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Florence Nightingale Journal of Nursing logoLink to Florence Nightingale Journal of Nursing
. 2026 Mar 26;34:e24139. doi: 10.5152/FNJN.2026.24139

Effects of Online Oncology Yoga and Mindfulness-Based Meditation on Fatigue, Sleep, and Quality of Life in Colorectal Cancer Survivors: A Mixed-Methods Study

Tuba Sengul 1,✉, Fahriye Oflaz 2, Ayise Karadag 1
PMCID: PMC13089036  PMID: 42077134

Abstract

AIM:

This study examined the effectiveness of oncology yoga and mindfulness-based meditation (OY and MB) intervention on sleep, fatigue, and quality of life in colorectal cancer (CRC) survivors.

This study employed a sequential explanatory mixed-methods design, with a primary focus on quantitative analysis.

METHODS:

The study was conducted from October 2021 to February 2022, involving 90 patients. Online OY & MB sessions were held over 12 weeks. Data were collected using the Brief Fatigue Inventory, Piper Fatigue Inventory, European Quality of Life-5 Dimensions, Pittsburgh Sleep Quality Index, and a patient information form. Three focus group interviews were conducted online to collect qualitative data.

RESULTS:

The mean age of the patients was 50.57 ± 10.74 years, and 50.0% were women. After the intervention, significant differences were observed in the post-test scores of Brief Fatigue (t = −5.22), Piper Fatigue (t = −3.72), Sleep Quality (t = −3.54), and Quality of Life (t = −3.41) in the intervention group (p < .001). Participants reported enhanced physical and psychological relaxation, a greater sense of well-being, and perceived benefits from the supportive group environment.

CONCLUSION:

Yoga and meditation may play a pivotal role in significantly ameliorating fatigue, sleep problems, and subjective conditions that adversely impact the quality of life of CRC patients. Medical challenges, technological limitations, and accessibility issues were also stated as difficulties in attending yoga and meditation practices.

Keywords: colorectal cancer, fatigue, mindfulness-based meditation, quality of life, sleep quality, yoga

What is already known on this topic?

  • Colorectal cancer (CRC) survivors commonly experience persistent fatigue, sleep disturbances, and reduced quality of life.

  • Yoga and mindfulness-based interventions have shown benefits for symptom management in cancer populations.

  • Evidence on online-delivered mind–body interventions and qualitative experiences of survivors is limited.

What does this study add to this topic?

  • Online oncology yoga and mindfulness-based meditation significantly improved fatigue, sleep quality, and quality of life in CRC survivors.

  • Mixed-methods findings revealed enhanced physical and psychological relaxation, as well as the value of peer support in online group settings.

  • The study identified medical, technological, and accessibility-related barriers affecting participation in online interventions.

Introduction

Colorectal cancer (CRC) is the third most common cancer worldwide in both men and women and ranks as the second leading cause of cancer-related deaths (American Cancer Society, 2023). Fortunately, advancements in early diagnosis and treatment have significantly improved cancer survival rates (Siegel et al., 2022). However, many patients commonly experience fatigue during and after cancer treatment. The level of fatigue may progressively increase post-treatment and adversely affect daily life. This fatigue cannot be alleviated by sleep or rest and diminishes an individual’s motivation to perform essential daily activities (Eyl et al., 2020; Lin et al., 2019). Fatigue and sleep problems often co-occur, further impacting patients’ daily activities and quality of life (Rodrigues et al., 2024). During this challenging period, a holistic approach can provide cancer patients with hope and strength, enabling them to improve their overall quality of life, reduce fatigue, and establish more effective sleep routines. Additionally, holistic nursing can serve as an approach to assess the mental state of cancer patients, enhance their hope and optimism, and activate fundamental support mechanisms (Lavdaniti, 2017). This approach extends beyond physical well-being to affect patients’ quality of life by addressing their psychological, social, spiritual, and overall well-being (Lavdaniti, 2017).

Fatigue and sleep disturbances are common complaints during cancer treatment, and these symptoms may sometimes indicate underlying depression (Suh et al., 2021; Hou et al., 2024). Therefore, improvements in fatigue and sleep disturbances often occur concurrently with enhancements in quality of life (Suh et al., 2021; Hou et al., 2024). In addition to medical treatment options, cognitive behavioral therapies and various lifestyle interventions are applied to support these improvements (Suh et al., 2021; Hou et al., 2024). One of these therapies may be oncology yoga and mindfulness-based meditation (OY & MB) practices (Agarwal & Maroko-Afek, 2018). Oncology yoga is a specialized form tailored to meet the unique physical and emotional needs of individuals undergoing cancer treatment or those who have survived cancer (Agarwal & Maroko-Afek, 2018). This type of yoga integrates gentle physical postures, breathing techniques, meditation, and mindfulness practices to help alleviate treatment-related side effects, promote relaxation, reduce stress, and enhance the overall well-being among cancer patients and survivors (Yoga4cancer, 2025). Today, oncology yoga and meditation practices are complementary interventions that provide physical and psychological benefits, especially for cancer survivors (Agarwal & Maroko-Afek, 2018). Mindfulness-based yoga specific to oncology is becoming increasingly common, serving as both a form of exercise and a mind-body practice (Hou et al., 2024; Lin et al., 2019). Adapted oncology yoga and meditation practices specifically designed for cancer survivors, encompassing activities such as meditative breathing and physical alignment, have a positive impact on physical and mental health, as well as health-related quality of life (Niu et al., 2023; Hou et al., 2024). A mindfulness-centered meditation program for cancer survivors can reduce both physical and psychological symptoms (McCloy et al., 2022). Similarly, Eyl et al. observed that an oncology yoga intervention reduced persistent symptoms of fatigue and exhaustion in breast cancer patients (Eyl et al., 2020), resulting in significant improvements in psychological well-being. Furthermore, Agarwal & Maroko-Afek (2018) summarized various types of oncology yoga and their potential benefits in their study, underlining the importance of incorporating them into cancer care as complementary therapies (Agarwal & Maroko-Afek, 2018). The results of these previous studies suggest that programs focusing on mindfulness may provide clinical benefits for cancer survivors. However, many systematic reviews have emphasized that including different cancer survivor groups and multiple interventions is necessary to draw robust conclusions regarding the impact of yoga- and mindfulness-based approaches (Mosher et al., 2017; Ngamkham et al., 2019). In the current literature, studies focusing specifically on CRC survivors are limited, and there is a lack of oncology yoga programs tailored to this population. To date, no study has examined the combined effects of specialized OY & MB in CRC survivors. Therefore, this study aimed to address this gap by investigating changes in fatigue, sleep problems, and overall quality of life following participation in these two complementary approaches. Furthermore, the study explored how this holistic intervention influenced the lived experiences of CRC survivors.

Methods

Study Aim

The study aimed to evaluate the effectiveness of OY & MB for reducing fatigue, improving sleep, and enhancing quality of life in CRC survivors and to explore participants’ subjective experiences regarding the benefits, challenges, and sustainability of the intervention.

The hypotheses of the study were as follows:

H1: The oncology yoga and mindfulness-based meditation intervention reduces fatigue levels in CRC survivors.

H2: The oncology yoga and mindfulness-based meditation intervention reduces sleep problems in CRC survivors.

H3: The oncology yoga and mindfulness-based meditation intervention improves the quality of life in CRC survivors.

Study Design

This mixed-methods study employed a sequential explanatory mixed-methods design (Creswell & Plano Clark, 2018), with priority given to the quantitative phase. Quantitative data were collected through a quasi-experimental pretest–posttest design involving intervention and control groups. Following completion of the quantitative phase, qualitative data were gathered through three focus group discussions (FGDs) conducted during the final week of the oncology yoga program to further explain, contextualize, and elaborate on the quantitative findings. The FGDs included participants who completed the OY & MB interventions as well as those who discontinued, allowing for a broader range of perspectives. Additional interviews were deemed unnecessary, as recurring patterns observed across the FGDs indicated data saturation.

Study Setting and Sample Selection

The research population comprised approximately 200 patients whose records were reviewed in the CRC treatment unit registry between October 1, 2021, and February 1, 2022. The intervention, which included OY & MB practices, was conducted over 12 weeks, from October 4 to December 24, 2021. The required sample size was calculated using G*Power 3.1 software, assuming a medium effect size (d = 0.5), an alpha level of 0.05, and a statistical power of 0.80, resulting in 90 participants (45 per group). This calculation was based on previous randomized controlled trials and meta-analyses reporting medium to large effect sizes of oncology yoga and mindfulness-based interventions on cancer-related fatigue, sleep disturbances, and quality of life among cancer survivors (Chaoul et al., 2018; Song et al., 2021; Agarwal & Maroko-Afek, 2018; McCloy et al., 2022). Participants were allocated to the intervention or control group on a voluntary basis during the enrollment process, consistent with the quasi-experimental study design. The study was completed with 53 participants: 30 in the intervention group (15 dropped out) and 23 in the control group (22 dropped out). Qualitative data were collected through three online FGDs (with three, three, and four participants, respectively) involving 10 participants. All intervention sessions, interviews, and outcome measurements were conducted via Zoom.

The inclusion criteria of the study were as follows:

  • Consent of the patient’s primary physician to participate in the study

  • Aged 20–70 years

  • Cancer stage 1–4

  • Receiving outpatient treatment

  • At least three months since surgery

The exclusion criteria were as follows:

  • Conditions hindering physical activity (severe heart failure, walking or mobility limitations, presence of a current colostomy)

  • Serious respiratory problems

  • Cognitive impairments (Dementia or Alzheimer’s disease)

  • Communication barriers due to language or cultural differences

  • Presence of another cancer besides CRC

  • Failure to attend more than one session

None of the participants was receiving active chemotherapy or radiotherapy at the time of enrollment; treatment status was confirmed by their primary physicians. Individuals with mild to moderate depression or anxiety were not excluded, as these symptoms are highly prevalent among cancer patients and do not typically prevent participation in mind–body interventions (Getie et al., 2025). Only severe psychiatric conditions that could interfere with participation or pose safety concerns were considered exclusionary.

Data Collection

Informed consent was obtained from all the participants at the beginning of the study. Before the interventions commenced, both the intervention and control groups were provided with a demographic information form along with specific scales, including the Brief Fatigue Inventory (BFI), Piper Fatigue Inventory (PFI), European Organisation for Research and Treatment of Cancer Questionnaire (EORTC QLQ C-30 [V-3.0]), and Pittsburgh Sleep Quality Index (PSQI). These scales were sent to their email addresses and mobile phones through an online survey link (https://koc.qualtrics.com). At the end of the 12 weeks, the participants were asked to complete the same scales again. All participants in the intervention and control groups were invited to participate in a qualitative interview at the end of the intervention period.

Data Collection Tools

The 22-question patient information contains variables related to sociodemographic and disease characteristics, such as age, body mass index, diagnosis, stage of cancer, and treatment applications.

The BFI, developed by Mendoza et al. and adopted for the Turkish population by Çınar et al., evaluates whether a person feels fatigued and weak differently from usual in the last week, fatigue severity, and the impact of fatigue on daily life activities (Çınar et al., 2000; Mendoza et al., 1999; Piper et al., 1998). The BFI consists of nine items, and each item is scored between 0 and 10, with higher scores indicating higher levels of fatigue. The Cronbach’s alpha value of the BFI score was found to be 0.96 by Mendoza et al. and 0.97 by Çınar et al (Çınar et al., 2000; Mendoza et al., 1999). In this study, Cronbach’s alpha values for the scale were 0.95 and 0.97 before and after the intervention, respectively.

The PFI was developed by Piper et al. (1998), and its validity and reliability study for the Turkish population was conducted by Can (2001), in which a Cronbach’s alpha value of 0.94 was reported (Can, 2001; Piper et al., 1998). In this study, Cronbach’s alpha values for the scale were 0.95 and 0.97 before and after the intervention, respectively. The scale consists of 22 items and evaluates the patients’ subjective perceptions of fatigue using four subdimensions. High scores indicate high levels of perceived fatigue.

The EORTC QLQ C-30 (V-3.0) was developed by Aaronson et al. and adapted for the Turkish population with lung cancer by Guzelant et al. in 2004 (Aaronson et al., 1993; Guzelant, 2004). This scale comprises 30 items and is used to evaluate the quality of life in cancer survivors. The scale consists of two subdimensions, functional and symptom scales, and the items are scored from 0 to 100. A high score on the scale indicates a high level of functioning and symptomology. Güzelant et al. reported a Cronbach’s alpha value of 0.70 or higher for the scale (Guzelant, 2004). In this study, the Cronbach’s alpha values for the scale were 0.83 and 0.87 before and after the intervention, respectively.

The PSQI was developed by Buysse et al. and adapted for the Turkish population by Ağargün et al. (Ağargün et al., 1996; Buysse et al., 1989). The Cronbach’s alpha of the index was reported to be 0.80. The PSQI assesses sleep quality over the past month and consists of 19 questions, divided into seven components, with a total score ranging from 0 to 21. A total score of more than five indicates poor sleep quality. In this study, Cronbach’s alpha values for the scale were 0.63 and 0.72 before and after the intervention, respectively. Although the internal consistency of the PSQI in this study was slightly below the commonly accepted threshold, this is not uncommon for multidimensional sleep scales administered in small samples. The lower alpha values may reflect the heterogeneous structure of the PSQI, variability in sleep-related symptoms among CRC survivors, and the use of self-reported online data collection.

In terms of the qualitative data, the semi-structured interview form containing open-ended questions on facilitators, barriers, and recommendations for OY & MB experience for CRC survivors was used. The questions were framed around changes in their daily lives and the most challenging and facilitating aspects of oncology yoga and meditation practice. The qualitative interview guide was developed drawing on the principles of holistic nursing and mind–body interaction. These frameworks emphasize the interconnected nature of physical, psychological, emotional, spiritual, and social dimensions of health, and they recognize mind–body practices, such as yoga and mindfulness, as supportive modalities that can enhance overall well-being and facilitate adaptive coping (American Holistic Nurses Association [AHNA], 2019). Sample questions included: “Can you describe how the sessions affected your daily life, sleep, and fatigue?”

  • –“What was the most challenging or facilitating part for you in this program, and what were the hindrances?”

  • –“What motivated you to continue participating in the sessions?”

  • –“What are your suggestions?”

Interventions and Process

Colorectal cancer (CRC) survivors who met the inclusion criteria were identified, and a pool of patients was then established by the responsible physician and the coordinating nurse from the CRC treatment unit where the study took place. The researcher contacted patients from this pool via phone, providing them with information about the study. Those who expressed interest in participating were subsequently included in the study. Participants were assigned to either the intervention or control groups on a voluntary basis. The control group was composed of CRC survivors who had not taken part in the oncology yoga or meditation sessions. All participants underwent initial assessments before the study commenced. The intervention group was planned to be divided into three subgroups of 15 participants for online Zoom sessions. However, the sessions were ultimately conducted as a single group due to participant dropout and logistical considerations. The study report was prepared by checking the Mixed Methods Reporting in Rehabilitation & Health Sciences checklist (Tovin & Wormley, 2023) (Figure 1: CONSORT Diagram). No formal inclusion criteria were based on Zoom proficiency; however, participants were asked whether they required support in using the platform. Those needing assistance received informal help from family members, and all participants were able to access the online sessions without additional facilitation from the research team. The OY & MB sessions were delivered by an Oncology Yoga instructor and mindfulness-based meditation expert holding internationally recognized certifications.

Figure 1.

Figure 1.

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CONSORT Flow Diagram of Participant

The program introduced in the intervention groups was structured into two complementary modules and was implemented alongside participants’ regular standard treatment and care routines. The intervention lasted 12 consecutive weeks, from October 4 to December 24, 2021. Two sessions were delivered each week throughout this period: the oncology yoga module was conducted every Monday for 60 minutes, while the mindfulness-based meditation module was carried out every Friday for 30 minutes. The days and times were determined based on participants’ availability prior to the start of the program. Delivering the interventions on different days aimed to prevent participant fatigue and promote sustained engagement with each practice. These modules are illustrated in the corresponding application flow diagrams (Figures 2 and 3).

Figure 2.

Figure 2.

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Flow Diagram of the Yoga and Asanas

Figure 3.

Figure 3.

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Flow diagram of the Mindfulness-Based Meditation themes

Participants in the control group received only standard medical care, which consisted of routine oncology follow-up, symptom management, and consultations with their physicians, without any additional structured intervention. No structured physical activity, yoga, or mindfulness intervention was included in standard care. The timing of assessments in the control group was aligned with that of the intervention group to ensure consistency. Before the 12-week intervention, individuals in the intervention group received a brief theoretical introduction and practical orientation on safety precautions. This session, conducted one week before the program began, included guidance on preventing physical injuries during yoga practice and recognizing when to discontinue a pose. For example, during the “chair pose,” participants were advised to monitor pain intensity in the knee and to avoid continuing the pose if discomfort exceeded 4–5 on a 10-point scale. They were instructed to exit the pose slowly and report any sensation of pain immediately. In the final week of the intervention, participants who volunteered for the qualitative evaluation were invited to participate in focus group interviews. Three separate focus group sessions were held via the Zoom platform to explore participants’ experiences and perspectives regarding the yoga and meditation practices delivered throughout the study.

Data Analysis

The NCSS (Number Cruncher Statistical System) 2007 program (Kaysville, Utah, USA) was used for statistical analyses. Descriptive statistics were computed for all variables. The Shapiro–Wilk test was applied to assess normality. For variables that met normal distribution assumptions, independent samples t-tests were used to compare groups and paired samples t-tests were used to compare pre- and post-intervention scores. For non-normally distributed variables, nonparametric equivalents (Mann–Whitney U and Wilcoxon signed-rank tests) were applied. The chi-square test was used to determine associations between categorical variables. Statistical significance was set at p < .05.

The researcher transcribed audio recordings from the FGDs verbatim. After each session, transcripts were reviewed in conjunction with observer notes. To protect confidentiality, participants were coded by gender, age, and class. Researchers analyzed responses by identifying and organizing meaningful content in relation to the study’s purpose and conceptual framework. The data were synthesized into categories, themes, and subthemes, supported by direct participant quotes relevant to the topic. Qualitative data were analyzed using thematic analysis, a method that enables a deeper understanding of participants’ perspectives, emotions, and reactions (Nowell et al., 2017). The process involved familiarizing oneself with the data through repeated reading, generating initial codes, identifying and reviewing emerging themes, and finally defining and naming them (Nowell et al., 2017). To enhance the trustworthiness of the qualitative analysis, a second qualitative researcher independently reviewed the coding framework, thematic structure, and analytic decisions. Any discrepancies or alternative interpretations were discussed until consensus was reached. An audit trail was maintained throughout the process, and themes were compared across focus groups to ensure consistency. Additionally, participants were invited to confirm the accuracy of summarized themes during the final session, providing a brief form of member checking. The qualitative component was conducted by researchers with formal training and extensive experience in qualitative research, including multiple published studies using thematic analysis, which contributed to the rigor and credibility of the analytic process.

Ethical Considerations

Institutional approvals were obtained from the Istanbul Medipol University Traditional and Complementary Medicine (GETAT) Clinical Research Ethics Committee(No: 95961207-604.01.01-E.64779, 12/12/2019), the Ministry of Health, and the hospital where the study was conducted. The study was conducted at a large for-profit hospital that is part of an extensive health system in a metropolitan area. Written informed consent was obtained from all participants prior to the commencement of the intervention. Because the study was conducted online, participants first received detailed verbal information about the study during a phone call. Those who agreed to participate were then sent an electronic consent form via a secure, encrypted Qualtrics link. Participants were required to read the form and confirm their written consent by selecting the “I agree to participate” option before accessing any questionnaires. All online questionnaires were administered through encrypted Qualtrics links, and responses were stored on secure, password-protected servers accessible only to the research team. No personal identifiers were collected within the system. All participants informed their physicians and provided both verbal and written (electronic) consent, acknowledging that participation carried no risk. Participants were reminded that their participation was voluntary and that they could withdraw at any time. Access to study data was restricted to the research team, and confidentiality was strictly maintained. To protect the identities of CRC survivors, interviews were anonymized through a coding process. For example, the notation “P1, 51A, F” indicates CRC survivor 1, aged 51 and female, while “M” represents male participants. To minimize evaluation bias, qualitative interviews were conducted by a researcher who was not involved in delivering the oncology yoga or meditation sessions and was unaware of the participants’ individual experiences with the interventions.

Results

Quantitative Findings

The demographic and clinical characteristics of the intervention (n = 30) and control (n = 23) groups were broadly comparable. The groups did not differ significantly in age, marital status, educational level, employment status, time since diagnosis, cancer type, disease stage, or prior treatment (p > .05) (Table 1).

Table 1.

Demographic and Disease-Related Characteristics of Cancer Survivors

Demographics Intervention Group (n:30) Control Group (n:23) p
Age Mean ± SD 50.57 ± 10.74 54.78 ± 6.15 .127
Min-Max (Median) 23–68 (52.5) 45–67 (55)
n (%) n (%)
Marital status Married 26 (63.4) 15 (36.6) .129
Single 4 (33.3) 8 (66.7)
Education Primary school 3 (75) 1 (25) .714
Secondary school 0 (0) 1 (100)
High school 6 (50) 6 (50)
University 18 (58.1) 13 (41.9)
Graduate school 3 (60) 2 (40)
Active employment Yes 18 (64.3) 10 (35.7) .500
No 12 (48) 13 (52)
General Health Status
Diagnosis time Mean ± SD 2.4 ± 1.13 2.65 ± 0.89 .466
Min-Max (Median) 1–4 (2.5) 1–5 (3)
n (%) n (%)
Chronic illness Hypertension 6 (54.5) 5 (45.5) .066
Diabetes 3 (27.3) 8 ( 72.7)
Other 21 (67.7) 10 (32.3)
Disease diagnosis Colon cancer 22 (57.9) 16 (42.1) .500
Rectum cancer 8 (53.3) 7 (46.7)
Disease stage Stage-1 12 (66.7) 6 (33.3) .077
Stage-2 7 ( 36.8) 12 (63.2)
Stage-3 7 (58.3) 5 (41.7)
Stage-4 4 (100) 0 (0)
Treatment received Chemotherapy 25 (54.3) 21 (45.7) .336
Radiotherapy 5 (71.4) 2 (28.6)
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There were no significant differences between the intervention (5.25 ± 1.92) and control (5.82 ± 1.98) groups in BFI scores at baseline (p > .05). Post-intervention, BFI scores significantly decreased in the intervention group (2.83 ± 1.24) but remained high in the control group (5.91 ± 2.16), indicating a significant between-group difference (t = −5.22, p < .001) (Tables 2 and 3). Pre-intervention PFI scores were 4.01 ± 1.90 for the intervention group and 3.54 ± 2.63 for the control group. After the intervention, scores decreased significantly in the intervention group (2.60 ± 1.81) and increased in the control group (4.32 ± 2.88) (t = −3.72, p < .001) (Tables 2 and 3). In the intervention group, general health scores on the EORTC QLQ-C30 were 12.70 ± 4.23 at baseline and improved to 9.40 ± 2.08 after the intervention. In the control group, scores were 8.86 ± 1.89 at baseline and decreased to 7.21 ± 1.59 after the intervention. This difference between groups was statistically significant (t = −1.75, p = .044) (Table 3). The symptom scale subdimension also showed significant improvement, with scores of 20.20 ± 4.10 in the intervention group versus 34.96 ± 8.80 in the control group (t = −3.41, p < .001) (Table 3). The PSQI score in the intervention group improved from 8.80 ± 3.29 to 3.03 ± 1.88 after the intervention. In the control group, scores changed from 10.39 ± 1.56 to 7.61 ± 1.67. The between-group difference in change was statistically significant (t = −3.54, p < .001) (Tables 2 and 3). Post hoc power analyses based on these observed effects confirmed that the study retained sufficient statistical power to detect these differences. Although the final sample size (n = 53) was lower than initially planned, the effect sizes observed for key outcomes were large to very large. Cohen’s d was 1.81 for fatigue, and Hedges’ g was 1.79. The physical function score yielded a medium-to-large effect size (Cohen’s d = 0.74), while the general health domain of the EORTC QLQ-C30 showed a large effect size (Cohen’s d = 1.16). Considerable effects were also observed in symptom reduction (Cohen’s d = 2.25) and improvement in sleep quality (Cohen’s d = 2.56). Despite the reduced sample size, these findings support the clinical relevance and practical impact of the intervention.

Table 2.

Comparison of the Change Differences in Intervention and Control Groups’ BFI, PFI, EORTC QLQ, and PSQI Total Scores

Intervention Group (n =  30) Control group (n  =  23) Measurement Differences
0 Week 12 Week p 0 Week 12 Week p Intervention Control t p
BFI Total Score 5.25 ± 1.92 2.83 ± 1.24 .001 5.82 ± 1.98 5.91 ± 2.16 0.799 −2.42 0.087 −5.22 < .001
PFI Total Score 4.01 ± 1.90 2.60 ± 1.81 .001 3.54 ± 2.63 4.32 ± 2.87 0.086 −1.41 0.771 −3.72 < .001
EORTC QLQ C-30 (V-3.0) general health 12.70 ± 4.23 9.40 ± 2.08 .001 8.86 ± 1.89 7.21 ± 1.59 0.001 −3.30 −1.65 −1.75 .044
EORTC QLQ Functional
Scale		 21.60 ± 5.96 18.76 ± 3.51 .011 32.78 ± 6.54 33.13 ± 6.20 0.777 −2.83 0.347 −-2.55 .007
EORTC QLQ
Symptom Scale		 22.40 ± 6.06 20.20 ± 4.09 .002 33.00 ± 7.62 34.96 ± 8.80 0.001 −2.20 1.95 −3.41 < .001
PSQI Total Scale Score 8.80 ± 3.29 3.03 ± 1.88 .001 10.39 ± 1.56 7.61 ± 1.67 0.001 −5.76 −2.78 −3.54 < .001
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Note: BFI = Brief Fatigue Inventory; EORTC QLQ C-30 = Quality of Life; PFI = Piper Fatigue Inventory; PSQI = Pittsburgh Sleep Quality Index; t = t-test.

Table 3.

Comparison of the Intervention and Control Groups’ BFI, PFI, EORTC QLQ, and PSQI Total Scale Scores Before and after Oncology Yoga and Meditation

Intervention (n = 30) 0 Week Control (n = 23) 0 Week p* Intervention (n = 30) 12 Week Control (n = 23) 12 Week p*
Brief Fatigue Inventory (BFI) Total Score Ort ± Ss 5.25 ± 1.92 5.82 ± 1.98 .277 2.83 ± 1.24 5.91 ± 2.16 .001
Min-Max (Median) 0.67–10 (5.33) 2–9 (6) 0–5 (3) 2–9 (6)
Piper Fatigue Inventory (PFI) Total Score Ort±Ss 4.01 ± 1.90 3.54 ± 2.63 .240 2.60 ± 1.81 4.32 ± 2.88 .038
Min-Max (Median) 1.58–8.34 (3.86) 0.33–8.34 (2.35) 0–6,65 (1.92) 0.33–8.34 (3.13)
Quality of Life EORTC QLQ C-30 (V-3.0) Total Score Ort ± Ss 12.70 ± 4.23 8.86 ± 1.89 .001 9.40 ± 2.08 7.22 ± 1.59 .001
Min-Max (Median) 4–20 (12) 6–14 (9) 6–14 (10) 4–10 (7)
EORTC QLQ Functional Scale Ort ± Ss 21.6 ± 5.97 32.78 ± 6.54 .001 18.77 ± 3.51 33.13 ± 6.2 .001
Min-Max (Median) 13–37 (20) 15–40 (35) 13–28 (18) 15–38 (35)
EORTC QLQ Symptom Scale Ort ± Ss 22.40 ± 6.06 33 ± 7.63 .001 20.20 ± 4.10 34.96 ± 8.80 .001
Min-Max (Median) 13–37 (21.5) 13–38 (36) 13–31 (19) 13–43 (39)
Pittsburg Sleep Quality Index (PSQI) Total Score Ort ± Ss 8.80 ± 3.29 10.39 ± 1.56 .005 3.03 ± 1.88 7.61 ± 1.67 .001
Min-Max (Median) 5–18 (8) 7–14 (10) 0–8 (3) 4–10 (8)
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*Mann-Whitney U-test

Note: EORTC QLQ C-30 = Quality of Life; PFI = Piper Fatigue Inventory; PSQI = Pittsburgh Sleep Quality Index; Sleep Quality Index BFI = Brief Fatigue Inventory.

Qualitative Findings

Thematic analysis revealed that positive contributions, challengers, facilitators, and sustainers emerged as categories of symptom relief, with psychological relief being the overarching theme of these contributions. The themes under challenges were medical and physical adversities, social/relational situations, difficulties related to technological or daily life rhythms, work conditions, and personal characteristics. Themes under facilitators were feelings of benefits, doing something for oneself, having easy access, and having a positive and supportive environment. Sustainers required guidance on self-implementation and institutional continuity (Table 4).

Table 4.

Categories and Themes from Qualitative Data

Categories Themes Sub-themes Quotes
Contributors

  • Physical and psychological relief/ better quality of life

 Relief from symptomsFalling asleep easily
Reduced fatigue
Feeling rested, Increased physical well-being
Reduction of problems
Increase in balance
Reduction in constipation
Positive change in eating patterns		 I used to feel very tired when I woke up in the morning, but I no longer do, so I wake up feeling more refreshed. So I was sleeping, but didn’t know why I woke up tired. Now I can wake up easily. (P1, 45A,F)&Yes, the body is resting. Before, it was like carrying a lot of weight. Now my body is resting and enjoying sleep. Now, I can sleep very comfortably when I lay my head on a pillow. (P3, 58A,M)
Psychological ReliefMotivation increases/being more energetic
Confidence in being in a conscious application
Being informed
Having a positive atmosphere/positive interaction environment
Feeling better for doing a good thing for yourself
Receiving feedback on positive changes from one’s social environment
Anger and stress control with breathing exercises		 It was very good, so when I get angry at something, I immediately do breathing exercises and relax a lot. No more nervous breakdown (P8, 46A,F)&At least I had more respect for myself and my feelings. The feeling that I did something for myself felt very good to me. (P5, 68A,F)
Challengers

  • Medical and physical adversities

  • Social/relational situations

  • Technology-related issues

  • Personal Characteristics

 Medical problems (coinciding with surgeries, chemotherapy, etc., physical strains, other disorders)Social-relational situations (guest arrivals, dinner timing, TV show timing, going out of town, neighbors’ curiosity, the yoga and meditation program scheduled for the evening hours.eg, Work-related issues such as conflicted working hours)Technical problems (including internet network issues, insufficient sound, etc.)Personal characteristics (not being experienced, not being able to give oneself, not being able to keep quiet, not adopting the philosophy of oncology yoga Since the chemotherapy process continues, the days when I take the therapy, mainly because I was not very well that week (P9,52A, F) & I try to do the same movements during the week. But I’m just a little too indecisive in meditation. Because I am a very alive person. I mean, I can’t keep quiet like that. I’m having a little trouble with it. (P12,42A,F)
Facilitators

  • Sense of benefit

  • Doing something for oneself

  • Accessibility

  • The positive and supportive environment

 Providing medical/health benefitsSense of benefit
Working out the muscles
Benefits of sleep
Doing something good for oneself
To be relaxing
InformativeEase of access to the application (online)
No need for additional effort for the application
Keeping it regular/maintaining a routine Social/supportive/positive environmentEnergetic and positive features of the facilitator
Belief in/acquaintance with oncology yoga meditation
A sense of belonging to the group		 For me, for example, I enjoy thinking that it does a very good thing for my body. I think it is very useful for me (P11,50A,F)
Sustainer

  • The need for guidance for self-implementation

  • The need for institutional continuity

 The need for guidance for self-implementation
The need for institutional continuity		 It would be good to continue. The event is not only about physiology, but also the inclusion of the psychological dimension of the spiritual being in this practice will play a very effective role here, as in all diseases. (P2,52A,F) & After all, every illness has a psychosomatic side. In other words, in the formation of the disease, in its treatment, and in the later development process. That’s why I believe this type of support is so important. (P25,49A,M) & We feel lucky. You know, there are many psychosocial activities in oncology clinics, and there are also examples. We hope that these will become a permanent service. (P13,56A,F)
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Discussion

The results of this study supported the research hypotheses, indicating that OY & MB practices reduce fatigue levels and sleep problems in CRC survivors (H1 and H2). In addition, qualitative interviews with the intervention group who completed the entire program indicated that OY & MB were beneficial. Specifically, survivors of CRC reported an increase in body awareness and flexibility while also noting that previously existing back pain had diminished. Furthermore, consistent with the findings of previous studies, they emphasized that the interventions provided significant benefits for physical symptoms such as cancer-related fatigue and weakness (Hou et al., 2024; Song et al., 2021). These findings are clinically meaningful, as fatigue and sleep disturbances are among the most common and burdensome symptoms in CRC survivors and are strongly associated with daily functioning and overall well-being (Getie et al., 2025).

In this study, levels of fatigue and lethargy, as measured by the BFI scale, were significantly reduced from moderate levels before the intervention to mild levels after participants in the intervention group practiced oncology yoga and meditation. In contrast, the control group showed no significant changes in fatigue or lethargy, which remained moderate after the intervention. Furthermore, subjectively, the PFI scores used to assess fatigue in the intervention group also decreased from moderate to low levels. This significant decrease in BFI and PFI scores indicated that oncology yoga and meditation practices reduced fatigue levels. Fatigue is a common problem among CRC survivors and significantly affects their quality of life. Similar to these findings, several randomized controlled studies and clinical guidelines investigating the effect of oncology yoga on cancer-related fatigue have reported a significant decrease in fatigue levels following oncology yoga and meditation interventions (Lin et al., 2019; Lundt & Jentschke, 2019; Hou et al., 2024; Eyl et al., 2020; Song et al., 2021). Although no study provides direct evidence of the effects of complementary interventions on fatigue in CRC survivors, the results of this study are consistent with those of a meta-analysis (Hilfiker et al., 2018). Lundt & Jentschke (2019) examined fatigue symptoms in patients with cancer six months after completing oncology yoga therapy. They reported a significant reduction in fatigue symptoms compared with those during the start of treatment (Lundt & Jentschke, 2019). Although their work demonstrated long-term benefits, the present study did not include extended follow-up assessments. These findings are consistent with H1, which posited that the intervention would reduce fatigue levels in CRC survivors. The study’s qualitative and quantitative findings indicate positive outcomes, including relief from fatigue symptoms, reduced sleep disturbances, and increased energy levels among patients. Notably, the study reveals significant improvements in both physical and psychological well-being, accompanied by a marked decrease in fatigue-related issues. Together, these effects suggest that patients experience meaningful enhancements in their quality of life during treatment. These findings are further supported by high-level evidence from meta-analyses, which demonstrate that exercise- and yoga-based interventions lead to clinically meaningful reductions in cancer-related fatigue across diverse cancer populations (Mustian et al., 2017; Cramer et al., 2017). Although these studies were conducted in broader oncology cohorts rather than exclusively among CRC survivors, their results reinforce the potential of mind–body practices to alleviate fatigue and improve overall functioning in individuals undergoing or recovering from cancer treatment.

When examining sleep quality, as measured by the PSQI, the intervention group’s score decreased significantly after the intervention. A PSQI score <5 indicates good sleep quality; therefore, this reduction reflected a clinically meaningful improvement. No significant change was observed in the control group. Previous research suggests that mental and physical exercises, such as oncology yoga and meditation, can alleviate subjective sleep problems in individuals with breast cancer (Kreutz et al., 2019; Mirandola et al., 2019). Similarly, randomized controlled trials have demonstrated that practicing oncology yoga at least twice a week significantly improves sleep quality (Chaoul et al., 2018; Deepa et al., 2022). In the qualitative interviews, CRC survivors reported falling asleep more easily, waking up feeling more rested, and experiencing increased energy levels after practicing oncology yoga and meditation. They described early positive changes in their sleep patterns and noted that improved sleep contributed to an enhanced sense of physical well-being. Participants also reported reduced fatigue, changes in eating patterns, increased balance, psychological relief, and improved coping skills for managing stress and anger. Furthermore, they described positive social interactions and feeling more informed, which strengthened their emotional well-being. Collectively, these qualitative and quantitative findings support the study’s hypothesis (H2), suggesting that oncology yoga and meditation can effectively enhance sleep quality in CRC survivors.

Regarding the quality of life assessed using the EORTC QLQ-C30 (version 3.0), the most notable finding following the oncology yoga and meditation intervention was a significant decrease in symptom subscale scores in the intervention group. Although overall quality of life and functional subscale scores declined rather than improved, the reduction in symptom burden suggests that the intervention may have contributed to the alleviation of treatment-related discomfort. Current literature indicates that the quality of life of CRC survivors is generally lower than that of the general population, which underscores the relevance of symptom improvement even in the absence of significant changes in global Quality of LIfe (QoL) scores (Hou et al., 2024). Given that quality of life is a multidimensional construct influenced by rapidly changing physical, emotional, and social factors, interventions such as oncology yoga may not directly affect overall QoL scores but can still provide targeted benefits. This interpretation is supported by qualitative findings, in which CRC survivors reported increased body awareness and perceived physical relief following the program. Oncology yoga may therefore serve as a valuable adjunctive intervention, particularly when symptoms and functional disturbances are most prominent in the early stages of cancer treatment (Hou et al., 2024). Evidence from studies conducted among patients with breast cancer also supports this interpretation, showing that oncology yoga improves quality of life, reduces physical symptoms, and enhances emotional and role functioning (Galantino et al., 2020). Similarly, mindfulness-based therapies have been shown to alleviate fatigue and positively influence emotional well-being (McCloy et al., 2022), and an 8-week meditation intervention significantly improved QoL in patients with cancer (Suh et al., 2021). Consistent with these findings, recent research indicates that CRC survivors experience a lower health-related quality of life compared to the general population, with symptom burden playing a central role in shaping QoL outcomes (Dahouri et al., 2025; Flyum et al., 2021).

Methodological considerations also warrant discussion regarding the mode of intervention delivery. Face-to-face yoga and mindfulness sessions allow for close observation of participants, real-time feedback from the instructor, and correction of postures and movements when necessary, thereby enhancing both safety and effectiveness (Chaoul et al., 2018; Galantino et al., 2020; Mirandola et al., 2019). However, online delivery was chosen in this study due to several practical and contextual factors. Participants were geographically dispersed, and during the COVID-19 pandemic, minimizing exposure risks was particularly important for immunocompromised cancer survivors. Additionally, transportation difficulties and the need to ensure sustained participation throughout the intervention period underscored the value of online sessions. Recent evidence also supports the feasibility and effectiveness of tele-yoga during the pandemic. A randomized controlled trial demonstrated that online yoga significantly improved sleep quality, reduced stress and anxiety, and enhanced overall well-being among healthcare workers under pandemic-related strain (Naveen et al., 2024). These findings strengthen the rationale for selecting an online format in the present study. This approach facilitated accessibility for vulnerable patient groups and promoted continuity of engagement. Future research could further compare the relative benefits of online versus face-to-face yoga and mindfulness interventions for cancer survivors. It is also possible that external factors such as pandemic-related stress, reduced social support, and psychological burden may have influenced participants’ fatigue, sleep patterns, and overall well-being during the study period, although these variables were not directly assessed. Beyond these methodological considerations, several factors should be taken into account when interpreting the study findings. Therefore, the positive changes observed in this study may have been influenced by participant characteristics, differences in cancer diagnosis times and stages, and the combined application of oncology yoga and meditation. Interpreting the findings was challenging, as most existing studies focus on breast cancer or other survivorship groups, and interventions vary widely in structure, ranging from oncology yoga or meditation alone, delivered over 4 to 16 weeks, and assessed through diverse fatigue, sleep, and quality-of-life instruments. Based on available information, this study is the first to evaluate the combined effects of OY & MB specifically in CRC survivors. The results demonstrate that such mind–body practices may reduce fatigue levels by improving sleep and alleviating physical symptoms, offering a potentially valuable supportive-care approach for this population.

Conclusion and Recommendations

This study demonstrates that a 12-week live Zoom program incorporating yoga and mindfulness-based meditation interventions among CRC survivors resulted in significant improvements in subjective issues, such as sleep problems and fatigue, and positive changes in their quality of life. Nearly all participants expressed the value of integrating this program into treatments. In light of these findings, it is advocated to integrate oncology yoga and meditation under holistic healthcare practices to enhance sleep quality and reduce fatigue among CRC survivors. Future research is needed to examine the long-term effects of these interventions and to compare the relative benefits of standalone versus combined approaches, thereby further informing holistic care strategies.

Limitations

This study had several limitations. First, it was not designed to distinguish whether the observed improvements in fatigue, sleep problems, and quality of life were specifically attributable to oncology yoga or mindfulness-based meditation. The combined implementation of both interventions limits the ability to determine the individual effects of each. Second, no long-term follow-up assessments were conducted, which restricts conclusions regarding the sustainability of improvements in fatigue, sleep quality, and overall well-being. Third, external factors such as pandemic-related stress, psychosocial burden, and variations in social support were not evaluated, although they may have influenced the outcomes. Although three smaller subgroups were initially planned, the intervention was ultimately delivered as a single large group. Conducting the sessions in one combined group may have reduced opportunities for individualized feedback and limited the instructor’s ability to closely monitor posture accuracy and provide personalized pose corrections, particularly in the online format. The instructor attempted to mitigate these challenges by offering general safety cues and pose modifications; however, individualized assessment was inherently restricted. These factors should be considered when interpreting the effectiveness of the yoga component of the intervention. Additionally, individuals with a current colostomy were excluded from the study due to the potential impact of stoma-related physical limitations on yoga practice. As a result, the findings may not be generalizable to CRC survivors with a colostomy, who may experience mobility restrictions, abdominal discomfort, or adaptation challenges that could influence the feasibility or effectiveness of yoga-based interventions. The presence of mild to moderate psychological symptoms, such as depression or anxiety, among participants may also have influenced their responses to the intervention. Because these conditions were not included in the exclusion criteria, their potential impact should be considered when interpreting the results. Finally, approximately 30% of participants were unable to attend oncology yoga and meditation sessions due to scheduling difficulties and other factors, resulting in dropout rates higher than those anticipated during the preliminary sample size calculation. Because participants who withdrew did not complete post-intervention assessments, additional analyses, such as intention-to-treat or imputation, could not be performed. However, baseline characteristics did not differ significantly between completers and non-completers, and the large effect sizes observed across outcomes reduce the likelihood that attrition alone accounted for the findings.

Online yoga and mindfulness-based meditation interventions should be considered as integral components of survivorship care to address persistent fatigue, sleep disturbances, and quality-of-life impairments in CRC survivors. Given their low cost and scalability, digitally delivered mind–body programs offer a feasible and supportive care option, particularly for individuals with limited access to in-person services. Future research is warranted to strengthen the evidence base through randomized controlled trials with extended follow-up periods, allowing evaluation of long-term and sustained intervention effects. Additionally, the development of adaptive digital models that account for survivors’ medical conditions, technological readiness, and accessibility challenges may enhance engagement, adherence, and overall effectiveness of the intervention across diverse survivor populations.

Funding Statement

This research was supported by the Koç University Nursing Faculty Semahat Arsel Nursing Education and Research Center (SANERC number: 2020.21) within the scope of the project.

Footnotes

Artificial Intelligence Usage Statement: The authors declared that no Artificial Intelligence Tool was used in the preparation of the manuscript.

Ethics Committee Approval: Ethical approval was obtained from the İstanbul Medipol University Traditional and Complementary Medicine (GETAT) Clinical Research Ethics Committee (Approval No.: 95961207/604.01.01/E.64779; Date: 12/12/2019).

Informed Consent: Both verbal and written informed consent were obtained from all participants prior to participation in the study.

Peer-review: Externally peer-reviewed.

Author Contributions: Concept – T.S., F.O., A.K.; Design – T.S., F.O., A.K.; Supervision – T.S., F.O., A.K.; Resources – T.S.; Materials – T.S.; Data Collection and/or Processing – T.S., A.Y.; Analysis and/or Interpretation – T.S., F.O., A.K.; Literature Search – T.S.; F.O.; Writing – T.S., F.O., A.K.; Critical Review – T.S., F.O., A.K.

Declaration of Interests: The authors have no conflicts of interest to declare.

Data Availability Statement:

The data that support the findings of this study are available on request from the corresponding author.

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Associated Data

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

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author.

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