Impact of Active Iyengar Yoga Practice on Markers of Cell-mediated Cytotoxicity in Breast Cancer Survivors Sally E. Blank, FACSM1, Mel Haberman2, Joni Nichols3, Robert Short4, Jackie Banasik2, Melanie Matson2, Jacqueline Kittel5. 1Program in Health Sciences, Washington State University Spokane, Spokane, WA. 2College of Nursing, Washington State University, Spokane, WA. 3Cancer Care Northwest (US Oncology), Spokane, WA. 4Washington Institute for Mental Illness Research & Training, Washington State University, Spokane, WA.,5Harmony Yoga, Spokane, WA. : Impact of Active Iyengar Yoga Practice on Markers of Cell-mediated Cytotoxicity in Breast Cancer Survivors Sally E. Blank, FACSM1, Mel Haberman2, Joni Nichols3, Robert Short4, Jackie Banasik2, Melanie Matson2, Jacqueline Kittel5. 1Program in Health Sciences, Washington State University Spokane, Spokane, WA. 2College of Nursing, Washington State University, Spokane, WA. 3Cancer Care Northwest (US Oncology), Spokane, WA. 4Washington Institute for Mental Illness Research & Training, Washington State University, Spokane, WA.,5Harmony Yoga, Spokane, WA. Abstract
Sally E. Blank, FACSM1, Mel Haberman2, Joni Nichols3, Robert Short4, Jackie Banasik2, Melanie Matson2, Jacqueline Kittel5. 1Program in Health Sciences, Washington State University Spokane, Spokane, WA. 2College of Nursing, Washington State University, Spokane, WA. 3Cancer Care Northwest (US Oncology), Spokane, WA. 4Washington Institute for Mental Illness Research & Training, Washington State University, Spokane, WA. 5Harmony Yoga, Spokane, WA. Email: seblank@wsu.edu
PURPOSE: To determine if an eight-week yoga practice improved markers of cell-mediated cytotoxicity in female breast cancer (BrCa) survivors. METHODS: Survivors (Stages I-IV, age 61 ± 7.4 yrs.) were randomly assigned to yoga (Y, n=10) or waitlisted (WL, n=9) groups. Demands of Illness Inventory (DOII) and immune indices were evaluated pre- (T1) and post-yoga (T2). Iyengar yoga practice occurred twice weekly, 90-minute per day plus one home practice. Data were analyzed by Mann-Whitney U test. RESULTS: The %CD16+CD56+ cells, %CD16brightCD56dim cells, and cytotoxicity against human leukemia cells (K-562) were not altered from T1to T2. Cytotoxicity against human breast cancer cells (MCF7) decreased in WL (39.0±7.6 at T1 vs 19.1±6.1, LU per 107effectors, mean±SEM) but remained stable in Y (30.3±5.9 at T1 vs 31.2±5.3, LU per 107effectors), such that at T2, Y had a significantly greater cytolytic response (p<0.05). DOII for treatment, exercise and diet significantly declined from T1 to T2 with yoga. CONCLUSION: Yoga participation was associated with greater stability in cell-mediated cytotoxicity against a tumor target that is biologically relevant to the clinical diagnosis of breast cancer. Supported by Cancer Prevention and Research Center WSU; University of Washington Center for Women’s Health and Gender Research. Introduction
Approximately 36% to 83% of breast cancer survivors are estimated to use complementary and alternative medicine (CAM) to improve quality of life (Buettner et al., 2006). Yoga practice by breast cancer survivors in the Nurses’ Health Study was associated with improved quality of life as compared with survivors who did not use CAM (Buettner et al., 2006). A small body of experimental evidence indicates that in clinical populations participation in Iyengar yoga classes may reduce physical symptoms, such as fatigue (Oken et al., 2004) and attenuate anxiety and depression (Woolery et al., 2004). Yoga therapy, a form of yoga that progresses from gentle to more active asanas (poses) and influenced by the Iyengar tradition, was recently reported to improve global quality of life and emotional function of cancer survivors, including breast cancer survivors (Culos-Reed et al., 2006). Our research focuses on the impact of active yoga practice, taught in the Iyengar tradition, as an integrative medical intervention for breast cancer survivors.
The active practice of Hatha yoga postures generally incorporates nine types of asanas: standing, sitting, twists, supine and prone poses, inversions, balancing poses, backbends, jumpings, and relaxation. Hatha yoga asanas taught according to the Iyengar tradition emphasize the balance of energy flows within the body and should be practiced with precise body alignment, muscular balance, and maximal spinal extension. Iyengar yoga, developed by B.K.S. Iyengar, is unique in its inclusion of props to assist particularly the beginning practitioner in maintaining precise postural alignment in every pose. With this type of practice, self-discipline and self-awareness are developed through mindfulness of body alignment and balance (Mehta et al., 1997).
The purpose of this pilot study was to determine if an eight-week yoga practice improved markers of cell-mediated cytotoxicity and reported indices of psychosocial/quality of life in female BrCa survivors. The hypotheses were: as compared with BrCa survivors who receive treatment as usual, active yoga practice will: a) improve in vitro markers of tumor cytotoxicity and b) decrease cancer-related stressors resulting in improved overall quality of life. Summary and Conclusion
Over the course of an eight-week intervention, self-reported psychosocial measures were stable in the wait-listed control group. Yoga participation by breast cancer survivors reduced scores of self-reported demands of illness and anxiety. Group depression scores indicated a probable presence of a mood disorder (Snaith, 2003), which was not changed in response to the yoga intervention. In vitro cell-mediated cytotoxicity against K-562 leukemia cells was not associated with lytic activity against MCF7 mammary adenocarcinoma cells, consistent with the findings of Hamilton et al. (1988) and Wahlberg et al.(2001). Yoga participation was associated with greater stability in cytotoxicity against a tumor target that is biologically relevant to the clinical diagnosis of breast cancer. Acknowledgments
The authors gratefully acknowledge the women who volunteered to participate in the study and the technical contribution of Jorming Goh. This research was supported by Cancer Prevention and Research Center, WSU; University of Washington Center for Women’s Health and Gender Research. Experimental Design and Methods
The study was conducted as a randomized control trial, with two groups, Yoga (n= 10) and Wait-listed Control (n= 9). Inclusion criteria included: stage I-IV breast cancer estrogen receptor positive diagnosis; at least eight weeks post chemotherapy, use of anti-estrogen or aromatase inhibitor therapy, adequate cardiac functioning, and approval of physician. Exclusion criteria included: use of known immune modulating medications, diagnosis of other neoplasms, active infections, and diagnosis of addictions or psychiatric illness.
Iyengar yoga practice occurred twice weekly, 90-minute class per day plus one home practice. Wait-listed controls crossed-over to the yoga group following the first eight-week session. Data collection pre- (T1) and post-intervention (T2) included: Demands of Illness Inventory (DOII; Woods, Haberman & Packard © 1987, 1993) and Hospital Anxiety and Depression Scale (HADS; Zigmond & Snaith, 1983) assessment questionnaires and a 60 mL blood sample.
Peripheral blood mononuclear cells (PBMC) were isolated by centrifugation over Histopaque-1077 (Sigma Aldrich, St. Louis, MO) and used for in vitro cytotoxicity assay against K-562 Human chronic myelogenous leukemia cells (American Type Culture Collection (ATCC), Manassas, VA) in a standard 51chromium-release 4-hr assay (NKCA). Non plastic adherent PBMCs were used for in vitro cytotoxicity assay against MCF7 Human mammary adenocarcinoma cells (ATCC) in an 24-hr 3-(4,5-dimethylthiazol-2yl)-2,5-diphenyltetrazolium bromide (MTT)-based colorimetric assay (Heo et al., 1990). Leukocyte phenotyping was conducted using a Beckman Coulter Epics XL-MCL 4-color flow cytometer to identify the following positive subpopulations with the respective conjugate: CD45-PC5 / CD16-FITC / CD56-PE / CD3-ECD (Beckman Coulter, Miami, FL). From these profiles, cells were subsequently analyzed for the %CD45+CD3-CD16+CD56+ cells, and the %CD16brightCD56dim cells.
Data were tested for nomality and equal variance and analyzed by two-way analysis of variance and t Test. Non normally distributed data were analyzed by Mann-Whitney U test and by Spearman Rank Order using SigmaStat (SPSS Inc., Chicago, IL). The level of significance was set at p<0.05. Results
Subject Attrition: Five women in the control group dropped from the study for personal reasons after the first eight weeks and did not cross-over to the yoga group. Two women dropped from the yoga group; one for personal reasons and one because she was not physically capable of performing the active yoga practice. Combined group totals were Yoga, n = 12 and Control, n = 9.
Demographics: The groups did not differ in age (Control = 59.2 ± 2.2 yr, Yoga = 59.0 ± 2.2 yr; average ± SEM), time since initial cancer diagnosis (Control = 46.2. ± 6.6 mo; Yoga = 62.5 ± 8.1 mo), or stage of breast cancer (I-II) at initial diagnosis. Subject medications e.g.., anti-estrogen or aromatase inhibitor hormonal therapy did not differ between groups or over time.
Immunophenotyping:
The groups did not differ at T1
in the percentage of natural
killer (NK) cells defined as
%CD45+CD3-CD16+CD56+
cells or the cytolytically active
subset of NK cells, defined as
%CD16brightCD56dim cells
(Figure 1). Yoga participation
did not significantly change the
percentage of NK cells in
PBMC (Figure 1, Data represent
average values + SEM).
Results
In vitro Cell-mediated Cytotoxicity Analyses:
a) NKCA Against K-562 Leukemia Cells –
The change in cytolytic activity against K-562
leukemia cells from T1 to T2 was statistically
different between groups (p = 0.023), however
lytic unit absolute values were not different
between groups at T1 and T2 (Figure 2).
b) MTT Cytotoxicity Against MCF7 Mammary
Adenocarcinoma Cells – From T2 to T1,
cytotoxicity (LU per 107effectors) decreased in the
control group but remained stable in cells from the
yoga group such that at T2, yoga participants had a
significantly greater cytolytic response
(Figure 3 and Table 1).
Psychosocial Analyses: No differences were observed
between groups in reported DOII total score or the HAD
scores for anxiety and depression at T1 or T2 (Tables 2 & 3). Demands of Illness Inventory total score and the HAD anxiety score significantly decreased in the yoga group only from T1 to T2. Scores of 11+ on either HAD subscale are representative of a significant “case” of psychological morbidity, scores of 8–10 represent “borderline” and 0–7 are considered “normal” (Zigmond & Snaith, 1983). The DOII is a 68-item instrument that measures illness related demands in six domains (physical symptoms, personal meaning, social relationships, self-image, monitoring symptoms by self and others, and treatment issues). The range of total scores = 0-284. Significant associations and trends (0.05