[From the Doctor]
Managing chemotherapy side-effects with Taiji Quan (TJQ) and related complementary mind-body therapies (MBT): an aperçu.
By Claude Fournier, MD.
Centre de santé et de services sociaux de Beauce.
A diagnosis of cancer is already a source of distress in the life of an attained person (Bultz 2006, Carlson 2004 a) and chemotherapy is a conventional form of treatment for many types of cancer. This treatment adds on the initial burden related to the disease itself by its physical, psychological and social immediate and long term impacts (Love 1989). Speaking for colorectal cancer (CRC) patients, these treatment-related side-effects not only decrease their quality of life but also compromise treatment efficacy (Berg 1998).
Among the many non-specific side effects of chemotherapy, nausea, fatigue and sleep disorders are among the six more frequently apprehended ones (Hofman 2004, Mustian 2006) by patients.
Chemotherapy-induced nausea and vomiting (CINV) are common and distressing problems in the treatment of CRC patients (Berg 1998, Horiot 2005) as it is for other types of cancer (Redd 2001). Though regimens have improved and are more finely targeted (Grunberg 2004) and despite new antiemetic drugs development (Foubert 2005, Mahesh 2005), the pharmacologic approach remains limited to control CINV even following the recent guidelines (Horiot 2005).
Fatigue is the most frequent symptom cited in relation to cancer and its treatment; often lingering beyond that phase (Carlson 2004, 2006, Visovsky 2003). It was reportedly present at the time of diagnosis in approximately 50-75% of cancer patients and the prevalence increased to 80-96% in patients undergoing chemotherapy (Stasi 2004).
In cancer setting, fatigue is to be defined as a chronic form of tiredness, which is perceived by the patient as being unusual or abnormal, and absolutely disproportionate with respect to the amount of exercise or activity he/she has carried out and which is not removed by resting or sleeping (Tavio 2002).
Also demonstrated as the most distressing phenomenon experienced by cancer patients, fatigue and its manifestations are better appreciated if they are conceptualised as a syndrome, namely, cancer-related fatigue syndrome (CRFS). CRFS influences all aspects of quality of life (QOL) and aggravates the experience of other distressing symptoms like nausea (Winningham 2001). Beside physical and psychosocial impact, there are also adverse economic consequences for the patients and their family (Gregory 2000). For all these reasons, CRFS is now an ever more considered aspect of the toxicity of chemotherapy (Iop 2004). This said, evaluation of CRFS is of a multidimensional complexity (Tavio 2002) and its physiopathologic basis remains poorly understood to date (Stasi 2003).
Sleep disturbance is a prominent concern among cancer patients (Davidson 2002) and would occur in approximately 30 to 50% of this population (O’Donnell 2004, Theobald 2004). It is evident that the cause of chronic sleep difficulties is multifaceted but up until recently, little attention has been given to the potential factors associated with the pathogenesis of cancer related insomnia (Graci 2005). Among these factors, chemotherapy may bring distress to patients and adversely affect sleep quality (Redeker 2000, Simeit 2004, Kuo 2006).
Insomnia in the context of cancer is still undertreated (Theobald 2004) and it appears that the therapeutic approach has to be multimodal to augment its chances of success (Savard 2001, O’Donnel 2004). Cautious usage of hypnotics is recommended as they are associated with a poorer quality of life (Paltiel 2004).
A place for complementary and alternative medicine (CAM).
Merits and limits of the conventional medical and pharmacologic approaches have been noticed relatively to the management of nausea, fatigue and insomnia in the context of cancer and its treatment. Despite the efforts to manage those side-effects, a significant portion of cancer patients is seeking relief with CAM approaches (Lengacher 2006, Cassileth 2004).
CAM use in adults cancer patients could widely vary from 31 to 91% depending to consulted sources (Cassileth 1999, Deng 2005, Rosenthal 2005, Verhoef 2005, Yates 2005). According to research, dissatisfaction with conventional treatment would represent a minor reason for this quest outside of the orthodoxy (Vehoef 2005, Lengacher 2006); a major one would be a desire to enhance quality of life (QOL) and a diminution of cancer symptoms or treatment-related side-effects as a review reports in 17 of the 52 (32.7%) papers studied (Verhoef 2005). As a response to this trend, integrative oncology emerged combining with surgery, chemotherapy and radiation CAM modalities that have some high quality scientific evidence of safety and effectiveness (Rosenthal 2005, Deng 2004, 2005).
A subgroup of them is constituted by mind-body therapies (MBT) which are defined by the National Institute of Health (NIH) as “interventions that use a variety of techniques designed to facilitate the mind’s capacity to affect bodily function and symptoms” (Astin 2003). This definition encompass a vast array of disciplines that may include physical exercise, relaxation, meditation, yoga, qigong and taijiquan among many others. The fundamental element of these practices would be the elicitation of the relaxation response (MBMI.org 2005). The evidence is now strong to support the incorporation of MBT in the management of the treatment and disease-related symptoms of cancer (Astin 2003).
Though a large CAM utilisation by cancer patients, MBT are used by only less than 20% of them (Wolsko et al. 2004). According to the same authors, MBT should be more encouraged for indications with demonstrated efficacy, namely in integrated approach to cancer treatment where research is well supported.
MBT and CINV
Western cognitive and behavioural interventions are useful to mitigate CINV to a certain measure (Redd 2001). Maintaining or developing a physical exercise program may constitute a part of such interventions as many papers report the benefits of low to moderate intensity aerobic exercise on CINV (Abdulla 2001, Courneya 2002, Visovsky 2005).
Preliminary results indicate that yoga would also help to attenuate CINV (Peck 2003, Bower 2005).
Though recognised for its health benefits in general, qigong (literally “energy work”) , a vast system of traditional chinese health exercises, is neglected as a complement in cancer treatment (Chen 2002). According to a body of preliminary clinical observations qigong would reduce chemotherapy side effects (Sancier 1999) and it would be advantageous that its practice were more encouraged (Sancier 2004).
As a part of a cancer supportive care program, qigong has been reported in self administered questionnaires to reduce stress in 78% of 334 patients and to increase well being in 74% of the same patients (Spiegel 2003, 2004). Recently, a quasi-experimental design study reported that qigong significantly reduced pain, numbness, heartburn and dizziness associated with breast cancer and chemotherapy (Lee 2006).
MBT and fatigue
Aerobic exercise is one of the two tested interventions that showed consistent effects to alleviate CRFS (Stasi 2003). Experience has demonstrated the feasibility of exercise programs during chemotherapy for breast cancer for more than a decade (Winningham 1991, Mock 1994) and more recently for other types of cancer (Adamsen 2003, Stevinson 2004, Galvao 2005, Schmitz 2005).
Evidence suggests that low intensity aerobic exercise is sufficient to decrease fatigue levels over the course of cancer treatment (Visovsky 2005) though custom more demanding regimens may also be beneficial (Carlson 2006). Preliminary data suggest that group practice would add a sense of belonging and motivation, thus stimulating active lifestyles and supporting QOL during treatment (Midtgaard 2006).
Meditation’s impact on cancer and its treatment has been reported in medical literature for at least thirty years and what can be expected from that intervention described along the course of time (Meares 1976, 1979, 1982). According to a case load of 73 patients with advanced cancer who have been able to attend at least 20 sessions of intensive meditation, results indicates that nearly all such patients should expect significant reduction of anxiety and depression, together with much less discomfort and pain. There is reason to expect a ten per cent chance of quite remarkable slowing of the rate of growth of the tumour, and a ten per cent chance of less marked but still significant slowing. The results indicate that patients with advanced cancer have a ten per cent chance of regression of the growth. There is a fifty per cent chance of greatly improved quality of life and for those who die, a ninety per cent chance of death with dignity (Meares 1980).
Recently, a more scientific approach has been adopted toward meditation, specifically in regard to mindfulness-based stress reduction (MBSR) method for healthy people in general (Davidson 2003) and for cancer patients in particular (Speca 2000, Carlson 2001, 2003, 2004 b, 2005). A rationale has been demonstrated for MBSR application in cancer population (Mackenzie 2005); fatigue diminution and an increase of vigor measured by the Profile of Mood State (POMS) questionnaire subscales being significant elements. Numerous other QOL outcomes like anxiety, depressive mood and control perception also benefited from MBSR intervention (Carlson cited, Tacon 2003, 2004).
MBT and sleep disorders
An exploratory study revealed that MBSR positively affected the sleep quality of a heterogeneous sample of cancer patients. Overall sleep disturbance was significantly reduced and largest improvements occurred in the areas of subjective sleep quality, sleep efficiency and duration as measured by the Pittsburg Sleep Quality Index (PSQI) (Carlson 2005).
Yoga is a MBT for which preliminary evidence suggests positive psychological impact on cancer survivors, particularly for mood and stress (Culos-Reid 2006). It is also reported to significantly improve sleep-related outcomes in patients with lymphoma. These included better subjective sleep quality, faster sleep latency, longer sleep duration also measured with the PSQI. Less use of sleep medication has also been documented (Cohen 2004).
Outside cancer treatment context, taijiquan (TJQ) has been reported to improve self-rated quality of sleep in older adults (Li 2004).
Taijiquan as a MBT to complement cancer treatment
In seven out of seventeen controlled trials with or without randomization, TJQ is recognised to improve QOL and relieve stress (Klein 2004). Though successful cancer supportive programs including TJQ has been described (CancerWise 2002, HealthWorldOnline 2003) and the publication of a few studies concerning breast cancer survivors (Mustian 2004 a,b, Davis 2004), there has been no study assessing TJQ impact on chemotherapy side effects according to our knowledge at redaction time.
As TJQ is now recognised as a low to moderate intensity aerobic exercise (Taylor-Piliae 2004), it is normal to think that it would have at least the same benefits as those described earlier for aerobic exercise of the same intensity alone.
Both martial tradition (Diepersloot 1995, Liu 1986, Al Huang 1986) and scientific researchers (Li 2004, Yeh 2004, Fisher 2003, Sandlund 2000) acknowledge meditative aspects to TJQ. A theoretic mindfulness model proposes that three axioms (intention, attention and attitude) must be present for mindfulness (paying attention non-judgementally moment to moment, on purpose) to work (Shapiro 2006). According to this conception, TJQ could be considered a kind of mindfulness meditation in motion as the attention is deliberately and constantly maintained on each movement in a relaxed non judgmental manner.
Finally, TJQ could be considered a form of qigong initially applied to martial art development. Now incorporated in traditional medicine (Lalancette 2005), it is recognised as a proper modality to facilitate qi (vital energy) circulation. Regarding chemotherapy side effects, we should expect comparable benefits to those of qigong.
Summarising, TJQ is an art and a discipline per se but, as we just saw, it shares many characteristics of other disciplines that have demonstrated certain benefits in integrated cancer treatment. TJQ is a low to moderate aerobic exercise that shares similitudes with yoga, qigong and meditation. For these reasons, we think that it might be helpful for patients with colorectal cancer undergoing chemotherapy.
Abdulla A, Abdulla F, Exercise: a prescription for cancer patients, The Canadian Journal of Diagnosis, 2001 Jun;:111-116.
Adamsen L et al., Feasibility, physical capacity, and health benefits of a multidimensional exercise program for cancer patients undergoing chemotherapy, Supportive Care in Cancer 2003;11:707-716.
Al Huang Chungliang, Tai Ji, danse du tao, Guy Trédaniel Éditeur, France, 1986, p.49.
Astin JA, Shapiro SL, Eisenberg DM, Forys KL, Mind-body medicine: State of the science, implications for practice, J Am Board Fam Pract 2003;16:131-47.
Berg D, Managing the side effects of chemotherapy for colorectal cancer, Semin Oncol. 1998 Oct;25(5 Suppl 11):53-9.
Bower JE, Woolery A, Garet D, Yoga for cancer patients and survivors, Cancer Control, 2005 July;12(3):165-171.
Bultz B D, Carlson L E, Emotional distress: the sixth vital sign – future directons in cancer care, Psycho-oncology 2006; 15:93-95.
CancerWise, Tai Chi helps patients reach beyond cancer, 2002 July, www.cancerwise.org (valid 2004-01-06).
Carlson LE, Ursuliak Z, Goudey E, Angen M, Speca M, The effects of a mindulness meditation-based program on mood and symptoms of stress in cancer outpatients: 6-month follow-up, Support Care Cancer 2001;9:112-123.
Carlson LE, Speca M, Patel KD, Goodey E, Mindfulness-based stress reduction in relation to quality of life, mood, symptoms of stress, and immune parameters in breast and prostate cancer outpatients, Psychosomatic Medicine 2003;65:571-581.
Carlson LE et al., High level of untreated distress and fatigue in cancer patients, Br J Cancer. 2004 Jun 14;90(12):2297-304. (a).
Carlson LE, Speca M, Patel KD, Goodey E, Mindfulness-based stress reduction in relation to quality of life, mood, symptoms of stress, and levels of cortisol, dehydroepiandrosterone (DHEAS) and melatonin in breast and prostate cancer outpatients, Psychoneuroendocrinology 2004 May;29(4):448-474. (b).
Carlson LE, Garland SN, Impact of mindfulness-based stress reduction (MBSR) on sleep, mood, stress and fatigue symptoms in cancer outpatients, Int J Behav Med. 2005;12(4):278-85.
Carlson LE, Smith D, Russell J, Fibich C, Whittaker T, Individualized exercise program for the treatment of severe fatigue in patients after allogenic hematopoietic stem-cell transplant: a pilot study, Bone Marrow Transplantation, 2006, in press.
Cassileth B, Evaluating complementary and alternative therapiies for cancer patients, CA Cancer J Clin 1999;49:362-375.
Cassileth B, Deng G, Complementary and alternative therapies for cancer, The Oncologist, Feb 2004, 9(1):80-89
Chen K, Yeung R, A Review of Qigong Therapy for Cancer Treatment, Journal of International Society of Life Information Science (ISLIS), 2002;20 (2) :532-42.
Cohen L, Warneke C, Fouladi RT, Rodriguez MA, Chaoul-Reich A, Psychological adjustment and sleep quality in a randomized trial of the effects of a Tibetan yoga intervention in patients with lymphoma, Cancer. 2004 May 15;100(10):2253-60.
Courneya KS, Mackey JR, McKenzie D, Exercise for breast cancer survivors, The Physician and Sportsmedicine, Aug 2002;30(8). www.physsportsmed.com/issues/2002/08_02/courneya.htm (valide 2006-02-22).
Culos-Reid N, Carlson L E, Daroux L M, Hately-Aldous S, A pilot study of yoga for breast cancer survivors: physical and psychological benefits, Psycho-oncology 2006, Published online www.interscience.wiley.com DOI: 10.1002/pon.10221.
Davidson JR, MacLean AW, Brundage MD, Schulze K, Sleep disturbance in cancer patients, Soc Sci Med. 2002 May;54(9):1309-21.
Davidson R, Kabat-Zinn J et al., Alterations in brain and immune function produced by mindfulness meditation, Psychosomatic Medicine 2003;65:564-570.
Davis PG, Mustian KM, Katula JA, Wideman L, Tai Chi Chuan and insulin-like growth factor-I (IGF-I) in breast cancer survivors, Medicine & Science in Sports &Exercise 2004 May;36(5):S97-S98.
Deng G, Cassileth B, Yeung KS, Complementary therapies for cancer-related symptoms, J Support Oncol. 2004 sep-Oct;2(5)419-26.
Deng G, Cassileth B, Integrative oncology: complementary therapies for pain, anxiety, and mood disturbance, CA Cancer J Clin. 2005;55:109-116.
Diepersloot J, Warriors of stillnes, meditative traditions in the chinese martial arts, California, 1995, p. ii.
Fisher KJ, Promoting health through tai chi: Results from a controlled study, Californian Journal of Health Promotion 2003;1(4):79-87.
Galvao DA, Newton RU, Review of exercise intervention studies in cancer patients, J Clin Oncol. 2005 Feb1;23(4):899-909.
Graci G, Pathogenesis and management of cancer related insomnia, J Support Oncol. 2005 Sep-Oct;3(5):349-59.
Gregory A and al., Impact of cancer-related fatigue on the lives of patients: new findings from the Fatigue Coalition, The Oncologist 2000;5:353-360.
Grunberg SM, Chemotherapy-induced nausea and vomiting: prevention, detection, and treatment – how are we doing?, J Support Oncol. 2004 Jan-Feb;2(1 suppl 1):1-10.
HealthWorldOnline, Cancer patients find help in ancient martial art, 2003, http://www.healthy.net/asp/templates/news.asp?Id=7426 (valide 2003-08-12).
Hofman M, Morrow GR, Roscoe JA, Hickok JT, Mustian KM, Moore DF, Wade JL, Fitch TR, Cancer patients’ expectation of experiencing treatment-related side-effects: a University of Rochester Cancer Center-Community Clinical Oncology Program study of 938 patients from community practices, Cancer 2004 Aug 15;101(4):851-7.
Horiot JC, Antiemetic therapy in cancer: an update, Expert Opin Pharmacother. 2005 Aug;6(10):1713-23.
Iop A, Manfredi Am, Bonura S, Fatigue in cancer patients receiving chemotherapy: an analysis of published studies, Annals of Oncology 2004;15:712-720.
Klein PJ, Adams WD, Comprehencive therapeutic benefits of Taiji, American Journal of Physical Medicine & Rehabilitation, 2004 Sep;83:735-745.
Kuo HH, Chiu MJ, Hwang SL, Quality of sleep and related factors during chemotherapy in patients with stage I/II breast cancer, J Formos Med Assoc. 2006 Jan;105(1):64-9.
Lalancette M, Tai Ji Quan (Tai Chi), published online, http://www.passeportsante.net/fr/Therapies/Guide/Fiche.aspx?doc=tai_ji_quan_th (consulted 2006-01-17)
Lee TI, Chen HH, Yeh ML, Effects of chan-chuang qigong on improving symptom and psychological distress in chemotherapy patients, Am J Chin Med. 2006;34(1):37-46.
Lengacher CA, Bennett MP, Kip KE, Gonzalez L, Jacobsen P, Cox CE, Relief of symptoms, side effects, and psychological distress through use of complementary and alternative medicine in women with breast cancer, Oncol Nurs Forum 2006 Jan 1;33(1):97-104
Li F et al., Tai Chi and self-rated quality of sleep and daytime sleepiness in older adults: A randomized contolled trial, J Am Geriatr Soc. 2004 Jun;52(6):892-900.
Liu Da, T’Ai Chi Ch’uan & Meditation, Schocken Books, New York, 1986.
Love RR, Leventhal H, Easterling DV, Nerenz Dr, Side effects and emotional distress during cancer chemotherapy, Cancer 1989 Feb 1;63(3):604-12.
Mackenzie MJ, Carlson LE, Speca M, Minfulness-based stress reduction (MBSR) in oncology. Rationale and review, Evid Based Integrative Med 2005:2(3)1.
Mahesh R, Perumal RV, Pandi PV, Cancer chemotherapy-induced nausea and vomiting: role of mediators, development of drugs and treatment methods, Pharmazie 2005 Feb;60(2):83-96.
MBMI.org, Mind/body basics, 2005, http://www.mbmi.org/basics/default.asp (consulted 2006-03-17).
Meares A, Regression of cancer after intensive meditation, Medical Journal of Australia, July 31, 1976.
Meares A, The psychological treatment of cancer, the patient’s confusion of the time for living with the time for dying, Aust Fam Physician, 1979;8:801-805.
Meares A, What can the cancer patient expect from intensive meditation? Aust Fam Physician, 1980;9:322-325.
Meares A, Stress, meditation and the regression of cancer, Practitioner, 1982 226:1607-1609.
Midtgaard J, Rorth M, Stelter R, Adamsen L, The group matters: an explorative study of group cohesion and quality of life in cancer patients participating in physical exercise intervention during treatment, European Journal of Cancer Care, 2006;15:25-33.
Mock V et al., A nursing rehabilitation program for women with breast cancer receiving adjuvant chemotherapy, Oncol Nurs Forim. 1994 Jun;21(5):899-907.
Mustian KM, Katula JA, Lang D, Murphy K, Breast cancer, Tai Chi Chuan and health-related physical fitness, Medicine & Science in Sports &Exercise 2004 May;36(5):S284-S285.
Mustian KM, Katula JA, Gill DL, Roscoe JA, Lang D, Murphy K, Tai Chi Chuan, health-related quality of life and self-esteem: a randomized trial with breast cancer survivors, Support Care Cancer 2004;12:871-876.
Mustian KM et al., Exercise and side effects among 749 patients during and after treatment for cancer: a University of Rochester Cancer Center Community Clinical Oncology Program study, Support Care Cancer 2006 Feb 16 (Epub ahead of print).
O’Donnell JF, Insomnia in cancer patients, Clin Cornerstone. 2004;6 Suppl 1D:S6-14.
Paltiel O et al., Use of tranquilizers and sleeping pills among cancer patients is associated with a poorer quality of life, Qual Life Res. 2004 Dec;13(10):1699-706.
Peck P, Yoga helps breast cancer patients, eases nausea, improves well-being, WebMD, http://my.webmd.com/content/Article/66/79656.htm (valide 2005-09-28).
Redd WH, Montgomery GH, DuHamel KN, Behavioral intervention for cancer treatment side effects, Journal of the National Cancer Institute 2001 June; 93(11):810-23.
Redeker NS, Lev EL, Ruggiero J, Insomnia, fatigue, anxiety, depression, and quality of life of cancer patients undergoing chemotherapy, Sch Inq Nurs Pract. 2000 Winter;14(4):275-90.
Rosenthal DS, Dean-Clower E, Integrative medicine in hematology/oncology: benefits, ethical consideration, and controversies, Hematology (Am Soc Hematol Educ Program). 2005;:491-7.
Savard J, Morin CM, Insomnia in the context of cancer: a review of a neglected problem, J Clin Oncol. 2001 Feb 1;19(3):895-908.
Sancier KM, Medical Applications of Qigong, Alternative Therapies, January 1996, Vol 2. No.1.
Sancier KM, Therapeutic benefits of qigong exercises in combinations with drugs, Journal of Alternative and Complementary Medicine 1999;5(4):383-89.
Sancier KM, Multifaceted health benefits of medical qigong, J Alt Compl Med. 2004; 10(1):163-166.
Sandlund ES, Norlander T, The effects of tai chi chuan relaxation and exercise on stress responses and well-being: an overview of research, International Journal of Stress Management, 2000;7(2):139-49.
Schmitz KH, Holtzman J, Courneya KS, Masse LC, Duval S, Kane R, Controlled physical activity trials in cancer survivors: a systematic review and meta-analysis, Cancer Epidemiol Biomarkers Prev. 2005 Jul;14(7):1588-95.
Shapiro Shauna et al., Mechanisms of mindfulness, J Clin Psychol 2006 Mar;62(3):373-86.
Simeit R, Deck R, Marx B, Sleep management training for cancer patients with insomnia, Support Care Cancer. 2004 Mar;12(3):176-83.
Speca M; Carlson LE; Goodey E; Angen M, A randomized, wait-list controlled clinical trial: the effect of a mindfulness meditation-based stress reduction program on mood and symptoms of stress in cancer outpatients, Psychosomatic medicine, 2000 Sep-Oct;62 (5) :613-22.
Spiegel D et al, The Cancer Supportive Care Program (CSCP) at Stanford’s Center for Integrative Medicine : program development and evaluation, Abstract for the 39th American Society of Clinical Oncology, May 31-June 3, 2003, Chicago, IL (USA)
Spiegel et al., Cancer supportive care, improving the quality of life for cancer patients. A program evaluation report, Supportive Care in Cancer. 2004 May;12(5):293-301.
Stasi R, Abriani L, Beccaglia P, Terzoli E, Amadori S, Cancer-related fatigue: evolving concepts in evaluation and treatment, Cancer. 2003 Nov 1;98(9):1786-801.
Stevinson C, Lawlor DA, Fox KR, Exercise interventions for cancer patients: systematic review of controlled trials, Cancer Causes Control. 2004 Dec;15(10):1035-56.
Tacon AM, Meditation as a complementary therapy in cancer, Fam Community Health. 2003 Jan-Mar;26(1):64-73.
Tacon AM, Caldera YM, Ronaghan C, Mindfulness-based stress reduction in women with breast cancer, Families, Systems, and Health 2004;22(2):193-203.
Tavio M, Milan I, Tirelli U, Cancer-related fatigue (review), Int J Oncol. 2002 Nov;21(5):103-9.
Taylor-Piliae RE, Froelicker ES, The effectiveness od Tai Chi exercise in improving aerobic capacity. A meta-analysis, Journal of Cardiovascular Nursing 2004;19(1):48-57.
Theobald DE, Cancer pain, fatigue, distress, and insomnia in cancer patients, Clin Cornerstone. 2004;6 Suppl 1D:S15-21.
Verhoef MJ, Balneaves LG, Boon HS, Vroegindewey BN, Reasons for and characteristics associated with complementary and alternative medicine use among adult cancer patients: a systematic review, Integrative Cancer Therapies, 2005;4(4):274-286.
Visovsky C, Dvorak C, Exercise and cancer recovery, Online Journal of Issues in Nursing, 2005 March 10(2). http://nursingworld.org/ojin/hirsh/topic3/tpc3_2.htm
Winningham ML, Walking program for people with cancer. Getting started, Cancer Nurs. 1991 Oct;14(5):270-6.
Wolsko PM, Eisenberg DM, Davis RB, Phillips RS, Use of mind-body medical therapies, J Gen Intern Med. 2004 Jan;19(1):43-50.
Yates JS et al., Prevalence of complementary and alternative medicine use in cancer patients during treatment, Support Care Cancer. 2005 Oct;13(10):806-11.
Yeh Gloria Y et al., Effects of tai chi mind-body movement therapy on functional status and exercise capacity in patients with chronic heart failure: a randomized controlled trial, American Journal of Medicine, 2004, vol. 117, pp. 541-548.