Abstract
Objective
To conduct a pilot trial of internet-based, cancer-adapted yoga for women receiving breast cancer treatment
Design
Women undergoing radiation or chemotherapy for breast cancer were recruited for 12, 75-minute, biweekly, cancer-adapted yoga classes delivered via internet-based, multipoint videoconferencing. Data were collected on feasibility and acceptability, including qualitative feedback from participants and the yoga instructor.
Results
Among 42 women approached, 13 declined eligibility screening, and 23 were ineligible. All 6 women who were eligible provided consent, but 2 withdrew prior to beginning yoga classes. The remaining 4 participants attended 1–11 of 12 online yoga classes. In post-intervention interviews, participants and the instructor agreed that internet-based yoga classes hold great potential for increasing access and improving psychological outcomes in adults with cancer. Qualitative feedback from participants revealed suggestions for future trials of internet-based, cancer-adapted yoga classes, including: continued use of group format; offering more varied class times to accommodate patients’ demanding schedules and fluctuating symptoms; enrolling patients after they have acclimated to or completed cancer treatment; streamlining the technology interface; and careful attention to participant burden when designing surveys/forms. The instructor recommended closed session courses, as opposed to rolling enrollment; teaching the same modified poses for all participants, rather than individual tailoring; and using a large screen to allow closer monitoring of students’ class experience.
Conclusions
Internet delivery may increase patients’ access to cancer-adapted yoga classes, but cancer-related and technological barriers remain. This study informs how to optimally design yoga classes, technology, and research procedures to maximize feasibility and acceptability in future trials.
Keywords: yoga, breast cancer, eHealth, Internet delivery, radiation therapy, chemotherapy
Introduction
Evidence supports efficacy of yoga for improving adult cancer patients’ psychological outcomes.1 However, many lack access to instructors with cancer-specific training, and treatment schedules and symptoms limit patients’ ability to attend yoga classes.2,3 A review of psycho-oncology interventions suggests internet delivery may minimize these barriers.4
Research on remotely delivered yoga is scant. Program evaluation comparing veterans self-selecting into in-person versus Tele-yoga, where veterans gathered at VA facilities for yoga classes broadcast from another VA facility, found no differences in satisfaction or symptom improvement.5 A pilot of twice-weekly internet-based yoga for cardiopulmonary patients demonstrated feasibility and acceptability.6 Participants liked home-based classes, but half wanted to see other participants, not just the instructor.6
Online trials of other mind-body interventions support further study of internet-based yoga. One study demonstrated feasibility of synchronous online group delivery of mindfulness-based cancer recovery.7 In Tai Chi research, attrition and adherence were equivalent among older adults randomized to community classes versus home-based online videoconferencing; both were superior to home-based videos.8 Analyses further suggested that home-based interventions without contact with staff or other participants may not be acceptable to distressed participants.8
No known studies allowed individuals to take synchronous online yoga classes from home while interacting with the instructor and other participants, and no published internet-based yoga trials were tailored to cancer patients. These factors are important to patients, who want cancer-specific, live classes with expert instructors, delivered in a group setting to facilitate social support.3 We therefore conducted a pilot trial of cancer-adapted yoga classes delivered via internet-based, multipoint videoconferencing with breast cancer patients with elevated distress.
Methods
Recruitment occurred at a comprehensive cancer center in the southeastern US. Inclusion criteria were: female; age ≥18; stage 0-III breast cancer; scheduled for ≥4 weeks of radiation/chemotherapy during the intervention period; ECOG status 0–29; Internet-connected computer with full-size screen; English-speaking; elevated distress (Hospital Anxiety and Depression Scale depression ≥810 or Distress Thermometer ≥411). Exclusion criteria were: regular yoga or vigorous exercise; recent or planned surgery during the intervention period.
Cancer-adapted, 75-minute, Integral yoga classes delivered twice/week via multipoint videoconferencing (GoToMeeting) allowed women to participate from any location while seeing and interacting with other participants and the instructor, a Registered Yoga Teacher with specialized training in cancer-adapted yoga. Classes included the same gentle postures, breathing, meditation, and relaxation delivered in prior in-person research,12 using verbal cuing instead of manual adjustments. Participants were asked to attend ≥10 of 12 biweekly classes during the 6-week intervention period, concurrent with their course of radiation/chemotherapy.
Procedures and materials were designed to facilitate trust and clarity online.13 The brochure included research team photographs and biographies. For camera/software installation, staff provided detailed, printed instructions with photos, plus individual telephone support. Dedicated staff provided technological assistance during classes.
Primary endpoints were feasibility and acceptability (enrollment rate, retention, adherence, satisfaction ratings, qualitative feedback from program evaluation forms and telephone interviews). Additional measures (pre- and post-class distress and fatigue ratings; home practice; distress,10,11 fatigue,14 sleep;15 medical records) were not analyzed due to sample size. All procedures and materials received IRB approval.
Results
Thirteen (31%) of 42 women approached for recruitment declined screening (scheduling conflict, n=8; not interested, n=5). Of 29 women screened, most (n=23, 79%) were ineligible (no Internet/computer, n=10; no/low distress, n=8; regular yoga/exercise, n=4; non-English-speaking, n=1). The remaining 6 were eligible and consented (see Table 1).
Table 1.
Baseline characteristics of consented participants (N=6)
| Mean (SD) | Range | n (%) | |
|---|---|---|---|
| Age, years | 59 (12.7) | 41–76 | |
| Race | |||
| Black | 2 (33) | ||
| White | 4 (67) | ||
| BMI | 30.9 (5.8) | ||
| Healthy (normal) | 1 (17) | ||
| Overweight | 1 (17) | ||
| Obese | 4 (67) | ||
| ECOG score | |||
| 0 | 1 (17) | ||
| 1 | 5 (83) | ||
| Cancer stage | |||
| I | 2 (33) | ||
| II | 1 (17) | ||
| III | 3 (50) | ||
| Months since diagnosis | 4.7 (2.4) | 1–7 |
Note. BMI = body mass index; ECOG = Eastern Cooperative Oncology Group
Two withdrew before beginning yoga. In telephone interviews, both described feeling overwhelmed by initiating cancer treatment. Both thought yoga sounded promising, but ultimately decided against adding this new activity to the emotional, time-intensive context of cancer. One recommended recruiting after women acclimated to treatment. Both suggested that online yoga classes during cancer treatment might be more acceptable to younger adults.
Four women attended 1, 3, 5 or 11 of 12 online yoga classes. Despite assistance from study staff and family, two women missed classes due to technological difficulties. Additional barriers to class attendance and completion of surveys/forms included scheduling conflicts, treatment-related fatigue, feeling overwhelmed by cancer, and forgetfulness due to “chemo brain” or “mountains of [cancer-related] paperwork.”
All who attended >1 class (n=3) completed quantitative program evaluations. One was satisfied with yoga and internet-based delivery; one was satisfied with yoga but not internet-based delivery; one was dissatisfied with both. All positively rated the instructor.
Qualitative data were available for all four women who attended at least one class. The three women who attended >1 class enjoyed learning about yoga, relaxing, and meeting each other. One wanted more vigorous movements/postures. All four women indicated that offering classes at varied times of day could facilitate increased attendance, and two recommended beginning yoga post-treatment. One preferred shorter classes. All four women described negative experiences with the videoconferencing technology (e.g., “complicated,” “confusing”). Two appreciated the convenience of home-based classes, but one found her home setting stressful due to lack of well-lit, private space.
The instructor also completed a qualitative interview. She viewed technical issues as minor, infrequent, and quickly resolved. Remote delivery hindered her ability to perceive participants’ “subtle expressions” of interest, emotion, and physical comfort. In future internet-based trials, she would have everyone practice yoga at the same level, introducing more advanced poses only when all participants are ready. She also recommended closed-session courses, rather than rolling enrollment; ≤6 participants; and maximizing the instructor’s screen size.
Discussion
Pilot studies such as this one are critical for iterative development of mind-body interventions.16 Although feasibility of in-person yoga during breast cancer treatment is well-established,1 this study demonstrates that the combination of cancer-related stressors and technological barriers can impede participation in online delivery of cancer-adapted yoga. These results can inform design of classes, technology, and research procedures for future trials. Our findings suggest that internet-based, cancer-adapted yoga could be feasible and acceptable if researchers deliver yoga in a group format; offer varied class times to accommodate fluctuating schedules and symptoms; recruit after patients acclimate to or complete treatment; minimize surveys/forms; and simplify the technology interface.
Future online yoga studies might minimize technological challenges using methods from previous successful trials of internet-based groups – e.g., provide Internet access, embed all study materials and videoconferencing within a streamlined interface, hold a technology practice session.5,6,8,17–19 Our instructor also recommended using a larger screen for closer monitoring of students. Because videoconferencing difficulties may still occur,6,19 studies should dedicate staffing for technological assistance. This support may be particularly important for older participants, who have fewer Internet/videoconferencing skills,20–22 and for people with additional challenges (e.g., illness, distress, lack of yoga experience). Similarly, internet-based interventions might be especially useful for younger groups such as adolescent and young adult survivors.
Internet-based oncology interventions offer scalability and access to specialty providers,4 yet our findings demonstrate that cancer-related and technological barriers remain. Larger assessments of feasibility and acceptability are needed. To advance mind-body research,16 researchers should engage stakeholders throughout intervention development23 and examine which approaches benefit which patients.
Highlights.
This report describes challenges with recruitment and retention of women undergoing treatment for breast cancer in cancer-adapted yoga classes delivered by internet-based videoconferencing.
Data from qualitative interviews with participants and the yoga instructor can inform the development of future trials of internet-delivered mind-body interventions for adults with cancer.
Acknowledgments
The authors are grateful to the CALM study participants. In addition, we thank Lynn Felder and Terry Gray for their invaluable contributions to this study. The authors also wish to acknowledge the support of Amy Landon and the Biostatistics and Shared Resource, Comprehensive Cancer Center of Wake Forest Baptist Medical Center.
Dr. Addington is supported by training grant CA193193 from the National Cancer Institute (NCI) and Dr. Sohl is supported by the National Center for Complementary & Integrative Health of the National Institutes of Health under Award Number K01AT008219. The CALM study was funded by the Dubie Holleman Fund (through Wake Forest Baptist Medical Center), Comprehensive Cancer Center of Wake Forest Baptist Medical Center, and NCI Cancer Center Support Grant P30 CA012197. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Footnotes
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References
- 1.Danhauer SC, Addington EL, Sohl SJ, Chaoul A, Cohen L. Review of yoga therapy during cancer treatment. Support Care Cancer. 2017;25(4):1357–1372. doi: 10.1007/s00520-016-3556-9.. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Danhauer SC, Griffin LP, Avis NE, et al. Feasibility of implementing a community-based randomized trial of yoga for women undergoing chemotherapy for breast cancer. J Community Support Oncol. 2015;13(4):139–147. doi: 10.12788/jcso.0125.. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.McCall M, Thorne S, Ward A, Heneghan C. Yoga in adult cancer: An exploratory, qualitative analysis of the patient experience. BMC Complement Altern Med. 2015;15(1):1–9. doi: 10.1186/s12906-015-0738-9.. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Leykin Y, Thekdi SM, Shumay DM, Muñoz RF, Riba M, Dunn LB. Internet interventions for improving psychological well-being in psycho-oncology: review and recommendations. Psychooncology. 2012;21(9):1016–1025. doi: 10.1002/pon.1993.. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Schulz-Heik RJ, Meyer H, Mahoney L, et al. Results from a clinical yoga program for veterans: Yoga via telehealth provides comparable satisfaction and health improvements to in-person yoga. BMC Complement Altern Med. 2017;17(1):198. doi: 10.1186/s12906-017-1705-4.. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Selman L, McDermott K, Donesky D, Citron T, Howie-Esquivel J. Appropriateness and acceptability of a Tele-Yoga intervention for people with heart failure and chronic obstructive pulmonary disease: qualitative findings from a controlled pilot study. BMC Complement Altern Med. 2015;15:21. doi: 10.1186/s12906-015-0540-8.. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Zernicke KA, Campbell TS, Speca M, McCabe-Ruff K, Flowers S, Carlson LE. A randomized wait-list controlled trial of feasibility and efficacy of an online mindfulness-based cancer recovery program: the eTherapy for cancer applying mindfulness trial. Psychosom Med. 2014;76(4):257–267. doi: 10.1097/PSY.0000000000000053.. [DOI] [PubMed] [Google Scholar]
- 8.Wu G, Keyes L, Callas P, Ren X, Bookchin B. Comparison of telecommunication, community, and home-based Tai Chi exercise programs on compliance and effectiveness in elders at risk for falls. Arch Phys Med Rehabil. 2010;91(6):849–856. doi: 10.1016/j.apmr.2010.01.024.. [DOI] [PubMed] [Google Scholar]
- 9.Oken MM, Creech RH, Tormey DC, et al. Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol. 1982;5(6):649–655. [PubMed] [Google Scholar]
- 10.Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand. 1983;67(6):361–370. doi: 10.1111/j.1600-0447.1983.tb09716.x. [DOI] [PubMed] [Google Scholar]
- 11.Jacobsen PB, Donovan KA, Trask PC, et al. Screening for psychologic distress in ambulatory cancer patients. Cancer. 2005;103(7):1494–1502. doi: 10.1002/cncr.20940.. [DOI] [PubMed] [Google Scholar]
- 12.Danhauer SC, Mihalko SL, Russell GB, et al. Restorative yoga for women with breast cancer: Findings from a randomized pilot study. Psychooncology. 2009;18(4):360–368. doi: 10.1002/pon.1503.. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Mohr DC, Cuijpers P, Lehman K. Supportive accountability: a model for providing human support to enhance adherence to eHealth interventions. J Med Internet Res. 2011;13(1):e30. doi: 10.2196/jmir.1602.. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Yellen SB, Cella DF, Webster K, Blendowski C, Kaplan E. Measuring fatigue and other anemia-related symptoms with the Functional Assessment of Cancer Therapy (FACT) measurement system. J Pain Symptom Manage. 1997;13(2):63–74. doi: 10.1016/s0885-3924(96)00274-6. [DOI] [PubMed] [Google Scholar]
- 15.Buysse DJ, Reynolds CF, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989;28(2):193–213. doi: 10.1016/0165-1781(89)90047-4. [DOI] [PubMed] [Google Scholar]
- 16.Framework for Developing and Testing Mind and Body Interventions. NCCIH. https://nccih.nih.gov/grants/mindbody/framework. Published April 24, 2014. Accessed July 16, 2017.
- 17.Zhou ES, Partridge AH, Blackmon JE, Morgan E, Recklitis CJ. A pilot videoconference group stress management program in cancer survivors: lessons learned. Rural Remote Health. 2016;16(2):3863. [PubMed] [Google Scholar]
- 18.Yanez B, McGinty HL, Mohr DC, et al. Feasibility, acceptability, and preliminary efficacy of a technology-assisted psychosocial intervention for racially diverse men with advanced prostate cancer. Cancer. 2015;121(24):4407–4415. doi: 10.1002/cncr.29658.. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Burke SM, Carron AV, Eys MA, Ntoumanis N, Estabrooks PA. Group versus individual approach? A meta-analysis of the effectiveness of interventions to promote physical activity. Sport Exerc Psychol Rev. 2006;2(1) [Google Scholar]
- 20.McAlpine H, Joubert L, Martin-Sanchez F, Merolli M, Drummond KJ. A systematic review of types and efficacy of online interventions for cancer patients. Patient Educ Couns. 2015;98(3):283–295. doi: 10.1016/j.pec.2014.11.002.. [DOI] [PubMed] [Google Scholar]
- 21.Arthur AE, Delk A, Demark-Wahnefried W, et al. Pancreatic cancer survivors’ preferences, barriers, and facilitators related to physical activity and diet interventions. J Cancer Surviv. 2016;10(6):981–989. doi: 10.1007/s11764-016-0544-5.. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Vroman KG, Arthanat S, Lysack C. “Who over 65 is online?” Older adults’ dispositions toward information communication technology. Comput Hum Behav. 2015;43:156–166. doi: 10.1016/j.chb.2014.10.018.. [DOI] [Google Scholar]
- 23.Post KE, Flanagan J. Web based survivorship interventions for women with breast cancer: An integrative review. Eur J Oncol Nurs. 2016;25:90–99. doi: 10.1016/j.ejon.2016.10.004.. [DOI] [PubMed] [Google Scholar]