Yoga in addition to standard care for people with blood or lymph node cancer

Background

Blood and lymph node cancers are referred to as haematological malignancies. These are types of cancer that affect the blood, bone marrow and other parts of the lymphatic system. The most common ones are lymphomas, leukaemias and myelomas. Depending on the kind of cancer and how far it has spread, there are a lot of different options to manage the disease. Usually chemotherapy, radiotherapy or a combination of both is used to treat the disease. If the cancer is widespread, a transplantation of the patients’ own bone marrow cells combined with an aggressive chemotherapy can be a treatment option.

People with cancer most commonly experience high emotional distress, anxiety, fatigue, depression and sleeping problems. These symptoms can persist, even when the treatment has ended. In search of ways to manage and cope with such conditions, more and more patients are turning to complementary and alternative therapies.

Yoga

Yoga, originating in a thousand year old Indian tradition, is becoming more and more popular. There are hundreds of different styles of yoga, but in the Western world, yoga training mostly consists of three main elements: physical postures, breathing exercises and meditation. An increasing number of cancer patients use yoga as an additional way to improve their well-being. However, a systematic evaluation about the effects of yoga in the management of haematological malignancies is still missing.

Objectives

We reviewed the evidence about the effects of yoga on people with haematological malignancies. We also considered overall survival, distress, fatigue, depression, anxiety, sleep quality and adverse events as important outcomes. We compared people suffering from haematological malignancies treated with yoga and standard cancer care with those treated with standard cancer care only.

Findings

We included a single trial with 39 participants in the review (20 in the yoga group and 19 in the control group). The trial looked at a seven-week Tibetan Yoga program in a group of people with Hodgkin and non-Hodgkin's lymphoma. The average age was 51 years. The trial involved patients who were currently receiving anti-cancer therapy as well as patients who were not receiving active therapy. The trial found insufficient data to make a judgement about the efficacy of yoga on distress, fatigue, depression and anxiety compared with patients not practicing yoga. Yoga can improve the patients' quality of sleep. The trial gave no information about health-related quality of life, overall survival or adverse events.

On the basis of the GRADE criteria, we judged the overall quality of evidence for yoga concerning the outcomes distress, fatigue, anxiety, depression and quality of sleep as 'very low'.

Conclusion

There are not enough data to say how effective yoga is in the management of haematological malignancies. Therefore, the role of yoga for haematological malignancies remains unclear. Further large, high-quality randomised controlled trials are needed.

The evidence is up-to-date as of 4 February 2014.

Authors' conclusions: 

The currently available data provide little information about the effectiveness of yoga interventions for people suffering from haematological malignancies. The finding that yoga may be beneficial for the patients' quality of sleep is based on a very small body of evidence. Therefore, the role of yoga as an additional therapy for haematological malignancies remains unclear. Further high-quality randomised controlled trials with larger numbers of participants are needed to make a definitive statement.

Read the full abstract...
Background: 

Haematological malignancies are malignant neoplasms of the myeloid or lymphatic cell lines including leukaemia, lymphoma and myeloma. In order to manage physical and psychological aspects of the disease and its treatment, complementary therapies like yoga are coming increasingly into focus. However, the effectiveness of yoga practice for people suffering from haematological malignancies remains unclear.

Objectives: 

To assess the effects of yoga practice in addition to standard cancer treatment for people with haematological malignancies.

Search strategy: 

Our search strategy included the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1950 to 4th February 2014), databases of ongoing trials (controlled-trials.com; clinicaltrials.gov), conference proceedings of the American Society of Clinical Oncology, the American Society of Hematology, the European Haematology Association, the European Congress for Integrative Medicine, and Global Advances in Health and Medicine. We handsearched references of these studies from identified trials and relevant review articles. Two review authors independently screened the search results.

Selection criteria: 

We included randomised controlled trials (RCTs) of yoga in addition to standard care for haematological malignancies compared with standard care only. We did not restrict this to any specific style of yoga.

Data collection and analysis: 

Two review authors independently extracted data for eligible studies and assessed the risk of bias according to predefined criteria. We evaluated distress, fatigue, anxiety, depression and quality of sleep. Further outcomes we planned to assess were health-related quality of life (HRQoL), overall survival (OS) and adverse events (AE), but data on these were not available.

Main results: 

Our search strategies led to 149 potentially relevant references, but only a single small study met our inclusion criteria. The included study was published as a full text article and investigated the feasibility and effect of Tibetan Yoga additional to standard care (N = 20; 1 person dropped out before attending any classes and no data were collected) compared to standard care only (N = 19). The study included people with all stages of Hodgkin and non-Hodgkin's lymphoma, with and without current cancer treatment. The mean age was 51 years.

We judged the overall risk of bias as high as we found a high risk for performance, detection and attrition bias. Additionally, potential outcome reporting bias could not be completely ruled out. Following the recommendations of GRADE, we judged the overall quality of the body of evidence for all predefined outcomes as 'very low', due to the methodical limitations and the very small sample size.

The influence of yoga on HRQoL and OS was not reported. There is no evidence that yoga in addition to standard care compared with standard care only can improve distress in people with haematological malignancies (mean difference (MD) -0.30, 95% confidence interval (CI) -5.55 to 4.95; P = 0.91). Similarly, there is no evidence of a difference between either group for fatigue (MD 0.00, 95% CI -0.94 to 0.94; P = 1.00), anxiety (MD 0.30, 95% CI -5.01 to 5.61; P = 0.91) or depression (MD -0.70, 95% CI -3.21 to 1.81; P = 0.58).

There is very low quality evidence that yoga improves the overall quality of sleep (MD -2.30, 95% CI -3.78 to -0.82; P = 0.002). The yoga groups' total score for the Pittsburgh Sleep Quality Index (PSQI) was 5.8 (± 2.3 SD) and better than the total score (8.1 (± 2.4 SD)) of the control group. A PSQI total score of 0 to 5 indicates good sleep whereas PSQI total score 6 to 21 points towards significant sleep disturbances. The occurrence of AEs was not reported.

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