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Evidence-Based Nursing Online First, published on November 25, 2017 as 10.1136/eb-2017-102673
Systematic review
Yoga intervention may improve
health-related quality of life (HRQL),
fatigue, depression, anxiety and sleep
in patients with breast cancer
10.1136/eb-2017-102673
Marcy McCall
Nuffield Department of Primary Care Health Sciences,
University of Oxford, Oxford, UK
Correspondence to: Dr Marcy McCall, Nuffield Department of Primary
Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK; ​
marcy.​mccall@​phc.​ox.​ac.​uk
Commentary on: Cramer H, Lauche R, Klose P, et al. Yoga for
improving health-related quality of life, mental health and
cancer-related symptoms in women diagnosed with breast
cancer Cochrane Database Syst Rev 2017;1:CD010802.
Implications for practice and research
►► Yoga intervention may slightly improve short-term health-related
quality of life, fatigue, depression, anxiety and sleep in patients with
breast cancer.
►► The evidence base for yoga intervention could be strengthened if
future studies concentrate on replicability of results and limiting po-
tential bias.
Context
Breast cancer is the most prevalent cancer among women in both devel-
oping and developed countries1 where over 1.67 million new cases are
diagnosed each year worldwide.2 As such, there is a growing need to
address the quality of life of patients with breast cancer throughout the
treatment trajectory, from their point of diagnosis to remission. This
study by Cramer and colleagues responds to a trend in using yoga and
other complementary therapies to produce benefit in healthcare, with
their promise of fewer adverse effects than other biomedical or conven-
tional treatments.
Methods
This study reports findings from a systematic review of 24
randomised controlled studies (randomised controlled trial, RCT) and
meta-analysis conducted in 23 included RCTs. The purpose of the research
was to quantify changes in five primary outcomes: HRQL, depression,
anxiety, fatigue and sleep disturbances following yoga intervention in
women diagnosed with breast cancer (stages I–IV) or women with a
diagnosis of breast cancer who have completed treatment. Researchers
also investigated safety of the intervention and assessed the number of
women with adverse advents.
Findings
The moderate-quality evidence was extracted from 24 studies with a total
of 2166 participants. The quality of evidence was downgraded by authors
Evid Based Nurs Month 2017 | volume 0 | number 0 |
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Women’s health and midwifery
due to perceived threats of selection bias, inadequate blinding of partici-
pants and outcome assessors, and concerns of attrition bias. Of the primary
outcomes, statistically significant effects of yoga intervention (vs no therapy)
were found in short-term outcome measures of: HRQL standardised mean
difference (SMD) 0.22, P=0.016 (95% CI 0.04 to 0.40); fatigue SMD −0.48,
P<0.001 (95% CI −0.75 to −0.20); and sleep disturbances SMD −0.25 (95%
CI −0.40 to −0.09). Yoga outperformed other psychological interventions
in anxiety SMD −2.21, P=0.010 (95% CI −3.90 to −0.52) and fatigue SMD
−0.90, P<0.001 (95% CI −1.31 to −0.50). No studies reported any adverse
effects or safety concerns of yoga intervention.
Commentary
In considering results of this systematic review, we ask: does yoga work
to improve psychological and mental health outcomes in patients with
breast cancer? And if yoga works, how, why, and to what extent can we
expect a replicable benefit for other patients? The results of the review
suggest that yoga may have a slight statistical significance in improving
psychosocial outcomes, but it is unclear if that difference is significant
enough to translate into a clinical difference for patients. What does an
SMD of 0.22 in HRQL mean to a patient? Is that size of effect worth a
patient’s time and money? As the included studies in this review report
no adverse effects, the evidence-based medicine paradigm drives the
question back to the patient values and preferences. Patient preferences
are a key element to the success of any treatment, but especially for inter-
ventions that are seeking to address subjective, or self-reported measures
including HRQL. But then, what kind of yoga and how much of it?
Yoga is a complex therapeutic intervention3 in healthcare, and as such,
presents a research challenge in how to capture a replicable design, imple-
mentation, and record its effectiveness with the number of its moving parts.
The sources of variation include setting, teacher style, duration, intensity,
type of yoga, as well as differences that occur during the class due to partic-
ipant requests, and group dynamics. This variability can create inconsistency
in data and has been discussed elsewhere as a limitation in current yoga
literature.4 The implication in research is that the systematic development of
higher quality RCTs is needed to test the effectiveness of this intervention,
and then ultimately, synthesise that evidence to understand the overall story
and give us a roadmap as to what type of yoga, where, and how much mean-
ingful impact is likely for patient benefit.
What this review does reveal are two things: first, a paucity of high-
quality evidence to show if, and what type of yoga intervention will
improve primary outcomes in patients with breast cancer; and second,
adverse effects of practising yoga are not reported in current evidence—
which is either a good thing, or a gap that also needs further investigation.
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.
© Article author(s) (or their employer(s) unless otherwise stated in the
text of the article) 2017. All rights reserved. No commercial use is
permitted unless otherwise expressly granted.
References
1. World Health Organization. Breast cancer: prevention and control. http://www.​who.​
int/​cancer/​detection/​breastcancer/​en/ (accessed 30 Oct 2017).
2. Globocan. Estimated cancer incidence, mortality and prevalence worldwide in 2012,
2012. http://​globocan.​iarc.​fr/​Pages/​fact_​sheets_​cancer.​aspx (accessed 20 Oct 2017).
3. Craig P, Dieppe P, Macintyre S, et al. Developing and evaluating complex
interventions: the new Medical Research Council guidance. Int J Nurs Stud
2013;50:587–92.
4. McCall MC, Ward A, Roberts NW, et al. Overview of systematic reviews: yoga as a
therapeutic intervention for adults with acute and chronic health conditions. Evid
Based Complement Alternat Med 2013;2013:1–18.
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 Downloaded from http://ebn.bmj.com/ on November 28, 2017 - Published by group.bmj.com

Yoga intervention may improve health-related

quality of life (HRQL), fatigue, depression,
anxiety and sleep in patients with breast
cancer
Marcy McCall

Evid Based Nurs published online November 25, 2017

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