Yoga and cancer care: Guide your patients down the right path

ABSTRACT: While yoga’s adaptability makes it appropriate for most cancer patients, not all classes are created equal.

Dr. McCall is a board-certified internist and the medical editor of Yoga Journal. He is the author of Yoga as Medicine: The Yogic Prescription for Health and Healing (Bantam, 2007). He can be found on the Web at www.DrMcCall.com. Increasing evidence suggests that yoga, the ancient Indian mind-body discipline, can be a useful adjunct to standard care for cancer patients. Yoga-which includes a variety of techniques, including physical postures, breathing, meditation, and relaxation exercises-appears to have utility for patients undergoing radiation therapy and chemotherapy, patients in remission who have completed their treatments, and patients in hospice or palliative care.

One feature of yoga that makes it appropriate for most cancer patients is its adaptability. An experienced yoga teacher or yoga therapist (a teacher who specializes in using yoga for a variety of health problems) can evaluate each student and develop a personalized approach based on the student’s diagnosis, comorbidities, and overall health and fitness level.

While many yoga classes, especially those taught in health clubs, are too vigorous for patients undergoing cancer treatments or debilitated by disease, gentle classes tailored to individuals with cancer are available in a growing number of hospitals and community settings. Major institutions that offer yoga include Memorial Sloan-Kettering Cancer Center in New York, Duke Comprehensive Cancer Center in Durham, N.C., and Houston’s M.D. Anderson Cancer Center.

Yoga practices can be modified to allow even those who are bedridden or chair-bound to participate. For those unable to do any physical postures, simple breathing or meditation techniques can be substituted. Restorative yoga, a style often used in therapeutic settings, involves positioning the body in a variety of yoga poses. Props, such as blankets, bolsters, and chairs, are used to support body weight, allowing almost anyone to participate. The only requirement for yoga is a willingness to practice.

Research on yoga and cancer

A pilot study of gentle Iyengar yoga (named aft er yoga master B.K.S. Iyengar) for breast cancer survivors with marked fatigue was conducted at the University of California, Los Angeles. Eleven women with little or no prior yoga experience showed “strikingly large” improvements in fatigue, as well as significant improvements in depressive symptoms and in overall health.

The researchers are currently enrolling patients in a larger randomized controlled trial funded by the National Center for Complementary and Alternative Medicine.

Another study, led by Lorenzo Cohen, PhD, at M.D. Anderson, looked at the effects of a seven-week program of Tibetan yoga on 39 patients with Hodgkin’s disease and non-Hodgkin’s lymphoma. The yoga group compared with controls had significantly improved duration and quality of sleep and reduced use of sleeping pills. The eff ects were still present three months aft er the program was completed. There were no significant improvements noted, however, in anxiety, depression, or fatigue (Cancer 100:2253-2260, 2004).

Studies of mindfulness-based stress reduction (MBSR), which includes meditation and gentle yoga poses, suggest it can improve mood, fatigue, and feelings of stress in people with a variety of types of cancer.

A study of MBSR by Linda Carlson and colleagues found that at 12 months after completing the program, cortisol levels were continuing to decline, as were levels of pro-inflammatory cytokines in 49 patients with breast cancer and 10 with prostate cancer. Systolic blood pressure and heart rate, as well as self-reported stress levels, were also significantly reduced (Brain Behav Immun 21:1038-1049, 2007).

A randomized controlled trial by Rao M. Raghavendra, PhD, and colleagues compared 28 women with breast cancer who practiced one hour of yoga per day with 34 controls.

The yoga group showed a significant decrease in post-chemotherapy nausea frequency and intensity and in the intensity of anticipatory nausea and vomiting. The yoga group also had significant reductions in measures of depression and stress, which worsened in the controls (Eur J Cancer Care 16:462-474, 2007).

Even when the likelihood of a cure is remote, yoga may help. A 2007 study, led by James Carson, PhD, found a gentle yoga program was associated with significantly lower levels of pain and fatigue and higher levels of invigoration, relaxation, and acceptance in women with metastatic breast cancer (J Pain Symptom Manage 33:331-341, 2007).

There are many styles of yoga, and not all are appropriate for everyone. If patients express an interest in trying yoga, find out what style they intend to pursue. Having the student bring in a book showing the practices he or she would be doing can help you judge what is appropriate. Popular styles such as Astanga yoga, power yoga, vinyasa flow, Bikram yoga, and hot yoga demand at least a moderate degree of fitness and flexibility, and thus may not be appropriate for many people with cancer.

If yoga classes for cancer patients are not available in your area, another possibility is private instruction (for those who can afford it). Some yoga teachers teach privately or to small groups, which allows them to better personalize the program for each student. A growing field within yoga, usually done one-on-one, is yoga therapy, which uses a variety of yogic tools for medical conditions ranging from back pain to anxiety.

Yogis believe the key to success in yoga is regular practice. Fifteen minutes a day is said to bring greater benefits than long classes once a week. The idea of a yoga therapy session is to give students homework, a short practice they can do on their own, ideally every day. After a few weeks, or if the patient’s condition changes, the yoga therapist might schedule a return appointment to adjust the program.

The field of yoga therapy is relatively new, and so far there are no universally accepted standards of training and certification. In general, it’s best to find as experienced a teacher as possible, ideally one who has worked with cancer patients (see Sidebar on page 2).

Some yoga therapists are licensed as registered nurses, physical therapists, or workers in other healthcare fields, and these “dual-credentialed” instructors present advantages, including sometimes having their services reimbursed. After a small initial investment in instruction, and props like a yoga mat and blankets, however, yoga can be practiced indefinitely for free. While yoga DVDs can be useful, you lose the valuable component of an experienced teacher evaluating the student and tailoring the approach to his or her needs.

If you are unsure about yoga contraindications, my book Yoga as Medicine has extensive coverage of this topic. Also, good teachers should be knowledgeable about what is safe and what isn’t. If you simply provide general guidelines, they should be able to figure out the details.

If there is any doubt about whether a particular style or class is appropriate, suggest that the student speak with the teacher in advance. Even with students fit enough for regular community classes, a private session initially may be worthwhile to get them off on the right foot.