Effectiveness of Box Breathing Exercises in Reducing Stress among Women Postmastectomy: A Randomized Controlled Trial

Abstract

Background:

Breast cancer is the most common cancer among women globally. The emotional and psychological impact of the disease, particularly following mastectomy, can significantly affect quality of life.

Objective:

This study aimed to assess the effectiveness of box breathing exercises in reducing stress levels among women who have undergone mastectomy.

Materials and Methods:

A purposive sampling approach was employed, and 140 women, aged 25–65 years, who had undergone mastectomy were selected. Participants were divided into experimental (70 patients) and control (70 patients) groups. The experimental group participated in box breathing exercises, while the control group received routine care. Stress levels were measured using a validated 23-item self-assessment tool, administered at baseline, posttest I, posttest II, and posttest III.

Results:

The results revealed a significant reduction in stress levels in the experimental group over time. By posttest III, 22.86% of the experimental group attained low stress, while 77.14% showed moderate stress levels. In contrast, the control group remained predominantly in the high-stress category (90%). The differences between the two groups were statistically significant (P < 0.001).

Conclusion:

Box breathing exercises are an effective, noninvasive intervention for reducing stress in breast cancer patients following mastectomy. Further research is warranted to explore long-term outcomes and the broader applicability of this intervention in various healthcare settings.

INTRODUCTION

Breast cancer is recognized as the most prevalent cancer among women globally, accounting for approximately 25% of all new annual cancer cases worldwide. Breast cancer constitutes about 14% of all cancer cases among women. Statistics reveal that the lifetime risk of an Indian woman developing this malignancy is alarmingly high, with a diagnosis occurring every 4 minutes, contributing to significant emotional and psychological distress.[1]

Data from the World Health Organization (WHO) indicate that the estimated lifetime risk of breast cancer in women globally stands at about 1 in 12 (8.33%). In developing nations, this rate is approximately 1 in 27, but presents a higher mortality ratio. Moreover, cancer survival rates deteriorate significantly with advanced stages of the disease, as highlighted by evidence that over 60% of women in India present at stages III and IV upon diagnosis.[2]

The psychological impact of breast cancer and its treatment, especially mastectomy, further complicates patient outcomes. Research indicates a high prevalence of depressive symptoms (68.6%) and perceived stress (78.1%) in breast cancer patients. The importance of psychological interventions is underscored by findings, indicating that controlled breathing exercises can effectively reduce cortisol levels, a stress hormone, in patients undergoing acute stress conditions.[3]

MATERIALS AND METHODS

Study design and setting

This study employed a purposive sampling approach and was conducted in selected hospitals within the Madurai and Tirunelveli districts over the course of one year.

Study population and sampling

A total of 140 women, aged between 25 and 65 years, who had undergone mastectomy were selected. Participants were divided equally into experimental (70 patients) and control (70 patients) groups. The aim was to evaluate the effectiveness of box breathing exercises in reducing stress levels among women postmastectomy.

Inclusion and exclusion criteria

Inclusion criteria consisted of women who had undergone mastectomy, who could read and write Tamil, were fully conscious, willing to participate, and had undergone lymph node dissection. Conversely, women who had undergone breast reconstruction, those without axillary lymph node dissection, or those with preexisting neuromuscular, lymphatic, or musculoskeletal conditions affecting upper extremity testing were excluded.

Randomization and group allocation

Participants admitted at Meenakshi Mission Hospital were allocated to the experimental group, while those at Shifa Hospital were placed in the control group. The experimental group participated in box breathing exercises alongside standard nursing care, while the control group received only routine care.

Baseline characteristics and study tools

The study utilized a structured questionnaire divided into three parts. Part A collected demographic variables (age, education, income, etc.), Part B gathered clinical variables (BMI, cancer history, etc.), and Part C consisted of a validated stress questionnaire specific to cancer patients (23-item self-assessment tool with score ranges from 0 to 115) evaluating stress levels classified as low (0–38), moderate (39–76), or high (77–115). The reliability of the stress questionnaire was measured at 0.88.

Data collection

Stress levels were assessed on the third day postmastectomy using the stress questionnaire.

Intervention

For the experimental group, box breathing exercises were implemented, comprising four steps: inhaling through the nose for a count of 4, holding breath for 4, exhaling for 4, and holding breath for another 4. This sequence was to be repeated three times in a session, with 10 repetitions. The control group maintained regular hospital routine care only.

RESULTS

Table 1 presents the distribution of stress levels (low, moderate, and high) among experimental and control groups across four assessment periods: pretest, posttest I, posttest II, and posttest III, with a total of 70 participants in each group. In the pretest phase, all participants in both groups (100%) exhibited high stress levels, with no statistically significant difference between the groups (χ² = 0.00, P = 1.00). However, following the intervention, the experimental group showed a marked improvement. In posttest I, 42.86% of the experimental group moved to moderate stress levels, whereas 95.71% of the control group remained in the high stress category—a statistically significant difference (P < 0.001). By posttest III, the experimental group showed substantial improvement, with 22.86% attaining low stress and 77.14% moderate stress, while none remained in the high stress category. In contrast, 90% of the control group continued to experience high stress (P < 0.001). These findings indicate a statistically significant and consistent reduction in stress levels in the experimental group over time, highlighting the effectiveness of the intervention [Figure 1].

Table 1.

Distribution of pretest, posttest I, posttest II, and posttest III level of stress score among experimental and control groups (n=70+70)

Assessment	Level of stress score	Group				Chi-square value/Yates corrected Chi-square test	P
		Experimental group (n=7)		Control group (n=7)
		No.	%	No.	%
Pretest	Low	0	0.00	0	0.00	0.00	1.00 (NS) DF=1
	Moderate	0	0.00	0	0.00
	High	70	100.00	70	100.00
Posttest I	Low	0	0.00	0	0.00	28.90	0.001*** (S) DF=1
	Moderate	30	42.86	3	4.29
	High	40	57.14	67	95.71
Posttest II	Low	0	0.00	0	0.00	56.14	0.001*** (S) DF=1
	Moderate	48	68.57	5	7.14
	High	22	31.43	65	92.86
Posttest III	Low	16	22.86	0	0.00	115.21	0.001*** (S) DF=2
	Moderate	54	77.14	7	10.00
	High	0	0.00	63	90.00

Figure 1.

Line graph shows the pretest, posttest I, posttest II and posttest III of experimental and control group stress score

DISCUSSION

Breast cancer is a global public health issue, primarily affecting women. Geographic and socioeconomic factors influence diagnosis and treatment. In India, 14% of cases occur, requiring comprehensive support. Developing countries have higher late-stage diagnosis and mortality rates.[4]

Breast cancer, especially after mastectomy, causes significant psychological distress, including anxiety and depression. Box breathing exercises, may alleviate psychological distress and improve quality of life.[5]

Individualized psychosocial interventions, such as mindfulness-based therapy and box breathing, are gaining recognition for their effectiveness in reducing depression and anxiety in breast cancer populations.[6]

Disparities in psychosocial coping mechanisms highlight the need for targeted support systems for breast cancer patients, highlighting the importance of addressing both physical and mental health needs through an integrative treatment approach.[7]

Ethical clearance

The study was approved by the institutional human ethics committee, Vinayaka mission Annapoorna college nursing Salem (Tracking No: VMACON/IEC/43/2024 Dated: 12-10-2024). Informed written consent was obtained from all the study participants.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.