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Meta-Analysis
. 2025 May 27;5(5):CD015520.
doi: 10.1002/14651858.CD015520.

Yoga for fatigue in people with cancer

Sarah Messer  1 , Annika Oeser  1 , Carina Wagner  1 , Andreas Wender  1 , Nora Cryns  1 , Roberta W Scherer  2 , Shiraz I Mishra  3 , Ina Monsef  1 , Ulrike Holtkamp  4 , Marike Andreas  1 , Paul J Bröckelmann  5 , Moritz Ernst  1 , Nicole Skoetz  1
Affiliations
Meta-Analysis

Yoga for fatigue in people with cancer

Sarah Messer et al. Cochrane Database Syst Rev. .

Abstract

Background: Cancer-related fatigue (CRF) is one of the most prevalent symptoms in individuals with cancer. Various types of exercise have shown beneficial effects. While previous systematic reviews suggest exercise may improve CRF and quality of life, evidence specifically about yoga's impact, as well as evidence on long-term effects, is limited. Previous syntheses offer promising but inconclusive findings on yoga's effectiveness. This review is one of a suite of five reviews exploring exercise for cancer-related fatigue.

Objectives: To assess the effects of yoga versus no yoga on cancer-related fatigue in people with cancer: • before, during, and after anticancer treatment; • in the short, medium, and long term; • and effects on quality of life (QoL), adverse events, depression, and anxiety.

Search methods: We used CENTRAL, MEDLINE, Embase, five other databases and two trials registers, together with reference checking, citation searching and contact with study authors to identify studies that are included in the review. The latest search date was October 2023.

Selection criteria: We included randomised controlled trials (RCTs) comparing yoga to no yoga. We included studies in adults (aged 18 and older) with any type of cancer and anticancer therapy who received yoga before, during, or after anticancer therapy. We included trials evaluating at least one of the main outcomes (CRF or QoL). Yoga had to last for at least five sessions, and involve face-to-face instruction. We excluded trials with fewer than 20 participants randomised per group.

Data collection and analysis: The outcomes of interest in this review are cancer-related fatigue (CRF), quality of life (QoL), adverse events, depression, and anxiety. We used standard methods expected by Cochrane. For analyses, we pooled results within the same period of outcome assessment (i.e. short, medium, and long term), and employed a random-effects model. We assessed risk of bias with the Cochrane risk of bias (RoB) 1 tool, and used GRADE to assess the certainty of the evidence.

Main results: We included 21 RCTs with 2041 people with cancer who received yoga during (13 studies) or after (eight studies) anticancer therapy; none examined yoga initiated before therapy. Here we present results on CRF and QoL; findings on adverse events, depression, and anxiety are in the full review. Yoga during anticancer therapy The evidence is very uncertain about the effect of yoga compared to no yoga on: short-term CRF (standardised mean difference (SMD) 0.07, 95% confidence interval (CI) -0.18 to 0.32; mean difference (MD) on Brief Fatigue Inventory (BFI; lower values mean better outcome) of 0.16, 95% CI -0.41 to 0.71; 3 studies, 253 participants); medium-term CRF (MD on Multidimensional Fatigue Inventory (MFI; lower values mean better outcome) of -1.30, 95% CI -3.50 to 0.90; 1 study, 67 participants); and long-term CRF (MD 0.09 on BFI, 95% CI 1.16 to 0.98; 2 studies, 155 participants) (all very low-certainty evidence). Yoga may have a small beneficial effect or no effect compared to no yoga on short-term QoL (SMD 0.25, 95% CI 0.04 to 0.45; MD on Quality of Life Questionnaire-C30 (QLQ-C30; higher values mean better outcome) of 5.28, 95% CI 0.84 to 9.56; 4 studies, 374 participants) and medium-term QoL (MD on QLQ-C30 of 7.63, 95% CI 6.71 to 21.97; 2 studies, 151 participants), but the evidence is very uncertain (all very low-certainty evidence). None of the included studies reported long-term QoL. Yoga after anticancer therapy Yoga probably has a beneficial effect compared to no yoga on short-term CRF (SMD -0.26, 95% CI -0.42 to -0.09; MD 2.55, 95% CI 0.88 to 4.12; higher values mean better outcome; 5 studies, 602 participants; moderate-certainty evidence). Yoga might have a beneficial effect or no effect compared to no yoga on medium-term CRF, but the evidence is very uncertain (MD 3.02, 95% CI -1.48 to 7.52; 1 study, 54 participants (higher values mean better outcome; very low-certainty evidence). None of the included studies reported long-term CRF. Yoga may have a small beneficial effect or no effect compared to no yoga on short-term QoL (SMD 0.19, 95% CI -0.09 to 0.47; MD -3.27, 95% CI -8.08 to 1.55; higher values mean better outcome; 4 studies, 275 participants) and medium term QoL (MD 7.06, 95% CI -1.38 to 15.50; 1 study, 54 participants; higher values mean better outcome), but the evidence is very uncertain (all very low-certainty evidence). None of the included studies reported long-term QoL. A key limitation of the review was the included studies' methodological constraints: participants' awareness of treatment assignments (yoga or control) potentially introduced bias. Additionally, sample sizes were too small to determine medium- and long-term effects conclusively. Further research is needed to evaluate the sustainability of yoga's impact on cancer-related fatigue, quality of life, and adverse events.

Authors' conclusions: Our review provides uncertain evidence of the beneficial effects of yoga initiated during or after anticancer therapy compared to no yoga for people with cancer. Although there are indications supporting the use of yoga to address CRF, the uncertainty of the evidence underscores the need for caution in its implementation. Future RCTs should employ rigorous methodologies, enrol sufficient participants, and use appropriate controls.

Trial registration: ClinicalTrials.gov NCT00397930 NCT04441827 NCT04433793 NCT04775290 NCT04457895 NCT04812652 NCT05461534.

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Conflict of interest statement

Sarah Messer: is part of the Cochrane Haematology group but was not involved in the editorial process of this review. She has no conflict of interest.

Annika Oeser: is part of the Cochrane Haematology group but was not involved in the editorial process of this review. She has no conflict of interest.

Carina Wagner: is part of the Cochrane Haematology group but was not involved in the editorial process of this review. She has no conflict of interest.

Andreas Wender: has declared that they have no conflict of interest.

Nora Cryns: is part of the Cochrane Haematology group but was not involved in the editorial process of this review. She has no conflict of interest.

Roberta W Scherer: has declared that they have no conflict of interest.

Shiraz I Mishra: has declared that they have no conflict of interest.

Ina Monsef: is Information Specialist of Cochrane Haematology but was not involved in the editorial process of this review. She has no conflict of interest.

Ulrike Holtkamp: has declared that they have no conflict of interest.

Marike Andreas: reports a grant from the Federal Ministry of Education and Research, Germany (BMBF grant application, No: 01KG2017); paid to institution.

Paul J. Bröckelmann: is an advisor or consultant for Merck Sharp & Dohme, Need Inc., Stemline and Takeda; holds stock options in Need Inc., has received honoraria from BeiGene, BMS/Celgene, Merck Sharp & Dohme, Need Inc., Stemline and Takeda and reports research funding from BeiGene (Inst), BMS (Inst), Merck Sharp & Dohme (Inst) and Takeda (Inst).

Moritz Ernst: is part of the Cochrane Haematology group, but was not involved in the editorial process of this review. He has no conflict of interest.

Nicole Skoetz: is Co‐ordinating Editor of Cochrane Haematology but was not involved in the editorial process of this review. She has no conflict of interest.

References

References to studies included in this review

Anestin 2022 {published data only}
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Chandwani 2014 {published data only}
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Raghavendra 2007 {published data only}
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Vadiraja 2009 {published data only}
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References to studies excluded from this review

Banasik 2011 {published data only}
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Chandwani 2010 {published data only}
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Cheung 2021 {published data only}
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Loh 2014 {published data only}
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Oh 2008 {published data only}
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Pasyar 2019 {published data only}
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    1. Sohl SJ, Tooze JA, Johnson EN, Ridner SH, Rothman RL, Lima CR, et al. A randomized controlled pilot study of Yoga Skills Training versus an attention control delivered during chemotherapy administration. Journal of Pain and Symptom Management 2022;63(1):23-32. [DOI: 10.1016/j.jpainsymman.2021.07.022] - DOI - PMC - PubMed
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Zetzl 2019 {published data only}
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References to studies awaiting assessment

NCT04433793 {unpublished data only}
    1. NCT04433793. Yoga intervention for reducing fatigue in cancer patients (Carfi). https://clinicaltrials.gov/study/NCT04433793 (first received: 9 June 2020).
NCT04775290 {unpublished data only}
    1. NCT04775290. Yoga on QoL physiological distress and fatigue, on patients affected by breast cancer in adjuvant radiotherapy (YogaRT). clinicaltrials.gov/study/NCT04775290 (first received: 14 December 2020).
Taso 2014 {published data only}
    1. Taso CJ, Lin HS, Lin WL, Chen SM, Huang WT, Chen SW. The effect of yoga exercise on improving depression, anxiety, and fatigue in women with breast cancer: a randomized controlled trial. Journal of Nursing Research 2014;22(3):155-64. [DOI: 10.1097/jnr.0000000000000044] - DOI - PubMed

References to ongoing studies

NCT04457895 {unpublished data only}
    1. NCT04457895. Evaluation of the efficacy of a physical therapy-yoga-patient educational program for breast cancer patients with pain due to hormonal therapy treatment. clinicaltrials.gov/study/NCT04457895 (first received: 23 June 2020).
NCT04812652 {unpublished data only}
    1. NCT04812652. Digitally distributed yoga for women treated for breast cancer (DigiyogaCare). clinicaltrials.gov/study/NCT04812652 (first received: 3 February 2021).
    1. Nevo EO, Arvidsson-Lindvall ML, Börjeson SH, Hagberg L, Hörnqvist EH, Valachis A, et al. Digitally distributed Yoga Intervention in Breast Cancer Rehabilitation (DigiYoga CaRe): protocol for a randomised controlled trial. BMJ Open 2022;12(11):e065939. [DOI: 10.1136/bmjopen-2022-065939] - DOI - PMC - PubMed
NCT05461534 {unpublished data only}
    1. NCT05461534. Mindfulness yoga and sexual functioning. clinicaltrials.gov/study/NCT05461534 (first received: 30 June 2022).

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