the pros and cons of exercise for lung cancer patients, Chinese researchers suggested that studies on physical activity in this patient population focus on methods such as Tai Chi and yoga.

Researchers at the University of Texas MD Anderson Cancer Center in Houston answered that call with a feasibility study of a dyadic yoga program for lung cancer patients and their caregivers, which was presented at the ASCO 2017 Palliative and Supportive Care in Oncology Symposium in San Diego.

Partner Poses

Milbury’s group looked at the effects of their intervention on quality of life (QoL) and physical function versus a waitlist control group. Patients in the study had stage I-III non-small cell lung cancer (NSCLC), and were undergoing 25 fractions or more of intensity-modulated radiation therapy for 6 weeks.

“This program was particularly designed to address physical symptoms (e.g., dyspnea, fatigue) and psychological needs (e.g., distress, blame) common among lung cancer patients and their caregivers, a vulnerable yet understudied population,” the team wrote in a 2015 paper.

The dyadic yoga program was based on the Vivekananda yoga program. MD Anderson has an ongoing research collaboration with the Vivekananda Yoga Anusandhana Samsthana (VYASA), a yoga research foundation and university in Bangalore, India, Milbury noted.

The yoga program consisted of 15, 60-minute sessions with four main components:

• Joint loosening with mindfulness training
• Physical postures (called asanas) paired with deep relaxation techniques
• Breath work (called pranayama) with sound resonance
• Meditation and guided imagery

“With these patients undergoing radiation, we wanted to focus on keeping the upper chest flexible,” Milbury said of the asana work. “We focused on a lot of chest-opening exercises to loosen up the muscles around the lungs. In general, there was more emphasis on stretching the upper body.”

As for the meditation and guided imagery, “we also focused on the needs of the population. Most of these patients are smokers, and with smoking-related etiology, there tends to be a lot of self-blame. So we focused on the idea of self-acceptance — compassion toward self and their partners.”

Sessions were jointly attended by the 26 pairs of patients and caregivers. The mean age of patients was 66.7, while the mean age of caregivers was 59.3. The vast majority of patients had stage IIIA and IIIB disease, with 57% having an ECOG status of 1.

In terms of efficacy outcomes for the intervention, there was a statistically and clinically significant improvement for patients based on the 6 Minute Walk Test or 6MWT (478 m for the yoga mean versus 402 m for the control group (>70 m³, P<0.05).

The intervention patients also reported significant improvements in QoL domains, including physical function, stamina, and mental health (P<0.05), and clinically significant differences in symptoms at the end of radiotherapy, such as less distress, sadness, dyspnea, and fatigue, as well as better sleep.

One of the potential adverse events of radiotherapy in lung cancer patients is acute radiation pneumonitis, and the breathing techniques in the yoga program offered any benefits for patients who experienced symptoms such as breathlessness and cough.

“We found that the yoga intervention buffered against an increase in breathlessness,” Milbury said. “We weren’t able to eliminate this adverse event, but we were able to significantly buffer against it. Also, some patients experienced coughing, so we modified some of the yoga program components. For example, for some patients, lying flat on the ground in a supine position induced coughing, so we modified by propping their head up and so forth.”

As for the caregivers, “marginally to clinically significant” differences were seen in vitality (VT) and role performance (RP) versus waitlist controls, the authors noted. However, they pointed out that “based on dyadic analyses, [caregivers’] increase in VT and RP were significantly associated with patients’ 6MWT (P<0.01).”

While the randomized, controlled study was deemed feasible, study limitations included the racially homogenous sample (89% white patients; 100% white caregivers), the lack of a stringent control group, and the small sample size.

Milbury said the group is now in the process of seeking funding for an efficacy trial with a more stringent control group.

“We’ve known for some time that yoga can have a wide range of benefits for people who practice it,” commented Andrew S. Epstein, MD, of Memorial Sloan Kettering Cancer Center in New York City, a designated ASCO expert. “Ideally, the findings of this study will encourage people with advanced cancer and their caregivers to practice yoga.”

Into Practice

According to a 2014 Canadian study on yoga for health-related QoL, “patients across groups reported strong preferences for the following components of yoga: small class sizes, cancer-specific group, stretching, breathing practices, meditation, and physical postures for strength conditioning and restorative poses.”

While MD Anderson offers an in-house yoga program with classes that meet those criteria, many lung cancer patients will have to seek yoga outside their care facility. Given the incredible popularity of yoga – now estimated to be a $27 billion industry with more than 20 million practitioners in the U.S. alone — and the wide variety of yoga styles, how can lung cancer specialists best guide their patients to appropriate classes?

Milbury suggested that patients avoid yoga classes that contain the labels “power,” “hot,” or “flow,” as these will most likely be too vigorous for lung cancer patients. She also said patients may want to steer clear of gym-based classes versus those held at a dedicated yoga studio, as the latter will likely mean more individual attention. And she advised clinicians to emphasize that a patient should discuss the class style with the yoga teacher prior to attending.

Finally, “I’d recommend staying in the realm of gentle yoga,” she explained. “It’s also important that the yoga class focus on breathing exercises. Unfortunately in the West, a lot of the yoga classes are very focused on strengthening. That’s good to an extent, because lung cancer patients do experience deconditioning, so some strengthening is good, but the chest openers and breathing exercises have a lot of benefit for this population.”

Perkunas cautioned that sometimes classes called gentle can still be in the “flow” style, which consists of moving from one pose to the next fairly quickly. She advised directing patients to certified yoga therapists, through organizations such as the International Association of Yoga Therapists.

‘Yoga Therapy’ vs ‘Yoga’

What’s the difference between yoga therapy and yoga? As explained by yoga therapist Gary Kraftsow, writing in Yoga International, yoga therapy “fundamentally focuses on … clients’ needs. [A yoga therapist’s] job is to understand why their clients have come to see them and determine what they can do to support them … Therapists look for ways to help their clients reduce or manage their symptoms, improve their function, and help them with their attitude in relation to their health conditions … therapists choose yoga techniques in relation to how they will specifically benefit individual clients.”

Perkunas explained that when she has worked with lung cancer patients, they generally come to her post-treatment: “They are looking for a way regain a sense of trust with their bodies — to get back in touch with their bodies after this life-changing event.”

While she and the patients will often focus on asanas that promote chest opening, they will also look for ways to rebuild overall strength and mobility. But patients aren’t necessarily looking to improve QoL directly, Perkunas added.

“When I’ve worked with lung cancer patients, they are more interested in managing their physical symptoms — aches, pains. As a result of their ongoing [yoga] practice, they often notice they sleep better, they have less anxiety, they feel more relaxed. So these are benefits that come with a yoga practice, but they aren’t necessarily the person’s primary interest.”

Perkunas advised that clinicians focus more on yoga to regain strength and mindfulness: “Be careful not to set up expectations that yoga will fix or cure their symptoms. Yoga is not a cure-all, but it is an effective management tool for symptoms.”

Finally, Perkunas pointed out that yoga does have a spiritual and philosophical component to it that may not appeal to all patients. She suggested having patients experience a variety of yoga teachers to determine which style of teaching works best for them. Again, directing patients to a dedicated yoga therapy class may be the best option.

Of course, cost may be an issue as patients are likely to have to pay out-of-pocket. “I have people who call me and, after talking, we determine that I charge more than they are willing to pay,” Perkunas noted. “I’ll refer them to classes in the community, with teachers that I trust, that may be better for their budget. Asking around in your community is a route to finding an appropriate class.”