Examining Mediators and Moderators of Yoga for Women With Breast Cancer Undergoing Radiotherapy

A scoping review of the effect of chronic stretch training on sleep quality in people with sleep disorders

PURPOSE

The widespread and health-detrimental sleep disorders have resulted in stretching exercises being investigated as a non-drug solution for enhanced sleep quality. However, a comprehensive understanding of the impact of stretching exercises on individuals with sleep disorders is lacking.

METHODS

This scoping review systematically maps the existing literature and identifies research gaps on the impact of stretching exercises on sleep quality in individuals with sleep disorders.

RESULTS

Sixteen eligible studies were included, where the weighted mean changes indicate a positive trend in sleep quality improvement, ranging from trivial to very large magnitudes. However, concerning the individual study results only 5 out of 16 studies reported significant improvements. Notable enhancements include a small 1.22% overall sleep quality improvement, a large 6.51% reduction in insomnia severity, a large 8.88% increase in sleep efficiency, a moderate 4.36% decrease in sleep onset latency, a large 8.27% decrease in wake after sleep onset, and a very large 14.70% improvement in total sleep time. Trivial changes are noted in sleep duration (0.58%), sleep disturbance reduction (0.07%), and daytime dysfunction reduction (0.19%). Likely mechanisms for the improvement of sleep include autonomic nervous system modulation, muscle tension relief, cortisol regulation, enhanced blood circulation, and psychological benefits such as stress reduction and mood enhancement.

CONCLUSION

There is little evidence that stretching exercises positively impact sleep quality in individuals with sleep disorders. Additionally, further research is vital for designing optimal protocols, understanding of the long-term effects, and clarification of the mechanisms.

A survey of cancer patients' interest in undertaking exercise to promote relaxation during radiotherapy for breast cancer and metastatic cancer

BACKGROUND

Approximately 25-50% of patients undergoing radiotherapy (RT) experience psychological distress and anxiety, which can detrimentally affect both their quality of life and treatment outcomes. While previous research has demonstrated that relaxation exercises can enhance the tolerability of RT and alleviate associated stress and anxiety, the specific needs for such therapies in radiation oncology remain under-explored. This study aims to investigate the demand for and preferences toward relaxation exercises among radiotherapy patients, addressing a critical gap in patient-centered care.

METHODS

A prospective pseudonymized survey study using a one-time paper-based questionnaire was conducted from 2022 to 2023 among patients undergoing curative-intent RT for breast cancer or patients undergoing palliative RT for bone metastases. Patients were asked in a 11-item questionnaire about their anxiety, pre-existing practice of relaxation exercises/interventions, their interest in relaxation exercises, and preferences on the type and format of instruction. Data were analyzed descriptively.

RESULTS

100 patients (74 female and 26 male) responded, of whom 68 received curative-intent adjuvant RT and 32 palliative RT. Median age was 62 years. 78% of patients indicated a desire to be actively involved in their radiotherapy, but only 27% had used relaxation exercises prior to RT. 44.8% of both curatively and palliatively treated patients who wanted to be actively involved in their therapy desired to learn how to best relax. 56.4% of respondents were willing to spend extra time learning offered exercises.

CONCLUSION

The survey indicates that patients undergoing RT, both for curative or palliative intent, desire relaxation exercises to relieve stress and anxiety from RT. It is therefore important to assess the need for relaxation interventions in individual patients and to develop suitable programs or collaborate with other healthcare professionals to meet these needs.

Social Representativeness and Intervention Adherence-A Systematic Review of Clinical Physical Activity Trials in Breast Cancer Patients

Objectives

Representativeness in physical activity randomised controlled trials (RCT) in breast cancer patients is essential to analyses of feasibility and validity considering privileged- social groups. A step-by-step exclusion of less privileged groups through the trial process could reinforce health inequality. This study aimed at examining representativeness in breast cancer (BC) physical activity trials, investigate associations between socio-economic status (SES) and intervention adherence, and explore associations between representativeness and the relationship between SES and intervention adherence.

Methods

Systematic, computerised searches were performed in PubMed, CINAHL, AMED, EMBASE and PsycINFO. Additional citation-based searches retrieved 37 articles. Distributions of education level, ethnicity, and marital status in study samples were compared to national populations data to estimate representativeness in less privileged groups.

Results

A preponderance of studies favoured educated, married and white patients. Only six studies reported SES-adherence associations, hampering conclusions on this relationship and possible associations between representativeness and an SES-adherence relationship.

Conclusion

Less educated, unmarried and non-white individuals may be underrepresented in BC physical activity RCTs, while SES-adherence associations in such trials are inconclusive. Unintentional social misrepresentations may indicate that disguised inequity warrants revived attention.

Bibliometric Analysis of Randomized Controlled Trials on Yoga Interventions for Cancer Patients: A Decade in Review

This literature review presents a bibliometric analysis of the randomized controlled trials conducted between 2014 and 2023 on the potential benefits of yoga as a complementary therapy for cancer patients. To conduct this analysis, we searched medical and scientific databases, such as Scopus, Cochrane, and PubMed, using relevant keywords. Our search yielded 58 clinical trials involving 4,762 patients, which indicates a growing trend in this field of research. The studies we reviewed mainly focused on breast cancer patients and demonstrated the adaptability and versatility of yoga, offering a ray of hope and optimism. Among the various styles of yoga, Hatha yoga was the most frequently practiced style in these clinical trials. The analysis we conducted reveals that yoga interventions have a promising role in cancer care and can be a valuable complementary therapy for cancer patients. However, significant gaps and limitations still need to be addressed in this area of research. For instance, more rigorous and diverse investigations are needed to further establish the potential benefits of yoga interventions for cancer patients. Additionally, the standardization of yoga interventions is crucial to optimize therapeutic benefits. By addressing these gaps and limitations, we can further enhance the potential of yoga as a complementary therapy for cancer patients.

Comparative efficacy of mind-body exercise for depression in breast cancer survivors: A systematic review and network meta-analysis

BACKGROUND

As pharmacotherapy often leads to adverse reactions, mind-body exercise (MBE) treatments have become a more popular option for treating depression in people living with breast cancer (BC). However, the most effective type of MBE treatment for this population remains unclear.

AIMS

The aim of this systematic review and network meta-analysis (NMA) was to compare the efficacy of the different MBE modes for depression in people with BC.

METHODS

A systematic search for randomized controlled trials (RCTs) from inception to March 25, 2023, was conducted in the following database: EMBASE, PubMed, Web of Science, Cochrane Library, China National Knowledge Infrastructure, Wanfang Data, China Biology Medicine, OpenGrey, and ClinicalTrials.gov. A traditional meta-analysis was conducted using the random-effects model to directly assess the effectiveness of various MBE interventions. Stata 16.0 software was used for performing the NMA.

RESULTS

The NMA was performed in 32 eligible RCTs including 2361 participants. The efficacy of MBE treatments on depression was ranked as the following: Liuzijue (surface under the cumulative ranking curve [SUCRA] = 95.4%) > Tai chi (SUCRA = 76.9%) > yoga (SUCRA = 55.0%) > Baduanjin (SUCRA = 53.9%) > Pilates (SUCRA = 38.6%) > dance (SUCRA = 30.2%) > Qigong (SUCRA = 28.1%) > control (SUCRA = 21.9%).

LINKING EVIDENCE TO ACTION

Our research showed that Liuzijue and Tai chi might be the most significantly effective MBE intervention for mitigating depression among BC survivors. Healthcare professionals could consider recommending Liuzijue and Tai Chi as a complementary therapy for BC survivors who experience depression.

Efficacy of mind-body therapies for sleep disturbance in patients with early-stage cancer: A systematic review and network meta-analysis

OBJECTIVE

To evaluate and compare the efficacy of different mind-body therapies (MBTs) for sleep disturbance in patients with early-stage cancer.

METHODS

Randomised controlled trials that included patients (aged ≥18 years) with early stage cancer who underwent MBTs (mindfulness, hypnosis, relaxation, yoga, and qigong) were searched in the CINAHL via the EBSCO Host, Cochrane Library, Embase, MEDLINE, PsycINFO, PubMed, and Scopus databases, from the date of database inception to October 2022. The outcomes were subjective sleep disturbance and objective sleep efficiency. Network meta-analysis (NMA) and comparative effects ranking were performed using STATA (v14.0; STATACorp, College Station, TX, USA).

RESULTS

Forty-seven studies investigating five MBTs were included in the NMA. For cancer patients receiving active treatment, mindfulness demonstrated the largest effect size in reducing subjective sleep disturbance (standardised mean difference [SMD]: 0.85; 95% confidence intervals [CI]: 0.20-1.50; Grading of Recommendations Assessment, Development, and Evaluation assessment: moderate), and had the highest cumulative probability compared to usual care or waitlist. For cancer patients who had completed active treatment, qigong demonstrated the largest effect size in reducing subjective sleep disturbance (SMD: 0.99; 95% CI: 0.35-1.63; GRADE: low), followed by hypnosis (SMD: 0.87; 95% CI: 0.32-1.42; GRADE: moderate), and mindfulness (SMD: 0.42; 95% CI: 0.24-0.59; GRADE: moderate). Qigong also demonstrated the largest effect size in improving objective sleep efficiency (weighted mean differences: 10.76; 95% CI: 2.01-19.50; GRADE: low); however, the effect of qigong was tested in only one study in this NMA. Among the eight different treatment conditions, cognitive behavioral therapy (CBT) showed the highest cumulative probability (surface under the cumulative ranking curve: 96.3%) in reducing subjective sleep disturbance and the second highest cumulative probability (SUCRA: 83.3%) in improving objective sleep efficiency.

CONCLUSION

There is no evidence supporting the use of MBTs to replace or be comparable to CBT. Mindfulness can be recommended as an optional treatment for reducing sleep disturbance in patients with early-stage cancer. Some support was observed for qigong and hypnosis in reducing sleep disturbances in patients with early-stage cancer who had completed active treatment. More rigorous trials are warranted to confirm whether different forms of MBTs have different effects on sleep in patients with cancer.

Lessons From India: A Narrative Review of Integrating Yoga Within the US Healthcare System

The ancient practice of yoga has gained worldwide popularity as a way for people to improve their overall health and well-being. This manuscript reviews and examines the history of yoga, its physical and mental health benefits, its incorporation into the Indian healthcare system, and the public perception of yoga in India. Many initiatives for yoga exist, including promoting research on yoga, providing education and information on its benefits, and developing evidence-based standardized yoga therapy guidelines. With this in mind, this narrative review article explores the potential benefits of incorporating yoga into the United States (US) healthcare system and the possible challenges of doing so. It also provides valuable insights for policymakers and healthcare professionals.

Examining the Mechanisms behind Exercise's Multifaceted Impacts on Body Composition, Cognition, and the Gut Microbiome in Cancer Survivors: Exploring the Links to Oxidative Stress and Inflammation

This review focuses on the effects of exercise on various health-related outcomes in cancer survivors, encompassing body composition, cognitive function (including sleep), and gut microbiome health. By analyzing multiple studies, we aimed to summarize the existing evidence and shed light on underlying mechanisms. The findings strongly suggest that exercise serves as a multifaceted non-pharmacological strategy, playing a significant role in improving the overall health of cancer survivors by effectively reducing inflammation and oxidative stress. Exercise plays a crucial role in preventing muscle wasting, diminishing the presence of reactive oxygen species and pro-inflammatory cytokines, and enhancing antioxidant systems. Furthermore, exercise displays notable benefits in terms of executive cognitive functioning and fatigue alleviation, largely attributed to its anti-inflammatory impact on the central nervous system and its ability to induce neurogenesis via growth factors. Additionally, exercise positively influences microbial diversity, reduces gut inflammation, and enhances neurogenesis through the gut-brain axis. Our key findings underscore the reduction of oxidative stress and inflammation as primary mechanisms by which exercise effectively enhances health outcomes in cancer survivors. By delving deeper into these candidate mechanisms, we aim to provide valuable guidance for future research and interventions targeting the symptoms experienced by cancer survivors.

Meta-analysis of effects of yoga exercise intervention on sleep quality in breast cancer patients

Objective

This study seeks to systematically evaluate and test the effects of yoga exercise intervention programs on sleep quality in breast cancer patients in order to suggest more optimized exercise programs.

Method

Computer searches of the PubMed, Embase, Cochrane Library, Web of Science and CINAHL databases are conducted from the date of their inception to June 8^th, 2022 to collect randomized controlled trials on the effects of yoga exercise intervention on sleep quality in breast cancer patients. Two investigators independently carry out the inclusion and exclusion criteria literature screening, data extraction and methodological quality assessment of the included literature by applying the Cochrane risk of bias tool. Subgroup analysis is performed using RevMan 5.4.1 software, and the six moderating variables of intervention format, intervention type, weekly intervention frequency, total intervention duration, single intervention duration and intervention evaluation at different time points are set for the 782 subjects of the 12 included publications.

Results

Twelve randomized controlled trials with a total sample size of 782 subjects are included, including 393 subjects in the experimental group and 389 subjects in the control group. The meta-analysis shows that yoga exercise intervention is effective in improving sleep quality in breast cancer patients [SMD = -0.40, 95% CI: (-0.71, -0.09), P = 0.01]; yoga exercise intervention focusing on positive meditation [SMD = -0.55, 95% CI: (-1.08, -0.03), P = 0.04] is effective in improving sleep; yoga exercise intervention two or three times a week is effective in improving sleep quality [SMD = -0.69, 95% CI: (-1.19, -0.19), P = 0.007]; yoga exercise intervention for 6-8 weeks significantly improves sleep quality [SMD = -0.86, 95% CI: (-1.65, -0.08), P =0.03]; and evaluation immediately after the end of intervention improves sleep outcomes [SMD = -0.17, 95% CI: (-0.33, 0.00), P = 0.05], while differences in sleep quality improvement are not statistically significant for the remaining subgroup outcomes (P > 0.05).

Conclusion

The available evidence suggests that yoga exercise intervention has good effects on improving sleep quality in breast cancer patients. Positive meditation intervention type, intervention frequency of two or three times per week, total intervention duration of 6-8 weeks and evaluation immediately after the end of intervention are shown to be effective in improving sleep quality.

Mind-Body Therapies for Sleep Disturbance among Patients with Cancer: A Systematic Review and Meta-analysis

OBJECTIVE

s: To assess whether mind-body therapies (MBTs) are effective for relieving sleep disturbance among patients with cancer.

DESIGN

Systematic review and meta-analysis of randomized controlled trials (RCTs).

METHODS

Seven English electronic databases were searched from the date of inception to September 2022. All RCTs that included adults (≥18 years) who were treated with mindfulness, yoga, qigong, relaxation, and hypnosis were screened. The outcome was subjective and/or objective sleep disturbance.The revised Cochrane tool (RoB 2.0) was applied to evaluate the risk of bias. The RevMan software was applied to assessed each outcome according different control groups and assessment time points. Subgroup analyses were performed according to different categories of MBTs.

RESULTS

Sixty-eight RCTs (6339 participants) were identified. After requesting for missing data from corresponding authors of included RCTs, 56 studies (5051 participants) were included in the meta-analysis. The meta-analysis showed a significant immediate effect of mindfulness, yoga, relaxation, and hypnosis on subjective sleep disturbance, compared with usual care or wait list control, and the effect of mindfulness lasted at least 6 months. For objective sleep outcomes, we observed significant immediate effects of yoga on wake after sleep onset and of mindfulness on sleep onset latency and total sleep time. Compared with active control interventions, MBTs had no significant effect on sleep disturbance.

CONCLUSIONS

Mindfulness, yoga, relaxation, and hypnosis were effective in sleep disturbance severity reduction among patients with cancer at post-intervention, and the effect of mindfulness lasted at least 6 months. Future MBTs studies should apply both objective and subjective sleep measurement tools.

Exercise interventions for adults with cancer receiving radiation therapy alone

BACKGROUND

Radiation therapy (RT) is given to about half of all people with cancer. RT alone is used to treat various cancers at different stages. Although it is a local treatment, systemic symptoms may occur. Cancer- or treatment-related side effects can lead to a reduction in physical activity, physical performance, and quality of life (QoL). The literature suggests that physical exercise can reduce the risk of various side effects of cancer and cancer treatments, cancer-specific mortality, recurrence of cancer, and all-cause mortality.

OBJECTIVES

To evaluate the benefits and harms of exercise plus standard care compared with standard care alone in adults with cancer receiving RT alone.

SEARCH METHODS

We searched CENTRAL, MEDLINE (Ovid), Embase (Ovid), CINAHL, conference proceedings and trial registries up to 26 October 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that enrolled people who were receiving RT without adjuvant systemic treatment for any type or stage of cancer. We considered any type of exercise intervention, defined as a planned, structured, repetitive, objective-oriented physical activity programme in addition to standard care. We excluded exercise interventions that involved physiotherapy alone, relaxation programmes, and multimodal approaches that combined exercise with other non-standard interventions such as nutritional restriction.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodology and the GRADE approach for assessing the certainty of the evidence. Our primary outcome was fatigue and the secondary outcomes were QoL, physical performance, psychosocial effects, overall survival, return to work, anthropometric measurements, and adverse events.

MAIN RESULTS

Database searching identified 5875 records, of which 430 were duplicates. We excluded 5324 records and the remaining 121 references were assessed for eligibility. We included three two-arm RCTs with 130 participants. Cancer types were breast and prostate cancer. Both treatment groups received the same standard care, but the exercise groups also participated in supervised exercise programmes several times per week while undergoing RT. Exercise interventions included warm-up, treadmill walking (in addition to cycling and stretching and strengthening exercises in one study), and cool-down. In some analysed endpoints (fatigue, physical performance, QoL), there were baseline differences between exercise and control groups. We were unable to pool the results of the different studies owing to substantial clinical heterogeneity. All three studies measured fatigue. Our analyses, presented below, showed that exercise may reduce fatigue (positive SMD values signify less fatigue; low certainty). • Standardised mean difference (SMD) 0.96, 95% confidence interval (CI) 0.27 to 1.64; 37 participants (fatigue measured with Brief Fatigue Inventory (BFI)) • SMD 2.42, 95% CI 1.71 to 3.13; 54 participants (fatigue measured with BFI) • SMD 1.44, 95% CI 0.46 to 2.42; 21 participants (fatigue measured with revised Piper Fatigue Scale) All three studies measured QoL, although one provided insufficient data for analysis. Our analyses, presented below, showed that exercise may have little or no effect on QoL (positive SMD values signify better QoL; low certainty). • SMD 0.40, 95% CI -0.26 to 1.05; 37 participants (QoL measured with Functional Assessment of Cancer Therapy-Prostate) • SMD 0.47, 95% CI -0.40 to 1.34; 21 participants (QoL measured with World Health Organization QoL questionnaire (WHOQOL-BREF)) All three studies measured physical performance. Our analyses of two studies, presented below, showed that exercise may improve physical performance, but we are very unsure about the results (positive SMD values signify better physical performance; very low certainty) • SMD 1.25, 95% CI 0.54 to 1.97; 37 participants (shoulder mobility and pain measured on a visual analogue scale) • SMD⁠⁠⁠⁠⁠⁠ 3.13 (95% CI 2.32 to 3.95; 54 participants (physical performance measured with the six-minute walk test) Our analyses of data from the third study showed that exercise may have little or no effect on physical performance measured with the stand-and-sit test, but we are very unsure about the results (SMD 0.00, 95% CI -0.86 to 0.86, positive SMD values signify better physical performance; 21 participants; very low certainty). Two studies measured psychosocial effects. Our analyses (presented below) showed that exercise may have little or no effect on psychosocial effects, but we are very unsure about the results (positive SMD values signify better psychosocial well-being; very low certainty). • SMD 0.48, 95% CI -0.18 to 1.13; 37 participants (psychosocial effects measured on the WHOQOL-BREF social subscale) • SMD 0.29, 95% CI -0.57 to 1.15; 21 participants (psychosocial effects measured with the Beck Depression Inventory) Two studies recorded adverse events related to the exercise programmes and reported no events. We estimated the certainty of the evidence as very low. No studies reported adverse events unrelated to exercise. No studies reported the other outcomes we intended to analyse (overall survival, anthropometric measurements, return to work).

AUTHORS' CONCLUSIONS

There is little evidence on the effects of exercise interventions in people with cancer who are receiving RT alone. While all included studies reported benefits for the exercise intervention groups in all assessed outcomes, our analyses did not consistently support this evidence. There was low-certainty evidence that exercise improved fatigue in all three studies. Regarding physical performance, our analysis showed very low-certainty evidence of a difference favouring exercise in two studies, and very low-certainty evidence of no difference in one study. We found very low-certainty evidence of little or no difference between the effects of exercise and no exercise on quality of life or psychosocial effects. We downgraded the certainty of the evidence for possible outcome reporting bias, imprecision due to small sample sizes in a small number of studies, and indirectness of outcomes. In summary, exercise may have some beneficial outcomes in people with cancer who are receiving RT alone, but the evidence supporting this statement is of low certainty. There is a need for high-quality research on this topic.

Physical Activity and Cortisol Regulation: A Meta-Analysis

Physical activity participation is associated with effective stress coping, indicated by decreases in both physiological stress reactivity and perceived stress. Quantifying the effect of physical activity on the diurnal regulation of one key physiological stress indicator, the stress hormone, cortisol, across studies may demonstrate the extent to which physical activity participation is associated with diurnal HPA axis regulation. We meta-analyzed studies examining relations between physical activity participation and indices of HPA axis regulation: the diurnal cortisol slope and the cortisol awakening response. We also examined moderators of the relation. The analysis revealed a small, non-zero negative averaged correlation between physical activity and the diurnal cortisol slope (r = -0.043, 95% CI [-0.080, -0.004]). Examination of sample sociodemographic differences, study design characteristics, cortisol measurement methods, and physical activity variables as moderators revealed few effects on the relation between physical activity and diurnal cortisol slope. We did not observe lower levels of variability in the mean cortisol awakening response at higher levels of physical activity participation, and moderator analyses showed little evidence of reductions in heterogeneity for this effect. We found some evidence of systematic publication bias. Findings suggest higher physical activity is associated with a steeper diurnal cortisol slope. However, the cortisol awakening response did not differ by physical activity level. Future studies testing the physical activity and cortisol regulation association should use standardized physical activity measures, follow guidelines for better quality cortisol sampling collection and analysis, and test relations in large-scale empirical studies to confirm the direction and causality of the effect.

How do Body Practices Affect the Psychological Aspects of Survivors Women Undergoing Treatment for Breast Cancer? Systematic Literature Review

Introduction: Body practices can bring physical, psychological benefits and social rehabilitation and may be an alternative treatment for breast cancer. Objective: To analyze the evidence of the results of body practices over the psychological aspects of survivors women undergoing treatment for breast cancer. Method: Systematic blind and independent review from September to December 2021 following the PRISMA guidelines, carried out in the databases: Embase Elsevier; PubMed Central; ScienceDirect; Scopus Elsevier and Web of Science – Core Collection. Results: Of 1,372 studies identified, 22 were included in this systematic review. Among the practices that stood out are meditation and Yoga, with anxiety being the most investigated variable by the studies. It is clear that body practices are options for non-pharmacological clinical treatments utilized in clinical practice by different health professionals in women who have survived breast cancer. Conclusion: Body practices proved to be beneficial in the treatment and psychological health of women who survived breast cancer. This evidence may help to implement body practices as a therapeutic resource to be used in the clinical practice of health professionals. However, more randomized clinical trials that follow study protocols more rigorously are suggested, so that the effectiveness of this approach can be evaluated in different clinical outcomes.

Effects of yoga practice on physiological distress, fatigue and QOL in patients affected by breast cancer undergoing adjuvant radiotherapy

Background and purpose

In this study we want to evaluate the efficacy of yoga practice on dysfunctional stress, inflammation and QOL in breast cancer patients undergoing adjuvant radiotherapy.

Patients and methods

Patients with stage 0 to III breast cancer were recruited before starting radiotherapy (XRT) and were randomly assigned to yoga group (YG) two times a week during XRT or control group (CG). Self-report measures of QOL, fatigue and sleep quality, and blood samples were collected at day 1 of treatment, day 15, end of treatment and 1, 3 and 6 months later. Cortisol blood level, IL6, IL10, IL1RA, TNFα and lymphocyte-to-monocyte ratio were analyzed as measures of dysfunctional stress and inflammation.

Results

Patients started XRT and yoga classes in October 2019. Due to COVID-19 pandemic we closed the enrollment in March 2020. We analysed 24 patients, 12 YG and 12 CG. The analysis of blood cortisol levels revealed an interaction (p = 0.04) between yoga practice and time, in particular YG had lower cortisol levels at the end of XRT respect to CG (p-adj = 0.02). The analysis of IL-1RA revealed an interaction effect (p = 0.04) suggesting differences between groups at some time points that post-hoc tests were not able to detect.

Conclusions

To our knowledge, this is the first study to evaluate the effects of yoga in a cancer population studying inflammation markers, cortisol trend and QOL during and until 6 months after XRT. This study suggests that yoga practice is able to reduce stress and inflammation levels over time. Besides including a larger number of patients to increase the power, future studies should consider other inflammatory or pro inflammatory factors and long-term yoga program to gain more evidence on yoga practice benefits.

Physical Activity and Health-Related Quality of Life in Women With Breast Cancer: A Meta-Analysis

BACKGROUND

Physical activity (PA) is associated with improved health-related quality of life (HRQoL) among women with breast cancer; however, uncertainty remains regarding PA types and dose (frequency, duration, intensity) and various HRQoL measures. A systematic review and meta-analysis of randomized controlled trials was conducted to clarify whether specific types and doses of physical activity was related to global and specific domains of HRQoL, as part of the Global Cancer Update Programme, formerly known as the World Cancer Research Fund-American Institute for Cancer Research Continuous Update Project.

METHODS

PubMed and CENTRAL databases were searched up to August 31, 2019. Weighted mean differences (WMDs) in HRQoL scores were estimated using random effects models. An independent expert panel graded the evidence.

RESULTS

A total of 79 randomized controlled trials (14 554 breast cancer patients) were included. PA interventions resulted in higher global HRQoL as measured by the Functional Assessment of Cancer Therapy-Breast (WMD = 5.94, 95% confidence intervals [CI] = 2.64 to 9.24; I2 = 59%, n = 12), Functional Assessment of Cancer Therapy-General (WMD = 4.53, 95% CI = 1.94 to 7.13; I2 = 72%, n = 18), and European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30 (WMD = 6.78, 95% CI = 2.61 to 10.95; I2 = 76.3%, n = 17). The likelihood of causality was considered probable that PA improves HRQoL in breast cancer survivors. Effects were weaker for physical function and mental and emotional health. Evidence regarding dose and type of PA remains insufficient for firm conclusions.

CONCLUSION

PA results in improved global HRQoL in breast cancer survivors with weaker effects observed for physical function and mental and emotional health. Additional research is needed to define the impact of types and doses of activity on various domains of HRQoL.

The effects of physical activity on cortisol and sleep: A systematic review and meta-analysis

BACKGROUND

Managing stress and having good quality sleep are inter-related factors that are essential for health, and both factors seem to be affected by physical activity. Although there is an established bidirectional relationship between stress and sleep, remarkably few studies have been designed to examine the effects of physical activity on cortisol, a key biomarker for stress, and sleep. Research is particularly scarce in older people despite both sleep and cortisol changing with age. This systematic literature review addresses this gap.

METHODS

A systematic review was conducted following the PRISMA guidelines. Original, peer-reviewed records of intervention studies such as randomized controlled trials (RCTs) and non-RCTs with relevant control groups were eligible for inclusion. The Participant, Intervention, Comparison, Outcome (PICO) characteristics were (1) adults or older adults (2) physical activity programmes of any duration, (3) controls receiving no intervention or controls included in a different programme, (4) cortisol measurement, and subjective or objective measures of sleep.

RESULTS

Ten original studies with low-to-moderate risk of bias were included. Findings from this review indicated with moderate- and low-certainty evidence, respectively, that physical activity was an effective strategy for lowering cortisol levels (SMD [95% CI] = -0.37 [-0.52, -0.21] p < .001) and improving sleep quality (SMD [95% CI] = -0.30 [-0.56, -0.04], p = .02). Caution is needed to generalize these findings to the general population, as included trials were predominantly participants with breast cancer, included few males and no older adults.

CONCLUSION

Cortisol regulation and sleep quality are intertwined, and physical activity programmes could improve both in several ways. Further, physical activity may benefit adults with long term conditions or current poor (mental) health states the most, although more research is needed to support this claim fully. Few intervention studies have examined the inter-relationship between cortisol and sleep outcomes in males or older adults, indicating fruitful enquiry for future research.

Do Breast Cancer Patients Manage to Participate in an Outdoor, Tailored, Physical Activity Program during Adjuvant Breast Cancer Treatment, Independent of Health and Socio-Demographic Characteristics?

Exercise could reduce the side-effects of adjuvant breast cancer treatment; however, socio-demographic, health, and intervention conditions may affect patients’ adherence to interventions. This study aimed to examine adherence to a 12-month outdoor post-surgery exercise program among newly diagnosed breast cancer patients during adjuvant treatment, and to identify socio-demographic and health-related predictors. In total, 47 women with invasive breast cancer stage I–II or ductal/lobular carcinoma grade 3 were included pre-surgery and randomized two weeks post-surgery to exercise (2 × 60 min/week). Patient characteristics (body-mass index (BMI), socioeconomic status, comorbidity, physical activity, and maximal oxygen uptake (VO2max)) were recorded pre-surgery. Correlations between adherence and patient characteristics and statistics for between-group differences were performed. The mean age was 54.2 years, mean BMI 27.8 kg/m², and 54.2% received chemotherapy. Completers had a mean adherence of 81%, independent of season. Withdrawals (23%) occurred after a mean of 6.5 weeks (0–24 weeks), they were suggestively older, had lower socioeconomic status and pre-surgery VO2max, and higher BMI. Household income was significantly lower among withdrawals. There were insignificant correlations between adherence and health conditions. High adherence is achievable in a Nordic outdoor physical exercise program in breast cancer patients during adjuvant treatment, including chemotherapy. Additional studies are needed to clarify follow-up needs in some groups.

Sleep moderates the effects of Tibetan yoga for women with breast cancer undergoing chemotherapy

This study examined self-reported and actigraphy-assessed sleep and depression as moderators of the effect of a Tibetan yoga intervention on sleep and depression among women undergoing chemotherapy for breast cancer. This is a secondary analysis of an RCT examining a 4-session Tibetan yoga program (TYP; n = 74) versus stretching program (STP; n = 68) or usual care (UC; n = 85) on self-reported sleep (Pittsburgh Sleep Quality Index (PSQI), actigraphy-assessed sleep efficiency (SE)) and depression (Centers for Epidemiological Studies Depression Scale; CES-D) for women undergoing chemotherapy for breast cancer. Data were collected at baseline and 1-week and 3-month post-intervention. Baseline PSQI, actigraphy-SE, and CES-D were examined as moderators of the effect of group on PSQI, actigraphy-SE, and CES-D 1 week and 3 months after treatment. There was a significant baseline actigraphy-SE × group effect on PSQI at 1 week (p < .001) and 3 months (p = .002) and on CES-D at 3 months (p = .049). Specifically, the negative association of baseline actigraphy-SE with subsequent PSQI and CES-D was buffered for women in the TYP and, to a lesser extent in STP, compared to those in the UC. Baseline PSQI and CES-D were not significant moderators of the effect of group on any outcome. Behaviorally assessed sleep may be a more robust indicator of which patients are most appropriate for a yoga intervention than self-reported sleep quality. Women with poor sleep efficiency may derive the greatest benefit in terms of sleep quality and mood from a yoga intervention.

Biobehavioral Pathways and Cancer Progression: Insights for Improving Well-Being and Cancer Outcomes

The relationship between psychosocial factors and cancer has intrigued people for centuries. In the last several decades there has been an expansion of mechanistic research that has revealed insights regarding how stress activates neuroendocrine stress-response systems to impact cancer progression. Here, we review emerging mechanistic findings on key pathways implicated in the effect of stress on cancer progression, including the cellular immune response, inflammation, angiogenesis, and metastasis, with a primary focus on the mediating role of the sympathetic nervous system. We discuss converging findings from preclinical and clinical cancer research that describe these pathways and research that reveals how these stress pathways may be targeted via pharmacological and mind-body based interventions. While further research is required, the body of work reviewed here highlights the need for and feasibility of an integrated approach to target stress pathways in cancer patients to achieve comprehensive cancer treatment.

Perceptions of benefits and barriers to Yoga practice across rural and urban India: Implications for workplace Yoga

BACKGROUND

Even though Yoga is useful for prevention of obesity, diabetes and hypertension it is not universally practiced. The purpose of the study was to determine the benefits and barriers confronted by the community members while incorporating Yoga into routine practice and at workplace.

OBJECTIVE

This study explored the motivators and barriers to Yoga practice by estimating how these elements can be useful for development and incorporation of Yoga as a workplace activity and as a profession.

METHODS

A nationwide multi-centered prospective study was conducted recruiting individuals of different age groups and geographical zones in India. Participants of Yoga intervention group were administered a questionnaire with 19 items on benefits (YBS) and 18 items on barriers for Yoga practice (BFYS). Data was analyzed using SPSS v21 software.

RESULTS

Majority of the participants perceived Yoga improves "physical fitness", "relaxes mind and body", improves "stamina", across age groups. "Lifestyle", "Family commitments", "Physical over-exertion", "No Encouragement from family", "Occupational commitments" and "Few places to do Yoga" were perceived barriers across various geographical zones. Despite knowing the benefits of Yoga, these barriers prevented individuals from integrating it into their daily routine.

CONCLUSIONS

The present study may be considered as a starting point for development of Yoga as a workplace activity and a profession based on the perceptions of its various benefits and barriers faced by a large study population spanning an entire nation.

The effect of yoga on sleep quality and insomnia in women with sleep problems: a systematic review and meta-analysis

BACKGROUND

To examine the effectiveness and safety of yoga of women with sleep problems by performing a systematic review and meta-analysis.

METHODS

Medline/PubMed, ClinicalKey, ScienceDirect, Embase, PsycINFO, and the Cochrane Library were searched throughout the month of June, 2019. Randomized controlled trials comparing yoga groups with control groups in women with sleep problems were included. Two reviewers independently evaluated risk of bias by using the risk of bias tool suggested by the Cochrane Collaboration for programming and conducting systematic reviews and meta-analyses. The main outcome measure was sleep quality or the severity of insomnia, which was measured using subjective instruments, such as the Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), or objective instruments such as polysomnography, actigraphy, and safety of the intervention. For each outcome, a standardized mean difference (SMD) and confidence intervals (CIs) of 95% were determined.

RESULTS

Nineteen studies in this systematic review included 1832 participants. The meta-analysis of the combined data conducted according to Comprehensive Meta-Analysis showed a significant improvement in sleep (SMD = - 0.327, 95% CI = - 0.506 to - 0.148, P < 0.001). Meta-analyses revealed positive effects of yoga using PSQI scores in 16 randomized control trials (RCTs), compared with the control group in improving sleep quality among women using PSQI (SMD = - 0.54; 95% CI = - 0.89 to - 0.19; P = 0.003). However, three RCTs revealed no effects of yoga compared to the control group in reducing insomnia among women using ISI (SMD = - 0.13; 95% CI = - 0.74 to 0.48; P = 0.69). Seven RCTs revealed no evidence for effects of yoga compared with the control group in improving sleep quality for women with breast cancer using PSQI (SMD = - 0.15; 95% CI = - 0.31 to 0.01; P = 0.5). Four RCTs revealed no evidence for the effects of yoga compared with the control group in improving the sleep quality for peri/postmenopausal women using PSQI (SMD = - 0.31; 95% CI = - 0.95 to 0.33; P = 0.34). Yoga was not associated with any serious adverse events.

DISCUSSION

This systematic review and meta-analysis demonstrated that yoga intervention in women can be beneficial when compared to non-active control conditions in term of managing sleep problems. The moderator analyses suggest that participants in the non-breast cancer subgroup and participants in the non-peri/postmenopausal subgroup were associated with greater benefits, with a direct correlation of total class time with quality of sleep among other related benefits.

The relationship between post-traumatic stress and post-traumatic growth in cancer patients and survivors: A systematic review and meta-analysis

OBJECTIVE

Research on the relationship between post-traumatic stress disorder (PTSD)/post-traumatic stress symptoms (PTSS) and post-traumatic growth (PTG) in cancer patients and survivors is increasing.

METHODS

We conducted a systematic review and meta-analysis of 51 studies that assessed the relationship between PTSD/PTSS and PTG, in cancer patients/survivors. Five databases were searched through 29 April 2019. The purpose of this manuscript is to report a summary of this literature, the aggregate effect size of the relationship between PTSD and PTG, and the examination of potential moderators that may impact the relationship between PTSD and PTG.

RESULTS

The aggregate weighted effect size for the association between PTSD/PTSS and PTG was small, r = .08, but significantly different from zero. We examined whether time since diagnosis, stage of cancer, type of measure used to assess PTSD/PTSS, or type of measure used to assess PTG explained the significant heterogeneity among the individual effect sizes. The relationship was significantly stronger for the small subset of studies that included only stage 4 patients compared with those that included only non-stage 4 patients. Additionally, the strongest relationship was for those studies that used the Impact of Events Scale-Revised to assess PTSD.

CONCLUSIONS

The relationship between PTSD/PTSD and PTG is modestly positive and robust. There is evidence that the threat of advanced cancer is more strongly associated with growth, but none supporting that more time since cancer diagnosis allows survivors the opportunity to positively reinterpret and find meaning in the traumatic aspects of the disease resulting in more growth.

Yoga for symptom management in oncology: A review of the evidence base and future directions for research

Because yoga is increasingly recognized as a complementary approach to cancer symptom management, patients/survivors and providers need to understand its potential benefits and limitations both during and after treatment. The authors reviewed randomized controlled trials (RCTs) of yoga conducted at these points in the cancer continuum (N = 29; n = 13 during treatment, n = 12 post-treatment, and n = 4 with mixed samples). Findings both during and after treatment demonstrated the efficacy of yoga to improve overall quality of life (QOL), with improvement in subdomains of QOL varying across studies. Fatigue was the most commonly measured outcome, and most RCTs conducted during or after cancer treatment reported improvements in fatigue. Results also suggested that yoga can improve stress/distress during treatment and post-treatment disturbances in sleep and cognition. Several RCTs provided evidence that yoga may improve biomarkers of stress, inflammation, and immune function. Outcomes with limited or mixed findings (eg, anxiety, depression, pain, cancer-specific symptoms, such as lymphedema) and positive psychological outcomes (such as benefit-finding and life satisfaction) warrant further study. Important future directions for yoga research in oncology include: enrolling participants with cancer types other than breast, standardizing self-report assessments, increasing the use of active control groups and objective measures, and addressing the heterogeneity of yoga interventions, which vary in type, key components (movement, meditation, breathing), dose, and delivery mode.

A randomized controlled trial of a guided self-disclosure intervention to facilitate benefit finding in Chinese breast cancer patients: Study protocol

AIM

To describe a protocol that examines the feasibility and effectiveness of a face-to-face guided self-disclosure intervention for facilitating benefit finding and other related psychological outcomes for breast cancer patients.

BACKGROUND

Benefit finding can promote a positive attitude among patients facing disease. However, limited studies have focused on improving benefit finding among breast cancer patients. Previous research has been based on group interventions, which may not suit all patients. Self-disclosure was recognized as a strong predictor of benefit finding. This protocol is based on a brief face-to-face disclosure intervention to improve benefit finding for breast cancer patients.

DESIGN

A non-blinded randomized controlled trial.

METHODS

A total of 154 patients with breast cancer who have undergone radical mastectomy will be randomly assigned to either the experimental group, which will participate in a six-session face-to-face individual intervention, or the control group at a ratio of 1:1. Baseline assessments will take place after the breast cancer diagnosis, with follow-up assessments at 3, 6 and 9 months after baseline. The primary outcome is benefit finding; other outcomes are self-disclosure, cognitive reappraisal, social support, optimism and medical coping modes.

DISCUSSION

This study is to design a protocol for guided self-disclosure interventions to promote benefit finding in Chinese breast cancer patients. If this intervention is feasible and effective, it could be implemented in clinical practice.

IMPACT

This study will provide useful advice for health professionals to guide breast cancer patients in benefit finding during stressful events. If it is effective, it will be implemented broadly in clinical practice.

Examining cancer survivorship trajectories: Exploring the intersection between qualitative illness narratives and quantitative screening instruments

OBJECTIVE

This article examines the associations of quantitatively refined trajectories of adjustment to cancer survivorship determined by previously published qualitative narrative analysis.

METHOD

Patients completed measures of cancer-related worry (Cancer Related Worries Scale), depression (Patient Health Questionnaire-9), posttraumatic growth (Benefit Finding Scale), and open-ended survey questions 6, 12, and 18 months postdiagnosis of head and neck, esophageal, gastric, or colorectal cancer. Previously published narrative analysis revealed five distinct survivorship "paths," which were combined into four paths in the present article: Moving On, Seeing the World Differently, Taking One Day at a Time, and Never the Same. To determine the association of qualitatively determined paths with quantitatively assessed adjustment (i.e., Cancer Related Worries Scale, Patient Health Questionnaire-9, Benefit Finding Scale), we used linear multilevel modeling to regress the adjustment variables on time, path, the time-by-path interaction, and relevant covariates (age, stage, cancer site, ethnicity, and Deyo score).

RESULTS

There was a significant main effect of path on cancer worry, depression, and posttraumatic growth (p < 0.02 for all). Patients in the Moving On group reported consistently low worry, depression, and growth compared to the other groups. Patients in the Seeing the World Differently and Taking One Day at a Time paths both reported moderate worry and depression; but those in the Seeing the World Differently path reported the highest posttraumatic growth, whereas patients in the Taking One Day at a Time path reported little growth. Finally, patients in the Never the Same path reported the highest worry and depression but lowest posttraumatic growth.Significance of resultsThis longitudinal study reinforces the notion that cancer survivorship is not a one-size-fits-all experience nor a dichotomized experience of "distress" or "no distress." Additionally, this hypothesis-generating study suggests future directions for potential self-report measures to help clinicians identify cancer survivors' trajectory to develop a more patient-centered survivorship care plan.

Differences between Supportive Music and Imagery and Music Listening during Outpatient Chemotherapy and Potential Moderators of Treatment Effects

BACKGROUND

Supportive music and imagery and music listening interventions have been effective in decreasing distress and improving mood in cancer patients receiving chemotherapy, but it is unclear whether the two interventions differ in their treatment benefits. Furthermore, previous studies have not examined moderators to determine which subgroup(s) of patients may benefit most from each intervention.

OBJECTIVE

To examine the effects of supportive music and imagery compared with preferred music listening on responsiveness to music therapy, distress, anxiety and depression, and benefit finding. A secondary purpose was to explore sense of coherence and locus of control as potential moderators of intervention effectiveness.

METHODS

A single-session, two-group comparative effectiveness randomized trial in two cancer centers. Patients were randomized to supportive music and imagery or preferred music listening during outpatient chemotherapy treatment. Data were collected at baseline and immediately after the 45-minute session. ANCOVA models were used to determine main effects of intervention as well as pairing potential moderators with group assignment to explore differences in intervention effects by moderator.

RESULTS

There were differential effects between the two interventions with the supportive music and imagery group scoring higher in responsiveness to music therapy and benefit finding. The music listening group scores indicated lower distress. The exploratory moderating analyses suggested Health Locus of Control-Internal and Sense of Coherence influenced intervention effectiveness.

CONCLUSIONS

Music and imagery and preferred music listening experiences may serve different therapeutic purposes, access and activate different patient resources, and may be helpful at different stages of treatment.

Perceived stress moderates the effects of a randomized trial of dance movement therapy on diurnal cortisol slopes in breast cancer patients

Women with breast cancer are at risk of psychosocial distress and may suffer from aberrant diurnal cortisol rhythms. Dance movement therapy (DMT), a movement-based psychotherapy that incorporates exercise and artistic components, has demonstrated stress reduction effects. This study examined the effects of DMT on the diurnal cortisol rhythms of breast cancer patients undergoing radiotherapy treatment and the role of perceived stress in producing such effects. The study sample comprised 121 Chinese breast cancer patients randomized to the DMT (n=63) and control (n=58) groups. The intervention consisted of six 1.5-h group sessions held twice weekly over the course of radiotherapy. Participants completed validated self-report measures of perceived stress, fatigue, pain, and sleep disturbance and provided five salivary cortisol samples at baseline (Time 1) and post-intervention (Time 2). Moderated mediation analysis was used to evaluate the intervention effect on Time 2 diurnal cortisol slopes. Despite the absence of a significant DMT effect on diurnal cortisol slopes (B=-0.55, 95% CI=-1.20 to 0.08, β=-0.14), baseline perceived stress significantly moderated the intervention effect (B=-0.18, 95% CI=-0.32 to -0.05, β=-0.30). At high levels of baseline perceived stress (1 SD above the mean), the DMT group showed a steeper cortisol slope (M=-7.14) than the control group (M=-5.80) at Time 2. The present findings suggest that DMT might have a beneficial effect on diurnal cortisol slopes in breast cancer patients with high levels of distress.

Yoga research review

This paper is a review of empirical studies, review and meta-analysis publications on yoga from the last few years. The review includes demographics/prevalence of yoga as a practice, bibliometric analyses of the yoga publications and the use of yoga for physical fitness and cognitive function. Most of the studies reviewed here involve yoga effects on psychiatric and medical conditions. These include pregnancy, prenatal and postpartum depression; stress, PTSD, anxiety, and obesity; cardiovascular conditions including hypertension; pain syndromes including arthritis, headaches and low back pain; autoimmune conditions including asthma, type II diabetes and multiple sclerosis; immune conditions including HIV and breast cancer; and aging problems including balance, osteoporosis and Parkinson's. The methods and results of those studies are briefly summarized along with their limitations and suggestions for future research. Basically yoga has been more effective than control and waitlist control conditions, although not always more effective than treatment comparison groups such as other forms of exercise. More randomized controlled studies are needed in which yoga is compared to active exercise groups. Having established the physical and mental health benefits of yoga makes it ethically questionable to assign participants to inactive control groups. Shorter sessions should be investigated for cost-effectiveness and for daily practice. Multiple physical and physiological measures need to be added to the self-report research protocols and potential underlying mechanisms need to be further explored. In the interim, the studies reviewed here highlight the therapeutic effects of yoga, a practice that could come to be called yoga therapy.