Complementary Therapies in Medicine (2014) 22, 173—186

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Health benefits of qigong or tai chi for

cancer patients: a systematic review
and meta-analyses
Yingchun Zeng a,∗, Taizhen Luo a, Huaan Xie a,
Meiling Huang b, Andy S.K. Cheng c

a
Department of Obstetrics, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou,
China
b
Department of Nursing, The Third Affiliated Hospital of Guangzhou Medical University, China
c
Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, China
Available online 18 December 2013

KEYWORDS Summary
Qigong; Background: Cancer is a leading cause of death worldwide. Mind-body interventions are widely
Tai chi; used by cancer patients to reduce symptoms and cope better with disease- and treatment-
Exercise related symptoms. In the last decade, many clinical controlled trials of qigong/tai chi as a
intervention; cancer treatment have emerged. This study aimed to quantitatively evaluate the effects of
Cancer patients; qigong/tai chi on the health-related outcomes of cancer patients.
Meta-analysis Methods: Five databases (Medline, CINAHL, Scopus, the Cochrane Library, and the CAJ Full-text
Database) were searched until June 30, 2013. Randomized controlled trials (RCTs) of qigong/tai
chi as a treatment intervention for cancer patients were considered for inclusion. The primary
outcome for this review was changes in quality of life (QOL) and other physical and psychological
effects in cancer patients. The secondary outcome for this review was adverse events of the
qigong/tai chi intervention.
Results: A total of 13 RCTs with 592 subjects were included in this review. Nine RCTs involving
499 subjects provided enough data to generate pooled estimates of effect size for health-
related outcomes. For cancer-specific QOL, the pooled weighted mean difference (WMD) was
7.99 [95% confidence interval (CI): 4.07, 11.91; Z score = 4.00, p < 0.0001]. The standardized
mean differences (SMDs) for changes in depression and anxiety score were −0.69 (95% CI:
−1.51, 0.14; Z score = 1.64, p = 0.10), and −0.93 (95% CI: −1.80, −0.06; Z score = 2.09, p = 0.04),
respectively. The WMDs for changes in body mass index and body composition from baseline to
12 weeks follow-up were −1.66 (95% CI: −3.51, 0.19; Z score = 1.76, p = 0.08), and −0.67 (95%
CI: −2.43, 1.09; Z score = 0.75, p = 0.45) respectively. The SMD for changes in the cortisol level
was −0.37 (95% CI: −0.74, −0.00; Z score = 1.97, p = 0.05).

∗ Corresponding author. Department of Obstetrics, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou 510150,

China. Tel.: +86 18818808760; fax: +86 2081292736.

E-mail address: chloezengyc@hotmail.co.uk (Y. Zeng).

0965-2299/$ — see front matter © 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ctim.2013.11.010
174 Y. Zeng et al.

Conclusion: This study found that qigong/tai chi had positive effects on the cancer-specific QOL,
fatigue, immune function and cortisol level of cancer patients. However, these findings need to
be interpreted cautiously due to the limited number of studies identified and high risk of bias
in included trials. Further rigorous trials are needed to explore possible therapeutic effects of
qigong/tai chi on cancer patients.
© 2013 Elsevier Ltd. All rights reserved.

Contents

Introduction.............................................................................................................. 174
Aims ..................................................................................................................... 175
Methods.................................................................................................................. 175
Criteria for considering studies for this review ...................................................................... 175
Types of studies .............................................................................................. 175
Types of participants ..................................................................................................... 175
Types of interventions.................................................................................................... 175
Primary and secondary outcome.......................................................................................... 175
Search methods for identification of studies.............................................................................. 175
Selection of studies ...................................................................................................... 175
Data extraction and assessment of risk of bias ........................................................................... 175
Missing data.............................................................................................................. 176
Data synthesis............................................................................................................ 176
Results ................................................................................................................... 177
Description of included studies ...................................................................................... 177
Risk of bias in included studies ...................................................................................... 177
Effects of qigong/tai chi on health outcomes of cancer patients..................................................... 177
Health-related QOL: general and cancer-specific QOL ............................................................... 177
Psychological symptoms ............................................................................................. 181
Physical health effects .............................................................................................. 181
Inflammation and immune function.................................................................................. 181
Discussion ................................................................................................................ 181
Conclusion ............................................................................................................... 185
Conflict of interest statement............................................................................................ 185
Sources of funding ....................................................................................................... 185
References ............................................................................................................... 185

therapy or exercise, which involves a range of specifically

Introduction
Cancer is a leading cause of death worldwide.1 Due to
advances in medical technology and cancer treatment, the
prognosis associated with cancer has improved markedly.
The 5-year relative survival rate of all cancer sites is 65.8%.2
Diagnosis and treatment of cancer represent a major life-
time stressor for any patient, posing both physical and
psychological threats to the patient.3,4 The emotional dis-
tress of cancer diagnosis and the persistent side-effects of
treatment also significantly compromise patients’ quality
of life (QOL).5 Growing evidence suggests that mind-body
techniques are beneficial adjuncts to cancer treatment and
may be effective in addressing the multifaceted needs of
patients with cancer.6,7 Mind-body interventions are widely
used by cancer patients to reduce symptoms and cope better
with disease- and treatment-related symptoms.3 Mind-body
treatments evaluated for their utility in oncology included
qigong and tai chi.6
Qigong and tai chi were originally developed in China
based on theoretical principles that are inherent to tradi-
tional Chinese medicine.8,9 They are practiced as mind-body
and gently physical movements, and incorporates the pur-
poseful regulation of both breath and mind in coordination
with the regulation of the body.7,10 Practicing qigong/tai chi
simultaneously trains the mind, body, and qi (vital energy)
for the benefits of physical, psychological and spiritual
health.7,11 Globally, qigong and tai chi are practiced in a
variety of modern and traditional forms.12 Despite variation
among the myriad styles, qigong and tai chi are health-
oriented and emphasize the same principles and practice
elements.11 There is one difference between qigong and tai
chi that ‘‘traditional tai chi is typically performed as a highly
choreographed, lengthy, and complex series of movements,
while health enhancement qigong is typically a simpler,
easy to learn, more repetitive practice’’.11 However, tai
chi incorporate many movements that are similar to qigong
exercise, and the longer forms of tai chi include qigong exer-
cises as a warm up.11 Due to sharing the same basic principles
of the regulation of body focus, breath focus and mind focus
by practicing qigong or tai chi,11 the research literatures for
these two forms of mind-body interventions could be con-
sidered as one body of evidence in the health promotion and
wellness context.
Health benefits of qigong or tai chi for cancer patients: a systematic review and meta-analyses
Several reviews have suggested that qigong and tai chi
appear to have health benefits for cancer patients.3,13,14 In
a systematic review of controlled trials of qigong in cancer
patient care, two of nine trials indicated that qigong may
prolong the life of cancer patients.14 A more recent sys-
tematic review of qigong exercise as a supportive measure
for cancer patients included 23 trials and found some evi-
dence that the immune function of patients was better than
patients treated with conventional methods alone.13 Like-
wise, a review of the benefits of tai chi for cancer survivors
showed that it has therapeutic effects and suggested that it
may be beneficial for cancer patients.3 However, some other
reviews have indicated that the evidence is not convinc-
ing enough to suggest that tai chi is an effective supportive
cancer treatment.15,16
Aims
Previous studies examining the therapeutic value of using
qigong/tai chi for cancer treatment have so far proved inclu-
sive. In addition, there is a lack of meta-analysis to estimate
the treatment effects of qigong/tai chi for cancer patients.
The primary aim of this study, therefore, was to quantita-
tively evaluate the treatment effects of qigong/tai chi on
the health-related outcomes of cancer patients through sys-
tematic review and meta-analysis.
Methods
Criteria for considering studies for this review
Types of studies
Eligible studies were randomized controlled trials (RCTs).
Observational and other types of studies were considered
for exclusion in this review.
Types of participants
Eligibility criteria of participants were limited to adults
(with 18 years old and above), who were undergoing can-
cer treatment, cancer survivors (those who had completed
primary cancer treatment), and cancer patients who were
at the end of their life. The review aimed to include all types
of cancer diagnosis.
Types of interventions
Use of any type of qigong or tai chi for cancer patients
was included. This review included studies where qigong or
tai chi was used in the intervention group, and including a
control group without qigong or tai chi interventions.
Primary and secondary outcome
All studies were required to report QOL as a primary or
secondary outcome measure to be eligible for inclusion.
The primary outcome for this review was changes in QOL
in cancer patients, who had undertaken a qigong or tai
chi intervention, compared to those who had not. This
175
Box 1 Medline search strategy
1. tai chi
2. qigong
3. 1 or 2
4. cancer$.mp
5. carcino$.mp
6. neoplasms (MESH)
7. or/4—6
8. (randomized controlled trial).pt.
9. (clin$ adj5 trial$).ti,ab.
10. random$.ti,ab
11. control$.ti,ab
review also included other physical and psychological health
effects of qigong or tai chi interventions measured by vali-
dated measures. The secondary outcome for this review was
adverse events, referring to any harm caused to participants
from the qigong or tai chi intervention.
Search methods for identification of studies
Five databases (Medline, CINAHL, Scopus, the Cochrane
Library, and the CAJ Full-text Database) were searched until
June 30, 2013, and articles published in English and Chinese
were included in the data sample. Searchers were limited
to papers published from 2003 onwards due to the relatively
new focus of qigong/tai chi in QOL and wellbeing of cancer
patients. A Medline search strategy was developed (Box 1)
and adapted as appropriate for other databases.
Selection of studies
All studies identified were screened for inclusion based
on the study selection criteria. All titles and abstracts of
articles which clearly did not fulfill the eligibility criteria
were excluded. To ensure rigor in the study selection pro-
cess, two reviews Yingchun Zeng, Taizhen Luo (ZYC, LTZ)
independently checked through all the records identified
to minimize bias. Disagreements were resolved by a third
review author Huaan Xie (XHA). The selection of studies is
shown in Fig. 1.
Data extraction and assessment of risk of bias
For each study included, data were extracted from the orig-
inal paper independently by one of the main researcher
and then verified by another researcher. Disagreements con-
cerning data extraction were resolved by discussion. Risk of
bias was judged based on the quality assessment method of
the 2011 Cochrane Handbook. This mainly consists of seven
domains: random sequence generation, allocation conceal-
ment, blinding of participants and personnel, blinding of
outcome assessment, incomplete outcome data, selective
outcome reporting, and other biases.
176
Figure 1 PRISMA flow diagram of study selection. Randomized controlled trial (RCT).
Missing data
If data for standard deviations (SDs) were missing, missing
SDs were calculated where possible from other available
statistics, and were computed for the calculation of using
standard error of the mean or 95% confidence intervals
(CI).18
Data synthesis
The Cochrane Collaboration’s Review Manager (RevMan 5.2)
was used to generate pooled estimates of effect size.17
Heterogeneity was assessed with Higgins I2 statistics. The
Y. Zeng et al.
values of 0—25%, 25—50%, and 75—100% in I2 statistics reflect
low, moderate and high heterogeneity,19 which is one of
the influencing factors in grading the level of evidence. For
continuous variables, weighted mean difference (WMD) was
calculated when outcomes were measured using the same
scale, and the standardized mean difference (SMD) was used
when different scales were used in different trails, with cor-
responding 95% CI.18 The random effects model was used,
because it does not overstate the effects of an intervention
and is more conservative.19 The following sources of hetero-
geneity among the include studies were presumed: types of
intervention (qigong vs. tai chi), types of cancer. If possi-
ble, the potential sources of heterogeneity were explored
using sensitivity analyses. A value of p < 0.05 was considered
statistically significant.
Health benefits of qigong or tai chi for cancer patients: a systematic review and meta-analyses 177

Results

Blinding of participants and personnel (performance bias)

Description of included studies

Blinding of outcome assessment (detection bias)

Random sequence generation (selection bias)
A total of 13 RCTs with 592 participants were included in
this review. Of these 13 trials, five adopted qigong interven-

Incomplete outcome data (attrition bias)

Allocation concealment (selection bias)
tions for cancer patients, while the other eight used tai chi
as a study intervention. The characteristics of these trials

Selective reporting (reporting bias)

are summarized in Table 1. The majority of the studies was
pilot, parallel and open-label trials and had an extremely
small sample size. The duration of interventions ranged
from 5 to 12 weeks. Outcome measures included physi-
ological measures by assessing body composition through
body fat mass (BFM) and body mass index (BMI); psycholog-
ical measures by validated anxiety and depression scales,
biomarker measures were assessed through cortisol levels,
C-reactive protein (CRP), and QOL measures by general QOL

Other bias
and cancer-specific QOL scales.

Risk of bias in included studies

Campo 2013 + – – – + + ?
Each trial included was evaluated in terms of its risk of bias
(Fig. 2). Most had a high risk of bias. Major sources of risk of
bias were related to allocation concealment, blinding study Chen 2013 + + – ? + + ?
subjects or research personnel, and random sequence gen-
eration. Of 13 trials, only three studies7,20,21 described the – –
Galantino 2003 ? + ? + +
method of randomization. Other studies did not describe
their methods of sequence generation or allocation conceal-
ment. One trial4 addressed incomplete outcome data with Janelsins 2011 – ? – ? – + –
intention-to-treat (ITT) analysis. One trial22 with dropout
rates over 30% failed to address incomplete outcome by ITT Lam 2004 + + – + + + ?
analysis. Despite the difficulties of blinding participants and
intervention delivery, few trials attempted to blind the out-
Mustian 2004 – – – ? – + –
come assessors to minimize the potential methodological
bias. Therefore, a risk of biases might be introduced in most
of the RCTs included. Mustian 2006 – – – ? – + –

Effects of qigong/tai chi on health outcomes of Oh 2008 + – – ? + + –

cancer patients
Oh 2010 + – – ? + + ?
Of 13 RCTs with a total of 592 subjects included in this
review, nine studies involving 499 subjects reported enough
data to generate pooled estimates of effect size for health- Oh 2012 + – – ? – + ?
related outcomes.
Peppone 2010 – – – ? – + –
Health-related QOL: general and cancer-specific
QOL Rausch 2007 ? ? – ? + + –

Three studies20,21,23 examined the effects of qigong/tai chi – ? – ? + + –

Sprod 2012
on the general QOL among cancer patients. Graph 1 shows
change in general QOL from baseline to follow-up mea-
sured using SF-36. There were eight sub-scales of SF-36. Figure 2 Risk of bias summary on the 13 trials of qigong/tai
Four subscales’ change scores were in favor of qigong/tai chi chi for cancer patients.
interventions and indicated a statistically significant effect.
These four subscales were physical functioning, vitality,
social functioning and mental health. Their WMDs were 2.01
(95% CI: 1.37, 2.65), 1.50 (95% CI: 0.56, 2.44), 0.95 (95% CI: to 12-week follow-up. Using a random-effect model, the
0.55, 1.35), and 2.33 (95% CI: 1.70, 2.95), respectively. pooled WMDs was 7.99 (95% CI: 4.07, 11.91). The values of
For cancer-specific QOL measured by FACT-G, Graph 2 I2 statistics was 95%, indicated high heterogeneity of these
shows change in cancer-specific QOL scores from baseline five trials.4,7,21,22,24
178 Y. Zeng et al.

Table 1 Summary of the 13 clinical trials of qigong/tai chi for cancer patients.

Trials Study design Study Intervention Outcome Outcome/results

participants measures

Campo et al. RCT, parallel 54 senior TG: tai chi Feasibility and Retention rates (TG
201320 female cancer intervention, 1 h per acceptability of vs. CG = 91% vs. 81%),
survivors session, three times intervention class attendance
per week for 12 rates (TG vs. CG = 79%
weeks vs. 83%)
CG: health education SF-36 None of the SF-36
control, 1 h per scores differed
session, three times between the tai chi
per week for 12 group and health
weeks education group.
Chen et al. 20137 RCT 95 breast TG: Guolin new BFI The qigong group
cancer patients qigong, 40 min per reported less
session, five times per depressive symptoms
week for 5 or 6 weeks overtime than the
women in the control
group (p = .05).
Women in the qigong
group who had
elevated depressive
symptoms at the start
of radiotherapy (RT)
reported less fatigue
(p < .01) and better
QOL (p < .05).
CG: waiting-list with CES-D No significant
usual care differences were
observed for sleep
disturbance and
cortisol slopes.
FACT-G
PSQI
Cortisol level
Galantino et al. Pilot RCT, 11 breast TG: Yang style of tai BFI No significant
200327 parallel, cancer patients chi, 1 h per session, difference of
open-label three times per week outcome measures
for 6 weeks between the two
groups
CG: walking exercise, BMI
1 h per session, 3
times per week for 6
weeks
FACT-B
6-min walking test
Janelsins et al. Pilot RCT, 19 breast TG: Yang style tai chi Biomarkers Insulin levels
201126 parallel cancer chuan, 1 h per remained stable in
survivors session, three times the tai chi group, but
per week for 12 increased in the CG.
weeks
CG: psychosocial Body composition Bivariate analysis
support, 1 h per revealed significant
session, three times correlations among
per week for 12 body fat mass and
weeks biomarkers (all
p ≤ .05)
BMI
Insulin level
Health benefits of qigong or tai chi for cancer patients: a systematic review and meta-analyses 179

Table 1 (Continued)

Trials Study design Study Intervention Outcome Outcome/results

participants measures

Lam 200421 RCT 57 advanced TG: Guolin qigong Survival rate Qigong had significant
liver cancer exercise plus TACE treatment effect on
patients (2 h class, twice the survival of
weekly for 6 weeks patients
plus home-based
exercise, daily for 24
weeks)
CG: TACE only BAI Social/family
well-being in the
FACT-G is the only
variable that was
significantly changed
over time (p = .036),
and was significantly
different between the
two groups (p = .022)
BDI
FACT-G
SF-36
Mustian et al. Pilot RCT, 10 breast TG: Yang style tai chi FACIT-F No significant
200424 parallel, cancer chuan, 1 h per time, improvement of QOL
open-label survivors three times per week
for 12 weeks
CG: psychosocial Self-esteem by Significant
support, three times Rosenberg improvement of
per week for 12 self-esteem scale self-esteem (p < .01)
weeks
Mustian et al. Pilot RCT, 21 breast TG: Yang style tai chi 6-min walking test Significant
200625 parallel, cancer chuan, 1 h per improvement of 6-min
open-label survivors session, three times walking test, hand
per week for 12 grip strength, and
weeks flexibility (all p values
<.05)
CG: psychosocial Body composition
support, three times (fat mass
per week for 12 percentages)
weeks
BMI
Functional
capacity
Oh et al. 200828 Pilot RCT 18 TG: medical qigong EORTC QLQ-C30 No significant
heterogeneous once or twice a week difference of QOL
cancer patients for 8 weeks between the two
groups
CG: usual medical CRP No significant
care difference of
inflammation
biomarker between
the two groups
Oh et al. 20104 RCT 162 TG: medical qigong FACT-G By intergroup
heterogeneous twice per week for 10 comparison: overall
cancer patients weeks QOL improved
(p < .044); fatigue
improved (p < .001);
mood disturbance
(p = .021)
180 Y. Zeng et al.

Table 1 (Continued)

Trials Study design Study Intervention Outcome Outcome/results

participants measures

CG: usual medical FACT-F There was significant

care difference of
inflammation
biomarker (p < .044)
POMS Qigong improved
QOL, reduced
fatigue, mood
disturbance, and
inflammation
Inflammation by
CRP
Oh et al. 201222 RCT 81 TG: medical qigong, EORTC QLQ-C30 In the qigong group,
heterogeneous 90-min per session, there was
cancer patients twice per week for 10 significantly improved
weeks cognitive function
(p = .014), compared
to controls. The
qigong group also
reported significant
improvement of QOL
(p < .001) and
significant reduction
of CRP levels
(p = .042) compared
to controls.
CG: usual medical FACT-COG
care
FACT-G
Inflammation by
CRP
Peppone et al. Pilot RCT 16 breast TG: Yang style tai chi Bone health Bone remodeling
201029 cancer chuan, 1 h per index scores were
survivors session, three times significantly improved
per week for 12 from baseline to
weeks post-intervention in
the tai chi group,
whereas it remained
virtually unchanged
for the control group.
CG: standard support Growth factors Changes in bone
therapy with exercise and cytokines formation were
control positively correlated
with changes in
cytokine and
growth-factor levels
Rausch 200730 RCT, parallel 29 early stage TG: tai chi (1 h at the CES-D Significant difference
breast cancer first, 1.5 h from the for depression scores
patients second session, once but in favor of the
per week for 10 control group (p < .05)
weeks)
CG: six subjects on POMS No significant
the spiritual growth difference for mood
intervention group, disturbance among
and eight subjects on the three groups
the standard health (p = .08)
care
Health benefits of qigong or tai chi for cancer patients: a systematic review and meta-analyses 181

Table 1 (Continued)

Trials Study design Study Intervention Outcome Outcome/results

participants measures

FACT-B Significant difference for

QOL score, but in favor
of control group.
Sprod et al. 201223 Pilot RCT, 19 breast TG: Yang style tai chi Cortisol level Physical functioning
parallel cancer chuan, 1 h per significantly improved in
survivors session, three times the tai chi group, but
per week for 12 not in the control group
weeks
CG: standard support Insulin level There was a statistical
therapy with exercise trend toward an increase
control in insulin among CG, but
not among the tai chi
group
SF-36 Changes in cortisol and
insulin levels from pre-
to post-intervention
were directly associated
with changes in role
limitations
BAI, beck anxiety inventory; BDI, beck depression inventory; BFI, brief fatigue inventory; BMI, body mass index; CES-D, center for
epidemiological studies-depression scale; CG, control group; CRP, C-reactive protein; EORTC QLQ-C30, European organization for research
and treatment of cancer quality of life questionnaire-core 30; FACIT-F, functional assessment of chronic illness therapy-fatigue; FACT-B,
functional assessment of cancer treatment-breast; FACT-COG, functional assessment of cancer treatment-cognitive function; FACT-F,
functional assessment of cancer treatment-fatigue; FACT-G, functional assessment of cancer treatment-general; POMS, profile of mood
state; PSQI, Pittsburgh sleep quality index; RCT, randomized controlled trial; SF-36, MOS short form 36 survey; TACE, transcatheter
arterial chemoembolization; TG, treatment group.

Psychological symptoms Inflammation and immune function

Three studies4,7,21 explored the effects of qigong on the
depression of cancer patients. Graph 3.1 shows the change
scores of depression from baseline to 12-week follow-up.
The SMD was −0.69 (95% CI: −1.51, 0.14; Z score = 1.64,
p = 0.10), indicating that qigong had no statistically signif-
icant effects reducing the depression of cancer patients.
Only two studies provided enough data to generate esti-
mates of effect size for anxiety and fatigue of cancer
patients. Graph 3.2 shows the anxiety change scores from
baseline to 12-week follow-up. The SMD was 1.97 (95% CI:
−3.36, 7.31), indicating that qigong had no statistically sig-
nificant effects on the anxiety of cancer patients. Graph 3.3
shows the fatigue change scores. The SMD was −0.93 (95%
CI: −1.80, −0.06; Z score = 2.09, p = 0.04), indicating that
qigong had statistically significant effects of qigong reducing
the fatigue of cancer patients.
Physical health effects
Four trials27—30 were not included in the statistical pooling
due to the fact that they did not provide enough data to gen-
erate pooled estimates of effective size. One trial29 reported
that tai chi has positive effects in changes of cytokine
levels among cancer patients. Two studies4,22 consistently
reported that qigong could reduce inflammation by mea-
suring the biomarker of CRP, although another28 reported
that there was no significant difference in CRP changes
between the qigong and control groups.Graph 5 shows
qigong/tai chi interventions reducing the cortisol levels of
cancer patients with a statistically significant effect when
compared to the control group. The SMD of cortisol level
changes was −0.37 (95% CI: −0.74 to −0.00). The values of
I2 statistics was 0, indicating no heterogeneity of these two
trials.
Of 13 included trials, only one study reported the safety
issues of study interventions, and this study found none of
the serious adverse events related to qigong practice.21

Two studies25,26 were pooled for the effects of tai chi on can-
cer patients’ BMI and BFM. The WMD for BMI change scores
from baseline to 12-week follow-up was −1.66 (95% CI:
−3.51, 0.19). The WMD for BFM was −0.67 (95% CI: −2.43,
1.09). Graphs 4.1 and 4.2 indicate that tai chi had no sta-
tistically significant effects on the BMI and BFM percentages
on cancer patients.
Discussion
For the subjective measures reviewed, several studies
found that qigong/tai chi had a positive impact on the
fatigue cancer-specific QOL and two studies reported a
positive impact on the fatigue of people living with can-
cer. For general QOL measured by SF-36, qigong/tai chi
182 Y. Zeng et al.

Graph 1 Changes in general QOL scores by sub-domains of SF-36 from baseline to 12-week follow-up: (1.1) Physical functioning;
(1.2) Role physical; (1.3) Bodily pain; (1.4) General health; (1.5) Vitality; (1.6) Social functioning; (1.7) Mental health; (1.8) Role
emotional.

also had a positive impact on vitality and mental health.
A Cochrane systematic review of exercise interventions on
health-related QOL of various cancer survivors reported
consistent findings.31 This Cochrane review included 40 tri-
als with a total of 3694 participants, types of exercise
interventions were mainly including general types of aer-
obic exercise such as strength training, resistance training,
walking and cycling. But this Cochrane review reported exer-
cise interventions has no statistical significant difference on
cancer-specific QOL. The WMD of FACT-G change score up to
12 weeks’ follow-up was 4.94 (−0.08, 9.95).31
In this review, either qigong or tai chi interventions had
positive effects on cancer-specific QOL measured by FACT-
G within 12-week’s follow-up. The overall WMD was 7.99
(95% CI: 4.07, 11.91; Z score = 4.00, p = 0.008). Compared
with those general exercise interventions, qigong/tai chi
may have specific therapeutic effects on cancer patients.
Given that qigong and tai chi are gentle types of exercise
Health benefits of qigong or tai chi for cancer patients: a systematic review and meta-analyses 183

Experimental Control Mean Difference Mean Difference

Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
2.1.1 Qigong for cancer patients
Chen 2013 6.3 6.48 49 2.3 2.43 46 20.9% 4.00 [2.05, 5.95]
Lam 2004 -1.4 6.02 29 -1.3 6.02 28 19.3% -0.10 [-3.23, 3.03]
Oh 2010 8.86 3.21 79 -0.13 3.07 83 21.7% 8.99 [8.02, 9.96]
Oh 2012 8.41 2.54 37 -4.25 4.16 44 21.3% 12.66 [11.18, 14.14]
Subtotal (95% CI) 194 201 83.1% 6.57 [2.32, 10.83]
Heterogeneity: Tau² = 17.82; Chi² = 80.83, df = 3 (P < 0.00001); I² = 96%
Test for overall effect: Z = 3.03 (P = 0.002)

2.1.2 Tai Chi for cancer patients

Mustian 2004 14 5.7 6 -1 0.66 4 16.9% 15.00 [10.39, 19.61]
Subtotal (95% CI) 6 4 16.9% 15.00 [10.39, 19.61]
Heterogeneity: Not applicable
Test for overall effect: Z = 6.38 (P < 0.00001)

Total (95% CI) 200 205 100.0% 7.99 [4.07, 11.91]

Heterogeneity: Tau² = 18.17; Chi² = 87.86, df = 4 (P < 0.00001); I² = 95%
-20 -10 0 10 20
Test for overall effect: Z = 4.00 (P < 0.0001)
Favours control Favours experimental
Test for subgroup differences: Chi² = 6.93, df = 1 (P = 0.008), I² = 85.6%

Graph 2 Changes in cancer-specific QOL scores by FACT-G from baseline to 12-week follow-up.

Graph 3.1 Changes in depression scores from baseline to 12-week follow-up

Qigong Control Std. Mean Difference Std. Mean Difference
Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
Chen 2013 -3.6 2.8 49 -1 0.78 46 33.3% -1.24 [-1.68, -0.80]
Lam 2004 0.8 4.66 29 -0.5 4.46 28 32.0% 0.28 [-0.24, 0.80]
Oh 2010 -1.01 2.09 79 1.54 2.7 83 34.7% -1.05 [-1.38, -0.72]

Total (95% CI) 157 157 100.0% -0.69 [-1.51, 0.14]

Heterogeneity: Tau² = 0.48; Chi² = 22.37, df = 2 (P < 0.0001); I² = 91%
-2 -1 0 1 2
Test for overall effect: Z = 1.64 (P = 0.10)
Favours qigong Favours control

Graph 3.2 Changes in anxiety scores from baseline to 12-week follow-up

Qigong Control Std. Mean Difference Std. Mean Difference
Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
Lam 2004 0.2 0.46 29 -2 0.46 28 49.6% 4.72 [3.68, 5.75]
Oh 2010 -1.71 1.6 79 -0.47 1.79 83 50.4% -0.73 [-1.04, -0.41]

Total (95% CI) 108 111 100.0% 1.97 [-3.36, 7.31]

Heterogeneity: Tau² = 14.66; Chi² = 96.74, df = 1 (P < 0.00001); I² = 99%
-20 -10 0 10 20
Test for overall effect: Z = 0.72 (P = 0.47)
Favours qigong Favours control

Graph 3.3 Changes in fatigue scores from baseline to 12-week follow-up

Qigong Control Std. Mean Difference Std. Mean Difference
Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
Chen 2013 -0.4 0.29 49 -0.1 0.07 46 48.3% -1.39 [-1.84, -0.94]
Oh 2010 -2.42 2.66 79 -1.3 1.73 83 51.7% -0.50 [-0.81, -0.19]

Total (95% CI) 128 129 100.0% -0.93 [-1.80, -0.06]

Heterogeneity: Tau² = 0.36; Chi² = 10.15, df = 1 (P = 0.001); I² = 90%
-4 -2 0 2 4
Test for overall effect: Z = 2.09 (P = 0.04)
Favours qigong Favours control

Graph 3 (3.1) Changes in depression scores from baseline to 12-week follow-up; (3.2) Changes in anxiety scores from baseline to
12-week follow-up; (3.3) Changes in fatigue scores from baseline to 12-week follow-up.
184 Y. Zeng et al.

Graph 4.1 Changes in Body Mass Index levels from baseline to 12-week follow-up
Tai Chi Control Mean Difference Mean Difference
Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
Janelsins 2011 -0.42 0.75 9 0.29 0.61 10 49.8% -0.71 [-1.33, -0.09]
Mustian 2006 -1.2 0.11 11 1.4 0.92 10 50.2% -2.60 [-3.17, -2.03]

Total (95% CI) 20 20 100.0% -1.66 [-3.51, 0.19]

Heterogeneity: Tau² = 1.69; Chi² = 19.26, df = 1 (P < 0.0001); I² = 95%
-10 -5 0 5 10
Test for overall effect: Z = 1.76 (P = 0.08)
Favours tai chi Favours control

Graph 4.2 Changes in body composition (fat mass percentages) levels from baseline to
12-week follow-up
Tai Chi Control Mean Difference Mean Difference
Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
Janelsins 2011 -0.16 2.91 9 0.28 1.57 10 67.9% -0.44 [-2.58, 1.70]
Mustian 2006 -1.13 4.79 11 0.04 2.06 10 32.1% -1.17 [-4.28, 1.94]

Total (95% CI) 20 20 100.0% -0.67 [-2.43, 1.09]

Heterogeneity: Tau² = 0.00; Chi² = 0.14, df = 1 (P = 0.70); I² = 0%
-10 -5 0 5 10
Test for overall effect: Z = 0.75 (P = 0.45)
Favours tai chi Favours control

Graph 4 (4.1) Changes in body mass index levels from baseline to 12-week follow-up; (4.2) Changes in body composition (fat mass
percentages) levels from baseline to 12-week follow-up.

and belong to nonpharmacologic and noninvasive interven-
tions, recommending these exercises to patients with cancer
generally seems safe and appropriate.
On the other hand, of the objective measures reviewed,
qigong/tai chi had positive effects decreasing inflammatory
markers of CRP and cortisol level. Reduction of inflammatory
markers may indicate that qigong/tai chi can improve the
immune function of cancer patients. As most cancer patients
suffer from immune deficiency,32 improving immune func-
tion by practicing qigong/tai chi could be a significantly
important therapeutic effect. Nevertheless, better designed
and more rigorous trials are required to confirm that qigong
therapy can improve cancer patients’ immune functions,
and to examine the possible underlying mechanisms of how
it improves the immune function of cancer patients.
The present study found that qigong has no effects on
reducing the anxiety of cancer patients, as the pooled effect
of anxiety change score from baseline to follow-up was in
favor of control groups rather than the intervention group
using qigong. This finding was consistent with a systematic
review and meta-analysis of effects of qigong on depres-
sive and anxiety symptoms: Wang et al.33 concluded that
qigong may have no benefits for the management of anxiety
symptoms.
It is notable that most of the studies reviewed here had
different degrees of methodological flaws. For example,
seven studies had a high risk of bias involving no ade-
quate allocation concealment and no description of random
sequence generation. In addition, there was variation in
intervention frequency and duration. The duration of inter-
vention ranged from 45 min to 2 h per session, and the
frequency of intervention ranged from 2 to 5 times per week.
The total duration of intervention varied from 5 to 12 weeks.
Given the short-term duration of interventions (less than 3
months) in these studies, the long-term effects of qigong/tai
chi on cancer treatment were largely unknown, and the
optimal duration of qigong/tai chi intervention has not yet
been addressed.
This study had several limitations. Like most system-
atic reviews and meta-analyses, one possible limitation is
the potential incompleteness of the evidence reviewed.
In addition, as selective publishing and reporting bias is
well-documented, the positive effects of qigong/tai chi
interventions may be overestimated. Finally, a high risk of

Graph 5 Changes in cortisol levels from baseline to 12-week follow-up

Qigong/Tai Chi Control Std. Mean Difference Std. Mean Difference
Study or Subgroup Mean SD Total Mean SD Total Weight IV, Fixed, 95% CI IV, Fixed, 95% CI
Chen 2013 -0.24 0.63 49 0.01 0.62 46 83.2% -0.40 [-0.80, 0.01]
Sprod 2012 1.98 2.3 9 2.65 2.79 10 16.8% -0.25 [-1.15, 0.66]

Total (95% CI) 58 56 100.0% -0.37 [-0.74, -0.00]

Heterogeneity: Chi² = 0.09, df = 1 (P = 0.77); I² = 0%
-2 -1 0 1 2
Test for overall effect: Z = 1.97 (P = 0.05) Favours qigong/tai chi Favours control

Graph 5 Changes in cortisol levels from baseline to 12-week follow-up.

Health benefits of qigong or tai chi for cancer patients: a systematic review and meta-analyses
bias exists in most of the studies included, so more rigorous
trials with higher standards of trial methodology are needed
to determine the therapeutic effects of qigong and tai chi
on cancer treatment.
Conclusion
This study found that qigong/tai chi had positive effects
on the cancer-specific QOL, fatigue, immune function and
cortisol level of cancer patients. However, these findings
need to be interpreted with caution due to the limited num-
ber of studies identified and high risk of bias in included
trials. Further rigorous trials are needed to explore possible
therapeutic effects of qigong/tai chi on cancer patients.
Conflict of interest statement
None declared.
Sources of funding
None
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