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Tibetan yoga practice improved sleep quality for women with breast cancer
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Twice-weekly practice of Tibetan yoga led to modest short-term benefits in sleep quality and efficiency among women undergoing neoadjuvant treatment for breast cancer.
“Previous research established that yoga effectively reduces sleep disturbances for [individuals with cancer], but [these investigations] have not included active control groups or long-term follow-up. This study hoped to address these previous study limitations,” Lorenzo Cohen, PhD, professor and director of the integrative medicine program at The University of Texas MD Anderson Cancer Center, said in a press release.
The study assessed the effects of a Tibetan yoga program on sleep and fatigue among women undergoing neoadjuvant chemotherapy for stage I to stage III breast cancer.
Researchers randomly assigned participants to one of three groups: Tibetan yoga (n=74), a stretching program (n=68) or usual care (n=85).
Women assigned Tibetan yoga or the stretching program participated in four sessions during neoadjuvant chemotherapy treatment, followed by three booster sessions within the following 6 months. They then were encouraged to continue the practice at home.
Self-reported measures of sleep disturbances, fatigue and actigraphy — a more objective measure of sleep quality — were collected at baseline, as well as 1 week, 3 months, 6 months and 12 months after treatment.
Cohen and colleagues observed no between-group differences in total sleep disturbances or fatigue levels during the overall study period. However, women assigned Tibetan yoga reported significantly less daily disturbances — defined as sleepiness interfering with daytime activities — 1 week after neoadjuvant chemotherapy compared with those assigned the stretching program (difference, –0.43; 95% CI, –0.82 to –0.04) and usual care (difference, –0.41; 95% CI, –0.77 to –0.05).
In addition, women assigned Tibetan yoga who continued to practice at least twice weekly after the study period reported better sleep quality and actigraphy outcomes at 3 months and 6 months after treatment.
HemOnc Today spoke with Cohen about the study, the potential explanations for the observed benefits, and the clinical implications of the results.
Question: What prompted this study?
Answer: We know from decades of research that, despite the advent of pharmacological approaches for symptom management in the chemotherapy setting, patients with breast cancer still suffer from multiple side effects due to chemotherapy. These side effects include sleep disturbances, fatigue, nausea and vomiting, as well as mood disturbances, such as depression and anxiety. We thought incorporating a mind-body practice that focuses on aspects of stress management and centering — including movement and stretching, breath regulation and meditation — could be a wonderful way to help prevent or reduce the severity of some of the symptoms that patients experience.
Q: How did this study differ from previous investigations?
A: We, along with other groups, have published research showing that incorporating yoga for cancer survivors and patients while undergoing treatment does help with symptom control. What had not been previously done was comparing a yoga group to an active control group.
Q: How did you conduct the study?
A: Patients were recruited before the start of chemotherapy or within the first cycle. We randomly assigned them to Tibetan yoga or a program through which then engaged in stretching exercises commonly prescribed to individuals with cancer. Both groups participated in four 90-minute sessions during the course of four chemotherapy cycles. We also had a third group that consisted of ‘usual care.’ These study participants did not engage in any extra activity and did not receive extra attention from the medical staff. All patients then were encouraged to practice on a daily basis, and we followed them for 1 year to measure the primary outcomes of fatigue and sleep disturbances.
Q: What did you find?
A: We did not find any differences between the three groups in terms of cancer-related fatigue. In fact, levels of cancer-related fatigue remained relatively low across the course of chemotherapy and into the subsequent year. There were group differences in sleep disturbances — specifically what is called the ‘daytime dysfunction’ measure (eg, feeling sleepy during the day). Participants in the yoga group had the lowest scores in daytime disturbance measures. This was really only at one time point, however, and this was relatively modest. We then decided to look at the reports of whether patients were engaging in their yoga practice outside of those brief sessions that they had. We found patients who were practicing yoga two times per week or more during the subsequent follow-up period had substantially lower sleep disturbances in a number of areas. Patients assigned Tibetan yoga reported better sleep efficiency, quality and less daytime disturbances.
Q: What are the potential explanations of these benefits?
A: Yoga includes physical movement and possibly the more active ingredient of stress management. We know that stress interferes with sleep initiation and sleep maintenance. These practices had a significant focus on working with the breath, visualization and meditation. One goal was to help calm the mind and allow the patient to be less stressed.
Q: What are the clinical implications of the results?
A: The measures we used are not measures that determine clinical sleep disturbances. However, we know that people who have sleep disturbances and do not have the appropriate length of sleep have worse outcomes as cancer survivors, as well as outside of the cancer domain. There is ample evidence to suggest that improving a person’s sleep quality is going to be relevant to biological functioning, as well as clinical outcomes.
Q: Do you have plans for subsequent research on this topic?
A: We have a lot of ongoing research in this area as part of our effort to find ways to incorporate these mind-body interventions alongside conventional cancer treatments. We are doing studies incorporating yoga during treatment with radiotherapy or chemotherapy to try to help patients better manage symptoms in that moment, and also to give them a tool that they can start to use in other areas of their lives after treatment. Our goal is to help these women not just survive after a cancer diagnosis, but to thrive.
Q: Is there anything else that you would like to mention?
A: The evidence is very clear: Mind-body practices should be incorporated into the standard of care and, in particular, while patients are undergoing cancer treatment. There is A-level evidence from multiple randomized clinical trials and the findings are consistent. Yoga can help reduce or treat multiple symptoms and improve patients’ quality of life. Many physicians and patients are unsure about which type of yoga practice to recommend or choose. I tell them that the evidence is consistent across different practices. The one that will be the best is the one that the patient will practice on a regular basis. Patients should try different types of mind-body practices and find what works best for them so they can engage in it on a regular basis. – by Jennifer Southall
Reference:
Chaoul A, et al. Cancer. 2017;10.1002/cncr.30938.
For more information:
Lorenzo Cohen, PhD, can be reached at The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX 77030; email: lcohen@mdanderson.org.
Disclosure: Cohen reports no relevant financial disclosures.