Can yoga be Integrated in Palliative Cancer Care?

Surviving with cancer means a constant reminder about the disease, anxiety about recurrence and progression and impending death. This coupled with treatment-related side effects can lead to intrusive thoughts and feelings of anxiety, hopelessness and helplessness and can cause severe psychologic distress. Growing evidence suggests that psychosocial and psychoeducational interventions are beneficial adjunctive treatments for patients with cancer.

Question is “Can alternative medicine including Yoga be integrated in palliative cancer care.”

It is important to explore local healing traditions and mind‑body interventions such as in AYUSH systems of medicine Ayurveda, Yoga and Naturopathy, Unani Siddha, and Homeopathy to reduce treatment‑related morbidity and improve quality of life. Cancer care has been under the purview of conventional medicine in the country and AYUSH interventions exist only as a last resort or are sought for symptom mitigation. However, many patients take recourse to these therapies both as a firstline and in their survivorship period with an intent to reduce side effects of conventional treatment and improve anticancer immunity. Whether these interventions are beneficial or not is a question that needs to be answered through systematic research. Studies should look at the safety, efficacy and cost‑effectiveness of these therapies if these are to be integrated with mainstream medicine.

Yoga is an ancient discipline and its physical and mental health benefits have been described in early texts. Although it has been used in India for centuries, it has recently started to gain global recognition. Yoga is an ancient Indian science and is one among the six great Indian philosophies that have evolved over thousands of years. In the spiritual dimension, yoga is a path toward attainment of superconscious states beyond sensory perception and knowledge. It deals with the physical, mental, moral, and spiritual well-being of an individual. There are several studies that have used various forms and schools of yoga that tend to lay emphasis on either one or more of the above practices, popular among them being Iyengar Yoga, Integrated Approach of Yoga Therapy, Sudarshan Kriya Yoga, Vinyasa Yoga, Tibetian Yoga and Hatha Yoga, etc. These yoga traditions have been increasingly used in cancer patients to reduce stress, mood state symptom distress and improve QOL. Yoga is known to modulate this psychoneuroendocrine and psychoneuroimmune axis thereby restoring homeostasis and reducing the allostatic load. These effects have been observed in numerous studies of yoga that have shown reductions in cortisol, inflammatory cytokines, and improved natural killer cell counts. These changes have been shown to modulate distressful symptoms and improve QOL.

 Yoga as a mind‑body intervention has been increasingly used in cancer patients. Integrating these interventions into cancer care for symptom mitigation and quality of life may also reduce duration of hospital stay and costs. Further research is warranted in this area. Second, we need to identify and create feasible and safe yoga protocols for cancer patients. Setting goals of care and objectives will help rationalize use of yoga interventions in cancer patients. Identifying clinical situations where certain yoga interventions can pose significant risk is also warranted. For example, a patient receiving radiation for a lung lesion should not do hyperventilation practices such as Kapalabhati and Bhastrika for fear of causing pneumothorax. Studies have shown that it is feasible to implement yoga program at bedside in an oncology practice setting. Multiple hospital admissions and daily radiotherapy present an opportunity to engage the patients in regular yoga practice during their treatment visits. Nurses in hospitals can be taught to impart yoga intervention to patients during their surgery/chemotherapy/radiotherapy. Yoga can also be taught to the caregivers to reduce their burnout as well as to reinforce these practices among the patients. Home care team to manage pain can use yoga for morphine‑induced constipation, fatigue, nausea and vomiting, headache and other stress, and vasomotor symptoms.

Training AYUSH doctors in palliative care will help meet the unmet needs for home‑based palliative care services and rural palliative care services in the country. No doubt, these practices are known to help improve quality of life of cancer patients and reduce symptom burden. While beneficial effects of yoga are quite well known, its adoption by the oncology medical community is still wanting. Oncologists need to be exposed to beneficial effects of yoga intervention and educated about “What really is Yoga.” Yoga as per Sage Vasistha is a science of calming down the mind. Sage Pathanjali explains this systematically through eight‑fold steps called Astanga Yoga which uses ethics, disciplines, postures, regulated breathing, or breath control, to control the mind followed by concentration and meditation. These series of practices are known to identify the inherent stress responses and help cope with them through altered perception, controlled appraisal, sublimed emotions and detachment. Yoga helps patients cope with uncertainty of illness and more importantly reduces fear. We need to create think tank on formulating the way forward for Integrating Yoga and AYUSH streams into oncology care. We need to identify priority and thrust areas wherein these interventions can be used in clinical settings. Large multicenter studies are needed before yoga interventions become a reality in oncology

Stress management techniques that have proven helpful include progressive muscle relaxation,diaphragmatic breathing, guided imagery, and social support. Participating in intervention programs before treatment have enabled patients to tolerate therapy with fewer reported side effects. Stress-reduction methods are many and varied, and yoga is especially attractive as it combines many of these techniques with simple stretching exercises, breathing, and relaxation techniques that could be useful for patients with cancer. A growing literature shows the potential benefits of practicing yoga of these patients.Bone metastases in long bones present an increased risk of fracture with some asanas, especially in the elderly population. Second, hyperventilation practices have been shown to cause pneumothorax earlier. Patients having pleural effusion, ascites, abdominal surgeries, etc., need a more cautious approach with yoga interventions, slow deep breathing, pranayama, and relaxation techniques being useful in these conditions. The performance status and general condition of the patient are of paramount importance while selecting yoga interventions.

Dr. A. K. Dewan

Director – Surgical Oncology