Yoga's impact on inflammation, mood, and fatigue in breast cancer survivors: a randomized controlled trial.

PURPOSE To evaluate yoga's impact on inflammation, mood, and fatigue. PATIENTS AND METHODS A randomized controlled 3-month trial was conducted with two post-treatment assessments of 200 breast cancer survivors assigned to either 12 weeks of 90-minute twice per week hatha yoga classes or a wait-list control. The main outcome measures were lipopolysaccharide-stimulated production of proinflammatory cytokines interleukin-6 (IL-6), tumor necrosis factor alpha (TNF-α), and interleukin-1β (IL-1β), and scores on the Multidimensional Fatigue Symptom Inventory-Short Form (MFSI-SF), the vitality scale from the Medical Outcomes Study 36-item Short Form (SF-36), and the Center for Epidemiological Studies-Depression (CES-D) scale. RESULTS Immediately post-treatment, fatigue was not lower (P > .05) but vitality was higher (P = .01) in the yoga group compared with the control group. At 3 months post-treatment, fatigue was lower in the yoga group (P = .002), vitality was higher (P = .01), and IL-6 (P = .027), TNF-α (P = .027), and IL-1β (P = .037) were lower for yoga participants compared with the control group. Groups did not differ on depression at either time (P > .2). Planned secondary analyses showed that the frequency of yoga practice had stronger associations with fatigue at both post-treatment visits (P = .019; P < .001), as well as vitality (P = .016; P = .0045), but not depression (P > .05) than simple group assignment; more frequent practice produced larger changes. At 3 months post-treatment, increasing yoga practice also led to a decrease in IL-6 (P = .01) and IL-1β (P = .03) production but not in TNF-α production (P > .05). CONCLUSION Chronic inflammation may fuel declines in physical function leading to frailty and disability. If yoga dampens or limits both fatigue and inflammation, then regular practice could have substantial health benefits.

[1]  P. Deuster,et al.  Exercise and Circadian Rhythm-Induced Variations in Plasma Cortisol Differentially Regulate Interleukin-1β (IL-1β), IL-6, and Tumor Necrosis Factor-α (TNFα) Production in Humans: High Sensitivity of TNFα and Resistance of IL-6 , 1997 .

[2]  S. Maier,et al.  Prior stressor exposure primes the HPA axis , 2002, Psychoneuroendocrinology.

[3]  Clemens Kirschbaum,et al.  Sex-Specific Effects of Social Support on Cortisol and Subjective Responses to Acute Psychological Stress , 1995, Psychosomatic medicine.

[4]  H. Geinitz,et al.  Fatigue in patients with adjuvant radiation therapy for breast cancer: long-term follow-up , 2004, Journal of Cancer Research and Clinical Oncology.

[5]  A. Sood,et al.  Psychosocial factors and interleukin‐6 among women with advanced ovarian cancer , 2005, Cancer.

[6]  Blair T. Johnson,et al.  The Efficacy of Exercise in Reducing Depressive Symptoms among Cancer Survivors: A Meta-Analysis , 2012, PloS one.

[7]  R. Shephard.  Cytokine responses to physical activity, with particular reference to IL-6: sources, actions, and clinical implications. , 2002, Critical reviews in immunology.

[8]  D H Freeman,et al.  Depressive symptoms in relation to physical health and functioning in the elderly. , 1986, American journal of epidemiology.

[9]  M. Kenward,et al.  Small sample inference for fixed effects from restricted maximum likelihood. , 1997, Biometrics.

[10]  C. Salome,et al.  Sahaja yoga in the management of moderate to severe asthma: a randomised controlled trial , 2002, Thorax.

[11]  V. Jenkins,et al.  Randomised controlled trials of yoga interventions for women with breast cancer: a systematic literature review , 2012, Supportive Care in Cancer.

[12]  K. Courneya,et al.  Effects of exercise training on fasting insulin, insulin resistance, insulin-like growth factors, and insulin-like growth factor binding proteins in postmenopausal breast cancer survivors: a randomized controlled trial. , 2003, Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology.

[13]  C. Sherbourne,et al.  The MOS 36-Item Short-Form Health Survey (SF-36) , 1992 .

[14]  K. Clément,et al.  Dietary factors and low-grade inflammation in relation to overweight and obesity , 2011, British Journal of Nutrition.

[15]  L. Carlson,et al.  Mindfulness-based stress reduction in relation to quality of life, mood, symptoms of stress and levels of cortisol, dehydroepiandrosterone sulfate (DHEAS) and melatonin in breast and prostate cancer outpatients , 2004, Psychoneuroendocrinology.

[16]  M. Irwin,et al.  Effects of a Behavioral Intervention, Tai Chi Chih, on Varicella-Zoster Virus Specific Immunity and Health Functioning in Older Adults , 2003, Psychosomatic medicine.

[17]  D. Lawlor,et al.  Exercise interventions for cancer patients: systematic review of controlled trials , 2004, Cancer Causes & Control.

[18]  J. Cacioppo,et al.  The relationship between social support and physiological processes: a review with emphasis on underlying mechanisms and implications for health. , 1996, Psychological bulletin.

[19]  J. Rybakowski,et al.  Interleukin‐6 Serum Levels in Depressed Patients before and after Treatment with Fluoxetine , 1995, Annals of the New York Academy of Sciences.

[20]  P. Ganz,et al.  Quality of life in long-term, disease-free survivors of breast cancer: a follow-up study. , 2002, Journal of the National Cancer Institute.

[21]  B. Hatfield,et al.  Aerobic exercise training and cardiovascular reactivity to psychological stress in sedentary young normotensive men and women. , 2004, Psychophysiology.

[22]  L. Carlson,et al.  Mindfulness‐Based Stress Reduction in Relation to Quality of Life, Mood, Symptoms of Stress, and Immune Parameters in Breast and Prostate Cancer Outpatients , 2003, Psychosomatic medicine.

[23]  D. Panagiotakos,et al.  Anxiety in relation to inflammation and coagulation markers, among healthy adults: the ATTICA study. , 2006, Atherosclerosis.

[24]  R. Westendorp,et al.  High innate production capacity of tumor necrosis factor-α and decline of handgrip strength in old age , 2007, Mechanisms of Ageing and Development.

[25]  N. Sattar,et al.  High Innate Production Capacity of Proinflammatory Cytokines Increases Risk for Death from Cancer: Results of the PROSPER Study , 2009, Clinical Cancer Research.

[26]  J. Manson,et al.  C-reactive protein, interleukin 6, and risk of developing type 2 diabetes mellitus. , 2001, JAMA.

[27]  R. Westendorp,et al.  Inflammation and interleukin-1 signaling network contribute to depressive symptoms but not cognitive decline in old age , 2007, Experimental Gerontology.

[28]  H. Mcdevitt,et al.  Effects of a polymorphism in the human tumor necrosis factor alpha promoter on transcriptional activation. , 1997, Proceedings of the National Academy of Sciences of the United States of America.

[29]  J. Bower,et al.  Yoga for cancer patients and survivors. , 2005, Cancer control : journal of the Moffitt Cancer Center.

[30]  S. Rubin,et al.  Physical Activity, Exercise, and Inflammatory Markers in Older Adults: Findings from The Health, Aging and Body Composition Study , 2004, Journal of the American Geriatrics Society.

[31]  T. Harris,et al.  Insulin‐Like Growth Factor‐1 and Interleukin 6 Predict Sarcopenia in Very Old Community‐Living Men and Women: The Framingham Heart Study , 2003, Journal of the American Geriatrics Society.

[32]  E. Keller,et al.  Age-associated increased interleukin-6 gene expression, late-life diseases, and frailty. , 2000, Annual review of medicine.

[33]  R. Nagarathna,et al.  Yoga for bronchial asthma: a controlled study. , 1985, British medical journal.

[34]  I. Kullo,et al.  Markers of inflammation are inversely associated with VO2 max in asymptomatic men. , 2007, Journal of applied physiology.

[35]  O. J. Trask,et al.  Spousal caregivers of dementia victims: longitudinal changes in immunity and health. , 1991, Psychosomatic medicine.

[36]  H. Logan,et al.  Effects of acute stress, relaxation, and a neurogenic inflammatory stimulus on interleukin-6 in humans , 2004, Brain, Behavior, and Immunity.

[37]  S. Joshi‐Barve,et al.  Eicosapentaenoic Acid Prevents LPS-Induced TNF-α Expression by Preventing NF-κB Activation , 2004, Journal of the American College of Nutrition.

[38]  Ulf Lundberg,et al.  Stress Management: A Randomized Study of Cognitive Behavioural Therapy and Yoga , 2006, Cognitive behaviour therapy.

[39]  M. Kohut,et al.  Exercise and psychosocial factors modulate immunity to influenza vaccine in elderly individuals. , 2002, The journals of gerontology. Series A, Biological sciences and medical sciences.

[40]  Adrienne R. Sinden,et al.  Who Will Stay and Who Will Go? A Review of Older Adults’ Adherence to Randomized Controlled Trials of Exercise , 2001 .

[41]  H. Mathews,et al.  Aberrant Nuclear Expression of AP-1 and NFkB in Lymphocytes of Women Stressed by the Experience of Breast Biopsy , 2001, Brain, Behavior, and Immunity.

[42]  D. Ciraulo,et al.  Effects of yoga on the autonomic nervous system, gamma-aminobutyric-acid, and allostasis in epilepsy, depression, and post-traumatic stress disorder. , 2012, Medical hypotheses.

[43]  J. Sheridan,et al.  Chronic stress alters the immune response to influenza virus vaccine in older adults. , 1996, Proceedings of the National Academy of Sciences of the United States of America.

[44]  R. Cole,et al.  Feasibility of conducting a clinical trial on Hatha yoga for chronic low back pain: methodological lessons. , 2004, Alternative therapies in health and medicine.

[45]  R. Krishnan,et al.  Enhanced expression of cytokines and chemokines by blood monocytes to in vitro lipopolysaccharide stimulation are associated with hostility and severity of depressive symptoms in healthy women , 2004, Psychoneuroendocrinology.

[46]  Luigi Ferrucci,et al.  Serum IL‐6 Level and the Development of Disability in Older Persons , 1999, Journal of the American Geriatrics Society.

[47]  D. Papanicolaou,et al.  Circadian interleukin-6 secretion and quantity and depth of sleep. , 1999, The Journal of clinical endocrinology and metabolism.

[48]  Jean Marx,et al.  Inflammation and Cancer: The Link Grows Stronger , 2004, Science.

[49]  B. Rabin,et al.  Exposure to physical and psychological stressors elevates plasma interleukin 6: relationship to the activation of hypothalamic-pituitary-adrenal axis. , 1993, Endocrinology.

[50]  Martin R. Lindley,et al.  The anti-inflammatory effects of exercise: mechanisms and implications for the prevention and treatment of disease , 2011, Nature Reviews Immunology.

[51]  K. Courneya,et al.  Cardiopulmonary function and age-related decline across the breast cancer survivorship continuum. , 2012, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[52]  M. McGartland,et al.  The impact of Hatha yoga on smoking behavior. , 2004, Alternative therapies in health and medicine.

[53]  John D Potter,et al.  Influence of demographic, physiologic, and psychosocial variables on adherence to a yearlong moderate-intensity exercise trial in postmenopausal women. , 2004, Preventive medicine.

[54]  J. Richardson,et al.  Yoga for depression: the research evidence. , 2005, Journal of affective disorders.

[55]  N. D. Plavetić,et al.  Late effects of cancer and its treatment , 2010 .

[56]  John R Mackey,et al.  Physical exercise and immune system function in cancer survivors , 2002, Cancer.

[57]  C. Kirschbaum,et al.  The 'Trier Social Stress Test'--a tool for investigating psychobiological stress responses in a laboratory setting. , 1993, Neuropsychobiology.

[58]  Cannon Jg.  Cytokines in Aging and Muscle Homeostasis , 1995 .

[59]  K. Courneya,et al.  Effect of exercise training on C-reactive protein in postmenopausal breast cancer survivors: A randomized controlled trial , 2005, Brain, Behavior, and Immunity.

[60]  E. Bruera,et al.  Changes in plasma levels of inflammatory cytokines in response to paclitaxel chemotherapy. , 2004, Cytokine.

[61]  A. Jackson,et al.  The criterion-related validity of the sit and reach test: replication and extension of previous findings. , 1989, Research quarterly for exercise and sport.

[62]  R. Kurzrock.  The role of cytokines in cancer‐related fatigue , 2001, Cancer.

[63]  Daniel J Buysse,et al.  The Pittsburgh sleep quality index: A new instrument for psychiatric practice and research , 1989, Psychiatry Research.

[64]  T. Kamarck,et al.  A global measure of perceived stress. , 1983, Journal of health and social behavior.

[65]  R. Shephard,et al.  On the generality of the "sit and reach" test: an analysis of flexibility data for an aging population. , 1990, Research quarterly for exercise and sport.

[66]  R. MacCallum,et al.  Stress and immune responses after surgical treatment for regional breast cancer. , 1998, Journal of the National Cancer Institute.

[67]  R. Newton,et al.  Review of exercise intervention studies in cancer patients. , 2005, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[68]  M. Irwin,et al.  Inflammatory biomarkers for persistent fatigue in breast cancer survivors , 2006, Brain, Behavior, and Immunity.

[69]  S. Telles,et al.  Improvement in hand grip strength in normal volunteers and rheumatoid arthritis patients following yoga training. , 2001, Indian journal of physiology and pharmacology.

[70]  C. Morin,et al.  Randomized study on the efficacy of cognitive-behavioral therapy for insomnia secondary to breast cancer, part II: Immunologic effects. , 2005, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[71]  C. Wood,et al.  Mood Change and Perceptions of Vitality: A Comparison of the Effects of Relaxation, Visualization and Yoga , 1993, Journal of the Royal Society of Medicine.

[72]  R. Davidson,et al.  Alterations in Brain and Immune Function Produced by Mindfulness Meditation , 2003, Psychosomatic medicine.

[73]  D J Madden,et al.  Cardiovascular and behavioral effects of aerobic exercise training in healthy older men and women. , 1989, Journal of gerontology.

[74]  Markus Schwaninger,et al.  A mechanism converting psychosocial stress into mononuclear cell activation , 2003, Proceedings of the National Academy of Sciences of the United States of America.

[75]  C. Nemeroff,et al.  Increased Stress-Induced Inflammatory Responses in Male Patients With Major Depression and Increased Early Life Stress , 2006 .

[76]  C. Elder.  Ayurveda for diabetes mellitus: a review of the biomedical literature. , 2004, Alternative therapies in health and medicine.

[77]  E. Bosmans,et al.  The inflammatory response following delivery is amplified in women who previously suffered from major depression, suggesting that major depression is accompanied by a sensitization of the inflammatory response system. , 2001, Journal of affective disorders.

[78]  M. Febbraio,et al.  Muscle as an endocrine organ: focus on muscle-derived interleukin-6. , 2008, Physiological reviews.

[79]  P. Hall,et al.  Epidemiology of cancer‐related fatigue in the Swedish twin registry , 2005, Cancer.

[80]  M. Albitar,et al.  Cognitive impairment, fatigue, and cytokine levels in patients with acute myelogenous leukemia or myelodysplastic syndrome , 2005, Cancer.

[81]  M. Irwin,et al.  Yogic meditation reverses NF-κB and IRF-related transcriptome dynamics in leukocytes of family dementia caregivers in a randomized controlled trial , 2013, Psychoneuroendocrinology.

[82]  L. Breslow,et al.  Health and Ways of Living: The Alameda County Study , 1983 .

[83]  R. Pandey,et al.  Yogic Versus Conventional Treatment in Diarrhea-Predominant Irritable Bowel Syndrome: A Randomized Control Study , 2004, Applied psychophysiology and biofeedback.

[84]  A. Stewart,et al.  CHAMPS physical activity questionnaire for older adults: outcomes for interventions. , 2001, Medicine and science in sports and exercise.

[85]  A. Kristal,et al.  Yoga practice is associated with attenuated weight gain in healthy, middle-aged men and women. , 2005, Alternative therapies in health and medicine.

[86]  S. Rubin,et al.  Inflammatory Markers and Incident Mobility Limitation in the Elderly , 2004, Journal of the American Geriatrics Society.

[87]  B. Nicklas,et al.  Exercise Training as a Treatment for Chronic Inflammation in the Elderly , 2009, Exercise and sport sciences reviews.

[88]  C. Morin,et al.  Natural course of insomnia comorbid with cancer: an 18-month longitudinal study. , 2011, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[89]  J. Blumenthal,et al.  Exercise training in healthy type A middle‐aged men: effects on behavioral and cardiovascular responses. , 1988, Psychosomatic medicine.

[90]  J. Farrar,et al.  The impact of modified Hatha yoga on chronic low back pain: a pilot study. , 2004, Alternative therapies in health and medicine.

[91]  K. Courneya.  Exercise in cancer survivors: an overview of research. , 2003, Medicine and science in sports and exercise.

[92]  K. Gill-Body,et al.  A yoga-based exercise program for people with chronic poststroke hemiparesis. , 2004, Physical therapy.

[93]  R. D'Agostino,et al.  Cytokines, insulin-like growth factor 1, sarcopenia, and mortality in very old community-dwelling men and women: the Framingham Heart Study. , 2003, The American journal of medicine.

[94]  E. Ripoll,et al.  Hatha Yoga therapy management of urologic disorders , 2002, World Journal of Urology.

[95]  Andrew H. Miller,et al.  Depression in cancer: new developments regarding diagnosis and treatment , 2003, Biological Psychiatry.

[96]  R. Dishman,et al.  Cardiorespiratory fitness and laboratory stress: a meta-regression analysis. , 2006, Psychophysiology.

[97]  E. Winer,et al.  Changes in weight, body composition, and factors influencing energy balance among premenopausal breast cancer patients receiving adjuvant chemotherapy. , 2001, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[98]  S. Maier,et al.  Prior Stressor Exposure Sensitizes LPS-Induced Cytokine Production , 2002, Brain, Behavior, and Immunity.

[99]  D. Kiel,et al.  Inflammatory markers and the risk of Alzheimer disease , 2007, Neurology.

[100]  Sheldon Cohen.  Perceived stress in a probability sample of the United States , 1988 .

[101]  A. Kristal,et al.  Measurement characteristics of the Women's Health Initiative food frequency questionnaire. , 1999, Annals of epidemiology.

[102]  N. Andreasen,et al.  Reliability of lifetime diagnosis. A multicenter collaborative perspective. , 1981, Archives of general psychiatry.

[103]  P. Ganz,et al.  The BCPT symptom scales: a measure of physical symptoms for women diagnosed with or at risk for breast cancer. , 2005, Journal of the National Cancer Institute.

[104]  D. gallagher-Thompson,et al.  A pilot study of a yoga and meditation intervention for dementia caregiver stress. , 2004, Journal of clinical psychology.

[105]  C. Kirschbaum,et al.  Salivary cortisol in psychoneuroendocrine research: Recent developments and applications , 1994, Psychoneuroendocrinology.

[106]  A. Steptoe,et al.  Socioeconomic status and stress-induced increases in interleukin-6 , 2004, Brain, Behavior, and Immunity.

[107]  H. Cohen,et al.  Leading the Way in Exercise and Diet (Project LEAD): intervening to improve function among older breast and prostate cancer survivors. , 2003, Controlled clinical trials.

[108]  J. Blumenthal,et al.  Effects of Physical Exercise on Psychological and Cognitive Functioning of Older Adults , 1991 .

[109]  G. Fillenbaum,et al.  The development, validity, and reliability of the OARS multidimensional functional assessment questionnaire. , 1981, Journal of gerontology.

[110]  A. Steptoe,et al.  Psychological stress activates interleukin-1β gene expression in human mononuclear cells , 2005, Brain, Behavior, and Immunity.

[111]  K. Spiess,et al.  Lytic effector cell activity and major depressive disorder in patients with breast cancer: a prospective study , 1995, Journal of Neuroimmunology.

[112]  E. Bosmans,et al.  The effects of psychological stress on humans: increased production of pro-inflammatory cytokines and a Th1-like response in stress-induced anxiety. , 1998, Cytokine.

[113]  R. Fouladi,et al.  Psychological adjustment and sleep quality in a randomized trial of the effects of a Tibetan yoga intervention in patients with lymphoma , 2004, Cancer.

[114]  A. Beck,et al.  Reliability of DSM-III diagnoses for major depression and generalized anxiety disorder using the structured clinical interview for DSM-III. , 1987, Archives of general psychiatry.

[115]  Suzanne G. Leveille,et al.  Change in Muscle Strength Explains Accelerated Decline of Physical Function in Older Women With High Interleukin‐6 Serum Levels , 2002, Journal of the American Geriatrics Society.

[116]  M. Irwin,et al.  Yoga for persistent fatigue in breast cancer survivors , 2012, Cancer.

[117]  R. Yancik,et al.  Cancer survivors in the United States: age, health, and disability. , 2003, The journals of gerontology. Series A, Biological sciences and medical sciences.

[118]  Exercise therapy effect on natural killer cell cytotoxic activity in stomach cancer patients after curative surgery. , 2000, Archives of physical medicine and rehabilitation.

[119]  C. Emery,et al.  Determinants of physical activity among women treated for breast cancer in a 5‐year longitudinal follow‐up investigation , 2009, Psycho-oncology.

[120]  D. Papanicolaou,et al.  Elevation of plasma cytokines in disorders of excessive daytime sleepiness: role of sleep disturbance and obesity. , 1997, The Journal of clinical endocrinology and metabolism.

[121]  S. Segerstrom,et al.  Psychological stress and the human immune system: a meta-analytic study of 30 years of inquiry. , 2004, Psychological bulletin.

[122]  Andrew H. Miller,et al.  Cytokines sing the blues: inflammation and the pathogenesis of depression. , 2006, Trends in immunology.

[123]  P. Jacobsen,et al.  Further validation of the multidimensional fatigue symptom inventory-short form. , 2004, Journal of pain and symptom management.

[124]  K. Courneya,et al.  Randomized controlled trial of exercise and blood immune function in postmenopausal breast cancer survivors. , 2005, Journal of applied physiology.

[125]  C. Morin,et al.  Sleep and psychopathology , 1996 .

[126]  J. Kiecolt-Glaser,et al.  Stress-induced immune dysfunction: implications for health , 2005, Nature Reviews Immunology.

[127]  V. Mock.  Evidence-based treatment for cancer-related fatigue. , 2004, Journal of the National Cancer Institute. Monographs.

[128]  G. Montgomery,et al.  Cancer-related fatigue: a systematic and meta-analytic review of non-pharmacological therapies for cancer patients. , 2008, Psychological bulletin.

[129]  K. Courneya,et al.  Three independent factors predicted adherence in a randomized controlled trial of resistance exercise training among prostate cancer survivors. , 2004, Journal of clinical epidemiology.

[130]  E. Bosmans,et al.  Elevated serum interleukin-6 (IL-6) and IL-6 receptor concentrations in posttraumatic stress disorder following accidental man-made traumatic events , 1999, Biological Psychiatry.

[131]  R. Andridge,et al.  Omega-3 supplementation lowers inflammation and anxiety in medical students: A randomized controlled trial , 2011, Brain, Behavior, and Immunity.

[132]  W. Malarkey,et al.  Slowing of wound healing by psychological stress , 1995, The Lancet.

[133]  Lucy M. Browning,et al.  n-3 Polyunsaturated fatty acids, inflammation and obesity-related disease , 2003, Proceedings of the Nutrition Society.

[134]  K. Ness,et al.  Physical performance limitations and participation restrictions among cancer survivors: a population-based study. , 2006, Annals of epidemiology.

[135]  J. Mackey,et al.  Exercise intolerance in cancer and the role of exercise therapy to reverse dysfunction. , 2009, The Lancet. Oncology.

[136]  G. Noffal,et al.  The reliability and validity of a chair sit-and-reach test as a measure of hamstring flexibility in older adults. , 1998, Research quarterly for exercise and sport.

[137]  P. McDonald,et al.  The influence of bio-behavioural factors on tumour biology: pathways and mechanisms , 2006, Nature Reviews Cancer.

[138]  H. Cohen,et al.  Association of Interleukin‐6 and Other Biologic Variables with Depression in Older People Living in the Community , 1999, Journal of the American Geriatrics Society.

[139]  C. Johansen,et al.  Evaluation and outcome of behavioural changes in the rehabilitation of cancer patients: a review. , 2005, European journal of cancer.

[140]  L. Carlson,et al.  A pilot study of yoga for breast cancer survivors: physical and psychological benefits , 2006, Psycho-oncology.

[141]  L. Bernstein,et al.  Influence of exercise activity on quality of life in long-term breast cancer survivors , 2005, Quality of Life Research.

[142]  M. Irwin,et al.  Inflammation and behavioral symptoms after breast cancer treatment: do fatigue, depression, and sleep disturbance share a common underlying mechanism? , 2011, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[143]  B. Nicklas,et al.  Effect of exercise training on chronic inflammation. , 2010, Clinica chimica acta; international journal of clinical chemistry.

[144]  C. Bouchard,et al.  The use of anthropometric and dual-energy X-ray absorptiometry (DXA) measures to estimate total abdominal and abdominal visceral fat in men and women. , 1999, Obesity research.

[145]  P. Jacobsen,et al.  A multidimensional measure of fatigue for use with cancer patients. , 1998, Cancer practice.

[146]  L. Ferrucci,et al.  Cross-sectional and prospective relationships of interleukin-6 and C-reactive protein with physical performance in elderly persons: MacArthur studies of successful aging. , 2000, The journals of gerontology. Series A, Biological sciences and medical sciences.

[147]  P. Ganz,et al.  Fatigue in long‐term breast carcinoma survivors , 2006, Cancer.

[148]  P. Thompson,et al.  The effects of physical activity on serum C-reactive protein and inflammatory markers: a systematic review. , 2005, Journal of the American College of Cardiology.

[149]  K. Buckwalter,et al.  Life stress, mood disturbance, and elevated interleukin-6 in healthy older women. , 1999, The journals of gerontology. Series A, Biological sciences and medical sciences.

[150]  G. Dobos,et al.  Yoga for breast cancer patients and survivors: a systematic review and meta-analysis , 2012, BMC Cancer.

[151]  N. Schneiderman,et al.  Physical Activity Interventions in the Elderly: Cancer and Comorbidity , 2004, Cancer investigation.

[152]  P. Black.  The inflammatory response is an integral part of the stress response: Implications for atherosclerosis, insulin resistance, type II diabetes and metabolic syndrome X , 2003, Brain, Behavior, and Immunity.

[153]  B. Pinto,et al.  Riding the crest of the teachable moment: promoting long-term health after the diagnosis of cancer. , 2005, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[154]  J. Lau,et al.  Evidence report on the occurrence, assessment, and treatment of fatigue in cancer patients. , 2004, Journal of the National Cancer Institute. Monographs.

[155]  J Lee,et al.  Perceived social support and tumor estrogen/progesterone receptor status as predictors of natural killer cell activity in breast cancer patients. , 1990, Psychosomatic medicine.

[156]  E. Thiel,et al.  Physical performance, depression, immune status and fatigue in patients with hematological malignancies after treatment. , 2004, Annals of oncology : official journal of the European Society for Medical Oncology.

[157]  V. Helgeson,et al.  Surviving cancer: A comparison of 5‐year disease‐free breast cancer survivors with healthy women , 2005, Psycho-oncology.

[158]  Patricia A. Ganz,et al.  Fatigue and Proinflammatory Cytokine Activity in Breast Cancer Survivors , 2002, Psychosomatic medicine.

[159]  T. Puetz.  Physical Activity and Feelings of Energy and Fatigue , 2006, Sports medicine.

[160]  A. McTiernan.  Physical Activity After Cancer: Physiologic Outcomes , 2004, Cancer investigation.

[161]  M. Irwin,et al.  Journal Scan Inflammation accelerates athero-sclerotic processes in obstructive sleep apnea syndrome (OSAS) - Quercioli A Sleep loss activates cellular markers of inflammation: sex differences , 2012 .

[162]  D. Uebelhart,et al.  Physical exercise in cancer patients during and after medical treatment: a systematic review of randomized and controlled clinical trials. , 2005, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[163]  P. Ganz,et al.  Fatigue in breast cancer survivors: occurrence, correlates, and impact on quality of life. , 2000, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[164]  L. Radloff.  The CES-D Scale , 1977 .

[165]  Kristopher J Preacher,et al.  Chronic stress and age-related increases in the proinflammatory cytokine IL-6 , 2003, Proceedings of the National Academy of Sciences of the United States of America.

[166]  G. Uhlenbruck,et al.  Influence of a moderate exercise training on natural killer cytotoxicity and personality traits in cancer patients. , 1994, Anticancer research.

[167]  J. Bower.  Prevalence and causes of fatigue after cancer treatment: the next generation of research. , 2005, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[168]  J. Brug,et al.  Physical and psychosocial benefits of yoga in cancer patients and survivors, a systematic review and meta-analysis of randomized controlled trials , 2012, BMC Cancer.

[169]  Clemens Kirschbaum,et al.  Cortisol responses to psychological stress and correlations with personality traits , 1992 .

[170]  L. Jones,et al.  Effect of exercise training on peak oxygen consumption in patients with cancer: a meta-analysis. , 2011, The oncologist.

[171]  Sheldon Cohen,et al.  Positive Events and Social Supports as Buffers of Life Change Stress , 1983 .

[172]  K. Vedhara,et al.  Chronic stress in elderly carers of dementia patients and antibody response to influenza vaccination , 1999, The Lancet.

[173]  J. Fahey,et al.  Shaking up Immunity: Psychological and Immunologic Changes after a Natural Disaster , 1997, Psychosomatic medicine.

[174]  P. Ganz,et al.  Quality of life at the end of primary treatment of breast cancer: first results from the moving beyond cancer randomized trial. , 2004, Journal of the National Cancer Institute.

[175]  W. Malarkey,et al.  Exercise accelerates wound healing among healthy older adults: a preliminary investigation. , 2005, The journals of gerontology. Series A, Biological sciences and medical sciences.

[176]  Daniel J Bauer,et al.  Evaluating Group-Based Interventions When Control Participants Are Ungrouped , 2008, Multivariate behavioral research.

[177]  A. Stewart,et al.  An evaluation of three self-report physical activity instruments for older adults. , 2001, Medicine and science in sports and exercise.

[178]  D Hamerman,et al.  Toward an Understanding of Frailty , 1999, Annals of Internal Medicine.

[179]  C. Nemeroff,et al.  Higher than normal plasma interleukin-6 concentrations in cancer patients with depression: preliminary findings. , 2001, The American journal of psychiatry.

[180]  Robert E. Dustman,et al.  Aerobic exercise training and improved neuropsychological function of older individuals , 1984, Neurobiology of Aging.

[181]  A. Kriska,et al.  Physical activity levels before and after a diagnosis of breast carcinoma , 2003, Cancer.

[182]  A. Rush,et al.  Outcome measures of depression. , 1997 .

[183]  A. King,et al.  Effects of moderate-intensity exercise on physiological, behavioral, and emotional responses to family caregiving: a randomized controlled trial. , 2002, The journals of gerontology. Series A, Biological sciences and medical sciences.

[184]  S. Ancoli-Israel,et al.  The relationship between fatigue and quality of life and inflammation during anthracycline-based chemotherapy in breast cancer , 2005, Biological Psychology.

[185]  C. Rock,et al.  Nutrition and Physical Activity During and After Cancer Treatment: An American Cancer Society Guide for Informed Choices , 2006, CA: a cancer journal for clinicians.

[186]  Tamara B. Harris,et al.  The Associations Between Physical Activity and Inflammatory Markers in High‐Functioning Older Persons: MacArthur Studies of Successful Aging , 2003, Journal of the American Geriatrics Society.

[187]  K. Deepak,et al.  Study of pulmonary and autonomic functions of asthma patients after yoga training. , 1996, Indian journal of physiology and pharmacology.

[188]  E. Bixler,et al.  Impaired nighttime sleep in healthy old versus young adults is associated with elevated plasma interleukin-6 and cortisol levels: physiologic and therapeutic implications. , 2003, The Journal of clinical endocrinology and metabolism.

[189]  Graham A Colditz,et al.  Physical activity and survival after breast cancer diagnosis. , 2004, JAMA.

[190]  H. Kemper,et al.  The Validity of the Sit-and-Reach Test and the Modified Sit-and-Reach Test in Middle-Aged to Older Men and Women , 2003, Research quarterly for exercise and sport.

[191]  R. MacCallum,et al.  Chronic Stress Modulates the Immune Response to a Pneumococcal Pneumonia Vaccine , 2000, Psychosomatic medicine.

[192]  S. Kishiyama,et al.  Randomized controlled trial of yoga and exercise in multiple sclerosis , 2004, Neurology.

[193]  D. Golden-Kreutz,et al.  Depressive symptoms after breast cancer surgery: Relationships with global, cancer‐related, and life event stress , 2004, Psycho-oncology.

[194]  M. First,et al.  The Structured Clinical Interview for DSM-III-R (SCID). I: History, rationale, and description. , 1992, Archives of general psychiatry.

[195]  G. Baltaci,et al.  Comparison of three different sit and reach tests for measurement of hamstring flexibility in female university students , 2003, British journal of sports medicine.

[196]  L. Ferrucci,et al.  Inflammatory markers and depressed mood in older persons: results from the health, aging and body composition study , 2003, Biological Psychiatry.

[197]  H. Myers,et al.  A yoga intervention for young adults with elevated symptoms of depression. , 2004, Alternative therapies in health and medicine.

[198]  Carol J. Verboncoeur,et al.  Physical activity outcomes of CHAMPS II: a physical activity promotion program for older adults. , 2001, The journals of gerontology. Series A, Biological sciences and medical sciences.

[199]  M. Herring,et al.  Differential effects of exercise on cancer-related fatigue during and following treatment: a meta-analysis. , 2012, American journal of preventive medicine.

[200]  N Karstaedt,et al.  Adipose tissue determinations in cadavers--a comparison between cross-sectional planimetry and computed tomography. , 1990, International journal of obesity.