shown to be beneficial in reducing symptoms of depression among women with breast cancer during the trajectory of active treatment. Depression was strongly related to symptom scores.

• Small sample (< 100)
• Baseline sample/group differences of import
• Risk of bias (no blinding)
• Questionable protocol fidelity
• Subject withdrawals ≥ 10% 
• Other limitations/explanation: There was an initial drop-out rate of about 30% that was fairly evenly spread across both study groups. Patients were not blinded. This study had a repeated measures design with a potential testing effect. There was no information regarding the patients' actual adherence to the prescribed frequency of yoga practice. Control patients had only one session in the perioperative phase and one follow-up session compared to the weekly visits for the intervention group. Baseline depression scores were higher in the control group. No information was provided regarding symptom management.

The findings of this study suggest that yoga is beneficial to women with breast cancer during active treatment to manage depressive symptoms. They also show that adverse symptoms were strongly related to depression, and depression was higher with more severe adverse symptoms. This points to the importance of effective symptom management as part of the overall reduction of depression.

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.

• N = 60  
• MEAN AGE: Age and range not provided; about 50% were below or above 50 years
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: All participants had breast cancer and were receiving adjuvant chemotherapy.
• OTHER KEY SAMPLE CHARACTERISTICS: 45% had a high school education and 33.3% had a university-and-above education 

• SITE: Single-site    
• SETTING TYPE: Outpatient    
• LOCATION: Taiwan

• PHASE OF CARE: Active antitumor treatment

Randomized, controlled trial

• Brief Fatigue Inventory (BFI)
• Profile of Mood States (POMS)

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.

• Small sample (< 100)
• Risk of bias (no blinding)
• Risk of bias (no appropriate attentional control condition)

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.

4,900 references were identified that were published between January 1, 1990 and December 31, 2013. 203 articles were included in the final review although only 174 were referenced. Grades used and reported here were A: recommended, high certainty of benefit, B: recommended, high certainty of moderate to substantial benefit, D: recommends against use, moderate to high certainty of no net benefit, and H: recommends against use, moderate to high certainty that harms outweigh benefits.

Interventions for specific symptoms that had strong recommendations for or against use were:

• Anxiety: Music therapy during RT and chemotherapy sessions, meditation, and yoga for patients undergoing therapy (B-level recommendation)
• Depression: Mindfulness-based stress reduction for patients undergoing radiotherapy, relaxation, and yoga (level A recommendation); massage and music therapy (level B)
• Fatigue: Energy conservation (level B)
• CINV: Acupressure and electroacupuncture in addition to antiemetics (B level)
• Neuropathy: Acetyl L carnitine was not recommended because of harm (H level).
• Radiodermatitis: Aloe vera and hyaluronic acid cream were not recommended as standard therapy because of lack of effect (D level).

It appears that only specific types of interventions were included, and there are numerous types of integrative or complementary interventions that were not considered in this review. The findings considered were limited to women with breast cancer. Quality rating of evidence was not discussed individually.

These guidelines provided an evidence-based evaluation of various integrative therapies in women with breast cancer. This set of interventions is not all-inclusive; however, it does provide some guidance to clinicians and others regarding evidence strength in these areas as assessed by this specific study group.