INTRODUCTION
Tai Chi has been shown to be like conventional supportive care therapies in terms of reducing fatigue and depression and improving the quality of life (QoL) and sleep quality among patients with breast cancer.[ 1 ] Qigong is a self-directed exercise that incorporates meditation and breathing patterns.[ 2 ] Tai Chi is a slow-movement exercise that combines mindfulness, and deep and controlled breathing. Traditional Tai Chi incorporates Qigong, and in fact, Qigong is an essential component of Tai Chi .
Cancer therapies can result in severe long-term discomfort, which can impair QoL.[ 3 ] Fatigue is a common complaint among patients with cancer and has been associated with surgery, chemotherapy, and radiotherapy.[ 4 ] Furthermore, cancer-related fatigue may impair a patient’s capacity to complete routine therapies, affecting standard medical care, and perhaps lower overall survival rates.[ 5 ] Treatment of fatigue in women with breast cancer is thought to have a strong and clinically significant relationship with depression and anxiety. Cancer-related fatigue worsens QoL, including social, psychological, functional, and even financial well-being.[ 6 ] Limited data support the advantages of 40-60 min of supervised Tai Chi training three times a week for 8 to 12 weeks to reduce fatigue among cancer survivors. Although Tai Chi may reduce cancer-related fatigue, the quality of the existing studies on Tai Chi for cancer-related fatigue is low.[ 7 ] Studies that have reported on the benefits of Tai Chi and Qigong on QoL and fatigue among patients with cancer are limited in number, therefore any conclusions regarding the evidence should be made with caution.[ 8 ] Qigong and Tai Chi are both mind-body therapies that can improve physical and mental well-being.[ 9 ] Qigong and Tai Chi originated in ancient China, combining aspects of Chinese traditional medicine, martial arts, and a philosophy of living.[ 10 ] In general, Tai Chi has a positive impact on the QoL of patients with cancer.[ 11 ] The results of several clinical trials demonstrated that Tai Chi reduces inflammatory responses and improves QoL, muscle strength, shoulder function, bone formation, and insomnia in patients with breast cancer.[ 12 , 13 ] Several studies have shown that Qigong improves QoL and relieves depression and anxiety.[ 14 ]
The objective of this review was to evaluate the efficacy of Tai Chi and Qigong in improving QoL and reducing fatigue in patients with breast cancer and cancer survivors. We conducted this narrative review because of the lack of clarity in establishing the effectiveness of Tai Chi and Qigong in mitigating cancer-related fatigue and improving QoL among patients with breast cancer. We compiled all the evidence from the existing systematic reviews and meta-analyses on this topic to give a high-level overview. An overview of all the conducted reviews of each of these interventions will be useful in determining how to best translate the evidence into practice. Our goal was to determine what is known about this topic, and what remains unspecified, and to make appropriate recommendations for further research.
MATERIALS AND METHODS
Relevant systematic reviews and meta-analyses regarding the effects of Tai Chi and Qigong on fatigue and QoL in patients with breast cancer were systematically gathered and assessed. Data collection was carried out using the preferred reporting items for systematic reviews and meta-analyses checklist and the Cochrane systematic reviews guidelines[ 15 ] [Figures 1 and 2 ].
Figure 1: PRISMA checklist for studies that reported on the effects of Tai Chi and Qigong on cancer-related fatigue among patients with breast cancer
Figure 2: PRISMA checklist for studies that reported on the effects of Tai Chi and Qigong on quality of life among patients with breast cancer
Database search
Three electronic English medical databases (PubMed, Scopus, and Web of Science) were systematically searched from inception up to July 2021. The PICO framework–population (patients with breast cancer), intervention (Tai Chi and Qigong), comparison (no intervention), outcome (decrease in cancer-related fatigue, and improvement in QoL compared to no exercise and patients who only participated in normal or routine health care) was used to identify and select the papers. The following search terms were used in various relevant combinations to screen potential studies: ((((Tai Chi ) OR Qigong) AND breast cancer AND fatigue)) and ((((Tai Chi ) OR Qigong) AND breast cancer AND (quality of life))). There were no language or publication date restrictions.
Selection of studies
The first two authors (SG and CEO) individually screened the databases by reading the titles and abstracts. Subsequently, the full-text versions of the papers deemed to be potentially suitable were obtained. All four authors (SG, CEO, GT, and AM) discussed and made the final selection of the articles to be included.
Eligibility criteria
We included systematic reviews and meta-analyses of studies with various designs including observational, experimental, case-control, cross-sectional, and cohort to identify pertinent studies that examined the effects of Tai Chi and Qigong on fatigue and QoL among patients with breast cancer. We excluded studies that were not systematic reviews or meta-analyses. No language restriction was applied. All duplicate records were excluded.
Quality assessment
Quality assessment was independently conducted by the first two authors (SG and CEO) using a measurement tool to assess systematic reviews (AMSTAR).[ 16 ] The AMSTAR consists of 11 items that can be used to assess the methodological quality of systematic reviews by determining the presence of 1) a previous design, 2) a selection of duplicate studies and data extraction, 3) a thorough review of the literature, 4) utilization of publication status as an inclusion criterion, 5) a list of research studies that were included/excluded, 6) features of studies mentioned, 7) a detailed evaluation of the scientific quality of the included studies, 8) suitable use of scientific quality in developing findings, 9) proper application of methodologies to integrate the study findings, 10) evaluation of the possibility of publication bias, and 11) statement of a conflict of interest. Differences of opinion in the AMSTAR scoring were resolved by a discussion with the third and fourth authors.
The quality of the included reviews was classified as high (score ≥8/11), moderate (6 or 7), or low quality (scoring 5 or less), as assessed using the AMSTAR tool. The quality of the reviews varied; however, most studies scored 6/11 and slightly above on the AMSTAR tool, indicating moderate-quality evidence.
Extraction and synthesis
From each eligible systematic review and meta-analysis, information was extracted on the first author, country, study design, year of publication, the number of patients, outcomes, and quality assessment [Tables 1 and 2 ]. References were managed using Zotero. To address any issues about data extraction, one author (CEO) collected data from studies with assistance from the other authors. To synthesize the data, a descriptive technique was utilized, which included textual narrative summaries and data tabulation. The narrative synthesis was created to summarize the outcomes of the studies reviewed and assess the effectiveness of the treatments. Tables 1 and 2 illustrate the methodologies utilized for each research study as well as how the exercise was carried out in each study. The bulk of the studies that were included evaluated randomized controlled trials (RCTs) and interventional studies on the effects of Tai Chi and Qigong on fatigue and QoL in patients with breast cancer.
Table 1: Summary of studies that reported on the effects of Tai Chi and Qigong on cancer-related fatigue among patients with breast cancer
Table 2: Summary of studies that reported on the effects of Tai Chi and Qigong on quality of life among patients with breast cancer
RESULTS
We included nine systematic reviews and meta-analyses in this narrative review [see Tables 1 and 2 ]. Three systematic reviews and meta-analyses reported the effects of Tai Chi and Qigong on cancer-related fatigue and four reported their effects on the QoL of patients with breast cancer. Of these, two studies found that Tai Chi and Qigong improved both cancer-related fatigue and QoL.
Evaluation of the study design
One study comprised interventions that compared any kind of Qigong to any sort of control group.[ 14 ] There were no restrictions on the type of Qigong, duration of the program, frequency, and other parameters. Adult patients with breast cancer (18 years or older) were included in the study, regardless of the stage or previous or ongoing therapy. PubMed, Cochrane Central Register of Controlled Trials, Web of Science, Sinomed, Wanfang, Chinese Science and Technology Periodicals Full-Text Database, and China National Knowledge Infrastructure databases were searched for controlled clinical trials from their start until March 2020.[ 14 ] Until June 2019, Liu et al . searched Ovid MEDLINE, Allied and Complementary Medicine Database, Embase Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Central Register of Controlled Trials, and Wanfang Data for RCTs evaluating the effects of Tai Chi among patients with breast cancer.[ 1 ] For the resulting syntheses, a meta-analysis was performed. Sixteen RCTs involving 1,268 participants were included in this review by Liu et al . Duan et al . conducted a systematic review and meta-analysis in which all relevant citations published from inception to October 23, 2019, were searched in Medline via PubMed, Embase, and the Cochrane Library databases.[ 17 ] The study included 15 RCTs with 1,461 participants that met the inclusion criteria. The participants’ ages ranged from 44 to 66 years, with intervention durations ranging from 3 to 24 weeks and sample sizes ranging from 16 to 410. Tai Chi , Qigong, and yoga were among the most popular mind-body exercises. The exercise sessions ranged from around 20 to 90 min each, and they could be performed anywhere from twice a week to daily.[ 17 ] According to one study, a comprehensive search of four electronic databases was conducted to identify randomized and non-randomized clinical studies evaluating Tai Chi and Qigong for tiredness, sleep problems, depression, pain, and QoL in patients with cancer that had been published between August 2016 and August 2017.[ 18 ] The authors selected 22 studies, including 15 RCTs with a total of 1,283 participants, 75% of whom were women. Tai Chi and Qigong training lasted anywhere from 3 to 12 weeks.[ 18 ] To find RCTs that assessed the benefits of Tai Chi on fatigue, Song et al . searched nine databases (PubMed, Web of Science, Ovid, the Cochrane Library, Embase, and four Chinese databases).[ 19 ] To identify possibly relevant studies, they searched through the reference lists provided in the RCTs that they found.[ 19 ] The RCTs included studies in patients with breast (n = 7) and prostate (n = 2) cancers, lymphoma (n = 1), lung (n = 1), and a combination (n = 4) of malignancies. The active intervention (n = 7) was compared to normal care (n = 5). Tai Chi and Qigong training lasted between 3 and 12 weeks.[ 19 ] Zeng et al . searched three databases (Medline, CINAHL, and the China Academic Journals Full-text Database).[ 20 ] They included RCTs of Tai Chi /Qigong as a cancer treatment intervention.[ 20 ] This updated review included a total of 915 individuals from 12 research studies conducted since 2014. Participants in the studies ranged in age from 57 to 72 years, with sample sizes ranging from 19 to 197. All studies included in this review were RCTs. Seven of the 12 RCTs employed Qigong. Four studies combined Tai Chi and Qigong interventions, whereas one study only used Tai Chi .[ 20 ] The programs ranged in length from around 3 to 12 weeks, with each session lasting 60 min. The frequency of supervised exercise ranged from three times per day to twice a week.[ 20 ] One of the selected study search approaches yielded 574 studies, the majority of which were duplicate records or did not report RCTs.[ 21 ] Eventually, 149 full-text papers were thoroughly assessed based on the inclusion and exclusion criteria, yielding a final sample of 34 studies.[ 21 ] One study included available RCTs on the effectiveness of Tai Chi in relieving treatment-related side effects and QoL in women with breast cancer in the following databases: PubMed (1966–November 2014), Embase (1974–November 2014), Cochrane Library (issue 11, 2014), and Web of Science (1974–November 2014). A total of 93 studies were obtained in these databases. There were 28 duplicates and 57 that did not match the criteria for inclusion. Each trial’s baseline values were comparable, and the meta-analysis included nine RCTs.[ 22 ] One study assessed whether Tai Chi enhanced QoL in breast cancer survivors.[ 23 ] A systematic search of electronic databases was conducted to find relevant RCTs. The meta-analysis included five RCTs with a total of 407 patients.[ 23 ]
Effects of Tai Chi and Qigong on fatigue in patients with breast cancer
Duan et al . in their meta-analysis found that Tai Chi significantly decreased fatigue in survivors of any cancer (standardized mean difference [SMD], −0.95; 95% confidence interval [CI], −1.48 to − 0.43; P < 0.01).[ 17 ] Conversely, Meng et al . found that Qigong did not significantly relieve the symptoms of fatigue in women with breast cancer (n = 401; SMD, −0.32; 95% CI, 0.71 to 0.07; P = 0.11).[ 14 ] From their meta-analysis, Wayne et al .[ 18 ] found that Tai Chi and Qigong significantly decreased fatigue in patients with breast cancer (effect size, −0.53, P < 0.001). Liu et al .[ 1 ] evaluated two RCTs that recruited female patients with breast cancer. They found that Tai Chi as a supplement to conventional treatments was more effective in reducing fatigue after 3 months of practice (SMD, −0.91; 95% CI, −1.30 to −0.53). Similar to the findings of Liu et al. ,[ 1 ] Song et al .[ 19 ] also found that Tai Chi relieved fatigue in patients with breast cancer (SMD, −0.81; P < 0.00001). Furthermore, they found that short-term cancer-related fatigue was improved to a greater extent by a longer intervention time of 8 to 12 weeks compared to a shorter duration.[ 19 ]
Effects of Tai Chi and Qigong on QoL in patients with breast cancer
Meng et al .[ 14 ] reviewed 13 trials that used generic scales to assess the effects of Qigong on QoL. In comparison to the patients in the control group, Qigong had a beneficial effect on QoL (n = 950; SMD, 0.65; 95% CI, 0.23-1.08, P = 0.002).[ 14 ] However, Yan et al .[ 23 ] analyzed five RCTs involving 407 breast cancer survivors. The pooled SMDs were 0.10 (95% CI, −0.35 to −0.54) for physical well-being, 0.03 (95% CI, −0.18 to −0.25) for social/family well-being, 0.24 (95% CI, 0.02 to −0.45) for emotional well-being, and 0.23 (95% CI, −0.03 to −0.49) for functional well-being. The meta-analysis showed insufficient evidence to support Tai Chi ’s potential to improve the QoL in patients and survivors of breast cancer.[ 23 ] Duan et al .[ 17 ] found that Tai Chi , Qigong, and other mind-body exercises had no significant impact on the overall QoL. Similarly, Zeng et al .[ 20 ] found no statistically significant association between either Qigong alone or combined with Tai Chi and an improvement in the QoL (P = 0.17). According to Pan et al. ,[ 22 ] there was no statistically significant evidence that Tai Chi improved health-related QoL in patients with stages I-II breast cancer. However, Lin et al .[ 21 ] found that Qigong combined with mindfulness therapy improved the health-related QoL in patients with cancer.
DISCUSSION
Some researchers believe that the slow movements in Tai Chi and Qigong, combined with a decrease in the breath frequency, may alter the autonomic nervous system and restore homeostasis, thereby relieving the stress induced by the hypothalamus-pituitary-adrenal axis reactivity and shifting the autonomic nervous system’s balance toward parasympathetic dominance.[ 24 ] Most studies on the impact of Tai Chi and Qigong on cancer-related fatigue and QoL in patients with breast cancer have poor experimental design regarding the method, the content of the intervention, and research methodologies.[ 25 ] However, some researchers suggested that Tai Chi and Qigong improve QoL and relieve fatigue in patients with breast cancer, regardless of the stage of cancer.[ 26 ] Furthermore, research in the field of exercise oncology supports Tai Chi and Qigong as potential additional or alternative therapeutic exercises for patients with various cancers in addition to conventional treatment. Many areas of clinical research and application in this field are still being investigated.[ 27 ] This will also improve other treatment outcomes when performed by patients with breast cancer. According to several studies, regular Tai Chi practice boosts antioxidant capacity and decreases oxidative stress by increasing superoxide dismutase and catalase levels while also lowering lipoperoxide levels.[ 28 ] When performed by patients with breast cancer, this may improve treatment outcomes. According to the selected studies for this narrative review, most RCTs evaluating the effects of Tai Chi and Qigong on fatigue and QoL in patients with cancer were not of high research quality in terms of the design, method of conducting the exercise intervention, data analysis, and interpretation of the results. The quality of the reviews varied but most reviews received a 6/11 or slightly higher on the AMSTAR instrument, indicating an intermediate level of evidence. Tai Chi and Qigong are both easily adaptable types of mind-body exercises that may be conducted at any time and anywhere without the need for any special equipment. Qigong and Tai Chi should therefore be widely encouraged to enhance physical and emotional well-being in both young and older adults.
STRENGTHS AND LIMITATIONS
This is the first comprehensive assessment of systematic reviews and meta-analyses evaluating the effects of Tai Chi and Qigong on fatigue and QoL in patients with breast cancer. The major limitation was that most of the RCTs evaluated and pooled in the systematic reviews and meta-analyses were of low quality and had ambiguous methodology.
CONCLUSION
Tai Chi and Qigong have shown potential as supplementary therapies in the treatment of fatigue and in improving the QoL in patients with breast cancer. However, the evidence supporting this conclusion is only moderate. As a result, RCTs with larger sample sizes along with longer follow-ups are required to evaluate the effects of different tailored Tai Chi and Qigong regimens on fatigue and health-related QoL in patients with breast cancer at various stages.
Data sharing statement
Data collected included systematic reviews and supplemental primary studies are available on request from the corresponding author.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
1. Liu L, Tan H, Yu S, Yin H, Baxter GD The effectiveness of
tai chi in breast cancer patients:A systematic review and meta-analysis. Complement TherClinPract 2020;38:101078.
2. Hung SH, Hwang CY, Chang CY Is the Qi experience related to the flow experience?Practicing qigong in urban green spaces. PLoS On e2021;16:e0240180.
3. Asthana S, Bhatia S, Dhoundiyal R, Labani SP, Garg R, Bhatnagar S Quality of life and needs of the Indian advanced cancer patients receiving palliative care assessment of the quality of life, problems, and needs of the advanced cancer patient receiving palliative care. Cancer Res Stat Treat 2019;2:138.
4. Xiang Y, Lu L, Chen X, Wen Z Does
Tai Chi relieve fatigue?A systematic review and meta-analysis of randomized controlled trials. PLoS One 2017;12:e0174872.
5. Yin J, Tang L, Dishman R The efficacy of Qigong practice for cancer-related fatigue:A systematic review and meta-analysis of randomized controlled trials. Ment Health Phys Act 2020;19:100347.
6. Moosa Z, Kapoor AR, Chandra M, Bhalavat R, Pareek V, Srivastava A, et al. Fatigue in patients with head-and-neck malignancies receiving radiation therapy and impact on quality of life:A prospective observational study. Cancer Res Stat Treat 2022;5:429–36.
7. Yang L, Winters-Stone K, Rana B, Cao C, Carlson LE, Courneya KS, et al.
Tai Chi for cancer survivors:A systematic review toward consensus-based guidelines. Cancer Med 2021;10:7447–56.
8. Zeng Y, Luo T, Xie H, Huang M, Cheng AS Health benefits of qigong or
tai chi for cancer patients:Asystematic review and meta-analyses. Complement Ther Med 2014;22:173–86.
9. Carlson LE, Zelinski E, Toivonen K, Flynn M, Qureshi M, Piedalue KA, et al. Mind-body therapies in cancer:What is the latest evidence?. CurrOncol Rep 2017;19:67.
10. Jahnke R, Larkey L, Rogers C, Etnier J, Lin F A comprehensive review of health benefits of qigong and
tai chi . Am J Health Promot 2010;24:e1–25.
11. Chen YW, Hunt MA, Campbell KL, Peill K, Reid WD The effect of
Tai Chi on four chronic conditions-cancer, osteoarthritis, heart failure and chronic obstructive pulmonary disease:Asystematic review and meta-analyses. Br J Sports Med 2016;50:397–407.
12. Irwin MR, Olmstead R, Breen EC, Witarama T, Carrillo C, Sadeghi N, et al.
Tai chi , cellular inflammation, and transcriptome dynamics in breast cancer survivors with insomnia:Arandomized controlled trial. J Natl Cancer InstMonogr 2014 295–301.
13. Peppone LJ, Mustian KM, Janelsins MC, Palesh OG, Rosier RN, Piazza KM, et al. Effects of a structured weight-bearing exercise program on bone metabolism among breast cancer survivors:Afeasibility trial. Clin Breast Cancer 2010;10:224–9.
14. Meng T, Hu SF, Cheng YQ, Ye MN, Wang B, Wu JJ, et al. Qigong for women with breast cancer:An updated systematic review and meta-analysis. Complement Ther Med 2021;60:102743.
15. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JPA, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions:Explanation and elaboration. BMJ 2009;339:b2700.
16. Shea BJ, Grimshaw JM, Wells GA, Boers M, Andersson N, Hamel C, et al. Development of AMSTAR:A measurement tool to assess the methodological quality of systematic reviews. BMC Med Res Methodol 2007;7:10.
17. Duan L, Xu Y, Li M Effects of mind-body exercise in cancer survivors:A systematic review and meta-analysis. Evid Based Complement Alternat Med 2020;2020:7607161.
18. Wayne PM, Lee MS, Novakowski J, Osypiuk K, Ligibel J, Carlson LE, et al.
Tai Chi and Qigong for cancer-related symptoms and quality of life:Systematic review and meta-analysis. J Cancer Surviv 2018;12:256–67.
19. Song S, Yu J, Ruan Y, Liu X, Xiu L, Yue X Ameliorative effects of
Tai Chi on cancer-related fatigue:A meta-analysis of randomized controlled trials. Support Care Cancer 2018;26:2091–102.
20. Zeng Y, Xie X, Cheng ASK Qigong or
Tai Chi in Cancer care:An updated systematic review and meta-analysis. CurrOncol Rep 2019;21:48.
21. Lin WF, Zhong MF, Zhou QH, Zhang YR, Wang H, Zhao ZH, et al. Efficacy of complementary and integrative medicine on health-related quality of life in cancer patients:A systematic review and meta-analysis. Cancer Manag Res 2019;11:6663–80.
22. Pan Y, Yang K, Shi X, Liang H, Zhang F, Lv Q
Tai chi chuan exercise for patients with breast cancer:A systematic review and meta-analysis. Evid Based Complement Alternat Med 2015;2015:535237.
23. Yan JH, Pan L, Zhang XM, Sun CX, Cui GH Lack of efficacy of
Tai Chi in improving quality of life in breast cancer survivors:A systematic review and meta-analysis. Asian Pac J Cancer Prev 2014;15:3715–20.
24. Yeung A, Chan JSM, Cheung JC, Zou L Qigong and Tai-Chi for Mood Regulation. Focus (Am PsychiatrPubl) 2018;16:40–7.
25. Tao WW, Jiang H, Tao XM, Jiang P, Sha LY, Sun XC Effects of Acupuncture, Tuina,
Tai Chi , Qigong, and Traditional Chinese Medicine five-element music therapy on symptom management and quality of life for cancer patients:A meta-analysis. J Pain Symptom Manage 2016;51:728–47.
26. Tao W, Luo X, Cui B, Liang D, Wang C, Duan Y, et al. Practice of traditional Chinese medicine for psycho-behavioral intervention improves quality of life in cancer patients:A systematic review and meta-analysis. Oncotarget 2015;6:39725–39.
27. Klein PJ, Baumgarden J, Schneider R Qigong and
Tai Chi as therapeutic exercise:Survey of systematic reviews and meta-analyses addressing physical health conditions. AlternTher Health Med 2019;25:48–53.
28. Rosado-Pérez J, Castelán-Martínez OD, Mújica-Calderón AJ, Sánchez-Rodríguez MA, Mendoza-Núñez VM Effect of
Tai Chi on markers of oxidative stress:Systematic review and meta-analysis. Int J Environ Res Public Health 2021;18:3458.
