Yoga Therapy Across the Cancer Care Continuum: Evidence-Informed Practice
Leigh Leibel, MSc, C-IAYT, ACSM-CET
Cancer is a fantastically complex family of diseases whose wide variety of treatment options put patients at risk for acute, lingering, and late adverse effects that can impact wellbeing and quality of life. As a result, many of the world’s 32 million cancer survivors turn to complementary therapies and traditional systems of healthcare for additional symptom management and lifestyle support. Yoga is a popular example. As a movement-based practice that incorporates breathing and mindfulness, yoga has a strong evidence base showing efficacy in the management of various physical and psychosocial side-effects of a cancer diagnosis and treatment (1,2). It also can promote a healthy lifestyle, reduce stress, improve sleep and quality of life, and positively impact clinical outcomes (3,4). Based on well-designed studies, several national guidelines in the United States recommend yoga to cancer patients and survivors during treatment and beyond. For example, the joint Society for Integrative Oncology (SIO) and American Society for Clinical Oncology (ASCO) guidelines for the use of integrative therapies during and after breast cancer treatment recommend yoga to improve mood, symptoms of anxiety and depression, fatigue, sleep, and quality of life (5,6). The National Comprehensive Cancer Network (NCCN) recommends yoga to improve cancer-related fatigue and anticipatory nausea and vomiting, and suggests it as a non-pharmacological intervention in the management of distress, pain, cognitive function, and menopausal symptoms (7).
Introduction to Yoga Therapy Across the Cancer Care Continuum
In medicine, the term continuum of care describes the delivery of health services to individuals over a period of time via an organized and integrated system that spans the trajectory of wellness and illness. Given the importance of continuity of care, subject matter experts developed a framework for the clinical application of yoga therapy in oncology that puts the patient first and provides better coordination and management of treatment plans, progress, and priorities. The model describes diagnosis, treatment, post treatment, recurrence and living with chronic cancer, and end of life and prioritizes six quality aims: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity.
The model was presented at SIO’s Therapeutic Yoga in Cancer Patients: Research Methodology and Clinical Application half-day workshop held during the 15th International Conference “From Research to Practical Applications” in Arizona, USA. During breakout sessions, SIO and the International Association of Yoga Therapists (IAYT, the international credentialing body for yoga therapists) came to the table literally and metaphorically to discuss yoga therapy in cancer care and the need for safe, effective, equitable practice. This led to the launch in Q4 2019 of the SIO Yoga Special Interest Group (Yoga SIG). Today, the SIGs 40 active members are working to advance yoga as a key component of evidence-based, integrative healthcare to improve the lives of people affected by cancer. Through research and clinical consensus, the group is further refining the optimum delivery of yogic practices across cancer patient populations and treatment intensities, while noting the different medical needs of patients during various phases of cancer care, and the corresponding benefits and contraindications to yoga practice.
Membership in the Yoga SIG is free and open to all members of SIO and BSIO-SIO joint members. It is a busy and active multi-disciplinary group, and we welcome anyone with an interest in yoga and cancer to join!
Atha Yogānuśāsanam: And Now, Yoga
It is often said, if you can breathe, you can do yoga. In the forthcoming book Yoga Therapy Across the Cancer Care Continuum (Handspring Publishing UK), 38 yoga therapists and yoga professionals from the United States, Canada, Australia, India, and Singapore (many of whom are Yoga SIG members) were selected from an international open call to showcase the breadth and depth of evidence-informed yoga practices in cancer care from diagnosis to end of life. Informed by Patanjali’s eight-fold (ashtanga) path of yoga that integrates outer (bahiranga) and inner (antaranga) practices, these yoga professionals support medically fragile people at all stages and phases of cancer care. They work in hospitals, clinics, chemotherapy infusion centers, radiation departments, at the in-patient bedside, intensive care units, exam and diagnostic testing waiting rooms, yoga studios, private homes, and on Zoom. Their yoga sessions are delivered one-on-one, in dyads, or small groups. Many are involved in JEDI (justice, equity, diversity, and inclusion) and use the tools of yoga to amplify the voices of underrepresented people worldwide. Importantly, each of the 38 yoga professionals works alongside allied and integrative healthcare professionals to deliver the highest quality cancer patient-centered care.
Throughout the book, these yoga professionals honor stories of illness and bear witness to their patients’ joy and suffering. Firmly grounded in science and clinical experience, they elegantly apply the art and science of yoga in a garland of practices across the cancer care continuum, beautifully illustrating that yoga supports mind, body, spirit at every phase of the cancer journey.
Maximize Benefit, Minimize Harm
While yoga can offer tremendous benefits to cancer patients and survivors, it can also cause harm if treatment-induced changes in immune, neurological, and musculoskeletal functions (and comorbidities) aren’t observed and addressed. Currently, there are no universally agreed upon:
· Best practices for yoga in cancer populations
· Cancer specific safety and injury precautions
· Standards in the education/training of yoga professionals in oncology
In response, SIO and Yoga SIG convened in 2021 a multi-institution, multi-disciplinary working group of subject matter experts to define yoga parameters in breast cancer based on scientific research and expert clinical experience. Parameters for other cancers will follow.
The goal is to investigate yoga practices within the context of acute and longitudinal side effects of cancer and its treatment to:
· Make recommendations that will serve as practice guidelines for yoga in cancer care
· Inform yoga and cancer teaching curricula and educational competencies
· Provide public-facing information about yoga and cancer for patient and survivors, their families, and healthcare providers
Ideally:
· Yoga in an acute oncology setting is delivered by IAYT-certified yoga therapists who graduate from an accredited training program and meet or exceed an established set of standards that includes a minimum 800-1,000 classroom hours (and increasingly, a masters or doctoral degree); clinical rotation; defined scope of practice and code of ethics; and beginning in 2022, completion of a national certification exam (licensure is an ongoing conversation).
· Yoga for cancer survivors in a community setting is delivered by high-quality 200- or 500- hour Yoga Alliance-registered yoga teachers who have oncology experience and additional training to work with medical populations.
Health Equity
Cancer does not discriminate, but the grim reality is that the burden of cancer is not shouldered equally by all segments of the population. Some of our most vulnerable populations across rural or segregated areas of the United States and other developed countries, as well as in under-resourced and low-middle income countries (LMICs) don’t have access to a broad range of cancer therapies, clinical trials, lifesaving treatments, palliative and pain medications, or even supportive care for mental health and symptom management. Disparity in healthcare is among the world’s biggest social injustice. The World Health Organization (WHO) affirms it is the ethical duty of all stakeholders in our global healthcare community to respect a person’s dignity in illness and to relieve their suffering. To advance cancer health equity and ensure optimal wellness for all people, Yoga SIG advocates and works toward the development of a diverse and culturally sensitive yoga workforce that more accurately represents the racial, ethnic, religious, ability, sexual orientation, and gender diversity of our cancer patients and clients and elevates their individual and collective voice. By increasing the number of yoga professionals from under-represented backgrounds, the roots of the social determinants of health that drive disparity and lead to worse patient outcomes can begin to be addressed.
The Way Forward
To advance yoga and yoga therapy in oncological care, and to support yoga as an adjunct modality in managing cancer-related symptoms and as part of risk reduction and prevention, we must first characterize systems-level solutions around three thematic priorities:
· Develop standards and guidelines for the delivery of safe and effective yoga in medically fragile cancer populations, and articulate evidence-based benefits and contraindications of yoga at each stage of the care continuum.
· Advance yoga and cancer health equity by creating a more diverse and culturally competent yoga therapy workforce to elevate the voices of cancer patients and survivors in underrepresented communities.
· Promote the tremendous benefits of yoga as a mind-body science to all cancer stakeholders, including members of the medical team, cancer patients/survivors, families, and patient advocates.
These initiatives align with WHO Sustainable Development Goal (SDG) #3: To ensure healthy lives and promote well-being for all at all ages.
In Conclusion
Yoga is a time-honored mind-body therapy whose integration into standard cancer care can help global healthcare systems mind the gap in the delivery of equitable, evidence-informed, culturally sensitive, patient centered care across each stage of the cancer care continuum. The strong and growing science supporting yoga’s important role in cancer care validates what yogis have known for thousands of years – yoga is good medicine!
References
1. Mustian KM, Sprod LK, Janelsins M, et al. Multicenter, randomized controlled trial of yoga for sleep quality among cancer survivors. J Clin Oncol. 2013;31:3233-3241.
2. Lin PJ, Peppone LJ, Janelsins MC, et al. Yoga for the management of cancer treatment-related toxicities. Curr Oncol Rep. 2018;20:5.
3. Kiecolt-Glaser JK, Bennett JM, Andridge R, et al. Yoga’s impact on inflammation, mood, and fatigue in breast cancer survivors: a randomized controlled trial. J Clin Oncol. 2014;32:1040-1049.
4. Rao MR, Raghuram N, Nagendra HR, et al. Anxiolytic effects of a yoga program in early breast cancer patients undergoing conventional treatment: a randomized controlled trial. Complement Ther Med. 2009;17:1-8.
5. Greenlee H, DuPont-Reyes MJ, Balneaves LG, et al. Clinical practice guidelines on the evidence-based use of integrative therapies during and after breast cancer treatment. CA Cancer J Clin. 2017;67:194-232.
6. Lyman GH, Greenlee H, Bohlke K, et al. Integrative therapies during and after breast cancer treatment: ASCO endorsement of the SIO clinical practice guideline. J Clin Oncol. 2018;36:2647-2655.
7. Denlinger CS, Sanft T, Armenian S, et al. NCCN Clinical Practice Guidelines in Oncology: Survivorship. Version 1.2021. Accessed November 21, 2021. nccn.org/professionals/physician_gls/pdf/survivorship.pdf
Webinar notice
Please look out for our upcoming event for SIO and BSIO members on Thursday 2nd December at 5pm GMT entitled “Role of Yoga Across the Cancer Care Continuum: Evidence Informed Practice”. It’s going to be an incredible opportunity to hear from a panel of our amazing colleagues from the Society for Integrative Oncology.
Speakers:
Dr Lorenzo Cohen, MD Anderson Cancer Center, Houston, Texas
Dr Kelli Bethel, Maryland University of Integrative Health, Laurel, Maryland
Ms Smitha Mallaiah, MD Anderson Cancer Center, Houston, Texas
Dr Santosh Rao, Banner Health MD Anderson Cancer Center, Gilbert, Arizona
Moderator:
Ms Leigh Leibel, Columbia University Irving Medical Center, New York City, New York; Co-Chair, Yoga SIG
Please register for the webinar below:
Author
Leigh Leibel (she/her) is a senior mind-body specialist in the Division of Hematology Oncology at Columbia University Irving Medical Center in New York City, New York where she designs mind-body protocols for symptom management and lifestyle support for patients and families across the cancer care continuum. She serves on the SIO Board of Trustees, co-chairs the SIO Yoga Special Interest Group, and is a member of the SIO Health, Equity, Inclusion, and Belonging (HEIB) Task Force. She is a medical journalist (formerly with CNN) and editor of the forthcoming book Yoga Therapy Across the Cancer Care Continuum and cancer contributor to Yoga Therapy Foundations, Tools, and Practice: A Comprehensive Textbook. Ms. Leibel completed a summer fellowship in Cancer Prevention and Control at the National Institutes of Health/National Cancer Institute (NIH/NCI) and holds a Master of Science in Yoga with honors from S-Vyasa University in Bengaluru, India where she is pursing the PhD in Yoga. Her research interest is the yogic management of aromatase inhibitor arthralgia in breast cancer.
Ms. Leibel honors the thousands of years of yogic tradition originating in South Asia and shares the sacred teachings with gratitude and respect.