Approximately one-third of breast cancer survivors experiences persistent fatigue for months or years after successful treatment completion. There is a lack of evidence-based treatments for cancer-related fatigue, particularly among cancer survivors. This single-arm pilot study evaluated the feasibility and preliminary efficacy of a yoga intervention for fatigued breast cancer survivors based on the Iyengar tradition. Iyengar yoga prescribes specific poses for individuals with specific medical problems and conditions; this trial emphasized postures believed to be effective for reducing fatigue among breast cancer survivors, including inversions and backbends performed with the support of props. Twelve women were enrolled in the trial, and 11 completed the full 12-week course of treatment. There was a significant improvement in fatigue scores from pre- to post-intervention that was maintained at the 3-month post-intervention followup. Significant improvements were also observed in measures of physical function, depressed mood, and quality of life. These results support the acceptability of this intervention and suggest that it may have beneficial effects on persistent post-treatment fatigue. However, results require replication in a larger randomized controlled trial.
Breast cancer is the most common cancer diagnosed in females, with over 252,150 new cases expected in the United States in 2008 [
Fatigue is the most common and disabling symptom among women successfully treated for breast cancer [
Despite the prevalence of cancer-related fatigue, few evidence-based interventions are currently available to manage this symptom [
Yoga is a promising alternative treatment for cancer survivors with persistent fatigue [
A growing number of yoga interventions have been conducted with cancer patients. An early study conducted by Cohen and colleagues found that 7 weekly sessions of Tibetan yoga for patients with Stage I–IV lymphoma who were receiving or had recently completed chemotherapy led to significant improvements in sleep quality relative to a wait-list control, though no effects on fatigue or depression were observed [
The purpose of this pilot study was to evaluate the acceptability of an Iyengar yoga intervention for fatigued breast cancer survivors and to explore effects on fatigue and related outcomes. Iyengar yoga is a traditional form of Hatha yoga based on the teachings of B.K.S. Iyengar, a master practitioner and teacher [
Breast cancer survivors with persistent fatigue were recruited through newspapers advertisements and flyers distributed in local oncology clinics. Fatigue was assessed with the vitality subscale of the SF-36, a reliable and valid 4-item scale that assesses how much of the time respondents feel “worn out”, “tired”, have “a lot of energy”, and feel “full of pep” over the past 4 weeks [
A total of 62 women were screened by phone, 14 of whom met initial criteria and completed an in-person screen at UCLA. From this group, 12 were determined to be eligible for study participation and enrolled in the trial. Fifty women were not eligible: 8 scored above 50 on the SF-36 vitality subscale, 6 were older than 65 years old, 4 were actively receiving treatment for their breast cancer, 2 had breast cancer recurrences, 17 had chronic medical conditions and/or injuries (including 9 with a BMI > 30), 1 was engaged in a regular yoga program, 1 was a regular smoker, and 11 could not commit to the class schedule. One woman withdrew from the trial after several sessions because of a pre-existing knee condition and family-related demands. Thus, analyses are based on the 11 women who completed the full course of treatment. Demographic and medical characteristics of study participants are shown in Table
Demographic and medical characteristics of study participants.
Characteristic | |
---|---|
Age | |
53.8 | |
46–65 | |
Ethnicity, no. | |
9 | |
2 | |
Married or in significant relationship, no. | |
10 | |
1 | |
Education level, no. | |
1 | |
4 | |
6 | |
Employment status, no. | |
9 | |
2 | |
Income, no. | |
<$45,000 | 1 |
3 | |
>$75,000 | 7 |
Type of treatment, no. | |
3 | |
4 | |
4 | |
Years since diagnosis | |
4.6 | |
10 mo–15 yrs |
The yoga intervention was conducted in two groups. Participants in each group were assessed before and after the 12-week intervention and at a 3-month post-intervention follow-up. Pre- and post-assessments were conducted within 1-2 weeks of the intervention, and were not conducted on the same day as the yoga classes. Self-report measures were completed at each assessment point, and timed performance tasks were conducted at pre- and post-intervention. Women also completed weekly diaries assessing fatigue and other symptoms throughout the intervention. All 11 participants completed the pre- and post-intervention assessments; one woman withdrew before the 3-month post-intervention follow-up because of a breast cancer recurrence. Recruitment materials and the study consent form indicated that the purpose of the trial was to determine whether yoga classes could improve energy, mood, and physical function in breast cancer survivors.
Iyengar yoga classes were conducted for 90 minutes twice a week for 12 weeks. This 12-week time frame was designed to accommodate all of the prescribed poses and to allow sufficient time for beneficial effects on energy to emerge. A certified Junior Intermediate Iyengar Yoga teacher taught the classes under the guidance of an Advanced Iyengar Yoga teacher at her home studio. The teacher was not blind to the study design or hypotheses.
Iyengar yoga prescribes specific poses for individuals with specific medical problems and conditions; this trial emphasized postures believed to be effective for reducing fatigue among women with a history of breast cancer. Key postures from the trial are listed in Table
Key yoga postures for breast cancer survivors with fatigue. The following poses appear out of sequence and are not in the order in which they were taught.
Sanskrit name | Description |
---|---|
Supta Baddhakonasana | Reclining bound angle posture |
Supta Svatstikasana | Reclining cross legged posture |
Setubandha Sarvangasana on bolsters | Bridge pose on cross bolsters |
Setubandha Sarvangasana on bench | Bridge pose on bench with Viparita Karani box |
Purvottanasana | Extension of the front body supported on two chairs |
Viparita Dandasana on two chairs | Backbend over two chairs with thoracic support |
Salamba Sarvangasana on a chair | Shoulder stand on a chair |
Salamba Sirsasana on ropes | Hanging rope headstand |
Supta Konasana with two chairs | Variation of Halasana, plow pose, with legs spread apart and feet supported on two chairs |
Viparita Karani | Inverted lake pose |
Bharadvajasana on chair | Seated chair twist |
Adhomukha Svanasana on ropes with chair | Downward facing dog posture on ropes with chair |
Urdhva Mukha Svanasana with chair | Upward facing dog posture with chair support |
Tadasana Urdhva Hastasana | Mountain posture with arms stretched up |
Tadasana Urdhva Baddha Hastasana | Mountain posture with bound hands |
Savasana | Corpse posture with bolster support under chest |
Participants were not given “homework” or specifically instructed to practice postures outside of class; this was done to reduce participant burden. However, participants were not discouraged from home practice, and 7 women noted that they were practicing outside of class.
The primary outcome of interest was subjective fatigue, which was assessed using the 14-item
Secondary outcomes included depressed mood, sleep disturbance, pain, health-related quality of life, and measures of physical function. The
Timed performance tasks were used to provide an objective measure of physical function and were completed at pre- and post-intervention. These included the
One of the main goals of this pilot study was to evaluate the acceptability of an Iyengar yoga intervention for breast cancer survivors with persistent fatigue. Of the 12 women enrolled in the trial, 11 completed the full 12-week course of treatment, supporting the acceptability of the intervention. The average number of classes attended was 22.4 (93% of classes offered; range = 19–24 classes attended); reasons for missing class included illness, vacation, and travel. At interviews conducted after treatment, all participants reported that the intervention was beneficial, that they planned to continue with yoga, and would recommend the intervention to other fatigued cancer survivors. At the 3-month post-intervention follow-up, all but one participant reported that they were continuing to take yoga classes, and all but one (the one who had not continued with yoga) reported that they had experienced enduring benefits from the intervention.
The primary outcome of interest in this trial was subjective fatigue. Paired samples
Changes in fatigue and other outcomes following pilot yoga intervention.
Baseline | Post-treatment | 3-month follow-up | |
---|---|---|---|
Primary outcomes: (range) | Mean (SD) | Mean (SD) | Mean (SD) |
6.3 (1.1) | 2.7 (1.6)** | 4.4 (1.8)** | |
7 (0) | 4.6 (2.7)* | 4.5 (2.2)** | |
7.8 (1.3) | 4.0 (2.3)** | 5.8 (2.3)** | |
27.3 (18.4) | 50 (22.2)** | 47.5 (18.4)** | |
Secondary outcomes: (range) | Mean (SD) | Mean (SD) | Mean (SD) |
15.4 (8.0) | 7.5 (6.2)** | 7.3 (5.6)** | |
50.5 (22.1) | 65.0 (22.1)** | 67.3 (23.9)** | |
1.5 (1.4) | 0.8 (0.6) | 1.3 (0.9) | |
7.1 (4.1) | 6.4 (3.6) | 6.0 (3.7) | |
2.6 (0.9) | 3.5 (0.5) | n/a | |
3.4 (0.6) | 3.4 (0.6) | n/a |
Paired-samples
*
There was a significant decrease in depressive symptoms on the BDI-II from pre- to post-intervention (mean change = 7.9,
There was a trend towards a decrease in pain on the BCPT symptom checklist from baseline to post-intervention (
On the performance measures, there was a significant improvement in chair stands from baseline to post-intervention (i.e., participants were able to perform significantly more chair stands after the intervention;
Demonstrates positive outcomes of a 12-week Iyengar Yoga program for cancer-related fatigue in breast cancer survivors.
Participants’ comments in their weekly diaries provided additional insight into their intervention experience. One participant began to notice a change in her energy at week 3: “The physical and mental changes are subtle, but I feel like I'm thinking more clearly, have less brain fog, have more energy, fatigue later rather than sooner, feel better in general, feel stronger." At week 10, she wrote: “I'm really aware this week how much more energy I have to do more things in a week. I wouldn't describe it as “energetic,” I’d just say that I have reserves.” Another participant summed up her experience at week 12 as follows: “(The) effects of yoga have been small each week but the cumulative effect has been noticeable. I know that it is ameliorating the fatigue…. There’s been enough progress, subtle and incremental, to believe I can get much better.”
Results from this small, uncontrolled pilot study support the feasibility and acceptability of a tailored Iyengar yoga intervention for breast cancer survivors with persistent fatigue. Although the women had minimal prior yoga experience, they were enthusiastic about the classes and adherence was excellent; indeed, almost all participants reported that they continued taking yoga classes after the 12-week intervention was completed, and many had purchased props so that they could perform postures at home. Moreover, they were willing to attempt all of the postures and reported no adverse effects. We speculate that the careful selection of postures that would be appropriate for this patient population, the sequencing of postures from mild to more challenging over the course of the intervention, the in-depth screening of study participants and careful supervision throughout the trial, and instruction by an experienced teacher all contributed to treatment feasibility and acceptability.
Results also provide preliminary support for the efficacy of this intervention in reducing symptoms of fatigue. Scores on each of the fatigue measures showed a significant improvement from pre- to post-intervention; for example, scores on the “average fatigue” item of the FSI fell from 6.3 to below 3, the cut-off for clinically significant fatigue [
Intervention effects extended beyond subjective symptoms of fatigue to objective measures of physical performance, specifically chair stands. These findings suggest that the intervention may have beneficial effects on strength in addition to subjective symptoms. No changes were seen in the 8-foot walk test, although this may have been due to the restricted range of scores on this measure. Improvements were also seen in depressive symptoms and perceptions of general health. At the baseline assessment, average scores on the Beck Depression Inventory-II fell in the “mildly depressed” range (14–19), whereas average scores at follow-up fell in the “minimally depressed” range (0–13). On the SF-36 general health scale, average scores fell below the population norm of 70.5 at both assessments. Of note, multiple statistical tests were conducted to evaluate these secondary outcomes, increasing the risk of Type I errors.
Although these results are promising, the study has several key limitations that render the findings preliminary. The first is the small sample size; only 11 women participated in the intervention. These women are demographically and medically similar to a large cohort of fatigued breast cancer survivors we have previously characterized [
The authors thank Dr. Gail Greendale and Dr. Patricia Ganz for their contributions to this research. They also thank Manouso Manos, Senior Iyengar Yoga teacher, for his expertise, continued guidance and support in the development and implementation of the yoga intervention. This study was supported by the Jonsson Comprehensive Cancer Center at UCLA and the Cousins Center for Psychoneuroimmunology in the Semel Institute for Neuroscience at UCLA.