1. Kimberly M. Carson, MPH, RYT, Portland, Oregon; James W. Carson, PhD, Oregon Health & Science University; Laura S. Porter, PhD, & Francis J. Keefe, PhD, Duke University Medical Center Yoga Program Decreases Hot Flashes in Breast Cancer Survivors: Results from a Randomized Trial

2. 2 Yoga of Awareness Program for Menopausal Symptoms in Breast Cancer Survivors  recurrence prevention therapies tend to induce and/or exacerbate menopausal symptoms  HRT contraindicated for most survivors  limited treatment options for hot flashes and related symptoms  Speca et al., (2000) MBSR  mood,  stress in cancer patients  Culos-Reed et al., (2006) yoga  mood, QOL in breast cancer patients  Moadel et al., (2007) yoga improved QOL in breast cancer patients  Cohen et al., (2004) yoga  sleep disturbance in lymphoma patients  Carson et al., (2007) yoga improvements in pain, fatigue, vigor, acceptance, and relaxation in metastatic breast cancer patients

3. 3 Potential Therapeutic Processes vigor: ‘invigorating effect on mental and physical energy’ (Wood, 1993) which improves physical fitness and counteracts fatigue acceptance: increasing research and clinical attention to role of a healthy sense of acceptance in the face of unpleasant symptomology (McCraken, Carson et al., Pain, 2004) relaxation: shift balance in sympathetic vs. parasympathetic activity, likely to improve pain, fatigue and distress

4. 4 Present Study  randomized, wait-list controlled trial among early stage breast cancer survivors  funded by Susan G. Komen Foundation  primary outcomes: hot flash frequency, severity (0-9 scale) & total scores (frequency X severity)  secondary outcomes (all 0-9 scales): fatigue, joint pain, sleep disturbance, negative mood, night sweats, overall symptom- related distress  also changes in vigor, acceptance, relaxation (0-9 scales)  measurement: daily logs, collected via an interactive telephone voice system, for 2 wks during baseline (pre), during the last 2 wks of the yoga program (post), and for 2 wks at 3 months after post (follow-up)

5. 5 Yoga of Awareness Overview comprehensive yoga program, based on traditional schools (Kripalu Yoga, Siddha Yoga) 1. asana / gentle postures 2. pranayama / breathing exercises (eg, extended exhalation) 3. dhyana / meditation (eg, awareness of simple being) 4. satsang / group discussions (eg, experience of home practice, changes in symptoms during week) 5. swadhyaya / study of guiding tenets (literally, “self-study”)

6. 6 Riding the waves ~ living skillfully: finding your balance and keeping your poise amidst the tumult of life’s ever-changing waves Simple being ~ our immediate sense of simply being present, at any given moment; a reliable point you can come back to, to get centered and find your bearings Awareness ~ watching yourself in your daily life with alert interest - noticing sensations, thoughts, feelings, actions - with the intention to understand rather than to judge Love ~ within all of us there is a deep-down goodness which is the basis for qualities such as kindness and carefulness Acceptance ~ being willing to have the experience you are already having, versus resisting and struggling to escape your own experience Foundations of Yoga Practice

7. 7 Yoga of Awareness Overview (cont.)  8 wk course meeting weekly for 2 hrs  4 core classes  3 symptom-based classes with tailored practices (Hot flashes, emotional swings, fatigue)  1 review & closure class  formal and informal home practice  audio CDs, illustrated handouts, yoga mat and strap provided

8. 8 Yoga of Awareness Overview (cont.) postures - two series 1 st chair-based, 2 nd standing + floor-based

9. 9 Sample 182 disease-free survivors assessed for eligibility 79 did not meet criteria insufficient hot flashes 103 met criteria 66 declined 20% not interested 41% too far/no transportation 27% too busy 12% other reasons 37 randomized yoga = 17 wait-list = 20 age M=54.4 yrs since dx M=4.9 19% African American, 81% Caucasian 71% college graduates stages: IA=40.5%, IIA=29.7%, IIB=29.7%

10. 10 Results  6 out of 8 sessions average attendance  30 min per day home practice average  no pre-treatment group differences in demographic, breast cancer treatment history, credibility, outcome variables  data analyzed by intention to treat using multilevel modeling  at post: greater improvements relative to controls in: hot flash frequency (p<.002) hot flash severity (p<.002) hot flash total scores (frequency X severity) (p<.001)

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12. 12 Results (cont.)  at post also improvements in: daily fatigue (p=.001) joint pain (p<.001) sleep disturbance (p=.007) symptom-related distress (p<.001) vigor (p=.005)  with trends for improvements in: negative mood (p=.09) acceptance (p=.06)

13. 13 Results (cont.)  at follow-up, similar findings except that: 1.further gains shown in hot flash frequency, and in vigor 2.differences now shown in negative mood (p<.001), relaxation (p=.03), & acceptance (p<.001) 3.no longer significant difference in sleep disturbance  Practice effects: at post, greater practice significantly correlated with fatigue & acceptance scores in expected directions, with trends for sleep disturbance and symptom- related distress; similar results at follow-up

14. 14 Comments “the best thing about my yoga toolbox… is that anytime I can stop and be simple” “the acceptance part, that it is alright to let go” “ I can see the hot flash coming and I say ‘oh yea I can ride this wave’ ” “the simple being, that is is just me, that it is God, and it is always right here”

15. 15 Discussion  preliminary efficacy support for hot flashes and related symptoms in early stage breast cancer survivors  support for therapeutic processes of vigor, acceptance, relaxation  viability of program demonstrated ~ attendance good, adherence to practice good, typical level of attrition  Limitations: small sample, nonspecific factors, self-report measures

16. 16 Future Directions  PO1: mechanisms of Yoga of Awareness and acupuncture on pain in metastatic breast cancer – cortisol, inflammatory markers, acceptance, self-efficacy, etc  Yoga of Awareness for overweight osteoarthritis of the knee  Yoga of Awareness teacher training in fall www.yogaofawareness.org

17. 17 Thank you !