Benefits of Yoga for Cancer Survivors

Yoga and Cancer

Yoga teaches us presence and awareness—the heart of yoga. Patanjali teaches us these essential truths in the first two yoga sutras. The first of Patanjali’s yoga sutras states “Yoga occurs in the NOW.” When faced with major illness or trauma, it is normal for any person to experience fear. The problem with fear is not the fear we feel now, it’s the fear about the future or what is uncertain. When faced with uncertainty the mind often ruminates, overthinks, and this creates a lot of unnecessary stress. Stress can be detrimental to healing if it is not managed with presence, clarity, breath, and healing movement. The second sutra states that yoga is the practice of stilling the modifications of the mind. Practicing mindfulness, especially when healing the body, is transformational.

Yoga has been a practice for overall wellness for thousands of years. It has widely been accepted in India that yoga has healing properties, but it wasn’t until fairly recently that western medical science has also supported yoga as a tool for support before, during, and after cancer treatment.

The following are some of the benefits of a regular yoga practice that have been supported by research:

  • reduces and manages anxiety,
  • improves mood, less depression,
  • increases sense of well-being and quality of life,
  • improves social functioning,
  • improves breathing/lung volume, less dyspnea,
  • reduces in fatigue and joint pain,
  • reduces the number of hot flashes,
  • improves sleep quality,
  • increases flexibility and strength,
  • reduces pain,
  • is effective in treating PTSD (post-traumatic stress disorder),
  • reduces need for sleep medications,
  • improves “autonomic response” (response to stress), thereby reducing or eliminating the physiological symptoms of stress.

How can yoga possibly do so much? Yoga achieves so much because it is so much more than just exercise. Yes, exercise is incredibly beneficial to healing but when you also include adaptability, awareness, relaxation, breathwork, mindfulness, presence, meditation, connection and community, the healing powers are even more profound.

Modifications and Adaptability

It’s much easier to teach yoga asana in a way that is powerful and predictable where a lot of options are not offered. Advanced yoga is not advanced asana; however, it is advanced awareness. The key to teaching yoga asana to everybody, especially those who are healing, is to understand that yoga is a truly adaptable practice. All that is really needed to practice yoga is presence and awareness.

So, first and foremost, are we creating an environment that supports presence and awareness? Is there time to be still and focus on breath? Is the practice you are leading energetically balanced?

Second, how do we modify the poses we know well? First, by understanding that each and every body is truly different. We all have different shaped bones and ligament laxity, etc. Maintaining the sacredness of the tradition while adapting the postures to fit every body is key to healing.

In a class or private session, being open to truly seeing where a student might be struggling and then adapting what you are offering is essential to creating a healing environment. Because this takes practice and adaptability, this is easier when working with someone one-on-one. When teaching to a group, it’s important to keep the class small (6 – 12 students) in order to allow for you to be able to give individual instruction and attention as needed.

This book has options for many of the poses that you already know, but more importantly, we want you to understand how to creatively adapt poses beyond what is contained in these pages. How? One of the simplest approaches is to understand how to keep the body moving gently and comfortably through a limited and pain-free range of motion (ROM). Keeping the body flowing easily and gently through pain-free ROM (instead of holding a static arm reach, for example) is similar to what is taught in viniyoga, a therapeutic yoga approach. I integrate these kinds of modifications into my teaching every day, but I think it is even more important to integrate into a class geared specifically toward healing. Many cancer treatment patients will have tenderness, tightness, muscle loss or inactivity, and/or may even be healing sutures, and will need to limit ROM and keep gentle flowing movement happening to improve circulation and healing. Of course, all patients will need to be cleared by their doctor or therapist before engaging in physical movement (see CES Handbook for more on this).

Through postural assessment we learn the essentials of joint action and what limits range of motion (ROM). Once you understand where ROM is limited, you can offer asana options that provide the strength and flexibility needed to bring balance and healing to the body and energetic system.

Each pose page in this book details for you major joint action when moving into a pose so that you can assess where ROM may be limited in those joints and how to modify the pose. Each pose page also details for you which muscles are the prime movers for that particular joint action so you can create strength where it is needed for proper alignment and also assess where lack of flexibility is limiting ROM. Finally, the pages of this handbook also detail for you which muscles should be isometrically contracting in order to create optimal alignment in a pose.

Timothy McCall, MD, says the following about yoga and adaptability:

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.

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The Healing Power of the Relaxation Response

Yoga tones and awakens the parasympathetic nervous system also known as the PNS. The PNS is responsible for balancing the body and bringing its response system back into equilibrium. Stimulating the PNS helps to lower heart rate and blood pressure, it helps to healthily stimulate the immune system, and keep the endocrine system operating healthily. When this system gets out of whack, or when the sympathetic nervous system (SNS) gets over-stimulated, the PNS helps to bring all back in balance. It is believed that if the PNS is tapped out or under-active, illness pervades. Thus, forms of relaxation such as yoga and meditation that help to stimulate the PNS are generally beneficial for overall wellness.

David Spiegel, MD, author of Living Beyond Limits, reports, “In medicine, we are learning that physical problems, such as high blood pressure and heart disease, can be influenced by psychological interventions, such as relaxation training. Indeed, the Food and Drug Administration issued a report recommending these non-drug approaches as the treatment of choice for milder forms of hypertension. Mind and body are connected and must work together, and this should be a powerful asset in treating medical illness.”

When we are experiencing stress (SNS is overstimulated), the following systems get shut down:

  • digestion,
  • elimination,
  • growth,
  • repair,
  • reproduction.

These systems are absolutely vital for healing.

Savasana and deep breathing are ALWAYS the most beneficial part of our practice in terms of overall health and well-being. Stress is now believed to be the culprit of 75 – 90% of all doctor visits. Physical, emotional and environmental stress is wreaking havoc on our entire energetic systems. Dr. Ralph LaForge of Duke University in a workshop at ACSM’s conference in Reno, Nevada, in about 2001, stated, after studying over 300 articles on the health benefits of hatha yoga, that the most important parts of a yoga class for overall health and well-being are breath and savasana. He also taught that just 30 – 40 seconds of deep belly breathing can eliminate or reduce all physiological symptoms of stress. Given the number of doctor visits believed to be stress related, this is a simple and highly beneficial technique we can do anytime, anywhere.

Yoga practices that focus on relaxation help us to “rest and digest” by helping us to learn to relax, invoking a relaxation response (parasympathetic nervous system). Yoga practices that teach students to meet challenges with deep belly or diaphragmatic (ujayii) breath and a calm present mind, tone the autonomic nervous system, improving our “autonomic response.” Insomnia and digestive dysfunction are common symptoms of stress.

Extensive research shows the following benefits from either deeply relaxing or energetically-balanced yoga classes that invoke a relaxation response:

  • lowers stress hormones,
  • increases arousal from the drowsy state,
  • lowers blood pressure,
  • helps in relieving pain,
  • increases motivation and productivity,
  • improves decision making,
  • lowers anxiety and irritability,
  • promotes healthy digestion,
  • deeply relaxes the body, invokes relaxation response and its benefits,
  • stills the mind and improves healthy sleep, relieving symptoms of insomnia,
  • improves capacity for healing and balancing energy,
  • boosts the immune system,
  • develops qualities of compassion and understanding toward others and self,
  • enhances mood states, relieving symptoms of mild to moderate depression, and
  • due to many of the above benefits, can enhance fertility.

Yoga can work for many different types of bodies, during many different stages in life, and for a person’s many different moods. While for some a power yoga class may seem like the way to go, for others a gentle or restorative class may be optimal. For some people, their needs change daily; however, the restorative effects of yoga should never be overlooked, no matter what age, and sometimes slowing down the practice, going deeper in poses, and just feeling the restorative power of yoga does wonders for the body, especially when healing.

Presence, Awareness & Meditation

In a Yoga Journal article titled “Yoga for Cancer,” the author writes about the deeper benefits of yoga, beyond just the physical wellness:

Perhaps the most compelling reason cancer patients are turning to yoga is this: It shows us how a person stricken with a serious illness, instead of “running away” from their threatened body, can connect more strongly to that body and begin to experience self-empowerment and well-being. As we engage our physical selves in the precise body gestures of yoga, our minds come along, growing accustomed to focusing on the affairs of this moment and leaving worries and future-thinking behind. As we breathe and meditate, our minds grow more clear and steady.

Meditation can become just one of the myriad suggestions with which cancer patients are bombarded; but, there are numerous forms of meditation available to us today, and each individual student will find which method of meditation (dharana – concentration) works for them. Just a few examples of the ways a meditative mind can improve awareness, clarity and presence:

  • bring a present, meditative mind to movement or walking,
  • lie on the grass and look at the sky,
  • seated meditation,
  • focus on a candle (trataka),
  • awareness on a simple exhale and inhale,
  • practice Yoga Nidra or other guided meditative practices with an audio guide.

Although different traditions and lineages teach specific methods of meditation, what is most important in this case is that a student with cancer is encouraged to find peace through staying connected to what is here now, the present. Patanjali’s YS 1:1.

In becoming more connected to what is here now, yoga students are less burdened by the past and its memories and the future and its hopes or fears. In Eckhart Tolle’s book The Power of Now he explains that living too much in the future is the source of all stress or anxiety and that living too much in the past is the source of all non-forgiveness or guilt. Yoga teaches us non-attachment so that we can be grounded in the reality of now.

The method is not as important as the presence of mind that is found in the practice.

Community – Connecting with Yourself and Others

One of the most challenging aspects of cancer treatment for many students is a feeling of disconnection with themselves or others. For many, a cancer diagnosis can be life-changing. All change is hard – regardless of whether it is good or bad change. Change is stressful. Some family and friends can be helpful and supportive during times of change. Some friends and family are more inherently afraid of uncertainty or change, and may have a harder time being supportive. This also applies to cancer patients themselves—those who are more inherently afraid of uncertainty or change may have a harder time being present with what is and moving through daily life with a sense of presence.

A yoga class for cancer patients is an excellent offering for bringing those who may be struggling with some of the same issues of disconnection together; a private session or class is a time for a student to tend to their own wellness and self-care while being in community with others or another (you, the teacher). This is a powerful and important part of healing. Community is important to our thriving as happy and healthy people, and this is especially true for those who are healing. In 1989, Dr. David Spiegel, a Stanford psychiatrist, found that women with metastatic breast cancer who participated in a support group lived longer than those who did not. The community that is built in a yoga class reduces stress. If you are meeting privately with a cancer patient you become a support for them, as well. In a class environment, build in time for a share circle at the end of class to create opportunity for sharing and support.

What is the Evidence?

Research has shown that yoga can improve overall wellness and we’ve seen specific improvements in blood pressure, heart rate, breathing, metabolism, body temperature, brain waves, and skin resistance. Improvements in these physical functions can result in improved physical fitness, lower levels of stress, and increased feelings of relaxation and well-being.

One of the most recent published findings is a research article published in March 2014. This research supports what yoga teachers have been experiencing first-hand with their students in cancer treatment: that yoga not only improves physical recovery during cancer treatment, but also improves overall quality of life and meaning:

The preliminary findings were first reported in 2011 by Lorenzo Cohen, Ph.D., professor and director of the Integrative Medicine Program at M.D. Anderson, and are now published in the Journal of Clinical Oncology. This research is part of an ongoing effort to scientifically validate mind-body interventions in cancer patients and was conducted in collaboration with India’s largest yoga research institution, Swami Vivekananda Yoga Anusandhana Samsthana in Bangalore, India.

Researchers found that while simple stretching exercises counteracted fatigue, patients who participated in yoga exercises that incorporated controlled breathing, meditation, and relaxation techniques into their treatment plan experienced improved ability to engage in their daily activities, better general health and better regulation of cortisol (stress hormone). Women in the yoga group were also better equipped to find meaning in the illness experience, which declined over time for the women in the other two groups.

The study also assessed, for the first time, yoga benefits in cancer patients by comparing their experience with patients in an active control group who integrated simple, generic stretching exercises into their lives.

“Combining mind and body practices that are part of yoga clearly have tremendous potential to help patients manage the psychosocial and physical difficulties associated with treatment and life after cancer, beyond the benefits of simple stretching,” said Cohen.

To conduct the study, 191 women with breast cancer (stage 0—III) were randomized to one of three groups: (1) yoga, (2) simple stretching, or (3) no instruction in yoga or stretching. Participants in the yoga and stretching groups attended sessions specifically tailored to breast cancer patients for one hour, three days a week throughout their six weeks of radiation treatment.

Women who practiced yoga had the steepest decline in their cortisol levels across the day, indicating that yoga had the ability to help regulate this stress hormone. This is particularly important because higher stress hormone levels throughout the day, known as a blunted circadian cortisol rhythm, have been linked to worse outcomes in breast cancer.

Additionally, after completing radiation treatment, only the women in the yoga and stretching groups reported a reduction in fatigue. At one, three, and six months after radiation therapy, women who practiced yoga during the treatment period reported greater benefits to physical functioning and general health. They were more likely to find life meaning from their cancer experience than the other groups.

According to Cohen, research shows that developing a yoga practice also helps patients after completing cancer treatment.

“The transition from active therapy back to everyday life can be very stressful as patients no longer receive the same level of medical care and attention. Teaching patients a mind-body technique like yoga as a coping skill can make the transition less difficult.”

Excerpted from Lorenzo Cohen, Ph.D., “Yoga Regulates Stress Hormones and Improves Quality of Life for Women with Breast Cancer Undergoing Radiation Therapy”

Due to yoga’s relatively new appearance in the West, there is limited research available to support the benefits of yoga as a support for cancer treatment, but here are some of the highlights excerpted from an article by Dr. Timothy McCall:

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, Ph.D., 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, Ph.D., 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).

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Finally, one of the leaders in integration of complementary therapies in cancer recovery is Memorial Sloan Kettering Cancer Center. The following is an excerpt from an article they published about the usefulness of yoga in cancer recovery:

With the introduction of yoga in many cancer centers across the country, patients now use this modality at all disease stages to relieve various symptoms (20) (21) (22). The ability of yoga to reduce stress, increase sense of well-being, improve quality of life, and impart more restful sleep in both newly diagnosed and long-term cancer survivors is well documented (2) (23) (24) (25) (26) (27) (28) with the potential for reduced need for sleep medications (28) (29). Studies in breast cancer survivors indicate that yoga improves social functioning and mood, reduces stress levels (30) (31), and can help to address a range of psychological symptoms (32). In survivors with persistent fatigue and induced or exacerbated menopausal symptoms, yoga has also reduced fatigue, joint pain, and the number of hot flashes while increasing vigor, with benefits persisting at 3-month followup (22) (33). Yoga can improve quality of life in breast cancer patients undergoing radiation therapy (34). Preliminary studies in other cancers have also shown that yoga can increase forced expiratory volume in non-small cell lung cancer patients (35) and improve sleep quality for lymphoma survivors (29).

Adverse effects associated with improper yoga practices have been reported. However, appropriate and long-term yoga practices to relieve symptoms can have additional downstream benefits, such as genetic and physiologic changes (35), as well as the ability to adhere to exercise programs or make other lifestyle changes (1). Cancer patients interested in beginning yoga should first consult their physicians. In addition, it is advisable to learn proper technique from certified instructors who have experience working with cancer patients, because survivors may have special limitations due to surgery, chemotherapy, and radiotherapy.

Purported Uses

  • Anxiety
  • Depression
  • Dyspnea
  • Fatigue
  • Hot flashes
  • Sleep quality
  • Increased flexibility and strength
  • Pain
  • Post-traumatic stress disorder
  • Reduced need for sleep medications
  • Stress

Mechanism of Action

Because components of yoga practice include postural alignment and engagement of the extremities, yoga raises somatic self-awareness, educating the user of states in which the body experiences balance and calm, and identifying symptoms that may be problematic (3). The engagement of the mind, attention to comfort, and deep relaxed abdominal breathing reduces gastrointestinal symptoms by disrupting chronic patterns of functional disability and maladaptive coping strategies often experienced with irritable bowel syndrome (4).

Some studies have shown that the meditation component of yoga increases blood flow to the brain, releases endogenous dopamine, and reduces respiratory rate (6). The changes in breathing patterns that accompany various yoga practices may also alter airway hyper-responsiveness (5). Yoga postures and controlled breathing interact with both the somatic nervous system and endocrine mechanisms, thereby affecting insulin kinetics (8). Neuroplastic mechanisms for its antidepressant effects include elevated serum brain-derived neurotrophic factor (BDNF) levels (36). Yoga relieves stress and anxiety by increasing levels of the neurotransmitter gamma amino-butyric acid (GABA) (13) and improving hypothalamic-pituitary-adrenal (HPA) axis functioning (25). Improvements in fatigue, sleep disturbance, anxiety, and quality of life are also attributed to increased parasympathetic and decreased sympathetic activities, stimulation of the vagus nerve, and reduction in allostatic load which optimizes homeostasis in stress response systems (14), thereby replacing the flight-or-fight response with the relaxation response (19). By eliciting the relaxation response, long-term practice has been shown to promote mitochondrial resiliency via ATPase and insulin function upregulation and downregulation of NF-kB-dependent pathways (35).

Literature Summary and Critique

Mustian KM, et al. Multicenter, randomized controlled trial of yoga for sleep quality among cancer survivors. J Clin Oncol. 2013;31:3233-41.
This large RCT evaluated the efficacy of a standardized Iyengar-based yoga intervention vs standard care to improve global sleep quality among post-treatment cancer survivors. A total of 410 survivors with moderate or greater sleep disruption for 2 – 24 months after surgery, chemotherapy, and/or radiation therapy were randomized to either standard care or standard care plus the Yoga for Cancer Survivors (YOCAS) intervention, which comprises breathing exercises, 16 gentle hatha and restorative yoga postures, and meditation. Participants attended two 75-minute sessions weekly for 4 weeks. Sleep quality was assessed using the Pittsburgh Sleep Quality Index and pre/post-intervention actigraphy, a validated, non-invasive objective measure that assesses sleep and its components using a watch/sensor to collect activity data. Participants in the YOCAS program demonstrated greater improvements in global sleep quality, subjective sleep quality, daytime dysfunction, wake after sleep onset, sleep efficiency, and use of medication postintervention compared with those receiving standard care only. The investigators concluded that this particular yoga regimen was a useful therapy to improve sleep quality and reduce the need for sleep medications.

Bower JE, et al. Yoga for persistent fatigue in breast cancer survivors: A randomized controlled trial. Cancer. 2012;118:3766-75.
This RCT evaluated the effects of Iyengar yoga in breast cancer survivors with persistent fatigue. A total of 31 women were randomly assigned to yoga practice for 12 weeks, or to health education. The severity of fatigue declined significantly in the yoga group compared with controls, and the yoga group also had significant increases in vigor. However, there were no improvements in depressive symptoms, stress, sleep, and physical performance.

Carson JW, et al. Yoga of Awareness program for menopausal symptoms in breast cancer survivors: results from a randomized trial. J Sex MedSupport Care Cancer. 2009;17:1301-9.
This preliminary trial evaluated a yoga intervention for menopausal symptoms in a sample of early-stage (IA-IIB) breast cancer survivors. A total of 37 women who were disease-free and experiencing hot flashes were randomized to an 8-week Yoga of Awareness program that used gentle yoga poses, meditation, and breathing exercises, or to a wait-list control. Daily reports of hot flashes were collected at baseline, posttreatment, and 3 months posttreatment through an interactive phone system. Intent-to-treat analysis indicated that women in the intervention group showed significantly greater improvements vs. controls for hot flash frequency, severity, and total scores, joint pain, fatigue, sleep disturbance, symptom-related bother, and vigor at posttreatment reporting. At 3-month follow-up, patients maintained these treatment gains and showed additional significant gains in negative mood, relaxation, and acceptance.



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