Running head: BREAST CANCER FATIGUE

Effects of Yoga on Breast-Cancer Fatigue

Kailey Gay
University of South Florida

BREAST CANCER FATIGUE

Abstract

Clinical Problem: Patients with breast cancer have a high risk of fatigue from high stress on their
body from natural responses to chemotherapy.
Objective: To determine if yoga will reduce fatigue in patients suffering from breast cancerrelated fatigue. CINAHL, OVID and guidelines from Rock et al. (2012) were all used in
obtaining information on clinical trials and the guidelines about cancer-related yoga. The key
search terms used were breast cancer, yoga, exercise, intervention and fatigue.
Results: Rock et al. (2012) recommends participating in yoga or aerobic-focused exercises as a
non-pharmacological intervention to reduce fatigue. The literature found demonstrated a
significant decrease in fatigue in patients with breast cancer when consistently participating in a
yoga program.
Conclusion: Patients with breast cancer-related fatigue had a reduced rate of fatigue and thus
higher levels of vitality or energy. Literature did not show a statistically significant decrease in
depression, anxiety, or other mood disorders.

BREAST CANCER FATIGUE

Effects of Yoga on Breast-Cancer Related Fatigue
The National Cancer Institute (NCI) identifies fatigue as the most commonly reported
symptom in cancer patients currently receiving treatment (2014). Although fatigue often

improves after chemotherapy is finished, survivors can experience chronic-fatigue. Acute fatigue
often presents in healthy adults and is generally resolved with rest, while cancer-related fatigue is
considered chronic because it is not relieved by rest (NCI, 2014). Apart from the self-reported
symptoms such as weakness and general malaise, fatigue has an adverse effect on a patients
sense of self, mood, and physical and cognitive abilities (NCI, 2014). The Centers of Disease
Control (CDC) states that breast cancer is the most common cancer among women in the United
States (2012). Currently, chemotherapy is the most effective pharmacological treatment
available; although it is highly effective in the treatment of cancer, it is difficult for women
undergoing therapy to sustain a high quality of life. It is important to treat patients while also
helping them to maintain a healthy lifestyle. According to the Rock et al. (2012) guidelines for
the prevention or improvement of fatigue in cancer patients include the recommendation to
engage in physical activity.
This paper evaluates the effectiveness of yoga in breast-cancer patients as a nonpharmacological intervention of reducing chronic-fatigue. In breast-cancer patients experiencing
varying levels of fatigue, how do exercise programs such as yoga versus standard care or no
exercise improve quality of life and decrease fatigue over a three-month period?
Literature Search
CINAHL, OVID, and CDC guidelines were used to obtain clinical trials and guidelines
about cancer-related fatigue prevention. The key search terms used were breast cancer, fatigue,
yoga, exercise, and intervention.

BREAST CANCER FATIGUE

Literature Review
One guideline and three randomized controlled trials were used to evaluate the
effectiveness of yoga on rates of fatigue in breast-cancer patients. In a randomized controlled

trial, Chandwani et al. (2014) measured the effectiveness of yoga exercise on fatigue induced by
radiotherapy in breast cancer patients compared to patients with no exercise undergoing
chemotherapy. There were 163 women randomly assigned to either the yoga group (YG; n=53),
the active stretching group (ST; n=56), and the wait list group (WL; n=54). The women in the
study participated in yoga, active stretching, or no exercise three times a week for six weeks. The
interventional groups met for 60-minute classes up to three times a week at the clients
availability, usually immediately after chemotherapy treatments as the center was conveniently
located right next to the treatment location. The Brief Fatigue Inventory was used to measure the
rates of the fatigue at various points. At the end of the six weeks, the women in the YG and ST
had a significant decrease in cancer-related fatigue (p= .04) (p= .02). However yoga was proven
to be more effective in decreasing fatigue (p < .05). One of the main weaknesses of this trial is
that this was a pilot study. Other weaknesses include the difference between active stretching and
yoga was not well defined. Strengths for this trial were the large sample of patients, the random
patient assignment to the intervention and control groups, and the women were similar in terms
of baseline level of fatigue and treatment. In addition, the study measured results at the baseline,
end of study (6 weeks), and 1 month, 3 months, and 6 months after the intervention to assess
successfulness. Seventy-one percent of patients reported practicing yoga at home during and
after the trials, which shows they enjoyed the intervention.
Kiecolt-Glaser et al. (2014) conducted a randomized controlled trial to assess yogas
impact on inflammation, mood and fatigue in breast-cancer survivors. The trial consisted of 200

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women who had all recently completed chemotherapy treatment (within the past three years), n =
100 women practiced yoga and n = 100 were in the wait list or control group. The trial took place
in a period of 3 months or 12 weeks. The women in the intervention group attended two 90minute yoga classes per week and were encouraged to practice on their own supplementally. The
Multidimensional Fatigue Symptom Fatigue Inventory was used to assess the women in the
interventional yoga groups fatigue levels at baseline or before the trial began, immediately after
the trial ended at 12 weeks, and 3 months post-trial. Immediately after yoga intervention, fatigue
was not significantly different (p > .05). Vitality, or rates of energy, was increased (p = .01).
However, 3 months post-treatment, the assessment revealed the fatigue was significantly
decreased in comparison to the control, wait list group that did not practice yoga (p = .02).
Weaknesses of this trial include not reflecting the preferred sample group- breast cancer
survivors as opposed to patients currently undergoing treatment. However, chemotherapy has a
lasting affect on patients fatigue so it is still applicable to the PICOT. Strengths of this study
include women were randomly assigned to the control and intervention groups, it was the ideal
sample size, and there was great adherence to the interventional yoga regimen which led to very
accurate results.
Taso et al. (2014) designed a randomized controlled trial to measure whether breastcancer patients currently undergoing chemotherapy (interventional group) had a significant
decrease in fatigue compared to patients receiving standard care with no supplementary yoga
sessions. The trial consisted of 60 women with non-metastatic breast cancer, n=30 women were
in the control group, and n=30 women were the interventional yoga group. The trial took place
for a period of 8 weeks with two 60-minute sessions a week during the chemotherapy treatment
period. The Brief Fatigue Inventory was used as a measurement of womens rates of fatigue. All

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participants were assessed using the Brief Fatigue Inventory questionnaire before the trial for a
baseline, at 4 weeks (or halfway through the trial), and at 8 weeks after the trial had been
concluded. At the 4-week assessment, fatigue levels were not significantly different in the
intervention group. However, at the 8-week assessment, there was a significant decrease in
fatigue in the interventional yoga group (p < .01). Thus, attending yoga exercise groups for an
extended period of time is optimal in the reduction of fatigue. The control group did not have a
decrease in fatigue levels. Weaknesses of this study include a smaller sample size than preferred,
the women in the intervention and control groups varied greatly in terms of baseline status, and a
longer trial to further test fatigue levels would have been optimal. Strengths of this study include
it being a double-blind study, very high rates of adherence in the intervention group (over 90%),
the reasons why the women could not attend was well documented. In addition, although patients
varied in baseline status, the study did a good job of ensuring the study suited all of the patients
conditions.
The guidelines for post-cancer treatment by Rock et al. (2012) identifies consistently
engaging in an exercise program as a management option for chronic fatigue. Most peoples first
approach to fatigue would not be exercise for fear of injuring themselves. However, this
guideline outlines exercise as one of the primary options to manage chronic fatigue. They
recommend consistently maintaining physical activity, such as yoga specifically with aerobic
exercise and resistance training. In addition, they recommend to nutrition as the number one way
to recover after treatment because of the physical toll chemotherapy takes on the body. This
guideline further supports the trials findings.

BREAST CANCER FATIGUE

Synthesis
Chandwani et al. (2014) found that fatigue in breast-cancer patients receiving
chemotherapy significantly decreased with yoga and active stretching (p < .05). In addition,
Kiecolt-Glaser et al. (2014) demonstrated a reduction in fatigue in patients receiving
radiotherapy at 3-months post-intervention (p= 0.02). Taso et al. (2014) found a diminished rate

of fatigue (p < .01) in breast cancer survivors after yoga as well. Finally, the guideline by Rock et
al. (2012) proposes that patients recovering from cancer treatment need to consistently engage in
physical activity such as yoga.
Research indicates that yoga exercise decreases the rates of fatigue in patients who have
recently undergone or are currently undergoing chemotherapy treatment. Differences include the
varying population groups. The varying stages of cancer, amounts of chemotherapy, and thus
baseline levels of fatigue should have been documented better in each of the trials, as this would
directly affect the outcome ratings of fatigue. The yoga exercises should be more individualized
as each specific patient has varying levels of endurance based on their condition.
Clinical Recommendations
The guideline by Rock et al. (2012) demonstrates that exercise is of the utmost important
in terms of recovering from harsh chemotherapy treatment. With a more individualized approach
to yoga exercise based on ability and a nutritional diet plan in place, patients outcomes and
quality of life would increase. A plan for how this could be implemented to become standard
practice could be through referral of the primary care physician. If the primary care physician
referred the patient undergoing chemotherapy to a center located near them that provides yoga
classes and implemented that as standard care, more patients would become aware of the positive
benefits of a mild exercise program like yoga.

BREAST CANCER FATIGUE

References
Centers for Disease Control and Prevention (2015). Breast cancer. Retrieved from
http://www.cdc.gov/cancer/breast/
Chandwani, K., Perkins, G., Nagendra, H., Raghuram, N., Spelman, A., Nagarathna, R., . . .
Cohen, L. (2014). Randomized controlled trail of yoga in women with breast cancer
undergoing radiotherapy. Journal of Clinical Oncology, 32(10), 1058-1065.
Doi:10.1200/JCO.2012.48.2.752
Kiecolt-Glaser, J. K., Bennett, J. M., Andridge, R., Peng, J., Shapiro, C. L., Malarkey, W. B.,
Glaser, R. (2014). Yoga's impact on inflammation, mood, and fatigue in breast cancer
survivors: A randomized controlled trial. Journal of Clinical Oncology, 32(10), 10401049. doi:10.1200/JCO.2013.51.8860
National Cancer Institute (2014). Fatigue overview. Retrieved from
http://www.cancer.gov/about-cancer/treatment/side-effects/fatigue/fatigue-hp-pdq

Rock, C.L., Doyle, C., Demark-Wahnefried, W., Meyerhardt, J., Courneya, K.S., Schwartz, A.L.,
. . . Gansler, T. (2012). Nutrition and physical activity guidelines for cancer survivors. CA
Cancer J Clin. 2012 Jul-Aug; 62(4):243-74. doi: 10.3322/caac.21142
Taso, C., Lin, H., Lin, W., Chen, S., Huang, W., & Chen, S. (2014). The effect of yoga exercise
on improving depression, anxiety, and fatigue in women with breast cancer. Journal of
Nursing Research, 22(3), 155-164. doi:10.1097/jnr.0000000000000044

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