The following is a research paper I wrote for my yoga teacher training. In it, breast cancer patients, survivors and their families may find some helpful resources and approaches to finding stress reduction and health-promoting tools for mental and physical well-being. I referenced many books and research articles in the “Sources” section, and I invite those who are interested to look for good resources there. Namaste.
Yoga is one of the means by which cancer patients and survivors can actively take a hand in their own healing. They have the ability to manage their mental and emotional landscape through a potentially traumatizing situation; they have the ability to re-center and tune in to body wisdom when the entire healthcare system encourages them to look outside themselves to (sometimes conflicting or ambiguous) data and experts for guidance; they are able to actively cultivate an attitude and perspective of empowerment rather than helplessness; and they can actively work their bodies to prepare for surgery/treatment, to remain strong and healthy through treatment and surgical recovery, and to maintain their health after their active treatment has ceased. With awareness and sensitivity, a yoga teacher can adapt the yoga class to meet the needs of breast cancer patients before, during and after treatment to be a powerfully supportive experience.
This author will attempt to answer the following three questions regarding yoga for cancer patients in this paper:
- What are the some of the key challenges the cancer patient faces for which there is evidence that yoga can make a positive impact?
- How do we adjust the yoga practice for patients prior to treatments (after diagnosis), during/after treatments in order to make the practice effective, safe and meaningful?
- What particular cautions should teachers have in terms of their own boundaries, emotions and agendas?
The challenges and the evidence
The cancer patient yoga student potentially faces a number of challenges to the body and mind.
- Trauma: A sense that the body is no longer a safe place, that the body has betrayed the person. It’s difficult to feel “normal,” and a state of hyper-arousal occurs, making it difficult to find a sense of wellbeing.
- Loss of a feeling of personal power. Doctors and “experts” will tell the patient what treatments or lifestyle changes they should make (whether allopathic or holistic doctors); the patient may lose a sense of having meaningful choices.
- Existential concerns: Anxiety about the future – biopsies, surgeries, chemotherapy, radiation, reconstruction, lifestyle changes, impact on one’s partner, children, extended family, impact on career and finances; even after one is done with treatments, there is statistical chance of recurrence to contend with. Awareness of a desire for lifestyle changes, enhanced enjoyment of the life one has left (whether that appears to be a long or a short time), the uncertainties that exist in terms of prognosis, coming to terms with one’s own mortality (whether it is an imminent threat or an existential coming-to-terms) and a desire to be proactive in one’s healthcare landscape and live a meaningful life.
- Physical: Maintaining physical health leading up to surgery and treatments, despite sleep disturbance, appetite changes (from anxiety), and depression; maintaining physical health despite the pain, sickness and fatigue from chemotherapy, radiation, steroids and/or surgical interventions. Recovering a sense of physical wellbeing after treatments are complete; scars, limited range of motion, pain, lymphedema, body consciousness (feeling damaged), neuropathy, and hormone therapies (sometimes including induced menopause).
*This list of factors comes from my own personal experience; interaction on cancer support groups; much general reading (specifics are cited later in this paper). It is not a complete list but should at least serve to provide a sense for the complexity of what the cancer survivor may encounter.
Jayan Landry and Jasmin Cori are two therapists who work with trauma survivors and encourage their clients to use somatic practices to regain and maintain a sense of safety in the body.
Cori defines trauma in laymen’s terms when she says, “Trauma is by nature terrifying and completely overwhelming. Something is happening that you can’t control, and it feels big enough to destroy you. In fact, your awareness that you are endangered is an essential ingredient of trauma. It is the perception of a direct threat to your life, well-being or sanity that marks trauma. Freud recognized this when he said that in trauma a person feels completely helpless and ineffective in the face of what is perceived to be overwhelming danger.” (Cori 2) Jayan Landry echoes Cori’s definition, and adds “diagnosis of terminal illness,” specifically to the list of potentially traumatizing events. (Landry 22-23) Cancer is, frequently, a traumatic diagnosis, followed by traumatizing treatments, which themselves have the power to kill along with their promise to cure or at least prolong life.
Cori also points out that people who have been traumatized often see the body as the “scene of the crime,” and she specifically recommends yoga as one type of exercise one can use to regain a sense of restored safety in the body. (Cori 184-5)
When one navigates the healthcare system with a breast cancer diagnosis, one rather quickly finds out, if she** didn’t know it already, that her body is divided into parts that are treated as separate entities. Even the same body part (breast) may have at least two surgeons: the cancer surgeon and the plastic surgeon. There are many other professional caregivers who get involved in the care: pathologist, anesthesiologist, oncologist, nurses, physical therapist. However, unless the woman shows obvious distress or requests specific help, it’s unlikely that anyone will ask how her spirit is, her heart, her intuition, what her inner wisdom is telling her, and what her mind needs in order to not drive her crazy in the middle of the night.
**(Breast cancer affects women primarily, though a percentage of men will also receive a breast cancer diagnosis. For the purposes of simplicity, I will use the pronouns “she” and “her” throughout the remainder of the paper to refer to breast cancer patients, but the reader is invited to substitute the appropriate pronouns for male yoga students/breast cancer patients.)
Yoga is a tool of empowerment –
an ability to control your own recovery plan.
GlobalCures is a not-for-profit and free resource (located near Boston) for cancer patients of all kinds (not only breast cancer), and they research and share data with cancer patients regarding the “global” cures that have supporting data of their efficacy. They have published a blog based on the existing research to support the role of the mind-body connection of yoga and meditation that also touches upon the link between stress hormones and tumor growth (to date, no one has proven that stress causes cancer; however, stress hormones do cause existing tumors to grow; this is of particular importance for our post-treatment cancer patients, whose stress levels may be high for any number of reasons, and we will want to support them in reducing the emotional aspects of a life post-cancer). (Brown Web)
One author says, “While many members of the general public believe that stress can cause cancer, there is little scientific evidence to back this notion,” (McCall 208). That is technically correct: we don’t yet have scientific evidence that it causes cancer; however, we do now have scientific evidence that strongly suggests it causes tumor growth once a person has it. (Lutegendorf Abstract) There’s a compelling argument that the stress reduction benefit of yoga (and meditation) can be an important adjunct to one’s cancer care strategy for preventing recurrence or for managing a chronic condition.
William Broad has done a great deal of research on yoga’s proven (and disproven) claims. He noted a study on GABA (gamma-aminobutyric acid), a neurotransmitter and helps regulate the nervous system. “Many reports have linked depression to low GABA levels…[and] high levels of the neurotransmitter have a calming effect.” (Broad 99)
One research study showed that “brains of yoga practitioners showed an average GABA rise of 27 percent. By contrast, the comparison group experienced no change whatsoever.” (Broad 100) These results were published in 2007. In 2010, another study showed results that were not quite as striking, but were still notable: “The average GABA rise was less than in the previous study – 13 percent versus 27 percent, or about half as much. Still the new yogis did better than the walkers. And, judging from the evidence, they felt much better about themselves.” (Broad 100)
Often in the breast cancer journey, women only find out after the fact what exactly the consequences will be for their various treatment options, or even what options will be offered to them. This happens for many reasons: many things are not known by doctors except step-by-step. Biopsy indicates grade; surgery indicates part of the staging (and sometimes reconstruction paths won’t be known except one surgery at a time); pathology report and scans often help complete the staging picture; in hormone receptor positive cancers, the “oncotype” score can indicate whether or not chemotherapy or hormone therapies will be advised; other types of testing of tumor-specific treatments are available and require that the patient wait for results. Essentially, there is a decision tree, and each branch determines the branch that will next be explored. It’s not possible – or even desirable – to explore all the possible options before one has been completed, and there isn’t much a cancer patient can do to hasten these processes. Unfortunately, it can be even more disturbing to realize, if one obtains second or third opinions, that even among the best doctors and facilities, there is different opinion on the same patient’s disease diagnosis, recommended treatment and prognosis.
What the cancer patient/yoga student can do is stay in the present moment with her body, her breath and her awareness. Yoga, meditation and pranayama can support this goal, and we’ll discuss the specifics of this in the next section on specific adaptations for the cancer patient yoga student.
“For women with breast cancer, yoga has been shown to reduce mood disturbance, anxiety, depression, anger, stress, and confusion, and to improve sleep quality, cancer related distress, and cancer related symptoms. Women participating in yoga programs during treatment reported improvements in their quality of life – for example, there was a significant reduction in nausea, vomiting, and fatigue during chemotherapy…yoga significantly boosted energy and helped the women accept their condition.” (Kollak 11)
“[T]here is evidence that yoga can enhance many physiologic processes of the body, including immune function, digestion, circulation, and sleep.” (Geffen 118)
Lymphedema is one possible side effect of mastectomy, even if only one lymph node (usually the “sentinel node) was removed (and sometimes many are removed from both axilla and arm). (Mclaughlin Web) Yoga can specifically be used as a therapy for moving lymph.
Regarding hormones: some types of breast cancer are hormonally caused, particularly those caused by estrogen dominance. We know from scientific studies done so far that yoga can shift hormone balance. How specifically this happens and whether or not yoga can be used so precisely as to reduce hormone production/receptivity for hormone receptor positive breast cancers is beyond the scope of this paper. However, this paper will give us a glimpse of what little we do know and what that information might lead to in future study.
It’s very important to ask if there has been research to show what effect the practice of yoga can have on the hormone system because many breast cancers are linked with estrogen dominance.
One test that came out of the feeling of invigoration Katil Udupa got from his own yoga practice, involved a dozen men who were tested over six months of progressively more difficult yoga practice. Broad says that the first postures were Cobra, the Spinal Twist, the Wheel, and the Full Lotus. “New poses added over the months included the Plow, the Locust, the Bow, the Shoulder Stand, and the Headstand. The pranayamas included Bhastrika and Ujjayi, or Victorious Breath. Overall, by modern standards, the training was fairly rigorous.” (Broad 168). On average, urinary excretion of testosterone rose 57 percent. “The results, the scientists wrote in 1974, suggested that yoga could prompt a ‘revitalization of the endocrine glands.’’
…”the little molecule can influence behavior and sexuality – doing so in both males and females. Not the least significant, studies showed that it acts to improve mood and a person’s sense of well-being. It seems likely that the hormone forms a significant part of yoga’s cocktail of feel-good chemicals.” (Broad 169)
Currently, there is not a lot of research about estrogen and yoga, but one small study in post-menopausal women (not breast cancer patients) showed “an abnormal estrogen-level increase after 4 months of yoga practice and showed QOL [Quality of Life] improvements.” That would be great, if one’s tumors were not estrogen-receptor positive! (Alfonso Abstract)
Further research on hormones talks about metabolic syndrome and estrogen. “There’s a relationship of metabolic syndrome/insulin resistance and estrogen receptor positive cancers, and one study showed that there is reason to believe even a very modest yoga practice (60 minutes, one time per week) positively affected factors in metabolic syndrome: In conclusion, this study showed that a 12-week Hatha yoga program for Chinese adults produced beneficial changes in waist circumference, fasting glucose, triglycerides, MetS [metabolic syndrome) z score, and HRQoL. The reductions in waist circumference and MetS z score did not differ between MetS subgroups. Given the low-to-moderate intensity feature of yoga, the high adherence rate, and the encouraging results of this study, yoga may be a promising alternative form of exercise for Chinese individuals with or without MetS.” (Holger Abstract)
Bottom line: we know that yoga can and does change hormone balance; we don’t know enough at this point to know whether that can be used specifically to enhance (or harm) the health of yoga patients. There is no known contraindication for yoga and hormone-receptor positive breast cancer at this time, and we should be aware of any research that comes out on this issue. (One could argue that increasing testosterone would help estrogen-dominant cancer patients; however, testosterone can “aromatize” into estrogen in both men and women, and so simply increasing one’s testosterone is not clearly good in the overall.)
Systematic reviews are very useful articles, as they look at all the available applicable publications on the topic in question, and they sort out the poorly designed studies and collect the best in order to make reasonable conclusions. One such review concluded, “Yoga appeared to be a feasible intervention and beneficial effects on several physical and psychosocial symptoms were reported. In patients with breast cancer, effect size on functional well-being was small, and they were moderate to large for psychosocial outcomes.” (Buffart abstract)
Yoga also was shown to reduce inflammation for breast cancer patients: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4060606/ There is reason to believe that inflammation can actually be one of the factors that promotes metastases post-surgically, so reducing inflammation not only promises to reduce immediate discomfort but may actually reduce one’s chances of recurrence. (Sukhatme YouTube Video)(Forget Abstract) While we don’t know if yoga is as effective as the NSAID (non-steroidal anti-inflammatory drug) Ketorolac, as Dr. Sukhatme proposes in his video, the inflammation-reducing effects of yoga pre- and post-surgically might very well be helpful and could arguably be examined as a topic for future research.
“What’s the best exercise?”
The class asked one of my now forgotten instructors.
“The one you do!”
So why yoga rather than any other mind-body integrated exercise? Yoga is not the only therapy that harnesses the power of the mind to heal the body or the power of the body to heal itself, but it is one of the few that has some research behind it to validate its claims scientifically. This is a fortunate thing for the yoga industry. I cannot say that yoga is the only system for whom the claims of mental, physical and spiritual healing are true; only that it has been the one that is lucky enough to have been singled out for a decent amount of study. Of course, not all of yoga’s claims stand up to the gold standard of the double blind study, but so far, a number of them do. Mind-body systems of healing such as acupuncture and herbs, Ayurveda, tai chi, qigong, all promise healing benefits. What I found for myself is what I would encourage my students to do: do their research and listen to their bodies and their intuition in finding a healing system that works for them.
There are a lot of healing modalities a cancer patient can tap into, and they are healing not because they always prevent death from a particular disease (though it’s possible they may) but rather because they affirm the essential wholeness and connectedness of the person to a greater Whole. The spirit, the mind, the heart, the prana are all taken as part and parcel with the body and, in this case, the breast. While one’s medical experience may promote a sense of being sliced, diced and disempowered, yoga is one of several healing modalities that reunites the fragmented pieces into a coherent whole.
One of my favorite books on the topic of holistic healing methods is Remarkable Recovery. While they were able to identify many different factors that contributed to the “remarkable” healings cancer patients experienced, they found that variety of experience was the norm, rather than the exception. “When it comes to investigating the barely delineated realm of mind-body medicine, there is no cut-and-dried methodology. Even accomplished Tiebetan yogis…leave leeway in their colorful descriptions of how mind might affect anatomy…the variations of their description point to the fact that the meditator or adept has to find them for himself.’ In this last sentence perhaps, is one of the great secrets to unlocking the resources of the healng system: No one’s key is identical.” (Hirshberg 95-96)
While the specifics leave room for creativity and individuality, the general scientific findings on yoga and cancer are very promising.
These days, we are fortunate to have yoga classes of every type in every U.S. city, DVDs and Blueray yoga, YouTube, libraries with yoga books and video. Yoga is plentiful here, and probably the most challenging aspect of getting involved is picking between the many teachers, methods and locations while also finding a teacher who understands limitations with compassion and wisdom. A lot of the yoga Americans want to practice is the Ashtanga or Forrest-type yoga, where they’re feeling like they’re getting a “good workout,” but the cancer patient or recent survivor may feel intimidated by that level of athleticism initially and will need some patience with themselves and from their instructors in the transition period. At the very least, they need instructors who understand some of the factors at play for a post-cancer exercise program.
Yoga may have more research and more reputable research because the culture of yoga has invited that type of examination, (Vishnu-devananda 11) (Broad 37-38) but also because it’s one of the modalities that invites a standardized, repeatable effort and result. “This is because it is very difficult to measure the strength or quality of one’s prayers. Meditation studies are easier to design because you can take a group of people and lead them through concrete steps to teach them how to meditate. That does not mean that meditation is the best spiritual practice there is; it just means that it is one of the easier spiritual practices to measure. I hope in years to come, researchers will figure out better ways to measure the effects prayer has on the physical body. Until then, the spate of well-designed studies on meditation, yoga and tai chi have shown conclusively that these spiritual practices improve the health of the body (e.g., improved circulation, better sleep, stronger immune system) and the mind (e.g., less stress, more empathy).” (Turner 229)
William J. Broad has dug deeply into the research on cancer, and while there is active political influence at play to dissuade scientists from studying it further, his conclusions are compelling: “In 2011, the (National) Institutes (of Health) began a new cycle of studies, despite increasingly tight budgets. They include yoga for cancer survivors…Opponents of federal research love to disparage yoga investigations as extravagant wastes of taxpayer money. In 2005, Human Events, a conservative journal, ridiculed yoga studies as symptomatic of the ‘bloated bureaucracy syndrome.’ Such criticism is likely to grow in the years ahead as political battles heat up…” What then are Broad’s conclusions, based on his research? “A much larger investment seems wise, given that yoga’s demonstrated skills at disease prevention might result in savings of billions of dollars in traditional health-care costs. The outlay is highly leveraged, as actuaries like to say.” (Broad 219-220)
Broad’s quote touches on the political environment. It seems a disservice not to mention that in the general population and the political environment, there is some opposition and/or skepticism about yoga. I do not quote from The Death of Cancer (Vincent DeVita) in this paper, but it is an excellent resource to understand the political and economic factors at play in the allopathic cancer industry, from someone who was head of the NCI (National Cancer Institute) for 26 years. For those who have an interest in researching this bigger picture of the dynamics within the cancer care industry in the United States, this is an excellent book. DeVita was not, by any stretch of the imagination, a fringe player in the world of allopathic cancer care. Additionally, I would like to point out that GlobalCures’ (Vikas Sukhatme is the founder and is referenced in this paper in regard to inflammation and metastases) approach to off-label medication and alternatives to existing cancer patient care has recently (June 2016) been endorsed by DeVita.
Specific Adaptations for the Cancer Patient Yoga Student
Overall perspective on the cancer patient as yoga student
The following approach is a synthesis I’ve formulated based on 13 years of massage therapy, often with clients who were physically or psychologically traumatized and dealing with serious physical illness or injury; my own cancer survivorship and yoga practice; a recent (spring 2016) completion of a YMCA LiveStrong cancer survivor exercise program; and a general understanding of how to approach cancer through Yoga for Cancer and Yoga for Breast Cancer; and from my studies and experience as a life coach.
“Without discounting the knowledge of your doctors,
you know your body and mind best.
As a yoga teacher, I can guide you into the pose
with my words and hands,
but I cannot know exactly what you feel…
it’s important to…know your physical limits
and what feels right for you.”
Based upon my own background and experience, I will take the following approach for all cancer patients in my classes, at all points in the process of diagnosis, treatment and recovery:
- Let the student know that she is in control of what she tries in terms of asana and how quickly or deeply she approaches the topic of mind-body connection (not assuming anything about her needs, but making room for them, if the exist).
- Ask questions about the student’s goals for body and mind, and support her in her goals.
- Invite her to pay attention to the breath and breathe into places in the body where she feels tightness or discomfort, as well as paying attention to areas where she might explore feeling her power, groundedness, expansiveness, joy, etc. Invite her to build upon and draw from her positive experiences; invite her to hold her negative experiences with compassion and gentleness.
- Encourage her to practice equanimity throughout the class (i.e., non-judgment, non-reactivity) regarding whatever may come up.
- Let her know that all feelings are okay in my class.
Whether pre- or post-surgically, my goal as a yoga instructor has a two-pronged aspiration: to support my student’s physical well-being safely and as effectively as possible, while doing no harm in the process; and to support my student’s sense of wholeness, oneness with the Universal “One” and steadiness/peace of mind.
Yoga asana approaches pre-, during and post-treatment
Regardless of the phase of cancer treatment the student is in, it’s important to remind them that whatever their “new normal” may be, that’s where they are at that moment, and it’s okay. I began writing this paper with the thought that pre-, during and post-treatment stages would be rather obvious. However, there are overlapping categories (e.g., on-going hormonal therapies – often lasting for years; the completion of chemotherapy but the port remains installed for weeks or months). Therefore, I am going to address this as two categories, rather than three: pre-treatment and treatment and beyond. I invite the yoga instructor to use these categories as something of a continuum, not hard-and-fast categories.
First of all, regardless of whether a woman has just been diagnosed or is far into or beyond treatment, she may find herself surprised by the shift in her energy levels and recovery times needed post-exercise. The psychological blow of diagnosis and the physical blow of surgeries, chemotherapy, radiation and hormone treatments can create a “new normal” for what her energy levels will be and her recovery rate may be.
“Yoga philosophy has very practical implications for people with cancer,” offers Timothy McCall, an M.D. who writes about yoga for cancer. “Yoga encourages you to listen to messages from your body (physical, emotional and otherwise) and adjust your practice accordingly. This lesson can be extended to the rest of your life, too. If you tire after less work than you’re accustomed to, yoga would say honor that. Do less. Ask friends and family to step in to help out.” (McCall 209) This message is very important for cancer patients because they may experience massive shifts in what their bodies can tolerate, and it may take them awhile to adjust to new expectations.
McCall goes on to add that “a number of yogic practices may be helpful for people with cancer in reducing stress and managing side effects, both during chemotherapy and medical procedures and after. Although people being treated for cancer usually do not have enough strength to do vigorous asana practice, the poses can be adapted to meet almost anyone’s needs. Restorative postures and simple pranayama exercises can be both energizing and relaxing, and require almost no physical effort. Meditation and guided imagery…can be deeply relaxing and reduce anxiety.” (McCall 209)
The role of intention in the yoga practice at any phase of treatment
Regardless of the student’s treatment status, the actual cancer experience can be multi-layered, complex and overwhelming; the yoga studio is one place to practice focus on one thing at a time, for a period of time. The class becomes a meditative focus on whatever the teacher or students decide: on presence, on compassion, on grief, on letting go, on experiencing a sense of one’s wholeness or connectedness, on power, and so on. The instructor may either name an intention and weave that language into a class; or the instructor may invite the student to pick a focus and return to it with each asana, each breath.
The intentionality is part of what makes yoga a spiritual event, not just a physical one. Kelly Turner offers her perspective on why people are drawn to yoga as spiritual practice:
“I find that many people today are disillusioned
with weekly religious services that feel rote and outdated,
yet they attend them out of obligation;
meanwhile, experience-based activities
such as yoga or running are gaining in popularity.
Perhaps that is because having spiritual energy
actually course through our bodies and minds nourishes us
more than having spiritual beliefs that live only in our heads.”
Additionally, intentionality is not just about one’s head space, but also about the construction of the flow of asanas and their purpose. I would draw on principles Mark Stephens points out: if a student seems prone toward depression, avoid too many soothing asanas (he points out forward bends as one example), or anxiety (and therefore avoiding stimulating asanas, e.g., many back bends or stimulating, highly athletic yoga in the evening because of the effects this might have on ability to sleep). (Stephens 18) People, of course, can be a mixture of both, so a balance of techniques might be best in that case. It’s important to be sensitive to the student’s state of mind (which might change) and to encourage them to be aware of what they need. Hippocrates said, “Let food be thy medicine and medicine be thy food.” I would dare go out on a limb here and add, “Let exercise be thy medicine, too, and thy medicine be exercise.”
As instructors, we can support pre-surgical/pre-treatment students to focus on well-stretched, strong musculature, regardless of the reconstruction source (if they are going to reconstruct), which could be entirely local (implants placed under the pectoralis major) or it could be both local (to the breast area) and distal (from the abdomen, thigh, or upper back) in the case of “flap” reconstruction. Flap reconstruction can extend the recovery period by quite a bit, as muscle, nerve, fat and skin may all be relocated from one part of the body to the chest in order to create a breast.
Presurgery, it is easy psychologically, to experience a sense of fear and helplessness at this stage of things (pre-surgically, pre-treatment). I experienced it myself, and I have seen many cancer patients in the last year go through a very similar “dark night of the soul,” no matter where they were before the diagnosis. One can easily argue that the condition of the entire human race is that we’re dying (the only difference among us being the timing and precise cause), but we each have to face it at different times and in different settings. What happens to some of these cancer patients is something of a collapsing of the body out of helplessness and fear. For others, they may become superficially quite fierce and bristly. If the patient has any period of time before treatment, this can be a time (with doctor’s approval) when there is still no particular reason to reduce physical intensity of exercise, and the patient is most likely to benefit tremendously from the reminder of what is working in her body; to reconnect with the awareness that the body is not the enemy; that she can and should be in tune with her intuition, as well as her logical/strategic mind. The value of reducing stress through exercise cannot be overstated for this period of time.
One of the greatest challenges pre-surgically is the psychological aspect of uncertainty, as mentioned in our first section on “challenges.” During this time, it’s likely that most of a patient’s symptoms, particularly if the cancer was discovered early, is not physical but rather mental. There’s an entire section on meditation later in this paper, and that will be an important aspect of regaining mental grounding and reducing stress.
Sometimes women are encouraged to gain weight prior to surgical reconstruction in order to have enough fat for liposuction and actual relocation of fat tissue en masse. Yoga is one possible way to remain healthy while putting on additional fat, maintaining muscle tone and flexibility, in the process. For women who find the weight gain to be a challenge to their body image or self-esteem, yoga is something that can help them maintain their sense of wellbeing through that, as well.
Treatment and beyond
The precise medical picture of each patient is complex, and there are entire books written on the topic of how to adapt specific asanas to accommodate breast cancer patient needs. It’s outside the scope of this paper to go into that level of detail, but here are some of the highlights we as instructors need to keep in mind.
- It’s important that the client has received doctor’s permission to return to exercise. A breast cancer patient could cause herself harm if she returns to a practice that is too intense for her stage of recovery. One cannot assume that a doctor actually knows what’s involved with a yoga practice, unfortunately, but knowing that a patient is reasonably healed in order to resume exercise is important. In spite of the need for doctor’s permission and a need to be aware of limitations, it’s also important for the instructor to hold the yoga student with the awareness of the student’s essential wholeness and power. The patient may either be tired of being treated as being damaged or may have bought into that belief, and finding a place where her wholeness is acknowledged is something essential to her wellbeing.
- Bones: Metastases to bones, chemotherapy and induced menopause can cause early osteopaenia or osteoporosis, so caution should be observed in these cases for the amount of torque and torsion put on the pelvis and large bones of the body. Osteoporosis can occur in the arms, as well as the legs, particularly in instances of long disuse. (Kollak 41) Tumors in bones or radiation to bones may also weaken the bones and prohibit application of torque/twisting to the bones in a way that would put pressure on them. (Fein Web) Therefore, it’s important when instructing cancer patients/students to make sure they do not push their twists to the end point but rather explore a range of motion that is moderate and gentle. The student should build up exercise intensity more gradually than they might have done prior to treatments.
- Central lines and ports may require limitations of movement. These are usually in place for people who are either in active chemotherapy or who have completed chemotherapy but not yet had their lines removed. This can happen a number of weeks after the completion of chemo, so a cancer patient coming for yoga may say they have completed chemotherapy but still have this in place, so it cannot be assumed that there isn’t one. (Fein Web)
- Other yogic tools can help with pain, a frequent cancer symptom, particularly in its later stages, including relaxation, meditation, and breathing practices. The slower, deeper, more regular breathing that yoga facilitates can help you feel calmer and more energetic during the stressful period of being diagnosed with cancer and enduring treatment for it. Learning to cope with that stress can help you get through the ordeal, and may even improve the odds of survival. (McCall 209)
- After treatment is complete, the patient is faced with the challenges that happen post-surgically (e.g., scar tissue and adhesions, restricted range of motion in the shoulders from restricted use and guarding, other muscular tightness and/or weakness from immobility, fatigue, lymphedema, remote areas of healing from reconstruction, limitations to weight-bearing from sub-pectoral implants), post-chemotherapy (e.g., weakness, fatigue, bone loss, and post-radiation (e.g., lack of elasticity to the skin, weakened bones, heart, lung damage). Yoga asanas can influence the rate of healing and the ability to strength and regain flexibility with attention and gentleness.
- Of course, at any phase, the cancer patient/yoga student is faced with uncertainty and challenges to their self-image and choices in life. The yoga mat can be an excellent place to intentionally work with both the fears and the rebuilding, with the grief of losses and the return of joy and sense of personal power as she emerges into the daylight again.
- Special attention to adaptions of asanas locally (breast, chest, arms, shoulders) but also distally, depending on type of reconstruction, if any (“flap” reconstruction can involve moving tissue from the thigh, abdomen, or latissimus region of the back over to the reconstructed breast). Thus, adaptations may not just involve the pectoralis, deltoid and various arm muscles; they may need to be made for scar tissue and guarding that affect the abdominals, hip flexors, abductors and adductors, and all the muscles of the back. The teacher, in other words, needs to not have an expectation of where guarding or scarring may be an issue but should be sensitive that it could be very widespread. Additionally, it’s not always possible to gather such detailed and personal information from each student prior to a class, but the instructor can give general direction with this in mind.
- Some studies indicate that yoga may be useful in reducing needs for pain medication (McCall 6) The yoga student can be encouraged to gauge her pain prior to and after practice so she can become more conscious of using this tool for her pain management.
- Lymphedema can be an issue post-surgically and post-radiation, and yoga can help, with caution that one adapt one’s approach to holding static asanas. “As for using upright yogasanas to improve lymph circulations, repetitive motions are better than static holdings,” (e.g., it’s better not to hold downward dog for long periods of time), says Mel Robbins, who has studied and written extensively about the physiology of yoga. He adds, “However, the yoga practitioner must use caution in prescribing lymph-activating yogasanas for relief of edema in certain situations, for the lymphatic system can also be the pathway for the spread of cancer cells. As similar caution is in order for students having sinus infections, for inversions can help spread the infection to other sites.” As a former massage therapist and reasonably well-read yogi, I don’t find any evidence that exercise of any kind contributes to the metastases of cancer. This statement by Robins seems to be a simplistic/mechanistic view of how cancer spreads (and outdated). However, it makes sense, of course, to err toward the side of caution in the case of lymph-pumping movements when there is known or suspected cancer in the lymphatic system, but not to restrict exercise in general. Exercise has too much evidence for its benefits for insulin, inflammation, mood, function, strength and the immune system, all of which are critical in the case of the cancer patient. (And I will add that this is an area in which I will study more in the future.) Personally, based on my own research and interest in preventing lymphedema from occurring in my own case, I will be adding lymphatic-pumping movements and intention to my own practice, while realizing there is not yet any firm data regarding yoga’s ability to prevent lymphedema from sentinel lymph node/mastectomy surgery.
- Timothy McCall had an interesting perspective on intentionality as it relates to karma yoga, and he gave me food for thought on how to harness that for cancer patient yoga students. “Some cancer survivors, once they are in recovery and have regained their strength, find volunteer work or other forms of service (karma yoga) to be useful in providing a sense of purpose and meaning.: (McCall 209)
In personal observation and experience, I’ve seen many cancer patients go on to serve in volunteer roles in an effort to fight cancer and as cheerleaders for up-and-coming patients. It could be a useful tool for the yoga instructor to use in helping students to take on these “karma yoga” roles intentionally. This is particularly a useful and interesting exploration for breast cancer patients. Many women I’ve known, myself included, use their cancer experience as a “wake-up call” and find that they have imbalances in caretaking and ego. Some authors have even postulated (with a caution that we not be too rigid in categorizing people’s emotional contributors to disease) that there is a “Type C” personality correlation to breast cancer, just as there is often a “Type A” personality correlation to heart attacks. (Hirschberg 146-147) Inviting the cancer patient yoga student to participate in service mindfully, with the power to say “no,” when she needs to, to be supported in the process, and to contribute meaningfully to other cancer patients could be a powerfully healing process. (I have not read of anyone other than McCall mention this as an intentional tool to implement with cancer patients; it seemed a natural direction one might take his point of karma yoga.)
- As an instructor, I’m intrigued with the potential benefits of partner yoga for the cancer survivor. I have not seen any references on this topic, but after a brief experience of partner yoga in a general admission class, it seemed that partner yoga (either with one’s life partner, a good friend/caregiver, or just with another cancer survivor) could be a powerful way to restore a sense of connection with community. Feeling isolated by one’s diagnosis and the unique challenges of the psychological and physical hurdles of cancer treatment, a cancer patient could potentially find a powerful healing force here, and this is something I would explore in my classes.
- Complex emotions can continue for quite a while after physical interventions have ceased. Many people misunderstand the survivor’s experience and expect them to be relieved that the doctor’s “got it all,” for example However, what the patient may have a hard time communicating is that the oncologist’s offers of hope may very well be tinged with cautions, whether realistic or not, about the chances of recurrence. Every cancer is different, including the many subcategories of breast cancer. It’s important for the cancer patient/yoga student to find their own way through life post-cancer in a way that feels meaningful and in integrity with them. If someone is capable of a healthy dose of denial or compartmentalization, then as an instructor, I’m not going to be the one to attempt pierce that, and I will make a space in which a student may explore more difficult emotions as she is ready. However, if someone is actively dealing with anxiety, then calming poses, breathwork and meditation can be profoundly stabilizing therapies. The key for the instructor is to set a stage where whatever arises is okay; and to work with the yoga student’s agenda, not the instructor’s.
Pranayama for All Cancer Patient Yoga Students
In response to the challenges of trauma, anxiety and grief, Jayan Landry is one of the therapists whose work I draw upon personally, and I would suggest incorporating one of her favaorite tools – ujjayi (“ocean-sounding”) breathing – as part of pranayama for all cancer patients. Not only may it be used in the yoga classroom but also strategically throughout the day, any time anxiety or trauma arise. Landry describes ujjayi breathing in the following way:
“Inhale through your nose, filling up your lower abdomen, chest, and back, and then exhale through the back of your throat with your mouth open, making the sound ‘heeeeer.’ This stimulates the top of the tenth cranial nerve, which lowers heart and respiratory rate eliciting the parasympathetic branch two calms you down side. Use this anytime you need to feel calm.” She adds the caveat, “Some people describe feeling lighter or even lightheaded initially. If this is true for you, do not do this exercise while driving or operating machinery…” (Landry 61)
Tari Prinster has a great point about the power of simple breath movements, so simple that before cancer we might have scoffed at how powerful and important they could possibly be: “The thoracic duct is the main detention center of the lymphatic system. It runs parallel to and is nestled close to the spinal column from the top of the lumbar spine…to the base of the neck…,” she begins. “Why do we care? Because the location and function of this duct along its narrow, long, vertical path is in constant contact with the movement of the horizontal diaphragm muscle, which is massaged by the action of breathing. This knowledge reveals a little secret and creates magic to aid recovery and maintain lifelong health for everyone, not only for the cancer patient and survivor. “ (Prinsler 39). I think that’s one of the things I love most about yoga (and arts like it, including meditation): there is magic in the smallest things we can do for ourselves. This is great to know and practice in day-to-day life. It’s akin to a superpower when we’re in the pit of cancer diagnosis and treatment to know that our pranayama or meditation can be potent self-healing tools. They serve as timely focii for any stage of diagnosis, treatment or maintenance.
Meditation for the Cancer Patient Yoga Student
We’ve already looked at symptoms and the effects of yoga, meditation and pranayama on them. However, I would also like to address meditation (and yoga as moving meditation) as one way not only to combat dis-ease but also as a way to cultivate wellbeing.
Betty Edwards is one of the writers who helps her art students (primarily those who begin with little-to-no art background) make the shift from left brain to right brain activity. It’s essential to shift to right brain in order to “see” for the purpose of art. Edwards has a very clear way of describing the difference: “The left hemisphere analyzes, abstracts, counts, marks time, plans step-by-step procedures, verbalizes, makes rational statements based on logic…the analytical, verbal, figuring-out-sequential, symbolic, linear, objective mode.” (Edwards 35) Of course, we need these abilities to function well in life, for everything as simple as creating a grocery list, to being on time to pick up our children from the bus stop, to building skyscrapers. We need the linear part of our brains.
However, this part of the brain can go into overdrive during the cancer diagnosis, treatment and survivorship times of a cancer patient’s experience. What does the cancer patient do when dozens of options lie before them? What does the cancer patient do when she has to wait? What does the cancer patient do when the “right” path is ambiguous?
As a meditation instructor, I draw quite a bit on right brain/left brain as ways to help students demystify the shift that happens in consciousness during meditation (including moving meditation, such as in yoga practice). First, let’s define right brain with Edwards’ words: “[W]e have a second way of knowing: the right-hemisphere mode. We ‘see’ things in this mode that may be imaginary – existing only in the mind’s eye – or recall things that may be real (can you image your front door, for example?). We see how things exist in space and how the parts go together to make up the whole. Using the right hemisphere, we understand metaphors, we dream, we create new combinations of ideas. When something is too complex to describe, we can make gestures to communicate.” (Edwards 35). I would add that right-hemisphere is also aware of body sensation, connection to the fabric of existence, and loses track of time. (Salleh Web)
I offer my meditation students some indicators they can use to know if their left brains are “over functioning” at any particular moment, rather than being useful:
- Is the thought original or repetitive? If a thought is repetitive, and there is no new information to add to the cognitive process, it may be a good time to drop into right-hemisphere awareness.
- Is the thought anxiety-producing, with no clear action that can be taken? A little anxiety can be a good thing if there’s direct action we should be taking and are avoiding (e.g., the patient should go for a follow-up exam because she found a new lump, but she’s afraid to go; the anxiety is actually giving the patient the signal to take constructive action here, and to suppress the anxiety is a misguided effort, until the appointment is made or the patient has a clear plan to make the appointment). However, once all concrete action has been taken or at least planned and avoidance of important action has been eliminated, the anxiety is not useful. It’s a good indicator to drop into right-hemisphere awareness.
- Is it boring? This one can apply to cancer patients who get “stuck” in chemotherapy appointments, diagnostic procedures that require long periods of stillness, waiting in doctor’s offices, or simply being too fatigued to do much that is usually interesting and stimulating. Meditation is an underrated “thing” to do that has a great deal of constructive benefit and literally has almost no limits to when and how one can use it. (I point out to my meditation students that left brain quickly becomes bored by the things that right brain can use – like following the breath or noticing sensation or repetitive movements. To the left brain, one breath or action is the same as the next. To right brain, each one is new and different and interesting. So boredom can be a sign that left brain is ready to “check out” and let the right brain have some fun!)
For all of these reasons, the cancer patient yoga student may find the meditative aspects of either specific seated (or lying) meditation practice and more generally applied moving meditation of yoga asana to be particularly healing for the mind. Left brain activities, if not productive, can contribute to anxiety and distress. Right brain activities help the student to access a sense of wholeness, connection, peace, creativity and intuition, regardless of the circumstances she faces in her life. She may access meditation and its benefits through an attempt to deal with a particularly odious symptom; she will find, however, that many aspects of life begin to feel better when using meditative, right-hemisphere perception.
A book I found particularly helpful for doing some of this work post-treatment was Martha Becks’ Finding Your Way in a Wild New World, and it’s one I would highly recommend to my yoga students who are looking to find ways to apply meditative awareness to their daily lives and decision-making processes.
A large number of meditations is available for step-by-step relaxation on the Internet, in books, on CDs. Our own Aura Wellness meditation CD has an example; James Hewitt’s book Complete Yoga Book goes into a detailed description of this type of meditation. For the cancer patient yoga student, learning these meditations and self-application at bedtime (and other quiet moments) can be an extremely helpful way to ease a particularly distressing symptom (i.e., insomnia).
Additionally, for the cancer patient who may wish to dive deeply into meditation practice but either does not have the money or easy access to it, there is a free MBSR (Mindfulness-Based Stress Reduction) course online. MBSR has excellent research to show benefits to cancer patients (Brown Web); while MBSR typically costs several hundred dollars and requires significant time commitment over 12 weeks, there is one course of which I’m aware online available at no cost by a certified MBSR instructor. I have reviewed it myself and found it to be an excellent resource: http://palousemindfulness.com/.
For the cancer patient who is particularly expressing fear of death and is willing to explore this, there is a meditation practice that may be helpful. I daresay that a focus on or even discussion of death itself is not particularly socially acceptable in our culture, so some sensitivity is needed here. However, there can be tremendous power in making peace with the thing that frightens us.
The fear of death is a form of meditation practices by many Buddhists. (https://en.wikipedia.org/wiki/Tantra_techniques_(Vajrayana) – aka, “Death Yoga”). My own cancer diagnosis in the spring of 2015 became a 9-month meditation on my own death that led me back to yoga and to a deeply healing meditation practice.
There’s one other reading resource I would recommend for those with a fear of death: Anita Moorjhani’s Dying to be Me. She had very advanced cancer and was actively dying of multiple organ failure, and her “end of life” story offers a mystical perspective that can give the cancer patient/yogini a different and inspiring perspective on life and death.
For the yoga student who is looking for more she can do outside the yoga studio, she may be encouraged to keep a journal of her goals, what works for her, results, and an action plan for the future. (Kollak 20-21)
Yoga Instructor Boundaries and Self-Care
Cancer is an emotionally charged subject. According to the American Cancer Society, 1 in 8 (12%) of U.S. women will get breast cancer, so it’s the rare person who doesn’t know someone who has cancer, know someone who has died from cancer, or had cancer themselves. As an instructor, there are some specific cautions I need to keep in mind as I work with cancer patients.
- As the instructor, it’s my job, not my student’s, to hold my emotional reaction to their cancer. This means that whatever fears, anxieties, propensities toward collapsing/helplessness, depression, grief (etc.), anger, denial, empowerment, optimism or pessimism may come up for me around cancer, meaning-making, looking for metaphors or mind-body cause and effect, I’m in a professional role with the student, and their experience is the focus of our class time together. This doesn’t mean I can’t share with them from my own experience, but this is not the time or place for sharing raw, unprocessed emotion, for leaning on them for a listening ear, or for pushing them in the direction I feel most comfortable with them going. My own meditation practice, journaling and yoga practice are places where I can (and I would say must) do my own spiritual and psychological work so that when I come to the mat to teach, I’m teaching from my lived reality. When I’m teaching, that background work needs to be done before I go to try to teach, and my focus, during class, is on a non-judging, non pre-judging of what the student’s experience is. They may have emotions that are quite contrary to what I think they will be, and I need to be cautious about how I project my own feelings onto them.
- Keep my unsolicited advice to myself; deliver solicited advice cautiously. It’s a deeply ingrained part of the American culture that we need to do something in response to a perceived threat. In this case, that threat is cancer. We want to tell someone what they should do, not only because we care but because we, too, are afraid of what might happen if they don’t. It may or may not be based on our advanced research and professional study as doctors, nurses, physical therapists, nutritionists, psychotherapists and so on. We have to be cautious in terms of stepping outside our scope of practice. For example, unless I’m a nutritionist, I ought not to be giving nutritional advice. I may, however, have a good nutritionist I trust in my contacts to share with students; I may also recommend books I’ve found helpful. Unless one has either been a cancer patient or worked closely with one, one may not realize that the cancer patient in inundated with information on a daily basis. “You have to take turmeric!” one friend will say on FaceBook. “You need to eat vegan/ketogenic/vegetarian!” others will say. From personal experience, I will say that many people who loved me had no filters on speaking from their deep fear that I would die if I did not do what they were recommending. That’s a heavy burden for the cancer patient to bear. As yoga instructors, we need to be particularly aware of our “professional” tendency to speak out of our own fears, even if the intention is to be loving. We need to raise the bar on what “loving” means and truly offer our clients an open, non-judging environment in which to explore their bodies and minds. Our clients are particularly vulnerable and possibly even desperate. It’s important to be aware of our professional responsibility to 1) only speak from our professional training in terms of medical advice; 2) share from personal experience sparingly; 3) ask the student in-depth questions about what she has tried; what her values are; what her resources are (does she have the money for the expensive supplements I’m recommending? Does she have the time/energy for the type of exercise or treatment options I’m telling her about? Am I adding to her burden or relieving it by suggesting things she is not able or interested in doing?) Even if one does have other training/licensure, it’s important to note what context the cancer patient approached the instructor. For example, if one is a doctor who also happens to be a yoga instructor, whether the student came to the instructor first as their doctor or as their yoga instructor should give some bearing to what advice is proffered. I hate to add the “L” word here, but if something goes wrong, I am then open to litigation in addition to simply being out-of-line.
- Trust in the power of simple practices. We are not lacking for information in our age; we are lacking for practice. We are used to the model of learning that says if you didn’t walk away from a weekend seminar with a 500-page manual to memorize and implement, you didn’t get your money’s worth. However, in the realm of mind-body health and wellbeing, we’re going deep with a simple principle, something as simple as following the breath, as breathing into our pain, or as one intention to our hour on the mat. The more we as yoga instructors can experience and trust that power, the less we’ll need to talk to convince our students that what they’re doing is useful or to inundate them with our advice or opinions. We will know experientially from our own practices that their practice will lead them where they need to go. Aminah Raheem is a psychotherapist who also works with bodyworkers and energy workers of many disciplines and teaches them about their own state of energy and how that affects the client. She talks about entrainment, where the provider’s energy helps to shift the energy of the recipient/student. “The therapist’s energy system directly affects the state of the client…If the therapist’s energy systems are reasonably balanced and strong they will have a health-supporting effect on the client. But if they are seriously imbalanced or weak, the session can be diminished.” (Raheem 186) The more experienced yoga instructor will have gained some trust for a “less-is-more” approach to their own contributions to the student’s experience; will know that their own cultivated Presence is more important than advice or too many interventions; that one simple, targeted practice for the student may be far more powerful than a laundry list of lifestyle changes; that one small adjustment in class or one word may be ample to meet the student’s needs.
Yoga is a proven way to improve the cancer patient’s outcomes; it is also a proven way to improve quality of life. There is still plenty of room for research, however, and the yoga community and cancer patients can only benefit from more work on that front. On a deep level, yoga can serve as the laboratory for exploring the causes of one’s discomforts, identifying the healing means one will employ for addressing them, and for finding meaning and one’s place in the universe. Yoga is potent medicine. Instructors have the ability to be a powerful force for healing in their students’ lives, and should take caution in how they apply this medicine. The student can, if they wish, open up their hearts, minds and bodies in profound ways on the mat; it is the teacher’s responsibility to act with restraint, with loving intention, and with wisdom to that openness. With that respectful care, the yoga student with a cancer diagnosis can blossom.
Alfonso, RF (primary investigator) et. al. Menopause 2016 May;23(5):584-6. doi: 10.1097/GME.0000000000000593: Yoga increased serum estrogen levels in postmenopausal women-a case report. http://www.ncbi.nlm.nih.gov/pubmed/26926324. Web.
Beck, Martha. Finding Your Way in a Wild New World. New York: Atria Books, 2013. Print.
Bower, Julienne E. (primary investigator), et. al. Yoga reduces inflammatory signaling in fatigued breast cancer survivors: A randomized controlled trial Psychoneuroendocrinology 2014 May; 43: 20–29.
Published online 2014 Jan 30. doi: 10.1016/j.psyneuen.2014.01.019. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4060606/. Web.
Broad, William J. The Science of Yoga: The Risks and the Rewards. New York: Simon & Schuster, 2012. Print.
Brown, Eugene and Lora Williams. Powerful mind-body practices that can help control stress. Global-Cures. Spring 2016. Web. https://www.global-cures.org/blog/powerful-mind-body-practices-can-help-control-stress.
Buffart, LM (primary investigator) et. al. Physical and psychosocial benefits of yoga in cancer patients and survivors, a systematic review and meta-analysis of randomized controlled trials. BMC Cancer. 2012 Nov 27;12:559. doi: 10.1186/1471-2407-12-559. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4482438/. Web.
Cori, Jasmin. Healing from Trauma: A survivor’s guide to understanding your symptoms and reclaiming your life. Cambridge, MA: Marlowe & Company, 2008. Print.
Edwards, Betty. Drawing on the Right Side of the Brain. New York: The Putnam Publishing Group, 1989. Print.
Fein, Ellen. The Yoga Therapist and Cancer Care Special Cautions. (http://sequencewiz.org/2015/07/24/the-yoga-therapist-and-cancer-care-special-cautions/). Web.
Forget, P. (primary investigator), et. al. Do intraoperative analgesics influence breast cancer recurrence after mastectomy? A retrospective analysis. Anesth Analg, 2010 Jun 1. http://www.ncbi.nlm.nih.gov/pubmed/20435950. Web.
Geffen, Jeremy. The Journey Through Cancer: Healing and Transforming the Whole Person. New York: Three Rivers Press, 2006. Print.
Hirshberg, Caryle and Marc Ian Barasc. Remarkable Recovery: What extraordinary healings tell us about getting well and staying well. New York: Riverhead Books, 1995. Print.
Holger, Cramer (primary investigator) et. al. Yoga for breast cancer patients and survivors: a systematic review and meta-analysis. BMC Cancer. 2012; 12: 412. Published online 2012 Sep 18. doi: 10.1186/1471-2407-12-412. Web.
Kollak, Ingrid and Isabell Utz-Billing. Yoga and Breast Cancer: A journey to health and healing. New York: Demos Medical Publishing, 2011. Print.
Landry, Jayan Marie. Healing Emotional Trauma: Practical Pathways to Decrease Anxiety, Anger, and Lower Blood Pressure. Bloomington, Indiana: Balboa Press, 2015. Print.
Lutengorf, SK (primary investigator), et. al. Journal of Clinical Oncology 2010 Sep 10;28(26):4094-9. doi: 10.1200/JCO.2009.26.9357. Epub 2010 Jul 19 http://www.ncbi.nlm.nih.gov/pubmed/20644093. Web.
McCall, Timothy. Yoga As Medicine: the Yogic prescription for health and healing. New York: Bantam, 2007. Print.
Mclaughlin, Sarah A. Oncology: Lymphedema: Separating Fact from Fiction (Review Article). March 15, 2012. Web. (http://www.cancernetwork.com/cancer-complications/lymphedema-separating-fact-fiction)
Prinster, Tari. Yoga for Cancer: A guide to managing side effects, boosting immunity and improving recovery for cancer survivors. Rochester, Vermont: Healing Arts Press, 2014. Print.
Raheem, Ameenah. Soul Return: Integrating Body, Psyche & Spirit (Third Edition). Fairfield, Connecticut: Aslan Publishing, 2000. Print.
Robin, Mel. A Physiological Handbook for Teachers of Yogasana. Tucson: Fenestra Books, 2002. Print.
Salleh, Anna. Self-Awareness is in the Right Brain. January 19, 2001. Web. (http://www.abc.net.au/science/articles/2001/01/19/235077.htm)
Seaman, Andrew. Chicago Tribune: Some cancer docs say their income tied to treatments. December 26, 2012. Web.
Siddiqui, Mustageem and S. Vincent Raikumar. The High Cost of Cancer Drugs and What We Can Do About It. Mayo Clin Proc. 2012 Oct; 87(10): 935–943 doi: 10.1016/j.mayocp.2012.07.007 (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3538397/). Web.
Smith, Fritz. Inner Bridges: A guide to energy movement and body structure. Atlanta: Humanics New Age, 1998. Print.
Stephens, Mark. Yoga Sequencing: Designing Transformative Yoga Classes. Berkley, California: North Atlantic Books, 2012. Print.
Sukhatme, Vikas. https://www.youtube.com/watch?v=H8zVrYEW8vE. Presentation at MIT Laboratory for Financial Engineering, December 8, 2015. Web. https://www.global-cures.org/research/preoperative-ketorolac-prevent-recurrence-lung-cancer-patients-operable-disease (Web)
Turner, Kelly A. Radical Remission: Surviving Cancer Against All Odds. New York: Harper Collins, 2014. Print.
Ubel, Peter. Psychology Today: Who Pays Your Doctor? May 30, 2012.
Vishnu-devananda, Swami. The Complete Illustrated Book of Yoga. New York, Random House, 1988. Print.