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Published in final edited form as: Eur J Integr Med. 2024 Feb 21;67:102348. doi: 10.1016/j.eujim.2024.102348

Integrating Yoga into Comprehensive Cancer Care: Starting Somewhere

Kathryn M Glaser 1, Christina R Crabtree-Ide 2, Tessa F Flores 2, Mary E Reid 2
PMCID: PMC11449015  NIHMSID: NIHMS1978030  PMID: 39372426

Abstract

Introduction

The rapid increase in cancer survivors in the United States (US) highlights the importance of survivors’ long-term care needs and symptom management. Given evidence that yoga supports cancer related symptoms, our aim was to develop and implement a community yoga program available for cancer survivors, family members, and staff involved in cancer care at a public comprehensive cancer center in the US. Given the wide age range and potential side effects from cancer treatment, we adapted the yoga program to meet the needs of cancer survivors.

Methods

Beginning in May 2017, we offered sixty-minute gentle yoga sessions for all medically cleared cancer survivors and their family members, caregivers, and friends, as well as oncology staff. We aimed to evaluate acceptability, development, and implementation of an adaptive yoga program at our comprehensive cancer center using mixed methods. Classes were initially offered once a week, then increased to twice a week. A total of five service evaluations were sent approximately every six months between April 2018-October 2019 to evaluate participant satisfaction (n=90 responses). Qualitative data were collected and analyzed using thematic analysis of participant satisfaction, allowing us to continuously monitor the yoga program and adjust to meet participants’ needs.

Results

Between May 2017 and February 2020, 176 people attended our program. Ages ranged from 21 to 72 years, with an average age of 45 years. Based on these evaluations, 96% (n=86) of participants rated both the program and teachers excellent, and 4% (n=4) rated the program and teachers good. Qualitative themes highlighted positive aspects of the program, including accessibility, inclusivity, and adaptive yoga based on medical needs, skill level, and abilities.

Conclusions

Adaptive yoga programs are well-accepted by cancer survivors and caregivers and may contribute a solution to healthcare staff and physician burnout. It is essential to build a solid foundation of self-care and wellness programming for cancer survivors and to create and foster adaptive yoga classes. Next steps for our program include evaluating yoga within the clinical setting, including chemotherapy infusion center and further research on reduction in stress through yoga in cancer survivors.

Keywords: Yoga, Integrative Oncology, Mind-Body Therapy, Cancer Survivorship

1. Introduction

For thousands of years, yoga has yielded beneficial effects on physical and emotional health, both mind and body. Breathing exercises, postures, and meditation have significantly improved quality of life (QOL) in cancer survivors, specifically in reducing the symptom burden related to cancer treatment [1–3]. An estimated 65–80% of cancer survivors require additional physical and emotional support beyond their treatment [4]. In 2016, there were 7.4 million male and 8.2 million female survivors in the United States (US), and it is estimated there will be more than 20 million cancer survivors by 2026 [5–6]. With advances in therapy and improved outcomes, this growing number of cancer survivors presents a unique demand to support long-term survivorship needs. The goal of this article is to describe the development, implementation, and acceptability of an adaptive yoga program for cancer survivors, caregivers, and staff within an integrative oncology care model.

Living through cancer treatment represents a life-changing event, often including residual and long-term emotional, physical, and psychological sequelae. With the increasing number of people surviving cancer, it is important to plan for the long-term care and symptom management needs of this population. Cancer treatment, especially chemotherapy, radiation, and long-term hormone therapy such as aromatase inhibitors (AIs), can have a long-lasting symptom burden that can remain long after the completion of treatment [7–8]. Residual symptoms include stress, fatigue, reduced physical function, anxiety, depression, lymphedema, osteoporosis, and sleep disturbances [7]. Evidence is strong for yoga as a treatment for cancer-related pain and fatigue [9–14]. This evidence has been accepted and incorporated into guidelines by many professional oncology organizations, including the National Comprehensive Cancer Network (NCCN), European Society for Medical Oncology (ESMO), Society for Integrative Oncology (SIO), and American Society of Clinical Oncology (ASCO). As cancer survivors start a new chapter of life after treatment, we aim to describe the development and implementation as well as overall acceptability of establishing a yoga program based on program evaluation in a large academic cancer center within a public hospital-based setting in the US.

As these yoga interventions have been shown to improve cancer related symptoms, cancer survivors increasingly want access to adaptive programs that meet their specific needs. Many comprehensive cancer centers have implemented integrative oncology programs, including yoga based on clinical evidence and patient demand [11–13, 15–17]. Our yoga program is based in a gentle flow of traditional yoga poses utilizing props (blocks, bolsters, chairs, straps, and walls) and focused on restorative and adaptive postures. This yoga practice utilizes breathing practices, postures, relaxation, and meditation to create a profound experience of overall well-being.

2. Methods

In October 2016, we began delivering specialized survivorship and integrative oncology care at an urban National Cancer Institute (NCI) designated comprehensive cancer center in Buffalo, New York (NY). This program included a survivorship clinic with dedicated staff, a network of supportive care and wellness services, and an integrative oncology program [17]. A needs assessment survey delivered to cancer survivors in November 2015 captured cancer survivor characteristics in our community, experience with symptoms and side effects, and interest in specific integrative oncology services. The results of this survey informed the development of our survivorship program and identified key supportive care areas that were important for our patient populations. A web-based survey link was sent to 35,420 active patients treated at our cancer center. Results included 1,054 surveys completed (3%), of which 705 (67%) met the inclusion requirements of completing treatment. The top two services of interest were nutrition support (39%) and yoga (31%).

In response to the interest in yoga, we began offering sixty-minute in-person gentle yoga sessions for all levels to all cancer survivors medically cleared by their oncologist(s) in May 2017. The implementation strategy included the following criteria: 1) consistent programing, 2) oncology and trauma-informed trained yoga teachers, 3) program monitoring and evaluation. The implementation strategy was based on the RE-AIM model for evaluating public health interventions assessing five domains: reach, efficacy, adoption, implementation, and maintenance [18]. These domains were defined as: Reach-did we reach the target population of cancer survivors; Effectiveness – did we deliver program consistently over time; Adoption – was there willingness for the clinics to refer survivors to the program; Implementation – did we evaluate satisfaction over time and the cost to the organization; Maintenance – did we continue funding and sustaining the program over time.

We initially offered this program periodically in 8-week cycles between May 2017 and April 2018, and increased to twice week consistently between May 2018 and February 2020. Financial support was secured for the program through internal quality of life (QOL) grants supported by the cancer center’s fundraising efforts. Grant funds provided yoga equipment and props (mats, blocks, blankets bolsters and straps), in addition to funds for contracted yoga teachers, and a 200-hour teacher training for one employee (KG) for future program development, maintenance, and sustainability. As we implemented the program, classes were offered to caregivers, family members, and friends as well as cancer center staff. All were welcome to participate in the program in efforts to foster diversity, equity, and inclusion. The survivorship clinic and patient resource center recruited participants using flyers and sign-up sheets promoting the program. Spaces were identified across the medical campus based on availability with easy access, sufficient space to accommodate at least 30 people, as well as free and convenient parking. Classes were offered both during the day and in the evening at no cost to participants.

Program leaders (KG and MR) vetted yoga teachers based on years of experience teaching and ability to adapt the program to the needs of cancer survivors. This vetting was additionally based on survivorship research, yoga training, and practice experience (KG). In 2019, additional QOL funds were secured to train lead instructors in oncology specific yoga training. Although initial classes included an 8-week program, we eventually offered weekly classes for 48 weeks out of the year for consistency, accommodating holidays. Service assessments were collected approximately every six months at five different timepoints to track participant satisfaction and monitor potential changes in the program.

The primary aim was to evaluate overall acceptability, development, and implementation of an adaptive yoga program for cancer survivors and their caregivers using mixed methods evaluation data that included both quantitative and qualitative responses. The evaluation assessments allowed us to modify the program based on feedback from participants. During the pilot phase between May 2017 and March 2018, we tracked participation only as an indicator of interest. As attendance for the program grew, we began distributing service evaluations approximately every six months between April 2018 and October 2019 (n=5) to evaluate overall participant satisfaction with a total of 90 responses (51% of participants). Given the abrupt disruption in our program in March 2020 by the COVID-19 pandemic, our last service evaluation was disseminated in October 2019, despite holding classes through the end of February 2020.

Participants included cancer survivors medically cleared and had completed treatment at least two months prior to session initiation (excluding hormone therapy), as well as caregivers and survivorship staff. Since evaluation data was collected as part of the implementation strategy, no informed consent was required, although participants signed a liability waiver to participate in the program. Participant tracking was based on waivers and sign-in sheets. Gender identity was an open-ended response in efforts to be inclusive of all gender identities. The Institutional Review Board (IRB) approved a retrospective data review of evaluation data (BDR 101618) for publication, and tumor registry provided de-identified clinical data on survivors to determine cancer disease type.

3. Results

Between May 2017 and February 2020, 176 people attended our program. Overall attendance included cancer survivors (32%), caregivers and friends (30%), and employees (38%), indicating the additional need for yoga to address employee burnout and overall wellness. The majority of repeat attendances were by cancer survivors (54%). Most participants identified as female (92%), which is reflective of most cancer types seen in the survivorship program, comprised of breast or gynecologic cancers (65%). Caregivers were mothers and/or daughters of cancer survivors. Ages ranged from 21 to 72 years old, with an average age of 45. Given the variability in the age range, it is important to consider accessibility when designing yoga classes. It is essential to provide a level of instruction that will reach the entire group with varying degrees of ability, using props such as blocks, bolsters, and chairs as support to offer modifications.

The program was evaluated at five different time points (April 2018, September 2018, February 2019, April 2019, and October 2019). Evaluations were disseminated via email to all participants attending a class during the evaluation cycle, with a weekly follow-up reminder for two weeks to encourage survey completion. Evaluation data was captured using RedCAP, a secure web application for building and managing online surveys and databases. A total of 90 evaluations were received from cancer survivors (60%), caregivers (3%), and employees (37%). Based on program evaluations including a 4-point Likert scale (excellent, good, poor, terrible), 96% (n=86) of participants rated both the program and teachers excellent, and 4% (n=4) rated the program and teachers good. Additional questions related to time of day that classes were offered and day of the week (Tuesday at 5:30pm for patients/caregivers and Friday at 12:00pm for employees), of which 79% of participants (n=71) said that the times and dates were convenient. Qualitative data was collected on what participants liked most about the program and if there was anything they would like to change (Appendix A: Evaluation data), which allowed us to continuously monitor the yoga program and make any changes to meet the needs of the participants. The most notable change was related to consistency of space. Data analysis was guided by two independent reviewers conducting thematic analysis to categorize and identify themes.

Qualitative themes highlighted the positive aspects of the program, most notably: accessibility and inclusive of health-related needs, and that it was adapted to all skill levels and abilities. Participants spoke to the safe, comfortable, and inclusive environment; for example: “You have provided a safe, comfortable environment for us to move, stretch, gain strength and to various degrees, heal” and “I always felt welcomed into a community where I would not be judged for my inability to do certain positions.” Participants also highlighted the adaptability of the programs to meet their needs and skill levels, such as: “[The teacher] was very in tune to everyone’s level and provided alternate poses to help make everyone comfortable” and “This program gave me the opportunity to explore new ways for my body to heal and for me to feel comfortable with my own limitations.” When asked about what they liked least, participants reported wanting consistency of class location, including specific space request, as well as increasing class frequency. Most (56%) said they would not change anything/did not dislike anything to report in the program, and of those that commented requested consistency and quality of space used as there is currently no dedicated wellness space at the cancer center.

4. Discussion

Given the evidence that survivors suffer from an intense symptom burden that can last long after treatment, awareness and management of the symptom burden is an important consideration when working with the cancer survivor population. With these considerations in mind, our yoga program was adapted to meet the needs of each individual and maximize the benefits from yoga. Side effects are common for cancer patients based on treatment received, including surgery, chemotherapy, immunotherapy, radiation therapy and/or hormone therapy. These side effects from treatment may include muscle loss or pain, fatigue, lymphedema, neuropathy, sleep disorders, cognitive disfunction, stress and stress related disorders, as well as weight gain or loss [7,19–22].

When providing yoga to the cancer survivor population, it is important for yoga teachers and therapists to consider the different needs and restrictions of cancer survivors. Some important risk factors related to cancer survivors include fragile bones that increase the risk of fracture, abdominal obstructions and sensitivities, weak or missing muscles, peripheral neuropathy affecting balance, a potentially compromised immune system increasing the risk of infection, medications (steroids, hormones) and medical devices (ports, central lines), as well as lymphedema (fluid retention and swelling caused by a compromised lymphatic system or lymph node dissection) [7,8,19,21] Additionally, caregivers and oncology staff often carry a significant burden, and their care and wellbeing are often overlooked since the focus is primarily on the patient [20].

Our program success demonstrates that yoga is a feasible and well-accepted program for cancer survivors and caregivers, as well as for the staff who care for them. Group instruction was interrupted by the COVID-19 pandemic in March 2020, however one on one yoga resumed in September 2021 and group instruction resumed in July 2023. Participant feedback prior to that point included reports of good instruction, provision of inspiration, social and physical support and improving/building the mind and body connection. Limitations include lack of race/ethnicity as well as other socioeconomic and demographic data, therefore study results could not be generalized across populations. Although feedback was limited to service evaluations, these components merit future investigation related to the additional benefits of providing mind-body therapies, including yoga, to cancer survivors and their support system.

In addition, yoga offering adaptations make poses accessible to cancer patients. Adaptations in our program included the use of props, especially stable chairs with armrests for seated poses and walls for support in standing poses, as well as blocks, straps, and bolsters for seated or reclined postures. Modifications support participants in gaining the benefits of a yoga practice, primarily with the use of chairs based on range of motion and sit-to-stand strength, as well as providing instruction for seated chair yoga and support for standing postures. Teachers changed the orientation of poses (seated, standing, or reclined) as a consideration to make yoga accessible for all participants. These fundamental principles and adaptations are incorporated into the gentle yoga offered to our community of cancer patients and caregivers and are important considerations for yoga teachers.

The physical needs of a survivorship population are a critical consideration in providing safe yoga instruction and necessary modifications to accommodate these needs. This is especially important as yoga is being included in clinical guidelines, including the 2018 ASCO endorsement of the SIO integrative therapies for breast cancer and the 2022 pain guidelines by ASCO and SIO [14,24]. Additionally, incorporating a yoga program into cancer treatment also extends beyond cancer patients and their caregivers to staff. Reducing staff burnout and increasing resiliency is an increasingly important consideration for health care in general, and especially for those providing cancer care delivery and end of life care. Wellness and self-care programs, including yoga, support organizational culture change, which may help increase resiliency in high-intensity environments and in turn reduce staff turnover as well as measurably reduces staff burnout, increases patient satisfaction, and improves quality of care.

Our program has developed a path for structured research initiatives in the integrative oncology space at our cancer center. Although this article is based on a program evaluation of the implementation and acceptability of our yoga program, this was not structured like a standard research protocol. Future directions include a current clinical trial to enhance research and measure reduction in stress and stress-related disorders through yoga in cancer survivors, both at our cancer center and community oncology practices. This research includes stress management and effects on cancer outcomes. The next steps for our yoga program include introducing breathing and relaxation techniques into the clinical setting, such as chemo infusion, to reach those who may not be able to access our group classes. We also continue to evaluate the impact of our yoga program in addition to other wellness modalities such as acupuncture, nutrition, healthy lifestyle, meditation, Qigong, music, and art classes.

5. Conclusions

It is essential to build a strong foundation of yoga programming within the cancer setting that includes universal and inclusive access to adaptive yoga. It is also important to measure program progress as part of the implementation strategy. Programming should be scaled based on sound research methodology and accurate reporting. Outcome measurement should focus on advancing the field and improving mental and physical health for cancer survivors and their communities.

Supplementary Material

1

Highlights.

  • We developed and evaluated a community yoga program available for our cancer community.

  • Adaptive yoga programs are effective and well-accepted by cancer survivors and caregivers.

  • It is important to consider the different needs and restrictions of cancer survivors.

  • It is essential to build a strong foundation of integrative oncology for cancer survivors.

Acknowledgements

The authors want to thank and express gratitude to 1) all participants in the program whose constant feedback helped us develop a truly accessible program, 2) the Screening and Survivorship Team at Roswell Park, especially Jill Downen, Doug McDaniel, Karin Larkin, and Debbie Williams, who helped recruit participants and support the program, 3) all of the yoga instructors that participated in instructing and developing this program, especially Leslie Rothschild, Kristen Thomas, and Steve Procknal, 4) Yogis in Service (YIS), a local nonprofit organization whose mission is to create connection by creating access to yoga and mindfulness as a set of self-care tools through community-based classes in schools, hospitals, universities, community centers, and treatment centers, and 5) summer students including Michaela Navone and Emily Kuettel.

Funding

This work was supported by National Cancer Institute (NCI) grant P30CA016056, as well as the Roswell Park Alliance Foundation through generous donor funds via a Quality of Life grant.

Footnotes

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Ethical Statement: The Institutional Review Board (IRB) at Roswell Park Comprehensive Cancer Center approved a retrospective data review of this evaluation data (BDR 101618).

Appendix A: Evaluation data (supplemental material)

Credit author statement

Kathryn M. Glaser is responsible for conceptualization, methodology, formal analysis, investigation, investigation, data curation, writing original draft, project administration and funding acquisition.

Christina Crabtree-Ide is responsible for validation and writing – review & editing.

Tessa Flores is responsible for conceptualization, resources, and writing-review & editing.

Mary Reid is responsible fore conceptualization, methodology, investigation, writing – review and editing, and supervision.

Declaration of interests

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Data Availability

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

1
NIHMS1978030-supplement-1.pdf (85.3KB, pdf)

Data Availability Statement

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.

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