Running Head: Yoga Practice in Breast Cancer Patients

Yoga Practice in Breast Cancer Patients: A Literature Review Karen J. Davis Loyola University Chicago

Running Head: Yoga Practice in Breast Cancer Patients Abstract Cancer is one of the leading illnesses in the world, and over 2 million women in the United States have a history of breast cancer. Quality of life and symptom management is an every day struggle for those suffering with breast cancer.

Common practice is to treat symptoms with medications, however the side effects of the medications decrease an individuals quality of life. Complementary and alternative methods of treatment is a new practice that helps to maintain/enhance a persons quality of life and reduce their symptoms. Of the CAM treatments, yoga has shown much promise in maintaining/enhancing quality of life and decreasing symptoms. Due to yoga being a new alternative practice, more studies need to be conducted to determine the best evidence-based practice to be implemented into cancer programs. Keywords: yoga, pain management, breast cancer, fatigue, anxiety, nausea and vomiting and quality of life.

Running Head: Yoga Practice in Breast Cancer Patients Introduction It is estimated that 1.6 million people will be diagnosed with cancer in 2012.

Of those people, it is estimated that 230, 500 will be breast cancer. Of those 230,500 about 39,520 will die. As of January 1, 2008 there have been 2,632,005 women alive in the United States who have had a history of breast cancer (National Cancer Institute, 2012). Quality of life and symptom control is a major concern for patients diagnosed with cancer. Appropriate symptom control is a major concern for oncologists, as well as to maintain or increase a patients quality of life throughout their diagnosis, treatment and into remission. Currently patients symptoms are being managed by medications i.e. analgesics, antiemetics, antianxiety. Analgesics are used to treat pain patients may acquire from their cancer, chemotherapy treatments, radiation treatments or surgical sites. Narcotics are commonly used due to their ability to effect opiate receptors, which increase pain threshold and interfere with pain receptors. While analgesics may help control a patients pain, there are side effects that may decrease their quality of life; for example nausea, vomiting, drowsiness, and respiratory distress. Antiemetics are used to manage nausea and vomiting. There are different stages of nausea and vomiting in relation to cancer treatments. There is anticipatory nausea and vomiting that some patients get prior to their treatment, there is nausea and vomiting that is experienced during treatment and finally delayed nausea and vomiting that occurs 24-48 hours after treatment. Many antiemetics help to control a patients nausea and vomiting, but there are also side effects that may be experienced; for example, drowsiness, nervousness, anxiety.

Running Head: Yoga Practice in Breast Cancer Patients Antianxiety medications are used to control a patients anxiety related to their diagnosis, treatments or surgery. Many cancer patients will be placed on a daily dose of antianxiety medications to help control their symptoms. Complementary and alternative methods of treatment, also known as CAM, for symptom control and quality of life are not widely known by patients and medical staff. Alternative treatments such as meditation, yoga, hypnosis, and acupuncture are examples of alternative treatments that may help to manage a patient's symptoms and maintain their quality of life. Majority of cancer patients admitted to the hospital, are admitted for symptom management. Introducing alternative methods of treatment, for example yoga, to cancer patients may help to

decrease their symptoms and decrease the number of times they are admitted to the hospital. By decreasing the amount of symptoms a patient experiences, there may be a decrease in hospital stay, length of stay and a decrease in hospital expenses.

Clinical Scenarios and PICOT Question Jane Doe (45 y/o female) is diagnosed with breast cancer. After having her mastectomy and starting chemotherapy and radiation treatment, Jane is experiencing intractable pain, anxiety and in unable to accomplish her daily tasks like she used to. Her doctor has placed her Norco 10/325mg every 4 hours as needed for pain, as well as Morphine IR 5mg every 1 hour for severe pain. For her anxiety Jane is taking Ativan 1mg Q6 hours as needed. While Janes pain is being controlled from her pain medications and her anxiety is controlled by the Ativan, she is experiencing strong side effects from the medications. She is even more tired

Running Head: Yoga Practice in Breast Cancer Patients

then before she started taking the medications and she now frequently has bouts of nausea and emesis. Mary Doe (40 y/o female) is diagnosed with breast cancer. Mary has already had surgery for her mastectomy and is currently undergoing chemotherapy and radiation treatments. Mary is experiencing intractable pain and anxiety from her treatments. Marys doctor prescribes her pain medication and antianxiety medication, but also educates her on using yoga as an alternative treatment method for her symptoms. Mary begins to practice yoga twice a week, and after a couple of weeks begins to notice a decrease in her pain as well as her anxiety. One research/PICOT question that is appropriate to these clinical scenarios is: Problem: Patients diagnosed with breast cancer. Intervention: Breast cancer patients who practice yoga on top of prescribed medications for symptom management. Control: Breast cancer patients who use prescribed medications for symptom management, but do not practice yoga. Outcome: Breast cancer patients who practice yoga will maintain their quality of life, experience fewer symptoms and use less prescribed medication for symptom management. Time: Time of diagnosis through remission.

Review of Research Guideline Database Table 1 below displays all of the major guideline databases researched on the topic of yoga as an alternative treatment for symptom management and quality of life in cancer patients.

Running Head: Yoga Practice in Breast Cancer Patients Database Title of Document Clinical Journal of Oncology Nursing.(2008) Putting Evidence into Practice: Interventions for Depression. Clinical Journal of Oncology Nursing. (2007). Putting Evidence into Practice: Evidence Based Interventions for Fatigue during and following cancer and it's treatment. Clinical Journal of Oncology Nursing. (2007). Putting Evidence into Practice: Evidence Based Interventions to prevent, manage and treat chemotherapy induced nausea and vomiting. Guidelines for Using Complementary and Alternative Methods Learning About New Ways to Treat Cancer Complementary and Alternative Methods for Cancer Treatment Clinical Journal of Oncology Nursing. (2009). Putting Evidence into Practice: Interventions for Anxiety. Clinical Journal of Oncology Nursing. (2009). Putting Evidence into Practice: Interventions for Depression. Clinical Journal of Oncology Nursing. (2007). Putting Evidence into Practice: Evidence Based Interventions for Fatigue during and following cancer and it's treatment.

6 Type of Guideline

National Guideline Clearinghouse www.guidelines.gov

Systematic Review

Systematic Review

Systematic Review Editorial and Expert Opinion Editorial and Expert Opinion Editorial and Expert Opinion

American Cancer Society www.cancaer.org

Oncology Nursing Society www.ons.org

Systematic Review

Systematic Review

Systematic Review

Running Head: Yoga Practice in Breast Cancer Patients Clinical Journal of Oncology Nursing. (2007). Putting Evidence into Practice: Evidence Based Interventions to prevent, manage and treat chemotherapy induced nausea and vomiting. Clinical Journal of Oncology Nursing. (2009). Putting Evidence into Practice: Evidence Based Interventions for Sleep-wake disturbances. There are currently no guidelines for using yoga as a treatment method. There are also no guidelines for using complementary and alternative treatments methods.

Systematic Review

Systematic Review

Advocate Lutheran General Hospital

All of the guidelines that were published in the Clinical Journal of Oncology Nursing focused on CAM. Each of the articles mentioned yoga as an alternative treatment method, but there are no current guidelines that focus solely on yoga.

Review of Health Science Research Databases To obtain research literature, a search of Nursing OVID and CINHAL was performed. Once the initial limitations were implemented, the abstracts were reviewed for research studies that focused on yoga as an alternative treatment method for breast cancer patients. To limit the number of articles, articles published between 2005 and 2012 were reviewed. Studies that did not focus solely on yoga or breast cancer were excluded. Editorial and commentary articles were excluded, only research studies and systematic reviews were used. Due to the small amount of

Running Head: Yoga Practice in Breast Cancer Patients

studies conducted in the topic area, research conducted outside of the United States was included. 8 studies fit the criteria for valuation. Table 2 below displays the search strategy used in CINHAL and Nursing Ovid. Searches in both databases used the keywords yoga, breast cancer, pain management, fatigue, nausea and vomiting, anxiety and quality of life. Nursing OVID Searched

CINHAL Searched Yoga = 3005 + breast cancer = 59 + 2005-2012 = 53 Yoga = 3005 +pain management = 13 Yoga = 3005 + fatigue = 54 yoga = 3005 + nausea and vomiting = 7 yoga = 3005 + anxiety = 126 yoga = 3005 + quality of life = 153

Yoga = 1760 Yoga = 1760 + breast cancer = 173 yoga = 1760 + pain management = 102 yoga = 1760 + fatigue = 269 yoga = 1760 + nausea and vomiting = 73 yoga = 1760 + anxiety = 574 Yoga = 1760 + quality of life = 434

Matrix of the Research Evidence See Attached Excel Sheet. Literature Review From the studies reviewed, it can be concluded that yoga as an alternative therapy for patients with breast cancer can maintain/enhance their quality of life,

Running Head: Yoga Practice in Breast Cancer Patients decrease symptoms of fatigue, pain, and anxiety, and increase psychosocial wellbeing and spiritual well-being. Of all the studies reviewed, six of them were pilot

studies. Studying the effects of yoga on reducing symptoms and medication use, and maintaining/enhancing quality of life and quite limited. The use of complementary and alternative methods for cancer patients is a fairly new practice. Many studies have been conducted on using CAM, but few focus solely on yoga. Each study modified the yoga practice used in their study to reflect the ability of the participants. Besides practicing postures, meditation and focus groups were used. Of all of the studies reviewed, the Yoga of Awareness pilot study out of Duke University, was the best study that could most easily be enhanced upon and integrated into hospital and clinical settings. The Yoga of Awareness program was conducted over eight weeks, and not only focused on yoga postures, but used meditation, group discussion and had a focus group meeting after the study was completed. Participants were taught at home yoga practice and were also taught how to properly journal their data (Carson, 332). All of the reviewed studies noted that there were limitations to each study, and that more randomized clinical trials needed to be conducted on yoga as an intervention in order to have more adequate results. However, all of the studies showed promising results. Every study that was reviewed showed positive results. In some studies there was more of a significant result than others. The use of yoga as an alternative therapy to cancer patients is incredibly relevant to nursing practice. Participants in the yoga programs were able to maintain/enhance their quality of life, decrease their symptoms and reduce medications used to control

Running Head: Yoga Practice in Breast Cancer Patients their symptoms. More studies need to be conducted in order to find the best evidence-based practice that can be implemented in to the hospital and clinic setting.

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Running Head: Yoga Practice in Breast Cancer Patients References 1. Banasik, Jacquelyn., Williams, Hope., Haberman, Mel., Blank, Salle E., Bendel, Robert. (2011). Effect of Iyengar yoga practice on fatigue and diurnal salivary

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cortisol concentration in breast cancer survivors. Journal of the American Academy of Nurse Practitioners, 23, 135-142.

2. Carson, James W., Carson, Kimberly, M., Porter, Laura, S., Keefe, Francis, J., Shaw, Heather., Miller, Julie M. (2006). Yoga for Women with Metastatic Breast Cancer: Results from a Pilot Study. Journal of Pain and Symptom Management, 33(3), 331341.

3. Galantino, Mary Lou., Greene, Laurie., Archetto, Benjamin., Baumgartner, Melissa., Hassall, Paula., Murphy, Joanna Kluz., Umstetter, Jamie., Desai, Krupali. (2012). Explore, 8(1), 40-47.

4. Moadel, Alyson B., Shah, Chirag., Wylie-Rosett, Judith., Harris, Melanie S., Patel, Sapana R., Hall, Charles B., Sparano, Joseph A. (2007). Journal of Clinical Oncology, 25(28), 4387-4395.

5. Nagarathna, R., Raghavendra, R.M., Nagendra, H.R., Gopinath, K.S., Ravi, B.D., Patil, S., Ramesh, B.S., Nalini R. (2006). European Journal of Cancer Care, 16, 462-474.

6. Speed-Andrews, Amy E., Stevinson, Clare., Belanger, Lisa J., Mirus, Judith J.,

Running Head: Yoga Practice in Breast Cancer Patients 7. Courneya, Kerry S. (2010). Cancer Nursing,. 33(5), 369-381. Smith, Kelly B., Pukall, Caroline F. (2008). Psycho-Oncology, 18, 465-475.

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