1. Fuerst, Mark L.

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SAN DIEGO-Yoga can be an effective supportive therapy for advanced lung cancer patients as well as their caregivers, according to a new study.

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Thoracic radiation therapy is associated with respiratory toxicities, which may reduce patients' physical performance and their overall quality of life. Yoga therapy may buffer against disease and treatment-related sequelae, said lead author, Kathrin Milbury, PhD, Assistant Professor of Cancer Medicine in the Department of Palliative Care and Rehabilitation Medicine, University of Texas MD Anderson Cancer Center, Houston.


"It is never too late to engage in exercise, and we know from earlier studies that people can exercise while being treated with chemotherapy or radiation," noted Milbury. "Caregivers sometimes have more anxiety and sleeping problems than patients. Therefore, we thought that having the patient and caregiver go through yoga instruction together would be beneficial for both partners."


Milbury presented the study findings at the 2017 Palliative and Supportive Care in Oncology Symposium (Abstract 125).


Previous research shows that women with breast cancer can benefit from an exercise regimen. Lung cancer patients usually have more symptoms, are older, and in worse physical shape than women with breast cancer. The researchers recently showed that yoga can help improve quality of life for both glioma patients undergoing radiotherapy and their caregivers.


Studying Yoga

Yoga is a low-impact exercise that lung patients can perform easily, with a strong emphasis on breathing, an important issue for people with lung cancer who often have shortness of breath, she said. The researchers chose yoga poses that are known as chest openers-exercises that emphasize stretching the chest area along with deep breathing.


"Choosing yoga as the form of exercise to use in this study was important because it is a gentle form of exercise readily modifiable for patients' needs, and it easily allowed for partners to participate in the yoga practices," explained Milbury. "Because family caregivers also report symptom burden (distress, sleep disturbances), we included them as active participants in this trial."


All the patients in the study had advanced lung cancers that could not be removed surgically, were receiving radiation therapy to their chest, and most also received chemotherapy. Each patient participated with a family caregiver. The pairs were then randomly assigned to either yoga classes or a waitlist for future yoga instruction (control group).


The yoga program emphasized three key areas: physical postures, breathing exercises, and meditation. The design of the study to include 15 sessions of yoga lasting 60 minutes each was based on outcomes from earlier research on yoga in people with breast cancer in Bangalore, India, and confirmed by larger trials in the U.S.


Non-small cell lung cancer patients undergoing radiation therapy and their caregivers were randomized to 15 sessions of yoga or a waitlist control group. Prior to radiation therapy initiation and randomization, both groups completed measures of quality of life (SF-36 domains). Patients also completed the 6-minute walk test to measure physical performance. The pairs were reassessed at the last day of radiation therapy and then 3 months later.


The researchers approached 47 eligible dyads of which 32 (68%) consented and 26 (81%) completed all assessments. Patients had a mean age of 73 years, and two-thirds of them had stage III disease. Both the patients and their caregivers, mean age of 62 years, completed a mean of 12 sessions. Virtually all (96%) of them rated the program as "very useful."


After controlling for baseline levels and other relevant covariates, multilevel modeling revealed a clinically and statistically significant difference in patients' 6-minute walk test-the yoga group had a mean of 478 minutes against 402 minutes for the control group. There were clinically significant differences in the physical function, role performance, and mental health domains of the SF-36 as well in favor of the yoga group. For caregivers, clinically significant improvements were found in vitality and role performance.


Integration to Cancer Care

"Yoga therapy appears to be a feasible and beneficial supportive care strategy for lung cancer patients and caregivers," said Milbury. "This was a feasibility study, so it is very hard to tease out the specific effects of our intervention, but that will be a next step in our research." The researchers plan to conduct a larger efficacy trial with a more stringent control group.


The researchers cautioned that they have not shown that yoga is superior to other forms of exercise, such as swimming or hiking, but they do believe that they have demonstrated that it is a holistic experience. Enrollees included only patients at MD Anderson and did not comprise a racially diverse population. Greater inclusiveness will be a goal of future research efforts.


"There is currently very little research on behavioral supportive care for people with lung cancer," stated Milbury. "We tried to look at one way to boost patient and caregiver well-being, both physically and mentally, as a means to enhance supportive care."


Patients in the study reported that it was good to be away from their cancer experience during the yoga sessions, and the patients and caregivers both noted that they enjoyed learning something new together. "We were thrilled to hear that many of our pairs said they would continue to do yoga on their own," said Milbury.


ASCO Expert Andrew S. Epstein, MD, Medical Oncologist at Memorial Sloan Kettering Cancer Center in New York, commented: "There is a growing body of literature that yoga can be integrated into cancer care. We've known for some time that yoga can have a wide range of benefits for people who practice it. Ideally, the findings of this study will encourage people with advanced cancer and their caregivers to practice yoga."


Mark L. Fuerst is a contributing writer.