The Effect of Yoga on Cancer-Related Fatigue and Quality of Life Among Racially and Ethnically Diverse Cancer Survivors: A Secondary Data Analysis

Abstract

Introduction:

Survivors from racially and ethnically diverse backgrounds tend to experience cancer-related fatigue (CRF) at higher rates than non-Hispanic Whites (NHWs), often leading to a decline in quality of life (QOL). It is crucial to consider the impact their marginalized identities have on cancer outcomes. Although yoga has shown promise as a supportive intervention for CRF and QOL, existing research has largely centered on NHW populations. This study seeks to evaluate the impact of yoga on CRF and QOL among racially and ethnically diverse survivors and compare outcomes with NHW survivors.

Methods:

This study used data from two randomized controlled trials (RCTs; n = 1,153) examining a 4-week Yoga for Cancer Survivors (YOCAS) intervention designed to address insomnia in survivors. YOCAS integrates elements of gentle Hatha and Restorative Yoga, featuring breathing techniques, mindful movement, and posture alignment, for 150 min each week for 4 weeks. Survivors were eligible if they (1) were age 21+, (2) were randomized to YOCAS^©®, (3) identified as Hispanic or a non-Hispanic person of color, and (4) provided evaluable data on the Functional Assessment for Chronic Illness Therapy-Fatigue and Functional Assessment for Cancer Therapy-General at pre- and postintervention.

Results:

Forty-nine participants were eligible (mean age = 53; 96% female; 79% stage 0–II cancer; 74% breast cancer). Participants reported nonclinically meaningful improvements in overall CRF improvement (1.55, standard deviation [SD] = 14.67, p < 0.061), total QOL (3.04, SD = 0.055, p < 0.055), the emotional component of QOL (0.85, SD = 6.3, p < 0.061), and significant improvements in the physical component of QOL (1.32, SD = 7.0, p < 0.035). Session attendance averaged six out of eight sessions. Participants also engaged in an additional self-guided yoga practice at home each week. Most (86%) participants expressed that the program was beneficial in managing symptoms and indicated they would suggest it to survivors.

Discussion:

Findings suggest: (1) YOCAS^©® has the potential to alleviate fatigue and enhance QOL in racially and ethnically diverse survivors; (2) while participation rates remain modest, there is openness to yoga; and (3) diverse survivors are capable of completing a 4-week yoga program, report it as useful for controlling symptoms, and are likely to suggest it to survivors. Future research should include well-powered RCTs to verify YOCAS^©®’s effects on CRF and QOL in these populations.

Background

Cancer-related fatigue (CRF) remains a pervasive consequence of cancer and cancer therapeutics, frequently identified by survivors as a primary factor that impairs daily functioning and diminishes the quality of life (QOL).^1

–5 Even so, CRF often goes unrecognized and inadequately managed in clinical settings.^6

–9 According to the National Comprehensive Cancer Network (NCCN), CRF is characterized as an ongoing feeling of tiredness—physically, emotionally, or mentally—that arises from cancer and its treatments. This type of fatigue is disproportionate to a person’s recent levels of physical output and disrupts their ability to function in daily life.¹⁰ CRF is also known to co-occur with other symptoms such as pain, sleep difficulties, and emotional disorders.^11,12 Importantly, over 33% of cancer survivors remain affected by CRF long after completing cancer treatment.^13

–16

Much of the research surrounding cancer disparities has examined marginalized identities in isolation, rather than considering their overlapping or intersecting identities.¹⁷ The framework of intersectionality, developed by Kimberlé Crenshaw,¹⁸ highlights how overlapping social identities create unique systems of oppression (e.g., via marginalized identities such as people with disabilities, low-income individuals, and people of color) and privilege (e.g., via power identities such as white individuals, cisgender, and higher socioeconomic status). It emphasizes the need to understand and address the interconnected nature of these identities to fully capture the experiences of marginalized individuals and how they impact health outcomes.^19,20 These intersecting identities often lead patients to experience barriers in cancer care, impacting every stage of the cancer cycle and affecting access to early detection, timely diagnosis, treatment decisions, and ongoing survivorship support.^17,21
–23 A siloed research approach may lead to less patient-centered care and falls short of addressing the complex experiences of cancer survivors with multiple marginalized identities. Understanding how these intersecting identities contribute to disparities in cancer care is essential, especially given their role in shaping the frequency and intensity of cancer and cancer treatment-related symptoms among diverse survivors.

Cancer survivors of racial and ethnic backgrounds report more severe CRF compared with non-Hispanic Whites (NHWs).^24
–26 In general, these survivors encounter unique sociocultural stressors that increase CRF risk. This includes poverty,^27

–33 discrimination,^34

–40 acculturation challenges,^41

–46 and language barriers.^47

–50 Racially and ethnically diverse cancer survivors have a higher likelihood of being diagnosed with late-stage cancer and tend to experience prolonged delays before receiving a diagnosis and beginning treatment.^25,26 This can lead to more aggressive cancer treatments,⁵¹ resulting in more severe side effect burdens such as CRF.^51
–53 In addition, Hispanic and Black females are more likely than NHW females to receive a triple-negative breast cancer diagnosis, an especially aggressive breast cancer subtype with limited treatment options.⁵⁴ Despite efforts to address these disparities, racial and ethnic cancer survivors continue to be disproportionately impacted by the negative side effects associated with cancer and oncology therapies.⁵⁵

Managing CRF remains a challenge, as no standard of care currently exists. A range of strategies are available, including (1) pharmacological approaches such as stimulants or treatments targeting underlying contributors such as anemia, mood disturbances, and sleep disruption; (2) exercise-based interventions, which are supported by clinical guidelines but frequently underutilized in survivorship care planning; (3) rehabilitative modalities including massage; (4) cognitive and behavioral techniques; and (5) alternate options such as exposure to bright white light.^7,56

–59 Despite these options, consensus on a definitive first-line treatment for CRF has yet to be established.

Evidence suggests that yoga may be an effective supportive intervention for alleviating CRF and enhancing QOL.⁶⁰ The NCCN and the Society for Integrative Oncology, working jointly with the American Society of Clinical Oncology, have issued guidelines recommending yoga as a supportive intervention for managing CRF.^10,61 Nevertheless, most of this research has focused on NHW cancer survivors. Racially and ethnically diverse survivors are also less likely to engage in yoga⁶² for reasons including (1) not culturally identifying with yoga the way it is seen and available in mainstream culture, (2) a lack of investigators coming to their community to talk about yoga, (3) a lack of access and availability, and (4) a fear of injury, among others.^63,64 Limited yoga research has included racial and ethnic individuals. In one pilot randomized controlled trial (RCT) with African Americans, yoga participants reported lower depression scores than control participants.⁶² In another RCT, Latino youth in the yoga arm reported lower depression symptoms and less anxiety compared with control participants.⁶⁵

Our team conducted two nationwide, multicenter RCTs evaluating a 4-week structured yoga program aimed at improving sleep disturbances and insomnia in individuals who have completed primary cancer treatment.^60,66 Building on this prior research, the present secondary analysis investigated whether yoga improved CRF and QOL among racially and ethnically diverse participants enrolled in our two large parent RCTs.

Materials and Methods

Design

This analysis draws on two RCTs focused on the Yoga for Cancer Survivors (YOCAS^©®) program. These trials were conducted by the University of Rochester Cancer Center (URCC) NCI Community Oncology Research Program (NCORP) Research Base. Upon registration, subjects in the first parent trial (NCT00397930) were assigned at random to one of two groups: (1) a 4-week YOCAS^©® intervention or (2) usual cancer survivorship care. Participants in the second parent trial (NCT02613364) were assigned at random to one of three study groups: (1) a 4 week YOCAS^©® intervention, (2) a standard cognitive-behavioral therapy insomnia, or (3) an educational health program designed to match YOCAS^©® in duration and attention. Because only the YOCAS^©® arm is the same in both parent trials, here we report results from racial and ethnic participants enrolled in the YOCAS^©® arm in both trials. Findings related to the main outcome—sleep quality—and additional secondary outcomes, including pain, CRF, and cognitive function, have been reported in earlier publications.^{60,66

–70} This study followed the CLARIFY-21 guidelines for reporting yoga research.⁷¹

Study participants

Between 2007 and 2020, participants were recruited from 19 community cancer clinics affiliated with the NCORP network across the United States. To participate in the two RCTs, individuals had to meet the following criteria: (1) have a clinical cancer diagnosis; (2) completion of primary cancer treatment 2 to 60 months prior to enrollment (i.e., surgery, chemotherapy, and/or radiation), (3) indicate experiencing sleep difficulties (reflected by a score of 3 or higher on an 11-point scale [a score of 0 = no sleep difficulties and a score of 10 = extreme sleep difficulties]); (4) proficiency in reading English; (5) age 21 or older; (6) provision of signed informed consent; (7) no consistent yoga practice within the last 3 months and no plans to begin during the study period; (8) no clinical diagnosis of sleep apnea; (9) no current cancer treatment aside from hormonal or biological therapy; and (10) no distant metastases. All participants provided written informed consent.

For this present analysis, participants were eligible if they (1) were enrolled in one of these two parent YOCAS^©® trials, (2) self-identified as Hispanic of any race or non-Hispanic and non-White, (3) have provided evaluable data on the FACIT-F and FACT-G at the baseline and the follow-up assessment, and (4) assigned to the yoga arm. Human subjects’ ethical approval for both studies was provided by the institutional review boards at all participating NCORP oncology sites.

YOCAS^©® yoga intervention

The yoga intervention implemented in the study was based on our manualized YOCAS^©® program, a mild to moderate intensity style of exercise that includes gentle Hatha and Restorative yoga, foundational practices within many contemporary yoga forms.^72

–75 It integrates mindful movement, breath control, and meditative focus, utilizing a combination of active and passive postures to engage the musculoskeletal system.^72,73 The YOCAS^©® intervention includes 16 physical poses (asanas), alongside breathing techniques (pranayama) and meditation practices (dhyana). Participants attended eight 75-min sessions over 4 weeks, with sessions held twice weekly. These group classes, consisting of approximately 20 to 30 individuals, took place in community-based environments such as wellness centers, cancer clinics, support organizations, and yoga venues. All registered yoga instructors have completed a minimum of 200 h of training. YOCAS^©® instructors provided visual demonstration, verbal guidance, and adjustments (with participant permission). Asanas were given with modifications (i.e., seated position) to address multiple levels of experience. Each participant was also provided with a yoga kit that included essential items such as a mat, blocks, a strap, a duffel bag, an instructional DVD, and a manual to support self-guided home practice. Individuals enrolled were encouraged to use these materials at home without a prescribed frequency or duration.

Fidelity, quality, and drift

To ensure consistent delivery and uphold the integrity of the intervention across all sites, yoga instructors participated in a uniform training program and were provided with a detailed YOCAS^©® teaching manual and DVD. In addition, a designated coordinator at all NCORP sites completed this training and conducted unannounced observations of sessions to verify accurate delivery.

Measures

Participant demographic and medical characteristics were obtained from their electronic health records (e.g., cancer type, cancer stage, treatment history). Race and ethnic classification followed the NCI Cancer Therapy Evaluation Program guidelines for clinical trial reporting. For analytic purposes, racial categories were consolidated into three groups: White, African American, and Other. The “Other” group encompassed individuals identifying as Native Hawaiian or other Pacific Islander, Asian, American Indian, or Alaska Native, and those with an unspecified race.

The intensity of the yoga sessions was assessed through participants’ self-reported effort using the American College of Sports Medicine rating of perceived exertion scale (RPE). During the 4-week intervention, participants were encouraged to maintain their usual daily routines but were instructed to refrain from beginning any new yoga or exercise program to prevent interference with study outcomes.

Cancer-related fatigue

Levels of CRF were evaluated at baseline and immediately after the intervention using the validated FACIT-F scale, a 13-item questionnaire designed to assess fatigue as experienced during daily life over the prior week.⁷⁶ Each item is rated on a 5-point Likert scale, ranging from 0 (“Not at all”) to 4 (“Very much”), resulting in a total score range between 0 and 52. Higher scores reflect lower levels of fatigue (α = 0.86). A score change of 3 to 5 points on this scale is considered clinically meaningful for cancer patients.⁷⁷ In addition, we presented the proportion of participants who experienced a clinically meaningful improvement in CRF using two clinically meaningful thresholds: a lower bound defined as a score increase of 3 or more points, and an upper bound defined as a score increase of 5 or more points.

Quality of life

Participants’ QOL was evaluated at baseline and immediately after the intervention with the validated FACT-G,⁷⁸ a 27-item tool that yields a global QOL score along with subscale scores in four domains: physical, functional, social/family, and emotional well-being. All items are rated on a 5-point Likert scale from (0 = Not at all and 4 = Very much). Subscale scores for physical, social/family, and functional well-being range from 0 to 28, while the emotional well-being score ranges from 0 to 24. Higher scores indicate better well-being. The total QOL score can range from 0 to 108, with higher scores denoting improved QOL (α = 0.90).⁷⁹ A difference of 5 to 7 points on the total score and 2–3 points in subscales scores may represent clinically meaningful differences.⁸⁰ We also presented the proportion of participants who experienced a clinically meaningful improvement in total QOL using two clinically meaningful thresholds: a lower bound defined as a score increase of 5 or more points and an upper bound defined as a score increase of 7 or more points. For the FACT-G subscales, we presented the proportion of participants who experienced a clinically meaningful improvement, using two clinically meaningful thresholds: a lower bound defined as a score increase of 2 or more points, and an upper bound defined as a score increase of 3 or more points.

Adherence and compliance

These were examined via self-reported daily logs and yoga session attendance records collected by yoga instructors. Instructors reminded participants of their next session at the end of each class.

Safety

The URCC Data Safety Monitoring Committee oversaw the surveillance of adverse events (AEs) throughout the study. AEs were scored using the NCI’s Common Terminology Criteria for AEs (CTCAE).⁸¹ Scores ranged in severity from 1 (mild), 2 (moderate), 3 (severe), 4 (life-threatening), and 5 (death). Any AEs of any severity level were formally documented and reported.

Feedback survey

An end-of-study survey was administered to gauge participants’ perceived helpfulness of the YOCAS^©® intervention and their likelihood of recommending it to other survivors.

Statistical analyses

Descriptive statistics of participant demographics and characteristics were calculated. To evaluate changes in CRF and QOL within the intervention group, two-sided paired t tests were employed. All analyses were carried out with R software (version 4.2.1).

Results

Participant characteristics

Out of 1,153 participants enrolled in both parent trials, n = 62 racially and ethnically diverse participants enrolled in the yoga arm. Thirteen participants did not complete follow-up assessments (i.e., 6 = personal circumstances, 7 = not specified). Of the remaining 49 participants, 61.2% were Black/African American, 25.5% were Hispanic, and 16.3% were Other Non-White. Most participants (77.5%) reported having two or more marginalized identities, the most common being racial/ethnic minority and female (95.9%). All Hispanic participants self-reported White as their race. The majority of participants had a breast cancer diagnosis (73.5%), and 40.5% had stage I cancer (Table 1). Table 1 also compares the characteristics of racially and ethnically diverse survivors with NHW survivors. Racially and ethnically diverse survivors were significantly more likely to be younger and single. Racially and ethnically diverse survivors reported notably worse baseline scores in total QOL and physical, emotional, and functional QOL compared with NHW survivors. However, attrition rates among these participants did not differ significantly from those of NHW participants.

Table 1.

Demographics and Characteristics of Racially and Ethnically Diverse Survivors and White, Non-Hispanic Survivors Enrolled in Yoga Arm

Characteristics	Racially and ethnically diverse survivors (n = 49)	White, non-Hispanic survivors (n = 312)	Total (n = 361)	p value
Age, mean years ± SD	52.5 (11.3)	56.0 (10.7)	55.5 (10.8)	0.034
Age, n (%)				0.240
≤65 years old	43 (87.8%)	252 (80.8%)	295 (81.7%)
>65 years old	6 (12.2%)	60 (19.2%)	66 (18.3%)
Sex, n (%)				0.577
Female	47 (95.9%)	293 (93.9%)	340 (94.2%)
Male	2 (4.1%)	19 (6.1%)	21 (5.8%)
Relationship status, n (%)				0.019
Long-term relationship	26 (53.1%)	218 (69.9%)	244 (67.6%)
Single	23 (46.9%)	94 (30.1%)	117 (32.4%)
Race/ethnicity, n (%)				<0.001
Black/African American	30 (61.2%)	0 (0.0%)	30 (8.3%)
Other	8 (16.3%)	0 (0.0%)	8 (2.2%)
White	11 (22.4%)	312 (100.0%)	323 (89.5%)
Ethnicity				<0.001
Hispanic	12 (25.5%)	0 (0.0%)	12 (3.3%)
Non-Hispanic	35 (74.5%)	312 (100.0%)	347 (96.7%)
Missing data	2	0	2
Education, n (%)				0.072
More than high school	37 (75.5%)	267 (85.6%)	304 (84.2%)
High school or less	12 (24.5%)	45 (14.4%)	57 (15.8%)
Cancer type, %				0.800
Breast	36 (73.5%)	234 (75.0%)	270 (74.8%)
Hematological	3 (6.1%)	19 (6.1%)	22 (6.1%)
Alimentary	3 (6.1%)	13 (4.2%)	16 (4.4%)
Gynecological	4 (8.2%)	16 (5.1%)	20 (5.5%)
Other	3 (6.1%)	30 (9.6%)	33 (9.1%)
Cancer stage, %
Stage 0	0 (0.0%)	14 (6.2%)	14 (5.3%)	0.554
Stage I	17 (40.5%)	89 (39.7%)	106 (39.8%)
Stage II	16 (38.1%)	72 (32.1%)	88 (33.1%)
Stage III	8 (19.0%)	43 (19.2%)	51 (19.2%)
Stage IV*	1 (2.4%)	6 (2.7%)	7 (2.6%)
Unknown	7 (12.8%)	88 (28.2%)	95 (26.3%
Previous surgery				0.853
No	4 (8.2%)	28 (9.0%)	32 (8.9%)
Yes	45 (91.8%)	284 (91.0%)	329 (91.1%)
Previous chemotherapy				0.141
N-Miss	0	1	1
No	14 (28.6%)	123 (39.5%)	137 (38.1%)
Yes	35 (71.4%)	188 (60.5%)	223 (61.9%)
Previous radiation therapy				0.098
N-Miss	0	1	1
No	22 (44.9%)	102 (32.8%)	124 (34.4%)
Yes	27 (55.1%)	209 (67.2%)	236 (65.6%)
Previous hormonal therapy				0.150
No	26 (53.1%)	199 (63.8%)	225 (62.3%)
Yes	23 (46.9%)	113 (36.2%)	136 (37.7%)
FACT-G baseline scores (SD)			—
Physical well-being	19.3 (4.8)	20.7 (4.9)	—	0.012
Social/Family well-being	19.4 (6.6)	21.0 (5.2)	—	0.187
Emotional well-being	17.2 (4.2)	18.2 (4.0)	—	0.043
Functional well-being	15.8 (6.1)	18.3 (5.0)	—	0.006
Total QOL score	71.7 (16.5)	78.2 (15.5)	—	0.003
FACIT-F fatigue score	33.5 (10.9)	32.9 (10.3)		0.786

Participants with metastatic disease, not distant metastases, were eligible for both trials.

QOL, quality of life; SD, standard deviation.

Adherence and compliance

On average, racially and ethnically diverse survivors completed 6 out of 8 (75%) prescribed yoga classes and supplemented their practice with one additional home-based, self-guided session per week, similar to that reported in the main outcomes paper with the general study population.⁶⁶ The duration of yoga practice averaged 169 yoga min each week, translating into 676 total yoga min across the intervention. This is 76 min beyond the initially prescribed 600 yoga min. NHW cancer survivors practiced an average of 184 min of yoga per week, totaling 736 min over the 4-week intervention period. This exceeds the prescribed yoga dose by 136 min. Yoga classes averaged at a moderate intensity level, with participants reporting an average score of 3.3 on the RPE (0 = Nothing at all to 10 = Very strong). This is comparable with the score of 3.2 for NHWs.

Safety

Five participants in the YOCAS^©® arm reported AEs across both trials. One participant reported three separate AEs, for a total of seven AEs in both studies. All were unexpected. Six of the seven AEs were unrelated to the intervention. One AE was unlikely related to the intervention (the patient had a depression AE, CTCAE score was 4). The six unrelated AEs include stroke (CTCAE score of 5; patient expired), blood in stool (CTCAE score of 2), confusion/brain metastases (CTCAE score of 4), intracranial hemorrhage/brain metastases (CTCAE score of 4), aphasia/brain metastases (CTCAE score of 5; patient expired), and supraventricular tachycardia (CTCAE score of 2).

Cancer-related fatigue

T tests revealed improvements that were not statistically significant or clinically meaningful in overall CRF (mean change = 2.0, standard deviation [SD] = 15.3, p < 0.071) among racially and ethnically diverse participants after completing the 4-week YOCAS^©® yoga intervention (Table 2). Comparing CRF outcomes of racially and ethnically diverse participants with NHW participants, between-group mean differences did not reach statistical significance and were not clinically meaningful (mean difference = 0.92, p = 0.425; Table 3). At the lower threshold of ≥3-point increase, NHW participants had a significantly higher proportion of individuals with clinically meaningful CRF improvements compared with racially and ethnically diverse participants (53% vs. 37%, respectively; p = 0.036). They also had a slightly higher proportion at the upper threshold of a ≥5-point increase (40% vs. 33%; p = 0.3; Supplementary Tables S2 and S3).

Table 2.

Within-Group Mean Differences in CRF, QOL, and Subdomains of QOL for Racially and Ethnically Diverse Survivors in the YOCAS^©® Yoga Arm (n = 49)

	Preintervention	Postintervention	Within-group difference	p value
FACIT-F fatigue score	33.5 (10.9)	35.5 (10.7)	2.0 (15.3)	0.071
FACT-G total QOL score	71.7 (16.5)	75.2 (17.5)	3.5 (24.1)	0.026
FACT-G physical subscore	19.3 (4.8)	20.7 (5.0)	1.4 (6.9)	0.020
FACT-G functional subscore	15.8 (6.1)	16.7 (6.8)	0.9 (9.1)	0.169
FACT-G emotional subscore	17.2 (4.2)	18.1 (4.5)	0.9 (6.2)	0.031
FACT-G social/family subscore	19.4 (6.6)	19.6 (6.3)	0.02 (9.2)	0.730

CRF, cancer-related fatigue; QOL, quality of life; YOCAS^©®, Yoga for Cancer Survivors.

Table 3.

Comparison of CRF, QOL, and Subdomains of QOL Mean Differences at Postintervention in Racially and Ethnically Diverse Versus NHW Cancer Survivors

Variable	Difference	p value
Physical well-being	−0.34	0.579
Social/Family well-being	−0.19	0.714
Emotional well-being	−0.06	0.898
Functional well-being	−0.06	0.927
Fatigue	0.92	0.425
Total QOL score	−0.67	0.898

CRF, cancer-related fatigue; QOL, quality of life; NHW, non-Hispanic Whites.

Total QOL

T tests revealed statistically significant but not clinically meaningful improvements in total QOL (mean change = 3.5, SD = 24.1, p < 0.026) among racially and ethnically diverse participants after completing the 4-week YOCAS^©® intervention (Table 2). Comparing total QOL outcomes of racially and ethnically diverse participants with NHW participants, between-group mean differences did not reach statistical significance and were not clinically meaningful (mean difference = −0.67, p = 0.898; Table 3). Racially and ethnically diverse participants had a slightly higher proportion of individuals with clinically meaningful QOL improvements than NHW participants at both the lower threshold of ≥5-point increase (43% vs. 40%, respectively; p = 0.7) and the upper bound of a ≥7-point increase (37% vs. 30%, respectively; p = 0 .4; Supplementary Tables S2 and S3).

Physical, functional, emotional, and social/family QOL subdomains

T tests revealed statistically significant but not clinically meaningful improvements in the physical (mean change = 1.4, SD = 6.9, p < 0.020) and emotional (mean change = 0.9, SD = 6.2, p < 0.031) components of QOL (Table 2) among racially and ethnically diverse participants after completing the 4-week YOCAS^©® intervention. No statistically significant or clinically meaningful changes were seen in the functional and social/family QOL subdomains. Comparing QOL subdomain outcomes of racially and ethnically diverse participants with NHW participants, between-group differences did not reach statistical significance and were not clinically meaningful for any QOL subdomain (Table 3). Racially and ethnically diverse participants had a slightly higher proportion of individuals with clinically meaningful improvements than NHW participants at a lower threshold of ≥2-point increase for the social/family, functional, and emotional components of QOL (Supplementary Table S2) and a similar proportion to NHW participants for the physical component of QOL. At the upper threshold of ≥3-point increase, they had a higher proportion of individuals with clinically meaningful improvements across all QOL components than NHW participants (Supplementary Table S3).

Interaction between study and racially and ethnically diverse participants

To account for differences between study 1 and study 2, we ran interaction analyses that showed that the interaction of the study and racially and ethnically diverse participants significantly impacts QOL (p < 0.007) in addition to the functional (p < 0.021) and physical (p < 0.002) QOL subdomains.

Results from the feedback survey (Supplementary Table S1) show that most racially and ethnically diverse and NHW participants: (1) were familiar with yoga prior to enrolling in the trial (75.5% vs. 88.1%), (2) reported a more favorable view of yoga after participating (73.5% vs. 80.7%), (3) perceived improvements in sleep quality from “a little” to “very much,” (77.5% vs. 80.6%), and (4) expressed a strong likelihood of endorsing YOCAS^©® to other survivors (87.8% vs. 88.0%).

Discussion

This secondary analysis provides preliminary evidence that racially and ethnically diverse cancer survivors completing a manualized 4-week YOCAS^©® intervention had improvements in CRF that were not statistically significant or clinically meaningful. Moreover, NHW participants had a higher proportion of individuals with clinically meaningful CRF improvements compared with racially and ethnically diverse participants. For QOL and QOL subdomains, there were statistically significant but not clinically meaningful improvements in the overall QOL and the emotional and physical components of QOL. There were no significant or clinically meaningful improvements in the functional and social/family QOL domains. Between-group differences were not significant or clinically meaningful. Overall, the lack of clinically meaningful improvements in racial and ethnic survivors is likely attributable to the small sample size and absence of cultural adaptation. However, these participants had a higher proportion of individuals with clinically meaningful total QOL and social/family, functional, and emotional QOL subdomains than NHWs. Future research should culturally and linguistically adapt yoga interventions to enhance therapeutic impact for racially and ethnically diverse survivors. Most participants expressed a substantial likelihood of endorsing YOCAS^©® to other survivors.

In addition, we found that racially and ethnically diverse survivors had significantly worse baseline QOL and physical, emotional, and functional QOL subdomain scores than NHWs. After the 4-week YOCAS^©® program, there were no significant differences between both groups, indicating that racially and ethnically diverse survivors improved their CRF and QOL scores to levels comparable with those of NHWs. Notably, this improvement occurred despite these participants practicing, on average, 60 min less yoga than NHWs during the 4-week intervention. The greater improvements observed among racially and ethnically diverse survivors may reflect the higher symptom burden at baseline, allowing more room for improvement over the 4-week intervention. These participants may have experienced a greater relative benefit because they started with lower QOL scores, perhaps making even a shorter yoga duration impactful. In addition, this group may have been more receptive to the intervention due to fewer opportunities for supportive care or wellness programs, enhancing the perceived value and engagement despite the lower dose. These findings suggest that baseline symptom severity and unmet supportive care needs may be important moderators of intervention response.

Due to our small sample size, we could not conduct additional analyses to explore the impact of marginalized identities on CRF and QOL. Notably, the majority of participants (77.5%) reported having two or more marginalized identities (e.g., identifying as racial/ethnic minority and female), with power identities also present (e.g., cisgender, high socioeconomic status). This underscores the importance of acknowledging and addressing these intersecting identities in future research. Moreover, a significant proportion (78.6%) of racially and ethnically diverse survivors had cancers classified as local, corresponding to Stages 0–II, comparable with 78.0% of NHWs. This may reflect the influence of power-associated identities, such as higher educational attainment, being younger than 65, and English proficiency. Our findings may, therefore, not be generalizable to all racially and ethnically diverse cancer survivors across the United States, as the unique combination of power-associated and marginalized identities within our sample, may not reflect the broader survivor community. Future studies should prioritize analyses that investigate the impact of intersecting identities on cancer and cancer-related effects to ensure more comprehensive and representative findings.

Although only 4% of the enrolled participants in both parent trials were racially and ethnically diverse minorities, we see that once enrolled, they had high adherence to the yoga trial. Nevertheless, we were not primarily enrolling racial and ethnic survivors with more marginalized identities, such as the older, less-educated, racially, and ethnically diverse survivors who do not speak English. This points to the importance of cultural adaptation to yield higher enrollment of racially and ethnically diverse survivors and recruit our most vulnerable survivors with multiple marginalized identities into yoga clinical trials.^82

–85 Adequate representation of racially and ethnically diverse cancer survivors in yoga clinical trials is needed to equitably address CRF and overall cancer symptom management.

Limitations to this study include the following: (1) we did not have a comparator with the yoga arm; (2) our sample size was small, and thus, findings should be interpreted with caution; (3) we assessed secondary outcomes; (4) we did not control for home exercise in our analyses; (5) the yoga participants from both parent trials are likely heterogeneous, given each trial’s breadth of geographic and temporal representations. We were unable to conduct further analysis to assess whether geographic changes and differences in racial/ethnic categories may impact outcomes due to too many sites in our trials and too few racial/ethnic participants in each category; (6) the findings are not generalizable across all racially and ethnically diverse cancer survivors; (7) the YOCAS^©® program did not include a social component, which may explain the lack of improvements in the social/family subdomain of QOL; and (8) no biophysiological data were collected; thus, we were unable to evaluate how yoga influenced these specific pathways. While previous research suggests that yoga may reduce levels of inflammatory markers, cortisol, and potentially support circadian rhythm regulation in adult cancer survivors,^86
–88 there have been no studies addressing the pathophysiologic effects of yoga in racially and ethnically diverse survivors, who encounter higher rates of discrimination compared with NHWs.^39,89
–91 Exposure to discrimination is correlated with elevated levels of inflammatory markers;^92
–94 (8) sustained effects on CRF and QOL remain unknown, as no longitudinal assessments were performed; and (9) our YOCAS^©® intervention was not available in Spanish. Despite these limitations, YOCAS^©® is enjoyable, feasible, and safe for racially and ethnically diverse cancer survivors. Looking ahead, rigorously designed and adequately powered RCTs are essential to validate the impact of YOCAS^©® on CRF and QOL in racially and ethnically diverse survivors. Additional studies ought to prioritize strategies to enhance the participation of these marginalized groups through an intersectionality framework lens.

Conclusions

Results suggest that (1) YOCAS^©® has the potential to alleviate fatigue and enhance QOL in racially and ethnically diverse survivors; (2) while participation rates remain modest, there is openness to yoga; and (3) diverse survivors are capable of completing a 4-week yoga program, report it as useful for controlling symptoms, and are likely to suggest it to survivors. Most participants (95.7%) reported having two or more marginalized identities. To recruit our most vulnerable survivors (e.g., older, racial, and ethnic minorities, do not speak English, less educated), cultural adaptation of yoga clinical trials is needed. Research that primarily enrolls this population should also consider the influence of the intersecting identities of marginalized identities on cancer-related outcomes.

Footnotes

Acknowledgments

We thank the dedicated research teams at the University of Rochester Cancer Center NCI Community Oncology Research Program (NCORP) Research Base and the numerous NCORP Community Sites across the country for their efforts in recruiting, enrolling, and supporting participants throughout our YOCAS studies. We also sincerely thank the individuals affected by cancer and yoga instructors whose participation made this study possible.

Authors’ Contributions

E.A.-C.: Study concepts, study design, quality control of data and algorithms, data analysis and interpretation, statistical analysis, article preparation, article editing, article review; P.-J.L.: Study concepts, study design, article editing, article review; H.S.: Quality control of data and algorithms, data analysis and interpretation, statistical analysis, article editing, article review; U.G.: Quality control of data and algorithms, data analysis and interpretation, statistical analysis, article editing, article review; A.C.: Article editing, article review; L.M.: Article editing, article review; M.M.: Article editing, article review; J.R.: Article editing, article review; K.I.G.: Article editing, article review; A.P.C.: Article editing, article review; C.K.: Article editing, article review; B.A.: Article editing, article review; P.V.: Article editing, article review; S.G.M.: Article editing, article review; K.M.M.: Study concepts, study design, data acquisition, data analysis and interpretation, article preparation, article editing, article review.

Data Availability

The data supporting this study’s findings are not openly available due to the sensitive nature of the data but can be obtained from the corresponding author upon reasonable request.

Disclosure Statement

No competing financial interests exist.

Funding Information

This research was funded by the National Cancer Institute, part of the National Institutes of Health: UG1CA189961 to K.M.M., T32CA102618 to E.A.-C., and R01CA181064 to K.M.M.

Supplementary Material

Supplementary Data

Supplementary Table S1

Supplementary Table S2

Supplementary Table S3

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Supplementary Material

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The Effect of Yoga on Cancer-Related Fatigue and Quality of Life Among Racially and Ethnically Diverse Cancer Survivors: A Secondary Data Analysis

Abstract

Introduction:

Methods:

Results:

Discussion:

Background

Materials and Methods

Design

Study participants

YOCAS©® yoga intervention

Fidelity, quality, and drift

Measures

Cancer-related fatigue

Quality of life

Adherence and compliance

Safety

Feedback survey

Statistical analyses

Results

Participant characteristics

Adherence and compliance

Safety

Cancer-related fatigue

Total QOL

Physical, functional, emotional, and social/family QOL subdomains

Interaction between study and racially and ethnically diverse participants

Discussion

Conclusions

Footnotes

Acknowledgments

Authors’ Contributions

Data Availability

Disclosure Statement

Funding Information

Supplementary Material

References

Supplementary Material

YOCAS^©® yoga intervention