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Table of Contents
Year : 2022  |  Volume : 2  |  Issue : 2  |  Page : 95-101

Evaluation of the effect of yoga on symptom burden and quality of life impairment in head-and-neck cancer patients receiving radiotherapy

1 Swami Vivekananda Yoga Anusandhana Samsthana; Reset Tech Global Private Limited, Mumbai, Maharashtra, India
2 HCG Cancer Center, Bengaluru, Karnataka, India
3 HCG Cancer Center, Bengaluru, Karnataka; Central Council for Research in Yoga and Naturopathy, New Delhi, India

Date of Submission08-Jan-2023
Date of Decision14-Jan-2023
Date of Acceptance14-Jan-2023
Date of Web Publication06-Feb-2023

Correspondence Address:
Dr. Amritanshu Ram
HCG Cancer Center, Bengaluru, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jpo.jpo_2_23

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Introduction: Psychological stress has been implicated in the onset and exacerbations of several diseases, including cancer. Psychosocial factors have been associated with a higher cancer incidence, poorer survival, and higher cancer mortality. The present study aimed to see the relationship of symptom burden and quality of life (QoL) impairment in head-and-neck cancer (HNC) patients undergoing radiotherapy with perceptions of yoga intervention.
Methodology: The present study was a one-time survey conducted on 53 patients with HNC. The main outcome variables of the study were symptom severity and burden, which were assessed by The MD Anderson Symptom Inventory (MDASI) QoL impairment by using the European Organization for Research and Treatment in Cancer H and N 35 questionnaire and survey questions were prepared and administered to elicit the perceptions of patients toward a yoga.
Results: The mean age of the study population was 56.5 ± 12.34 years. The perceived benefit of yoga among the yoga practitioners was 66%, and on the other hand, the perceived benefit of conventional treatment among nonyoga practitioners was only 23%. The HNC patients performing yoga along with conventional treatment experienced significantly less distress as compared to the nonyoga practitioners.
Conclusion: The study has shown that the yoga practitioners experience less psychological distress as compared to the nonyoga practitioners and their perceived benefits were higher. Yoga also reinforced beliefs in conventional treatment. This may be probably useful in improving compliance with conventional treatment. Therefore, adding yoga to the conventional treatment can prove to be an important and useful adjunct.

Keywords: Cancer, head-and-neck cancer, quality of life, radiotherapy, yoga

How to cite this article:
Chobe M, Ram A, Rao R, Chobe S. Evaluation of the effect of yoga on symptom burden and quality of life impairment in head-and-neck cancer patients receiving radiotherapy. J Precis Oncol 2022;2:95-101

How to cite this URL:
Chobe M, Ram A, Rao R, Chobe S. Evaluation of the effect of yoga on symptom burden and quality of life impairment in head-and-neck cancer patients receiving radiotherapy. J Precis Oncol [serial online] 2022 [cited 2023 Jun 8];2:95-101. Available from: https://www.jprecisiononcology.com//text.asp?2022/2/2/95/369215

  Introduction Top

Cancer is a disorder caused by hyperproliferative cells that involve dysregulation of apoptosis and metastasis. Tumor cells are characterized by uncontrolled proliferation and altered apoptosis.[1] Epithelial carcinomas of the head and neck arise from the mucosal surfaces in the head-and-neck area and typically are squamous cells in origin. Head-and-neck squamous cell carcinomas arise from the mucosa of the upper aerodigestive tract. Majority of head-and-neck cancers (HNCs) are of squamous cell type, which is linked to tobacco and alcohol use and to human papillomavirus.[2] Psychological stress is also implicated in the onset and exacerbations of several inflammatory diseases including cancer. Cancer development and its therapy are influenced by the mediators like catecholamines and activated hypothalamic–pituitary–adrenal axis and sympathetic nervous system due to stress.[3],[4] Psychosocial factors are associated with a higher cancer incidence in initially healthy people, poorer survival in patients diagnosed with cancer, and higher cancer mortality.[5] Psychological stress can contribute to oxidative stress, which in turn leads to the development of various types of cancers.[6] Stress affects the pathogenic processes of cancer, such as DNA repair, cellular aging, and antiviral defenses.[7]

Cancer and its therapy are usually associated with a significant deterioration in the quality of life (QoL). There are a variety of integrative therapies available to patients, including education,[8] massage,[9] acupressure, Qigong, cognitive behavioral therapy/coping skills training, meditation, music, and virtual reality[10] (for example, relaxation, imagery, hypnosis, cognitive-behavioural therapy). Mindfulness-based interventions can alleviate physical and psychological symptoms in addition to nonpharmacological interventions like yoga.[11]

Yoga, a nonpharmacological strategy, is a combination of physical poses with breathing and meditation.[12] Yoga as an adjunctive approach has been shown to reduce side effects and improve sleep, fatigue, QoL, and psychological distress in cancer patients.[13],[14] A recent review by Gonzalez et al.[15] and Song et al.[16] provides evidence that yoga-based intervention is a promising therapeutic modality for the management of anxiety, depression, and fatigue in people with cancer. A review of 10 studies comparing the effects of yoga asanas (postures) with “regular” exercise indicated that yoga may be as effective as exercise for improving health outcomes such as blood glucose and lipids, fatigue, pain, and sleep in healthy people and in people with conditions such as diabetes and multiple sclerosis.[17] Previous reviews and a meta-analysis of intervention studies have reported that yoga is feasible for patients with cancer and cancer survivors[18] in improving sleep, QoL,[19] mood, and levels of stress. The results indicate that relaxation training could be a useful clinical physiotherapy intervention for breast cancer patients experiencing anxiety. Oxidative stress is a phenomenon associated with pathogenic mechanisms of several diseases, including atherosclerosis, neurodegenerative diseases, such as Alzheimer's and Parkinson's disease, cancer, diabetes mellitus, inflammatory diseases, as well as psychological diseases or aging processes. A review conducted by Rao et al.,[20] in 2012, suggests that mindfulness-based yoga practice done for 60–90 min at a moderate intensity level can relieve side effects and improve recovery and QoL in cancer patients. Hence, this study was conducted to understand if perceptions toward yoga practice also have an impact on the symptom burden and QoL Impairment in HNC patients, which is never been studied before among the HNC patients.

  Methodology Top

We obtained approval from HCG Pvt. Ltd. Institutional Review Board for the study. The study included patients diagnosed with HNCs and undergoing conventional treatment (concurrent CTRT or radiotherapy alone). Both male and female patients able to provide informed consent and aged between 25 and 80 years were included in the study. Patients were excluded if they had any diagnosed neuropsychiatric illness and had a physician-rated Eastern Cooperative Oncology Group (ECOG) performance status of >2. Research staff identified potentially eligible patients in the institution's electronic medical records, approached the in-patient, confirmed their study eligibility, and obtained their written informed consent to participate before data collection. After taking the consent, the patient completed paper–pencil survey measures. The trial was completed between January 2015 and October 2015.


Demographic and medical factors

Demographic details (e.g., age, occupation, and food habits) were included in the baseline questionnaires. Patients' medical data were extracted from their electronic medical records.

Symptom severity and burden were assessed using the MD Anderson Symptom Inventory. This inventory assesses the symptom severity and the interference in daily activities. The patient was asked to indicate the severity of the symptom and its interference in daily life over the last 24 h on a scale of 1–10.

QoL impairment was assessed using a 35-item questionnaire: the European Organization for Research and Treatment in Cancer H and N 35 questionnaire. Patients were asked to indicate the extent to which they experienced the symptoms or problems during the past week.

Yoga perception checklist, which included survey questions, was prepared and administered to elicit the perceptions of patients toward yoga. This checklist consists of three sections. Section 1 consists of 10 questions for those patients who did yoga along with conventional treatment. Section 2 consists of 9 questions to be answered by all patients, irrespective of whether they practice yoga or not. Section 3 consists of 2 questions for those who do not practice yoga.

A distress thermometer was used to assess the severity of psychological distress experienced by the HNC patients.

  Results Top

The mean age of the study population was 56.5 ± 12.34 years. There were 87% of males and 13% of females in the study cohort. Most of the patients, i.e., 85% in our study, were Hindus and 74% of patients were nonvegetarians. However, education, occupation, and income status of the patients showed much variation. Most of them, i.e., 83%, were educated, and only 26% of the study population was nonsalaried [Table 1]. The psychological distress among the yoga practitioners was significantly less than the nonyoga practitioners (P = 0.04) on Mann–Whitney test. QoL, symptom severity, and symptom distress did not show any difference; however, there was a trend for lower scores among the yoga practitioners as compared to the nonyoga practitioners [Table 2]. The perceived benefit of yoga among the yoga practitioners was 66%, and on the other hand, the perceived benefit of conventional treatment among nonyoga practitioners was only 23%. The HNC patients performing yoga along with conventional treatment experienced significantly less distress as compared to the nonyoga practitioners. From this, we infer that adding yoga to the conventional treatment can prove to be a useful adjunct [Table 3]. [Table 4]a, [Table 4]b, [Table 4]c reveals the perceptions of HNC patients regarding yoga and conventional treatment. In these tables, we have arranged the responses in descending order of their frequency among patients. The most common reason that people opt for conventional treatment is that they feel the treatment to be beneficial. However, they do feel that the treatment is expensive and has got side effects. There is a perception among patients (whether practicing yoga or non-yoga) that yoga is a mind and body relaxing practice that enhances awareness and involves twisting and turning of the body. Most patients performed yoga with conventional treatment in order to alleviate symptom distress, improve their quality of life and calm down their minds. Non-yoga practitioners generally believed that yoga takes a longer amount of time to show effects, may not work at all, or may interfere with the treatment they are currently receiving.
Table 1: Comparison of sociodemographic measures between the yoga and nonyoga groups

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Table 2: Comparison of quality of life, symptom severity, symptom distress, and psychological distress between the two groups

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Table 3: Comparison of perceived benefit of yoga and conventional treatment among yoga and nonyoga practitioners using the Chi-square test

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  Discussion Top

The present study evaluated the perceptions and distress along with the QoL, symptom distress, and symptom severity among the HNC patients undergoing cancer-directed treatment. This was a cross-sectional study that evaluated patients' perceptions regarding yoga. The study shows that there was a lesser symptom burden in patients taking recourse to yoga intervention; the study also shows that patients taking recourse to yoga had better perceptions regarding conventional treatment compared to those not doing yoga intervention. It was found that those who practice yoga had a more or less positive perception of yoga, whereas those who did not practice yoga thought yoga was prolonged, took a long time to act, and would interfere with existing treatment.

Although the yoga perceptions did not show any relation/influence on QoL and symptom severity, this could be because our study was not adequately powered. Hence, yoga perceptions could be considered one but not the sole factor that influences the QoL and symptom severity in HNC patients.

In the present study, the psychological distress in the yoga practitioners was significantly lower as compared to the nonyoga practitioners. Other parameters also showed a trend towards lower scores among yoga practitioners, though not significantly. The perceived benefits of yoga among practitioners were also higher than the perceived benefits of conventional treatment among nonyoga practitioners.

In our study, we compared the yoga and nonyoga practitioners for their symptom severity, distress, and QoL. Patients with any type of cancer are known to have poor QoL. Previous studies (randomized controlled trials) of yoga as intervention on breast cancer patients have been shown to reduce psychological and symptom distress and improve QoL.[20],[21] Yoga intervention is helpful in modulating the psychological symptoms in breast cancer patients undergoing conventional treatment.[22] Our study results on HNC patients also showed similar results as revealed by the previous studies on breast cancer patients in terms of significantly reduced psychological distress in patients already performing yoga.

The perceived benefit of yoga among practitioners was found to be higher in our study as compared to nonyoga practitioners, results similar to earlier studies,[23] like in an observational study on complementary and alternative medicine (CAM) use among HNC patients where meditation and yoga were associated with greater perceived benefit.[24]

Patients with cancer have hopelessness, depression, and negativity toward treatment outcomes. Moreover, these attitudes of helplessness and hopelessness, in turn, increase the risk of cancer development.[25],[26] Both depression and hopelessness are mutually reinforcing toward their effect on hastening cancer progression.[27],[28] In most cases, patients turn to yoga not out of frustration, but because they feel that it will improve their quality of life and assist in stress management. The CAM is most commonly chosen as a part of treatment by cancer patients to reduce the ill effects of disease and its treatment.[29] In this study, we observed that the negative attitude toward treatment outcomes was lower in the yoga practitioners, thereby reducing the attitudes of helplessness and hopelessness in them which, in turn, can slow the progression of the disease.

The main concern while determining to choose yoga as an intervention includes various safety and efficacy issues. The most common concerns are regarding treatment duration, drug interactions, and its efficacy to successfully alleviate the symptoms and provide a cure.

The popularity of holistic approaches to health care is increasing, and individuals are becoming more interested in how CAM can augment the treatment (s) they are receiving from the conventional health-care system.[30],[31],[32] Complementary therapy (CT) differs from AM in that CT is used as an adjunct, a complement or supplement, to conventional care to foster symptom management, whereas AM replaces evidence-based, conventional care.[33] The acronym CAM is commonly used to refer to either CT or AM therapies or the combined use of both. It is evident that there are a number of factors contributing to CAMs' current popularity.[34] They are related to the social and cultural context. In cases of severe illness, the hope to “leave no stone unturned” is a powerful motivator.[35] Consequently, cancer patients are prime candidates for the use of complementary and alternative medicine (CAM).[36] There is evidence to suggest that oncologists, although often unfamiliar with CAM, may take a less negative view of CAM use today than they did previously.[37] This was the first study to look for the influence of yoga perceptions among HNC patients on their QoL and symptom severity and distress. The data from this pilot observational study could be used to conduct a larger study in this population. Although this was an observational study, the study was limited due to a small sample size. Larger observational studies are necessary to validate the findings of this study.

  Conclusion Top

The study has shown that the yoga practitioners experience less psychological distress as compared to the nonyoga practitioners and their perceived benefits were higher. Yoga also reinforced beliefs in conventional treatment and removed negativity regarding its side effects. This may be possibly effective in promoting compliance with conventional treatment. Consequently, the addition of yoga to conventional treatment may show to be a crucial and beneficial adjuvant.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Table 1], [Table 2], [Table 3], [Table 4]


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