Integrating Yoga in Cancer Care: Scope and Challenges

We see an increasing burden of cancer in the country today probably attributed to rise in lifestyle-related noncommunicable diseases and better detection of cancer. Coupled with this increasing burden are also high mortality rates for cancers in the country. Although treatment modalities for detection and treatment of cancer are improving, the lack of awareness, accessibility to quality care, and affordability are hampering good outcomes. Majority of the cancer centers are located in urban cities with people having to travel long distances and be away from work indirectly increasing the cost of care. Although government schemes have helped offer subsidized care to the people, the survivorship and care continuity are nonexistent with people not having access to care in their towns and villages following first line of treatment. As a result, studies have shown that more than 90% of patients die at their homes without any access to palliative care. Only 0.4% of the cancer patients have any access to palliative care in the country. The cost of cancer care in the country though low in comparison to west is still beyond the reach of common man. A large percentage of population afflicted with cancer are thrust into poverty with people selling off homes, land for their treatment, people being incapacitated from work with loss of earnings due to long treatment schedules, and treatment-related morbidity. It is therefore 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, improve quality of life, and identify any novel plant-derived drug targets against cancer.

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 first line 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.

SCOPE OF YOGA

Yoga as a mind-body intervention has been increasingly used in cancer patients. However, in the last decade, several large phase III studies on yoga and cancer have shown light on the beneficial effects and cost-effectiveness of these interventions. 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 the area. Second, we need to identify and create feasible and safe yoga protocols for cancer patients. Setting goals of care, plan 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 patients 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 a very feasible to implement a 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 need 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. Whether this translates to reduced duration of hospital stay and cost reduction needs more evidence. Studies should look at the efficacy of these services in reducing cost. Insurance companies should encourage hospitals to adopt these interventions to mitigate costs and reduce hospital visits.

CHALLENGES

While beneficial effects of yoga are quite well known, its adoption by the oncology medical community is still wanting. Most of them still perceive “Yoga” as an “Asana” or as some form of body contortion, which can expose the patient to unnecessary risk of musculoskeletal injuries. Their concerns are genuine as we also need to educate the yoga practitioners on the medical condition of cancer patients and their vulnerability to fractures and pain. We need to use services of organizations such as Indian association of palliative care and Indian Naturopathy Yoga graduates’ Medical Association to bridge this divide. 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, nonexpectation, and detachment. Yoga helps patients cope with uncertainty of illness and more importantly reduces fear.

Our studies on cancer patients in India and abroad are promising. We need to formulate 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. We need to encourage government to set up center for excellence in yoga and oncology to develop the evidence and setup integrative wellness centers in all regional cancer centers across India. Large multicenter studies are needed before yoga interventions become a reality in oncology.