A scoping review on randomized controlled trials investigating effects of breathwork in women with breast cancer

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Kaiser, Anjani Allada, Alekhya Puppala, and 9 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5921372/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 07 Jul, 2025 Read the published version in Lifestyle Medicine → Version 1 posted You are reading this latest preprint version Abstract Background: Patients with breast cancer experience distress, treatment-related discomfort, and fear of recurrence, from initial diagnosis through survivorship. Aims: This study aimed to assess the effects of breathwork interventions on the mental health and quality of life of breast cancer patients and survivors. Methods: We searched multiple databases for randomized controlled trials involving breathwork interventions in patients with breast cancer. Results: Of the 5,909 items screened, 16 studies involving 1,726 participants met the inclusion criteria. Breathing interventions included yoga (n=9), qigong (n=4), and other breathing techniques (n=3). We found that the highest average risk of bias was in the randomization process, with challenges in accurately evaluating deviations from intended interventions due to unquantified adherence to at-home practices, although overall bias in the included studies was generally low. Interventions were prescribed daily or weekly, lasting from one week to two years. Outcomes included treatment side effects, fatigue, sleep, quality of life, biomarkers (e.g., inflammatory markers), psychosocial factors, anxiety, and depression. Conclusions: Although positive outcomes were reported in domains of quality of life and emotional wellbeing, null findings were reported for vasomotor symptoms such as hot flashes for breathing interventions. The wide range of interventions and outcomes administered to patients in various phases of the breast cancer care continuum complicates firm conclusions. Recruitment and adherence issues were noted in multiple studies. Future research should standardize outcome measures, increase accessibility of the intervention (ie via Telehealth) to improve adherence, and include longer follow-up periods to evaluate survival and recurrence. Psychology breast cancer cancer survivorship quality of life breathwork interventions yoga pranayama qi qi gong paced breathing Figures Figure 1 Figure 2 Figure 3 Background In 2022, approximately 4 million women were living with breast cancer in the US alone 1 . Breast cancer diagnosis is an impactful event in an individual’s life that affects physical and mental health and overall quality of life. Women with stage I-IV breast cancer receive various combinations of different treatment modalities including surgery, radiation, and systemic therapies − chemotherapy, anti-estrogen therapies, and other targeted therapies depending on their clinical needs 1 , 2 . These cancer therapies have numerous adverse physical and psychological consequences, including fatigue, nausea, vomiting, hot flashes, night sweat, musculoskeletal and other pain, insomnia, brain fog, neuropathy, premature ovarian failure, infertility, and sexual dysfunction 3 . In addition, women with breast cancer are an elevated risk of depression, anxiety, and suicidal ideation 4 . Non-pharmacological interventions are greatly needed to reduce the breast cancer related physical and psychological symptoms to improve the well-being and quality of life of women with breast cancer. Patient demand for non-pharmacological interventions rooted in Eastern and/or Ayurvedic approaches often outstrips the knowledge level of providers trained in Western models. Knowing which interventions would be effective and safe for patients and for cancer centers to invest in to ameliorate diagnosis and treatment related toxicities is key. Studies have shown that mind-body interventions improve physical and psychological functioning. Moreover, various forms of meditation can reduce cortisol levels and stimulate the production of anti-inflammatory cytokines, endorphins, and neurotropic factors, thereby improving immune status 5 . The term breathwork is a relatively new umbrella term that has been used in publications in the last few years to describe breathing-based practices that involve intentional breathing during at least 50% of the session 6 . Breathwork is distinguished from practices such as meditation, which may include observing the breath rather than active and intentional breathing exercises. Breathwork encompasses several practices that may be rooted in the traditions of yoga and Chinese medicine, including intentional breathing modulation to restore life force energy, referred to as prana in Sanskrit and qi in Mandarin. Qigong is a set of movement-based practices that may combine breathing, visualization, and meditation to restore qi . Yoga is a practice that has three main components: postures for balance and stability (asanas), breathing to channel lifeforce energy (pranayama), and meditation (dhyana). Breathwork has also been explored as a standalone intervention, and various studies have compared cyclic sighing, hyperventilation, and slow-paced breathing, classifying the breathing techniques based on the pace and rhythm of breathing involved 7 , 8 . Breathwork has gained traction over the last 5 years for its purported benefits in reducing anxiety and burnout and improving psychophysiological well-being 6 , 8 – 10 . Nevertheless, research is scattered and encompasses a wide array of interventions and interest populations. The objective of this scoping review was to identify the landscape of randomized controlled trials (RCTs) investigating the benefits of various breathwork interventions for improving mental health and quality of life and reducing cancer and treatment-related symptom burden in women with breast cancer. This review aimed to identify gaps in the existing literature and inform future studies to explore the science of breathwork, considering the unique challenges of delivering interventions to breast cancer patients across the continuum of care. Methods Protocol and registration The protocol for this scoping review was registered in Open Science Framework 11 . Preferred Reporting Items for Scoping Reviews (PRISMA-ScR) guidelines were used in the preparation of this scoping review manuscript 12 . Eligibility criteria We searched for all published articles and conference abstracts with no time limits for the data platforms listed below, from inception to the search date of June 21, 2023. The following inclusion criteria were used: the study was primarily on women who had a diagnosis of breast cancer (any stage or treatment plan), and the intervention was any type of yogic breathing or other breath exercises. Exclusion criteria were as follows: studies of men with breast cancer or those that included men that were not reported in the outcomes separately, studies of patients with other types of cancers besides breast cancer. We also excluded studies where the breathing method was minimal, not quantified or described, or where the focus was on physical movement exercises or poses rather than focused breathwork. A meta-analysis on breathwork categorized interventions based on the percentage of the breath component during each session of practice 6 . Similarly, we attempted to determine the percentage of breath component within each intervention session; however, breathwork duration or frequency could not be determined solely based on the percentage of breath component as the type of breathwork and the total duration and frequency of practice varied between different studies. Information sources and search methods We searched the following platforms and databases for primary studies, conference abstracts, and review articles: MEDLINE (PubMed), Scopus, EMBASE, Cochrane CENTRAL, CINAHL, Alt HealthWatch, and WHO trial registry (Cochrane CENTRAL interface). The EBSCO platform was used for the CINAHL and Alt Health Watch databases. We developed a search strategy based on the PICO framework with the support of an information specialist at the UAB Lister Hill Library (MB). Search terms were related to the population of patients with breast cancer (any stage); various breathing practices, including yoga, pranayama, Sudarshan kriya, and qigong; comparison groups could be placebo, sham intervention or waitlist control; and RCT as study design, with a minimum of 30 participants randomized at baseline. Outcomes were not limited to any specific category, but we expected to find some of the following cancer-related outcomes: pain, treatment side effects, physical functioning, quality of life, biomarkers, cognitive function, psychosocial outcomes, and mood. Details of the exact search syntax can be found at https://osf.io/jgzsx/?view_only=96a64f1f1a2a49f29ab39a218d063465 . We used a standard hedge search in PubMed for randomized trials in humans. We did not apply filters for sex or age. Screening and study selection process Results from the database searches were deduplicated via Endnote (Clarivate), and items such as popular press, titles without abstracts, and non-English articles were excluded manually. Reviews were sequestered for later examination in a separate Endnote library, and the remaining citations were imported into Covidence 13 , which also applied a deduplication procedure. A team of two senior researchers (VG and KAK) and five other researchers (HG, JK, AM, MM, and DW) screened all the items in duplicate, and one of the two senior researchers resolved any conflicts before the items were advanced to the full-text evaluation stage. The same approach was used for full-text evaluation. Once the initial items were retained through the data extraction stage, the citation lists of relevant review articles were scanned, and trial registries were cross-checked to identify any additional studies. Data extraction A standard data extraction form was pilot tested in Covidence, and two researchers independently extracted data. One of the senior researchers resolved any conflicts. VG contacted the corresponding authors to request missing data that were needed to determine whether a study met the inclusion criteria. We made two attempts to request data before deciding whether the study would be excluded because of missing key data. Critical appraisal and risk of bias assessment Since this was a scoping review, we had no a priori plan to conduct a quantitative synthesis because of the expected heterogeneity of interventions and outcomes; however, we opted to present a qualitative summary of the 16 studies that met our inclusion criteria. We used the Cochrane ROB-2 form for risk of bias assessment 14 . This tool allows assessment across five domains of potential sources of bias: 1) randomization process, 2) deviations from intended interventions, 3) missing outcome data, 4) measurement of the outcome, and 5) selection of the reported result. Two researchers (AA, AP, or VG) independently evaluated each included study, and a senior author (KK) reviewed and resolved any conflicts. Results The search and screening process is shown in Fig. 1 . A total of 16 studies that were reported in 15 papers met the inclusion criteria and had a considerable duration of practice comprising intentional breathing (Tables 1 – 3 ). Table 1 Characteristics of yoga-based breathwork studies Study Country Total randomized individuals Study completers (%) Intervention & % breath component Comparator BC treatment phase Intervention Duration Frequency/duration of breathwork practice Statistically significant outcomes Observations (approaching significance) 100% breathwork Chakrabarty 2013 17 India 160 160 (100%) Sheeethali pranayama, 100% breath component Usual care Radiotherapy 6 weeks 30 minutes twice daily Increased serum concentration of protein thiols and glutathione NR Kumar 2013 18 India 147 98 (66.7%) Sudarshan kriya and pranayama, 100% breath component Usual care Survivorship 6 months 20 minutes daily Reduced fasting blood cortisol levels Reduced pain perception in SKY group when compared to usual care at 3 and 6 months but pain increased over time ≤ 50% breathwork or unspecified Bao 2020 21 (NCT03292328) United States 41 36 (87.8%) Yoga with emphasis on pranayama, 50% breath component Waitlist control Survivorship 8 weeks 60 minutes daily Reduced CIPN related pain Improved functional reach Reduced use of pain medication in yoga group Vadiraja 2009 22 India 88 75 (85.2%) Yoga - asana and pranayama with 50% breath component Brief supportive therapy Radiotherapy 6 weeks 60 minutes daily Decreased psychological and physical distress Increased physical activity levels Reduced fatigue, pain, insomnia, and appetite loss NR Jong 2018 24 (NTR 3701) Netherlands 83 67 (80.7%) Dru yoga, 40% breath component Standard of care Neoadjuvant chemotherapy 12 weeks 5–20 minutes daily Reduced depression Decreased nausea and vomiting No change in fatigue NR Greaney 2022 25 (NCT03262831) United States 30 26 (86.7%) Hatha and restorative yoga as personalized therapy (% of breath component cannot be determined) Standard of care Neoadjuvant chemotherapy 12–20 weeks 30 minutes, 3 per week Quality of life remained stable Body weight remained stable Non-significant trend towards decreased systemic inflammation, CRP, and TNF-alpha were measured Moadel 2007 26 (NCT00179348) United States 164 128 (78%) Yoga with 33% breath component Waitlist control Chemotherapy 12 weeks 12 weekly classes, 90 minutes each Improved social wellbeing, quality of life Improved spiritual wellbeing Protective and promoting effects on psychological wellbeing Khedmati Zare 2021 27 (IR.SSRI.REC.1398.111) Iran 30 30 (100%) Pranayama yoga, 20% breath component Vitamin D supplementation Survivorship 12 weeks 60–90 minutes, 2 per week Body fat percentage improved Shoulder flexibility and walking improved Lowered anxiety Observed gene expression changes in NF-κB, Pax, and p53 in combination with a high dose of vitamin D, but not significantly different Carson 2009 23 United States 37 30 (81%) Yoga of Awareness, 30% breath component Waitlist control Survivorship 8 weeks 8 weekly classes, 120 minutes each Improved daily joint pain, fatigue, sleep disturbance, symptom related bother, and vigor Improved negative mood, relaxation, and acceptance No change in hot flashes NR CIPN, chemotherapy-induced peripheral neuropathy. NR, none reported Summary of study characteristics The included studies were categorized as nine yoga-based breathwork studies (Table 1 ), four qigong-based breathwork studies (Table 2 ), and three other breathwork studies (Table 3 ) based on the type of intervention. For each study, the country, sample size (number of individuals randomized vs. study completers), type and name of the breathwork intervention, percent breath component in practice, comparator or control type, frequency of breathwork practice, intervention duration, and statistically significant outcomes and observations were recorded. Seven of the 16 included studies were conducted in the USA. Details about the description of each breathwork practice, outcome measures and battery of survey instruments used in each study can be found in the Supplementary Information. Figure 2 illustrates the timing of the intervention with respect to the breast cancer care continuum in each study. Table 2 Characteristics of qigong-based breathwork studies Study Country Total randomized individuals Study completers (%) Intervention & % breath component Comparator BC treatment phase Intervention duration Frequency/duration of breathwork practice Statistically significant outcomes Observations (not statistically significant) 50–100% breathwork Chen 2013 3 China 100 95 (95%) Qigong, 83% breath component Waitlist control Radiotherapy 5–6 weeks 5 classes per week, 40 minutes each Improved depressive symptoms Improved overall quality of life and fatigue in women with high baseline depressive symptoms Larkey 2015 19 (NCT02690116) United States 101 87 (86.1%) Qigong -Tai Chi Easy, 100% breath component tested Sham qigong Survivorship 12 weeks 60-minute classes – 1–2 times a week 30 minutes a day home practice, 5 days a week Reduced fatigue Improved depression, sleep quality, cognitive function ≤ 50% breathwork or unspecified Chang 2023 28 (NCT05385146) Taiwan 66 NR Chan-Chuang qigong with breathing meditation, 43% breath component Usual care Chemotherapy 15 weeks 35 minutes a day, 5 days a week Improved emotional function Increased self-regulation Within Qigong group, attention regulation, emotional awareness, self-regulation, and body listening improved Lee 2006 29 Taiwan 67 NR Chan-Chuang Qigong, at least 25% breath component Waitlist control Chemotherapy 21 days 15–60 minutes daily Reduced pain, numbness, heartburn and dizziness Improved items in psychological distress: “unwillingness to live” "hopelessness about the future” NR, none reported Critical appraisal of intensive breathwork intervention studies We evaluated the articles that met all initial inclusion criteria for study aspects that may have affected the risk of bias in the results or interpretation (Fig. 3 ). Overall, the domain with the highest average risk of bias was the randomization process (D1), followed by deviations from the intended intervention (D2) and measurements of the outcome (D4). Across all studies evaluated, the risk of bias was generally low. Deviations from the intended interventions could not be accurately evaluated, as we could not quantify how much of the breathwork intervention the participants actually performed as part of their prescribed practice given that some protocols involved individual practice at home. Thus, we may have underestimated bias for deviations from intended interventions relative to adherence. Results of individual sources of evidence Four types of outcomes were investigated in the studies: a) cancer- or treatment-related quality of life and functional outcomes assessing symptomology (reported in 12 studies); b) psychological or cognitive functioning-related measures (depression, anxiety, mood, and sleep; reported in 16 studies); c) body composition/physical functioning-related measures (reported in nine studies); and d) blood-based biomarkers (reported in five studies). Tables 1 – 3 list the statistically significant findings and non-significant observations. Table 3 Characteristics of other breathwork studies Study Country Total randomized individuals Study completers (%) Intervention and % breath component Comparator BC treatment phase Intervention duration Frequency/duration of breathwork practice Statistically significant outcomes Observations (not statistically significant) 100% breathwork Aybar 2020 15 Turkey 62 60 (96.7%) Breathing exercise for reducing nausea and vomiting, 100% breath component Waitlist control group Chemotherapy 7 days 5 minutes as needed, at least once a day Reduced chemotherapy induced nausea, vomiting Affected positively functional status NR Carpenter 2013 20 (NCT00819182) United States 218 196 (89.9%) Paced respiration, 100% breath component Breathing control & usual care control Survivorship 16 weeks Twice daily, 15 minutes each time No significant findings in reduction of hot flashes NR 50–100% breathwork Hoogland 2018 16 (NCT01599520) United States 240 239 (99.5%) Spanish-Language Self-Administered Stress Management Training (SL-SAT)/ daily (at least 50% breath component) Usual care Chemotherapy 13 weeks 18 Minutes daily No significant changes in anxiety, depression, or cancer-related distress Improved emotional well-being NR, none reported Most studies did not separate intervention components other than breathwork, such as meditative state, poses, gentle stretches, and movement. Six studies delivered interventions that primarily involved breathwork 15 – 20 . Among these, Larkey et al. 19 included a sham qigong practice arm to control for movement and delineate the benefits of breathing and meditative states. The study showed a significant reduction in fatigue; however, no significant benefits in sleep or depression were observed. The authors noted that this particular qigong intervention was developed to reduce fatigue and suggested that other protocols could be designed based on desired outcomes 19 . Two of the six studies that primarily involved breathwork reported not many significant findings 16 , 20 . The study using a research-tested breathwork intervention in Spanish speaking populations by Hoogland et al. 16 had the largest sample size (N = 240), and reported that emotional well-being improved significantly over the follow-up period of 13 weeks, however, significant declines were observed in functional and physical well-being. The authors reasoned that the lack of significant findings on anxiety, depression and cancer-related distress may be due to a lack of social support to follow through with breathwork practice and cultural differences across Spanish speaking participants originally from 16 countries. Carpenter et al 20 with a sample size of 218 using a rigorous 3-arm study that included a placebo and control arm, reported that paced respiration is unlikely to provide clinical benefit for vasomotor or other menopausal symptoms in breast cancer survivors or menopausal women without cancer, although some minor benefits were seen with paced respiration for sleep in reducing sleep medication. However, it is to be noted that almost all participants practiced paced respiration once daily for 15 minutes each time instead of the twice daily frequency of 15-minute breathwork prescribed in the protocol 20 . Aybar et al. 15 found significant reductions in nausea and vomiting due to breathwork 15 . Chakrabarty et al. 17 delivered a combination of pranayama (a yoga-based breathing techniques) along with radiotherapy and reported a significant improvement in antioxidant status, which is relevant for patients undergoing radiotherapy 17 . Kumar et al. 18 studied the benefits of Sudarshan Kriya Yoga, a breath meditation based on yoga, with a 6-month follow-up. Cancer survivors practicing Sudarshan Kriya Yoga reported a significant reduction in fasting serum cortisol levels and perceived pain compared to control participants 18 . Overall, in studies of interventions involving 100% breathwork or in which the effects of breathwork were reported separately, breathwork improved numerous outcomes, including fatigue, antioxidant status, fasting serum cortisol levels, and perceived pain. It is challenging to draw definitive conclusions about the comparative effectiveness of 100% breathwork interventions versus those with 50% or less breath component due to the diverse breathing practices used in the existing research. However, it is worth exploring the effects of interventions that combine breathwork with physical posture or focused attention. Seven of the 16 studies investigated the effects of yoga-based interventions that included a breathwork component (≤ 50% breathwork or unspecified; Table 1 ) 21 – 27 . Two RCTs investigated the effects of yoga on quality of life in patients undergoing cancer treatment 25 , 26 . The studies showed that yoga programs that included breathing exercises helped patients maintain their quality of life during chemotherapy compared with usual care controls, with yoga participants showing stable quality of life scores. In contrast, the control group experienced deterioration in the overall quality of life and mood 25 , 26 . The integration of breathwork through yoga therapy has also been associated with improvements in fatigue levels 24 and may help ameliorate treatment-related weight gain. One study showed that yoga participants maintained their weight during chemotherapy, whereas control participants gained an average of 2.63% body weight 25 . Additionally, yoga incorporating breathing practices, combined with a high dose of vitamin D supplementation, has been shown to reduce inflammatory markers and improve lymphocyte health compared to controls 27 . Carson et al. 23 found that an 8-week Yoga of Awareness program that included breathing exercises improved hot flashes, joint pain, fatigue, sleep disturbance, and vigor in breast cancer survivors compared to waitlist controls. The benefits were maintained at the 3-month follow-up, with additional improvements in mood, relaxation, and acceptance 23 . Another 8-week yoga intervention focused on breathwork and conditioning improved chemotherapy-induced peripheral neuropathy symptoms and functional outcomes in breast cancer survivors. The yoga group showed significant improvements in neuropathy-related quality of life and functional measures, such as balance, compared to usual care controls 21 . Vadiraja et al. 22 demonstrated that a 6-week integrated yoga program during radiotherapy led to significant improvements in positive affect, emotional function, and cognitive function and decreases in negative affect compared to supportive therapy controls. Four of the 16 studies investigated the effects of qigong-based interventions that included a breathwork component (50–100% or ≤ 50% breathwork; Table 2 ) 3 , 19 , 28 , 29 . In a randomized controlled trial of 96 women receiving radiotherapy, those who practiced qigong reported significantly fewer depressive symptoms than controls, with particularly strong benefits observed in women who had elevated depressive symptoms at baseline 3 . A 15-week program of Chan-Chuang qigong with breathing meditation improved emotional function and self-regulation in women undergoing chemotherapy 28 . However, the intervention did not significantly influence physical symptoms or the overall quality of life 28 . Another study of Chan-Chuang qigong in patients receiving chemotherapy for breast cancer showed that the practice helped reduce certain physical symptoms, including pain, numbness, heartburn, and dizziness, and showed some benefits for psychological distress related to hopelessness and unwillingness to live. However, the overall psychological distress scores were not significantly different between the groups 29 . Discussion A previous systematic review 30 suggested that studies should investigate the effects of different yoga interventions and clarify which components of yoga (physical exercise, breath control, and meditation) are essential for their effects on quality of life in women with breast cancer. The present review broadens the scope of inquiry by comparing the effects of various levels of breath components in yoga and qigong interventions in patients with breast cancer. Despite the heterogeneity in intervention types and components, ten of 16 studies we reviewed showed significant improvements in emotional well-being 3 , 22 , 24 , 28 , quality of life 3 , 25 , 26 , and cancer or treatment-related symptomology, such as pain 21 , 22 and nausea 15 , 24 , 29 . The overall risk of bias among the studies in which breathwork was a major component of the intervention was low. However, for some self-reported outcomes, some bias may be present in the reporting by the participants, as well as by researchers who knew the treatment assignment of participants. Given the nature of the interventions, participants were aware of their group assignment. Future studies should aim to limit measurement or analysis bias by blinding outcome assessors and statisticians to the group assignments. Furthermore, our ability to assess true compliance or determine the standard frequency and duration of breathwork among the included studies is limited. It is unknown whether a participant’s change in studied outcomes from baseline or if a certain threshold of duration and frequency of practice is needed to detect intervention effects. Interoceptive awareness is the capacity to detect, interpret, and consciously integrate signals related to the physiological condition of the body, and is central to emotion experience and regulation. Interoceptive ability can be trained and improved through mind-body intervention 31 . One recent study examined interoceptive awareness as an effect of qigong, and several self-reported items, such as self-regulation, emotional awareness, attention regulation, and body listening, improved among participants in the qigong group. 28 Two of the included studies investigated hot flashes and night sweats, and both reported non-significant improvements 20 , 23 . A pilot study of the Yoga of Awareness program reported no significant change in hot flashes in breast cancer survivors post-intervention when compared to waitlist controls; however, the study noted several confounding factors, such as treatment with antidepressants, tamoxifen, or aromatase inhibitors, which may have contrasting effects on hot flashes 23 . Although paced respiration has been shown to have no effect on vasomotor symptoms, such as hot flashes and night sweats 20 , other types of breathwork may improve menopausal symptoms and should be explored in future studies on breathwork interventions in studies with high adherence rates. Participant recruitment challenges are commonly reported in studies of neoadjuvant chemotherapy, as treatment typically begins immediately after diagnosis when patients are busy scheduling appointments for imaging, surgery, and consultation with physicians 24 , 25 . In one of the included studies 24 , researchers were able to recruit only 83 patients undergoing neoadjuvant chemotherapy over four years and had to modify their protocol to include post-surgery patients undergoing chemotherapy. Several studies have shown that breathwork improves the quality of life in patients with breast cancer, suggesting that breathwork interventions can be used for patient rehabilitation, reducing the time needed for patients to return to work. However, more research is required to verify the benefits of breathwork at each phase of cancer care with larger sample sizes and consistent intervention lengths. Adherence rates were not reported in many of the included studies because adherence may be difficult to track. Two studies reported non-significant findings, and low adherence may have contributed to the limited efficacy of the interventions 16 , 20 . Using telemedicine to implement the interventions or guide the practice might increase access for patients living in rural areas. When designing studies, social support and rigorous follow-up are important factors for improving adherence to overcome cultural or communication gaps; higher adherence to interventions will strengthen confidence in any findings. Very few studies have used active comparators to delineate the benefits of the different aspects of breathwork interventions 19 , 20 , 22 . Evidence supporting the benefits of breathwork for physical functioning is limited. Larkey et al. 19 , 32 demonstrated that qigong/Tai Chi Easy significantly reduced cancer-related fatigue among breast cancer survivors, suggesting that these practices may enhance physical resilience during and after treatment. Similarly, Aybar et al. 15 reported improvements in functional status and reductions in nausea and vomiting among patients undergoing chemotherapy when engaging in breathing exercises. The findings of these studies underscore the potential of breathwork to alleviate cancer- and treatment-related physical challenges. Evidence supporting the benefits of breathwork on inflammatory biomarkers is also limited. Kumar et al. 18 found that Sudarshan Kriya and Pranayama breathing techniques significantly reduced serum cortisol levels, a stress marker linked to inflammation. This reduction in cortisol levels may correlate with improved immune function. In addition, Khedmati Zare et al. 27 reported that yoga training combined with high-dose vitamin D supplementation resulted in significant changes in the expression of genes involved in immune cell survival (p53 and Bcl2). The study also demonstrated that participants assigned to yoga combined with vitamin D supplementation led to downregulation of NF-κB, an inflammation-related transcription factor, although this effect was not statistically significant. 27 This study has a higher risk of bias due to randomization and unclear reasons for excluding some data. Clinical Implications The reviewed studies suggest that breathwork interventions can have multifaceted benefits for women with breast cancer. The outcomes assessed in these studies included physical functioning, inflammatory biomarkers, and psychosocial outcomes. Several studies have shown the positive effects of breathwork on various psychosocial outcomes, including symptom distress, quality of life, sleep quality, mood, anxiety, depression, and stress levels 16 , 24 , 25 . These psychosocial benefits are critical as they can lead to -improved adherence to cancer treatment and improved health outcomes. Evaluation of complementary interventions in clinical studies involving long-term follow-up of thousands of patients is challenging. Projects such as REBECCA (REsearch on BrEast Cancer induced chronic conditions supported by Causal Analysis of multi-source data), which collect real-world data across breast cancer survivors in Europe, could help shape future guidelines and practices for post-cancer treatment 33 . Long-term studies that track real-world data may reveal new trends in cancer treatment outcomes in patients receiving complementary care (e.g., breathwork) along with cancer treatment, and could enable researchers to assess the effects of lifestyle changes that are difficult to capture in the control settings of RCTs. Limitations A key limitation of this review is that, unlike breathwork studies included in other systematic reviews that were not restricted to any particular disease population 6 , 8 , we could not exclude yoga-based or qigong practices that have other components, such as movement, postures, visualization, or meditation. The number of studies that met the inclusion criteria was limited when the breast cancer population was considered, resulting in the inclusion of many heterogeneous studies. The few breathwork trials conducted are heterogeneous in terms of patient demographics (e.g., cancer stage and treatment type) and the type of intervention. The included studies involved various breathwork practices that could not be categorized as slow- or fast-paced breathing, cyclic breathing, rhythmic breathing, or hyperventilation. Although the RCTs discussed in this article met our inclusion criteria for breathwork, the findings should be interpreted with caution. The duration of interventions in the included studies ranged from 7 days to 6 months, which is an extremely wide range when comparing and synthesizing the results. The sample sizes for these studies also varied widely (ranging from 30 to 240 participants), with most studies having between 62 and 160 participants. Maintaining a larger sample size and longer intervention length will help with population validity. The high heterogeneity among the studies precludes the conduction of a meta-analysis; therefore, we cannot draw definitive conclusions on which type of breathwork is associated with statistically and clinically significant improvements. Conclusion As studies delineate the effects of different types of breathwork, specific modules could be developed according to the needs of patients with breast cancer across the care continuum, as patients face differing challenges during each phase of treatment. In healthy individuals, breathwork improves vagal tone and regulates the nervous system to handle physiological stress 9 . Breathwork practices such as Sudarshan Kriya Yoga have been shown to improve anxiety, immune status, and social connectedness, as well as reduce burnout 10 , 34 . These findings may be relevant to patients with breast cancer and should be further studied both in health care settings as well as during survivorship for rehabilitation. Some evidence points to breathwork interventions causing an improvement in inflammatory biomarkers 3 , 18 , 25 , 27 . Nevertheless, this is a gap that we have identified in the landscape presented here, with few studies examining blood-based markers. The effects of breathwork interventions on the immune system have yet to be studied in patients with breast cancer. There is also a lack of studies that focus on specific breast cancer subtypes. With the accumulation of data from more heterogeneous studies of breathwork interventions, it may be possible to conduct a meta-analysis to determine the characteristics of breathwork interventions that are more suitable for specific breast cancer subtypes, which are associated with unique cancer- and treatment-related symptoms. Recently, immunotherapy has become the standard of care for TNBC 35 ; thus, we can hypothesize that improving patients’ general immune responses may play a vital role in their treatment outcomes, aiming for a truly integrative therapy. Breathwork is safe and widely accessible, and a better understanding of its molecular effects is required to leverage breathwork interventions to enhance patient outcomes. Declarations Data availability See protocol registration or request to the corresponding author Code availability Not applicable Acknowledgments Funding for some team members (VG, AA, AP, DKW, and JK) was provided by UAB Institutional startup funds awarded to Ritu Aneja, PI. Funding for some team members (KAK and MM) was provided in part by the UAB Center for Outcomes and Effectiveness Research (COERE). Editorial assistance was provided by Christos Evangelou, PhD. Author contributions Conceptualization: RA, KAK, and VG; data curation: KAK; formal analysis: VG, KAK, AA, and AP; funding acquisition: KAK and RA; investigation: KAK, VG, AA, AP, DKW, MM, AM, JK, and HG; methodology: MB, KAK, and VG; project administration: VG and KAK; resources: KAK and RA; supervision: KAK, VG, and RA; visualization: KAK, VG, and AP; writing: VG, KAK, and AA. All authors reviewed and approved the final manuscript. Competing interests All authors declare no competing financial or non-financial interests. Data availability Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study. References Miller KD et al (2022) Cancer treatment and survivorship statistics, 2022. CA Cancer J Clin 72:409–436. https://doi.org:10.3322/caac.21731 (NCCN) (2024) N. C. C. N. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines): Breast Cancer, Version 4.2023 , https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf (Nov Chen Z et al (2013) Qigong improves quality of life in women undergoing radiotherapy for breast cancer: results of a randomized controlled trial. Cancer 119:1690–1698. https://doi.org:10.1002/cncr.27904 Carreira H et al (2018) Associations Between Breast Cancer Survivorship and Adverse Mental Health Outcomes: A Systematic Review. JNCI: J Natl Cancer Inst 110:1311–1327. https://doi.org:10.1093/jnci/djy177 Venditti S et al (2020) Molecules of Silence: Effects of Meditation on Gene Expression and Epigenetics. Front Psychol 11:1767. https://doi.org:10.3389/fpsyg.2020.01767 Fincham GW, Strauss C, Montero-Marin J, Cavanagh K (2023) Effect of breathwork on stress and mental health: A meta-analysis of randomised-controlled trials. Sci Rep 13:432. https://doi.org:10.1038/s41598-022-27247-y Balban MY et al (2023) Brief structured respiration practices enhance mood and reduce physiological arousal. Cell Rep Med 4:100895. https://doi.org:10.1016/j.xcrm.2022.100895 Banushi B et al (2023) Breathwork Interventions for Adults with Clinically Diagnosed Anxiety Disorders: A Scoping Review. Brain Sci 13. https://doi.org:10.3390/brainsci13020256 Zaccaro A et al (2018) How Breath-Control Can Change Your Life: A Systematic Review on Psycho-Physiological Correlates of Slow Breathing. Front Hum Neurosci 12:353. https://doi.org:10.3389/fnhum.2018.00353 Korkmaz A et al (2024) Sudarshan Kriya Yoga Breathing and a Meditation Program for Burnout Among Physicians: A Randomized Clinical Trial. JAMA Netw Open 7:e2353978. https://doi.org:10.1001/jamanetworkopen.2023.53978 Kaiser K, Ganesan V, Aneja R (2024), February 14. Systematic Scoping Review of Breathwork Intervention Trials in Women with Breast Cancer. Retrieved from osf.io/jgzsx () Tricco AC et al (2018) PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Ann Intern Med 169:467–473. https://doi.org:10.7326/m18-0850 Covidence systematic review software (2023) Sterne JA et al (2019) RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ 366 Aybar DO, Kılıc SP, Çınkır HY (2020) The effect of breathing exercise on nausea, vomiting and functional status in breast cancer patients undergoing chemotherapy. Complement Ther Clin Pract 40:101213. https://doi.org:10.1016/j.ctcp.2020.101213 Hoogland AI et al (2018) Efficacy of a Spanish-Language Self-Administered Stress Management Training intervention for Latinas undergoing chemotherapy. Psychooncology 27:1305–1311. https://doi.org:10.1002/pon.4673 Chakrabarty J et al (2013) Effectiveness of pranayama on the levels of serum protein thiols and glutathione in breast cancer patients undergoing radiation therapy: a randomized controlled trial. Indian J Physiol Pharmacol 57:225–232 Kumar N et al (2013) Randomized Controlled Trial in Advance Stage Breast Cancer Patients for the Effectiveness on Stress Marker and Pain through Sudarshan Kriya and Pranayam. Indian J Palliat Care 19:180–185. https://doi.org:10.4103/0973-1075.121537 Larkey LK et al (2015) Randomized controlled trial of Qigong/Tai Chi Easy on cancer-related fatigue in breast cancer survivors. Ann Behav Med 49:165–176. https://doi.org:10.1007/s12160-014-9645-4 Carpenter JS et al (2013) Paced respiration for vasomotor and other menopausal symptoms: a randomized, controlled trial. J Gen Intern Med 28:193–200. https://doi.org:10.1007/s11606-012-2202-6 Bao T et al (2020) Yoga for chemotherapy-induced peripheral neuropathy and fall risk: a randomized controlled trial. JNCI Cancer Spectr 4:pkaa048. https://doi.org:10.1093/JNCICS/PKAA048 Vadiraja SH et al (2009) Effects of yoga on symptom management in breast cancer patients: A randomized controlled trial. Int J Yoga 2:73–79. https://doi.org:10.4103/0973-6131.60048 Carson JW, Carson KM, Porter LS, Keefe FJ, Seewaldt VL (2009) Yoga of Awareness program for menopausal symptoms in breast cancer survivors: results from a randomized trial. Support Care Cancer 17:1301–1309. https://doi.org:10.1007/s00520-009-0587-5 Jong MC et al (2018) A Randomized Study of Yoga for Fatigue and Quality of Life in Women with Breast Cancer Undergoing (Neo) Adjuvant Chemotherapy. J Altern Complement Med 24:942–953. https://doi.org:10.1089/acm.2018.0191 Greaney SK et al (2022) Yoga Therapy During Chemotherapy for Early-Stage and Locally Advanced Breast Cancer. Integr Cancer Ther 21:15347354221137285. https://doi.org:10.1177/15347354221137285 Moadel AB et al (2007) Randomized controlled trial of yoga among a multiethnic sample of breast cancer patients: effects on quality of life. J Clin Oncol 25:4387–4395. https://doi.org:10.1200/jco.2006.06.6027 Khedmati Zare V, Javadi M, Amani-shalamzari S, Kaviani M (2021) The high dose of vitamin D supplementation combined with yoga training improve the leukocytes cell survival-related gene expression in breast cancer survivors. Nutr Metabolism 18. https://doi.org:10.1186/s12986-021-00607-7 Chang CI, Yeh ML, Liao J (2023) Chan-Chuang qigong with breathing meditation improves quality of life and interoceptive awareness in patients with breast cancer: a randomised controlled trial. Support Care Cancer 31:140. https://doi.org:10.1007/s00520-023-07578-w Lee TI, Chen HH, Yeh ML (2006) Effects of chan-chuang qigong on improving symptom and psychological distress in chemotherapy patients. Am J Chin Med 34:37–46. https://doi.org:10.1142/s0192415x06003618 Cramer H et al (2017) Yoga for improving health-related quality of life, mental health and cancer‐related symptoms in women diagnosed with breast cancer. Cochrane Database Syst Reviews. https://doi.org:10.1002/14651858.CD010802.pub2 Lazzarelli A et al (2024) Interoceptive Ability and Emotion Regulation in Mind-Body Interventions: An Integrative Review. Behav Sci (Basel) 14. https://doi.org:10.3390/bs14111107 Larkey L, Huberty J, Pedersen M, Weihs K (2016) Qigong/Tai Chi Easy for fatigue in breast cancer survivors: Rationale and design of a randomized clinical trial. Contemp Clin Trials 50:222–228. https://doi.org:10.1016/j.cct.2016.08.002 < https: //rebeccaproject.eu/about-the-project/ ( Seppala EM et al (2020) Promoting Mental Health and Psychological Thriving in University Students: A Randomized Controlled Trial of Three Well-Being Interventions. Front Psychiatry 11:590. https://doi.org:10.3389/fpsyt.2020.00590 O'Rourke H, Hart C, De Boer RH (2024) Current usage of pembrolizumab in triple negative breast cancer (TNBC). Expert Rev Anticancer Ther 24:253–261. https://doi.org:10.1080/14737140.2024.2341729 McGuinness LA, Higgins JPT (2021) Risk-of-bias VISualization (robvis): An R package and Shiny web app for visualizing risk-of-bias assessments. Res Synth Methods 12:55–61. https://doi.org:10.1002/jrsm.1411 Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Published Journal Publication published 07 Jul, 2025 Read the published version in Lifestyle Medicine → Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5921372","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":408406011,"identity":"1ef5a6d5-1c31-404b-8068-dadf227907bd","order_by":0,"name":"Vinitha Ganesan","email":"","orcid":"","institution":"Department of Nutrition Sciences, School of Health Professions, The University of Alabama at Birmingham, Birmingham, AL, USA","correspondingAuthor":false,"prefix":"","firstName":"Vinitha","middleName":"","lastName":"Ganesan","suffix":""},{"id":408406012,"identity":"d2eba5ed-7cfa-4ee8-951d-2843ee662315","order_by":1,"name":"Kathryn A. 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01:38:32","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-5921372/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5921372/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1002/lim2.70033","type":"published","date":"2025-07-08T00:00:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":75088900,"identity":"4c8898f8-5669-4da4-94cb-75438ce78e95","added_by":"auto","created_at":"2025-01-30 10:32:37","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":95141,"visible":true,"origin":"","legend":"\u003cp\u003eFlow diagram of search and screening process\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5921372/v1/3ed6fb7b88a73c9d556b7b96.png"},{"id":75088345,"identity":"bdcde956-2c94-4953-a8c1-c7ff33c1b072","added_by":"auto","created_at":"2025-01-30 10:24:37","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1281010,"visible":true,"origin":"","legend":"\u003cp\u003eSummary of outcomes reported across the care continuum for included studies\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5921372/v1/1c267126148b2946f0f8a0d2.png"},{"id":75088899,"identity":"468fd42f-09a9-46c9-8607-d33d913302d3","added_by":"auto","created_at":"2025-01-30 10:32:37","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":388247,"visible":true,"origin":"","legend":"\u003cp\u003eRisk of bias assessment using ROB-2.The graph was generated using the ROBVIS tool\u003csup\u003e36\u003c/sup\u003e available from \u003ca href=\"https://mcguinlu.shinyapps.io/robvis./\"\u003ehttps://mcguinlu.shinyapps.io/robvis.\\\u003c/a\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-5921372/v1/450bb1a89562f90bdca14744.png"},{"id":87954746,"identity":"55a18bb9-4c69-4665-9f83-882323b98680","added_by":"auto","created_at":"2025-07-30 18:40:34","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3059931,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5921372/v1/c6da6c81-2e31-4068-b659-b1f909c26e0b.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eA scoping review on randomized controlled trials investigating effects of breathwork in women with breast cancer\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eIn 2022, approximately 4\u0026nbsp;million women were living with breast cancer in the US alone\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. Breast cancer diagnosis is an impactful event in an individual\u0026rsquo;s life that affects physical and mental health and overall quality of life. Women with stage I-IV breast cancer receive various combinations of different treatment modalities including surgery, radiation, and systemic therapies\u003csub\u003e\u0026minus;\u003c/sub\u003echemotherapy, anti-estrogen therapies, and other targeted therapies depending on their clinical needs\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. These cancer therapies have numerous adverse physical and psychological consequences, including fatigue, nausea, vomiting, hot flashes, night sweat, musculoskeletal and other pain, insomnia, brain fog, neuropathy, premature ovarian failure, infertility, and sexual dysfunction\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. In addition, women with breast cancer are an elevated risk of depression, anxiety, and suicidal ideation\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. Non-pharmacological interventions are greatly needed to reduce the breast cancer related physical and psychological symptoms to improve the well-being and quality of life of women with breast cancer. Patient demand for non-pharmacological interventions rooted in Eastern and/or Ayurvedic approaches often outstrips the knowledge level of providers trained in Western models. Knowing which interventions would be effective and safe for patients and for cancer centers to invest in to ameliorate diagnosis and treatment related toxicities is key.\u003c/p\u003e \u003cp\u003eStudies have shown that mind-body interventions improve physical and psychological functioning. Moreover, various forms of meditation can reduce cortisol levels and stimulate the production of anti-inflammatory cytokines, endorphins, and neurotropic factors, thereby improving immune status\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. The term breathwork is a relatively new umbrella term that has been used in publications in the last few years to describe breathing-based practices that involve intentional breathing during at least 50% of the session\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. Breathwork is distinguished from practices such as meditation, which may include observing the breath rather than active and intentional breathing exercises. Breathwork encompasses several practices that may be rooted in the traditions of yoga and Chinese medicine, including intentional breathing modulation to restore life force energy, referred to as \u003cem\u003eprana\u003c/em\u003e in Sanskrit and \u003cem\u003eqi\u003c/em\u003e in Mandarin. Qigong is a set of movement-based practices that may combine breathing, visualization, and meditation to restore \u003cem\u003eqi\u003c/em\u003e. Yoga is a practice that has three main components: postures for balance and stability (asanas), breathing to channel lifeforce energy (pranayama), and meditation (dhyana). Breathwork has also been explored as a standalone intervention, and various studies have compared cyclic sighing, hyperventilation, and slow-paced breathing, classifying the breathing techniques based on the pace and rhythm of breathing involved\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eBreathwork has gained traction over the last 5 years for its purported benefits in reducing anxiety and burnout and improving psychophysiological well-being\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. Nevertheless, research is scattered and encompasses a wide array of interventions and interest populations. The objective of this scoping review was to identify the landscape of randomized controlled trials (RCTs) investigating the benefits of various breathwork interventions for improving mental health and quality of life and reducing cancer and treatment-related symptom burden in women with breast cancer. This review aimed to identify gaps in the existing literature and inform future studies to explore the science of breathwork, considering the unique challenges of delivering interventions to breast cancer patients across the continuum of care.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eProtocol and registration\u003c/h2\u003e \u003cp\u003eThe protocol for this scoping review was registered in Open Science Framework\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Preferred Reporting Items for Scoping Reviews (PRISMA-ScR) guidelines were used in the preparation of this scoping review manuscript\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEligibility criteria\u003c/h3\u003e\n\u003cp\u003eWe searched for all published articles and conference abstracts with no time limits for the data platforms listed below, from inception to the search date of June 21, 2023. The following inclusion criteria were used: the study was primarily on women who had a diagnosis of breast cancer (any stage or treatment plan), and the intervention was any type of yogic breathing or other breath exercises. Exclusion criteria were as follows: studies of men with breast cancer or those that included men that were not reported in the outcomes separately, studies of patients with other types of cancers besides breast cancer. We also excluded studies where the breathing method was minimal, not quantified or described, or where the focus was on physical movement exercises or poses rather than focused breathwork. A meta-analysis on breathwork categorized interventions based on the percentage of the breath component during each session of practice\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. Similarly, we attempted to determine the percentage of breath component within each intervention session; however, breathwork duration or frequency could not be determined solely based on the percentage of breath component as the type of breathwork and the total duration and frequency of practice varied between different studies.\u003c/p\u003e\n\u003ch3\u003eInformation sources and search methods\u003c/h3\u003e\n\u003cp\u003eWe searched the following platforms and databases for primary studies, conference abstracts, and review articles: MEDLINE (PubMed), Scopus, EMBASE, Cochrane CENTRAL, CINAHL, Alt HealthWatch, and WHO trial registry (Cochrane CENTRAL interface). The EBSCO platform was used for the CINAHL and Alt Health Watch databases.\u003c/p\u003e \u003cp\u003eWe developed a search strategy based on the PICO framework with the support of an information specialist at the UAB Lister Hill Library (MB). Search terms were related to the population of patients with breast cancer (any stage); various breathing practices, including yoga, pranayama, Sudarshan kriya, and qigong; comparison groups could be placebo, sham intervention or waitlist control; and RCT as study design, with a minimum of 30 participants randomized at baseline. Outcomes were not limited to any specific category, but we expected to find some of the following cancer-related outcomes: pain, treatment side effects, physical functioning, quality of life, biomarkers, cognitive function, psychosocial outcomes, and mood. Details of the exact search syntax can be found at \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://osf.io/jgzsx/?view_only=96a64f1f1a2a49f29ab39a218d063465\u003c/span\u003e\u003cspan address=\"https://osf.io/jgzsx/?view_only=96a64f1f1a2a49f29ab39a218d063465\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eWe used a standard hedge search in PubMed for randomized trials in humans. We did not apply filters for sex or age.\u003c/p\u003e\n\u003ch3\u003eScreening and study selection process\u003c/h3\u003e\n\u003cp\u003eResults from the database searches were deduplicated via Endnote (Clarivate), and items such as popular press, titles without abstracts, and non-English articles were excluded manually. Reviews were sequestered for later examination in a separate Endnote library, and the remaining citations were imported into Covidence\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e, which also applied a deduplication procedure.\u003c/p\u003e \u003cp\u003eA team of two senior researchers (VG and KAK) and five other researchers (HG, JK, AM, MM, and DW) screened all the items in duplicate, and one of the two senior researchers resolved any conflicts before the items were advanced to the full-text evaluation stage. The same approach was used for full-text evaluation. Once the initial items were retained through the data extraction stage, the citation lists of relevant review articles were scanned, and trial registries were cross-checked to identify any additional studies.\u003c/p\u003e\n\u003ch3\u003eData extraction\u003c/h3\u003e\n\u003cp\u003eA standard data extraction form was pilot tested in Covidence, and two researchers independently extracted data. One of the senior researchers resolved any conflicts. VG contacted the corresponding authors to request missing data that were needed to determine whether a study met the inclusion criteria. We made two attempts to request data before deciding whether the study would be excluded because of missing key data.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eCritical appraisal and risk of bias assessment\u003c/h2\u003e \u003cp\u003e Since this was a scoping review, we had no a priori plan to conduct a quantitative synthesis because of the expected heterogeneity of interventions and outcomes; however, we opted to present a qualitative summary of the 16 studies that met our inclusion criteria.\u003c/p\u003e \u003cp\u003eWe used the Cochrane ROB-2 form for risk of bias assessment\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. This tool allows assessment across five domains of potential sources of bias: 1) randomization process, 2) deviations from intended interventions, 3) missing outcome data, 4) measurement of the outcome, and 5) selection of the reported result. Two researchers (AA, AP, or VG) independently evaluated each included study, and a senior author (KK) reviewed and resolved any conflicts.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe search and screening process is shown in Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. A total of 16 studies that were reported in 15 papers met the inclusion criteria and had a considerable duration of practice comprising intentional breathing (Tables \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e\u0026nbsp;\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eCharacteristics of yoga-based breathwork studies\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eStudy\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCountry\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTotal randomized individuals\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eStudy completers (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eIntervention \u0026amp;\u003c/p\u003e\n \u003cp\u003e% breath\u003c/p\u003e\n \u003cp\u003ecomponent\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eComparator\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eBC treatment phase\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eIntervention\u003c/p\u003e\n \u003cp\u003eDuration\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFrequency/duration of breathwork practice\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eStatistically significant outcomes\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eObservations (approaching significance)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"11\"\u003e\n \u003cp\u003e100% breathwork\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eChakrabarty 2013\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e17\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIndia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e160\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e160 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSheeethali pranayama, 100% breath component\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUsual care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRadiotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003cp\u003eminutes\u003c/p\u003e\n \u003cp\u003etwice\u003c/p\u003e\n \u003cp\u003edaily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIncreased\u003c/p\u003e\n \u003cp\u003eserum\u003c/p\u003e\n \u003cp\u003econcentration of\u003c/p\u003e\n \u003cp\u003eprotein\u003c/p\u003e\n \u003cp\u003ethiols and\u003c/p\u003e\n \u003cp\u003eglutathione\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eKumar 2013\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e18\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIndia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e147\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e98 (66.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSudarshan kriya and pranayama, 100% breath component\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUsual care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSurvivorship\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003cp\u003eminutes\u003c/p\u003e\n \u003cp\u003edaily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReduced\u003c/p\u003e\n \u003cp\u003efasting blood\u003c/p\u003e\n \u003cp\u003ecortisol\u003c/p\u003e\n \u003cp\u003elevels\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReduced\u003c/p\u003e\n \u003cp\u003epain\u003c/p\u003e\n \u003cp\u003eperception\u003c/p\u003e\n \u003cp\u003ein SKY\u003c/p\u003e\n \u003cp\u003egroup\u003c/p\u003e\n \u003cp\u003ewhen\u003c/p\u003e\n \u003cp\u003ecompared\u003c/p\u003e\n \u003cp\u003eto usual\u003c/p\u003e\n \u003cp\u003ecare at 3\u003c/p\u003e\n \u003cp\u003eand 6\u003c/p\u003e\n \u003cp\u003emonths but\u003c/p\u003e\n \u003cp\u003epain\u003c/p\u003e\n \u003cp\u003eincreased\u003c/p\u003e\n \u003cp\u003eover time\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"11\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026le;\u0026nbsp;50% breathwork or unspecified\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eBao 2020\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e21\u003c/strong\u003e\u003c/sup\u003e \u003cstrong\u003e(NCT03292328)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnited States\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36 (87.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYoga with emphasis on pranayama, 50% breath component\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWaitlist control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSurvivorship\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e60 minutes daily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReduced\u003c/p\u003e\n \u003cp\u003eCIPN\u003c/p\u003e\n \u003cp\u003erelated pain\u003c/p\u003e\n \u003cp\u003eImproved functional reach\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReduced use of pain medication in yoga group\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eVadiraja 2009\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e22\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIndia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e75 (85.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYoga - asana and pranayama with 50% breath component\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBrief supportive therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRadiotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003cp\u003eminutes\u003c/p\u003e\n \u003cp\u003edaily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDecreased psychological and physical distress\u003c/p\u003e\n \u003cp\u003eIncreased physical activity levels\u003c/p\u003e\n \u003cp\u003eReduced fatigue, pain, insomnia, and appetite loss\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eJong 2018\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e24\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(NTR\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e3701)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNetherlands\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e67 (80.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDru yoga, 40% breath component\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStandard of care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNeoadjuvant chemotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u0026ndash;20\u003c/p\u003e\n \u003cp\u003eminutes\u003c/p\u003e\n \u003cp\u003edaily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReduced\u003c/p\u003e\n \u003cp\u003edepression\u003c/p\u003e\n \u003cp\u003eDecreased\u003c/p\u003e\n \u003cp\u003enausea and\u003c/p\u003e\n \u003cp\u003evomiting\u003c/p\u003e\n \u003cp\u003eNo change\u003c/p\u003e\n \u003cp\u003ein fatigue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGreaney 2022\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e25\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(NCT03262831)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnited States\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26 (86.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHatha and restorative yoga as personalized therapy (% of breath component cannot be determined)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStandard of care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNeoadjuvant\u003c/p\u003e\n \u003cp\u003echemotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12\u0026ndash;20 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003cp\u003eminutes,\u003c/p\u003e\n \u003cp\u003e3 per\u003c/p\u003e\n \u003cp\u003eweek\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQuality of life remained stable\u003c/p\u003e\n \u003cp\u003eBody weight remained stable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNon-significant trend towards decreased systemic inflammation, CRP, and TNF-alpha were measured\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMoadel 2007\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e26\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(NCT00179348)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnited States\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e164\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e128 (78%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYoga with 33% breath component\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWaitlist control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eChemotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003cp\u003eweekly\u003c/p\u003e\n \u003cp\u003eclasses,\u003c/p\u003e\n \u003cp\u003e90\u003c/p\u003e\n \u003cp\u003eminutes\u003c/p\u003e\n \u003cp\u003eeach\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eImproved\u003c/p\u003e\n \u003cp\u003esocial\u003c/p\u003e\n \u003cp\u003ewellbeing,\u003c/p\u003e\n \u003cp\u003equality of\u003c/p\u003e\n \u003cp\u003elife\u003c/p\u003e\n \u003cp\u003eImproved\u003c/p\u003e\n \u003cp\u003espiritual\u003c/p\u003e\n \u003cp\u003ewellbeing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eProtective\u003c/p\u003e\n \u003cp\u003eand\u003c/p\u003e\n \u003cp\u003epromoting\u003c/p\u003e\n \u003cp\u003eeffects on\u003c/p\u003e\n \u003cp\u003epsychological\u003c/p\u003e\n \u003cp\u003ewellbeing\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eKhedmati Zare 2021\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e27\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(IR.SSRI.REC.1398.111)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIran\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePranayama yoga, 20% breath component\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVitamin D supplementation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSurvivorship\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e60\u0026ndash;90\u003c/p\u003e\n \u003cp\u003eminutes,\u003c/p\u003e\n \u003cp\u003e2 per\u003c/p\u003e\n \u003cp\u003eweek\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBody fat percentage improved\u003c/p\u003e\n \u003cp\u003eShoulder flexibility and walking improved\u003c/p\u003e\n \u003cp\u003eLowered anxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eObserved gene expression changes in NF-\u0026kappa;B, Pax, and p53 in combination with a high dose of vitamin D, but not significantly different\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCarson 2009\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e23\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnited States\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003cp\u003e(81%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYoga of Awareness, 30% breath component\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWaitlist control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSurvivorship\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 weekly classes, 120 minutes each\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eImproved daily\u003c/p\u003e\n \u003cp\u003ejoint pain, fatigue,\u003c/p\u003e\n \u003cp\u003esleep\u003c/p\u003e\n \u003cp\u003edisturbance,\u003c/p\u003e\n \u003cp\u003esymptom\u003c/p\u003e\n \u003cp\u003erelated\u003c/p\u003e\n \u003cp\u003ebother,\u003c/p\u003e\n \u003cp\u003eand vigor\u003c/p\u003e\n \u003cp\u003eImproved\u003c/p\u003e\n \u003cp\u003enegative\u003c/p\u003e\n \u003cp\u003emood,\u003c/p\u003e\n \u003cp\u003erelaxation,\u003c/p\u003e\n \u003cp\u003eand\u003c/p\u003e\n \u003cp\u003eacceptance\u003c/p\u003e\n \u003cp\u003eNo change\u003c/p\u003e\n \u003cp\u003ein hot\u003c/p\u003e\n \u003cp\u003eflashes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"11\"\u003eCIPN, chemotherapy-induced peripheral neuropathy. NR, none reported\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n\u003c/div\u003e\n\u003ch3\u003eSummary of study characteristics\u003c/h3\u003e\n\u003cp\u003eThe included studies were categorized as nine yoga-based breathwork studies (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e), four qigong-based breathwork studies (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e), and three other breathwork studies (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e) based on the type of intervention. For each study, the country, sample size (number of individuals randomized vs. study completers), type and name of the breathwork intervention, percent breath component in practice, comparator or control type, frequency of breathwork practice, intervention duration, and statistically significant outcomes and observations were recorded. Seven of the 16 included studies were conducted in the USA. Details about the description of each breathwork practice, outcome measures and battery of survey instruments used in each study can be found in the Supplementary Information. Figure\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e illustrates the timing of the intervention with respect to the breast cancer care continuum in each study.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eCharacteristics of qigong-based breathwork studies\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eStudy\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCountry\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTotal randomized individuals\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eStudy completers (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eIntervention \u0026amp;\u003c/p\u003e\n \u003cp\u003e% breath\u003c/p\u003e\n \u003cp\u003ecomponent\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eComparator\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eBC treatment phase\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eIntervention duration\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFrequency/duration of breathwork practice\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eStatistically significant outcomes\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eObservations (not statistically significant)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"11\"\u003e\n \u003cp\u003e50\u0026ndash;100% breathwork\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eChen 2013\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eChina\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e95 (95%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQigong, 83% breath component\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWaitlist control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRadiotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u0026ndash;6 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 classes per\u003c/p\u003e\n \u003cp\u003eweek, 40\u003c/p\u003e\n \u003cp\u003eminutes each\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eImproved depressive symptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eImproved overall quality of life and fatigue in women with high baseline depressive symptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLarkey 2015\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e19\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(NCT02690116)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnited States\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e101\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e87 (86.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQigong -Tai Chi Easy, 100% breath component tested\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSham qigong\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSurvivorship\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e60-minute classes \u0026ndash; 1\u0026ndash;2 times a week\u003c/p\u003e\n \u003cp\u003e30 minutes a day home practice, 5 days a week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReduced\u003c/p\u003e\n \u003cp\u003efatigue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eImproved depression, sleep quality, cognitive function\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"11\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026le;\u0026nbsp;50% breathwork or unspecified\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eChang 2023\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e28\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e(NCT05385146)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTaiwan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eChan-Chuang qigong with breathing meditation, 43% breath component\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUsual care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eChemotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35 minutes a\u003c/p\u003e\n \u003cp\u003eday, 5 days a\u003c/p\u003e\n \u003cp\u003eweek\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eImproved emotional function\u003c/p\u003e\n \u003cp\u003eIncreased self-regulation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWithin\u003c/p\u003e\n \u003cp\u003eQigong group, attention regulation, emotional awareness, self-regulation, and body listening improved\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLee 2006\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e29\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTaiwan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eChan-Chuang Qigong, at least 25% breath component\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWaitlist control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eChemotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15\u0026ndash;60\u003c/p\u003e\n \u003cp\u003eminutes daily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReduced pain, numbness,\u003c/p\u003e\n \u003cp\u003eheartburn and dizziness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eImproved items in psychological distress: \u0026ldquo;unwillingness to live\u0026rdquo; \u0026quot;hopelessness about the future\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"11\"\u003eNR, none reported\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003eCritical appraisal of intensive breathwork intervention studies\u003c/h2\u003e\n \u003cp\u003eWe evaluated the articles that met all initial inclusion criteria for study aspects that may have affected the risk of bias in the results or interpretation (Fig. \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e). Overall, the domain with the highest average risk of bias was the randomization process (D1), followed by deviations from the intended intervention (D2) and measurements of the outcome (D4). Across all studies evaluated, the risk of bias was generally low. Deviations from the intended interventions could not be accurately evaluated, as we could not quantify how much of the breathwork intervention the participants actually performed as part of their prescribed practice given that some protocols involved individual practice at home. Thus, we may have underestimated bias for deviations from intended interventions relative to adherence.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003eResults of individual sources of evidence\u003c/h2\u003e\n \u003cp\u003eFour types of outcomes were investigated in the studies: a) cancer- or treatment-related quality of life and functional outcomes assessing symptomology (reported in 12 studies); b) psychological or cognitive functioning-related measures (depression, anxiety, mood, and sleep; reported in 16 studies); c) body composition/physical functioning-related measures (reported in nine studies); and d) blood-based biomarkers (reported in five studies). Tables \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e list the statistically significant findings and non-significant observations.\u003c/p\u003e\n \u003cdiv\u003e\u0026nbsp;\u003ctable border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 3\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eCharacteristics of other breathwork studies\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eStudy\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCountry\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTotal randomized individuals\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eStudy completers (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eIntervention and % breath component\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eComparator\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eBC treatment phase\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eIntervention duration\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFrequency/duration of breathwork practice\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eStatistically significant outcomes\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eObservations (not statistically significant)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"11\"\u003e\n \u003cp\u003e100% breathwork\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAybar 2020\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e15\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTurkey\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e60 (96.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBreathing exercise for reducing nausea and vomiting, 100% breath component\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWaitlist control group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eChemotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 minutes as\u003c/p\u003e\n \u003cp\u003eneeded, at\u003c/p\u003e\n \u003cp\u003eleast once a day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReduced chemotherapy\u003c/p\u003e\n \u003cp\u003einduced nausea, vomiting\u003c/p\u003e\n \u003cp\u003eAffected positively functional status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCarpenter 2013\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e20\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(NCT00819182)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnited States\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e218\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e196 (89.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePaced respiration, 100% breath component\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBreathing control \u0026amp; usual care control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSurvivorship\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTwice daily, 15 minutes each time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo significant findings in reduction of hot flashes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"11\"\u003e\n \u003cp\u003e\u003cstrong\u003e50\u0026ndash;100% breathwork\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHoogland 2018\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e16\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(NCT01599520)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnited\u003c/p\u003e\n \u003cp\u003eStates\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e240\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e239 (99.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSpanish-Language Self-Administered Stress Management Training (SL-SAT)/ daily (at least 50% breath component)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUsual care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eChemotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003cp\u003eMinutes\u003c/p\u003e\n \u003cp\u003edaily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo significant changes in anxiety, depression, or cancer-related distress\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eImproved\u003c/p\u003e\n \u003cp\u003eemotional\u003c/p\u003e\n \u003cp\u003ewell-being\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"11\"\u003eNR, none reported\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eMost studies did not separate intervention components other than breathwork, such as meditative state, poses, gentle stretches, and movement. Six studies delivered interventions that primarily involved breathwork\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. Among these, Larkey et al.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e included a sham qigong practice arm to control for movement and delineate the benefits of breathing and meditative states. The study showed a significant reduction in fatigue; however, no significant benefits in sleep or depression were observed. The authors noted that this particular qigong intervention was developed to reduce fatigue and suggested that other protocols could be designed based on desired outcomes\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\n \u003cp\u003eTwo of the six studies that primarily involved breathwork reported not many significant findings\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. The study using a research-tested breathwork intervention in Spanish speaking populations by Hoogland et al.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e had the largest sample size (N\u0026thinsp;=\u0026thinsp;240), and reported that emotional well-being improved significantly over the follow-up period of 13 weeks, however, significant declines were observed in functional and physical well-being. The authors reasoned that the lack of significant findings on anxiety, depression and cancer-related distress may be due to a lack of social support to follow through with breathwork practice and cultural differences across Spanish speaking participants originally from 16 countries. Carpenter et al\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e with a sample size of 218 using a rigorous 3-arm study that included a placebo and control arm, reported that paced respiration is unlikely to provide clinical benefit for vasomotor or other menopausal symptoms in breast cancer survivors or menopausal women without cancer, although some minor benefits were seen with paced respiration for sleep in reducing sleep medication. However, it is to be noted that almost all participants practiced paced respiration once daily for 15 minutes each time instead of the twice daily frequency of 15-minute breathwork prescribed in the protocol\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\n \u003cp\u003eAybar et al.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e found significant reductions in nausea and vomiting due to breathwork\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. Chakrabarty et al.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e delivered a combination of pranayama (a yoga-based breathing techniques) along with radiotherapy and reported a significant improvement in antioxidant status, which is relevant for patients undergoing radiotherapy\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. Kumar et al.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e studied the benefits of Sudarshan Kriya Yoga, a breath meditation based on yoga, with a 6-month follow-up. Cancer survivors practicing Sudarshan Kriya Yoga reported a significant reduction in fasting serum cortisol levels and perceived pain compared to control participants\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. Overall, in studies of interventions involving 100% breathwork or in which the effects of breathwork were reported separately, breathwork improved numerous outcomes, including fatigue, antioxidant status, fasting serum cortisol levels, and perceived pain.\u003c/p\u003e\n \u003cp\u003eIt is challenging to draw definitive conclusions about the comparative effectiveness of 100% breathwork interventions versus those with 50% or less breath component due to the diverse breathing practices used in the existing research. However, it is worth exploring the effects of interventions that combine breathwork with physical posture or focused attention. Seven of the 16 studies investigated the effects of yoga-based interventions that included a breathwork component (\u0026le;\u0026thinsp;50% breathwork or unspecified; Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e. Two RCTs investigated the effects of yoga on quality of life in patients undergoing cancer treatment\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. The studies showed that yoga programs that included breathing exercises helped patients maintain their quality of life during chemotherapy compared with usual care controls, with yoga participants showing stable quality of life scores. In contrast, the control group experienced deterioration in the overall quality of life and mood\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\n \u003cp\u003eThe integration of breathwork through yoga therapy has also been associated with improvements in fatigue levels\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e and may help ameliorate treatment-related weight gain. One study showed that yoga participants maintained their weight during chemotherapy, whereas control participants gained an average of 2.63% body weight\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. Additionally, yoga incorporating breathing practices, combined with a high dose of vitamin D supplementation, has been shown to reduce inflammatory markers and improve lymphocyte health compared to controls\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e. Carson et al.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e found that an 8-week Yoga of Awareness program that included breathing exercises improved hot flashes, joint pain, fatigue, sleep disturbance, and vigor in breast cancer survivors compared to waitlist controls. The benefits were maintained at the 3-month follow-up, with additional improvements in mood, relaxation, and acceptance\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\n \u003cp\u003eAnother 8-week yoga intervention focused on breathwork and conditioning improved chemotherapy-induced peripheral neuropathy symptoms and functional outcomes in breast cancer survivors. The yoga group showed significant improvements in neuropathy-related quality of life and functional measures, such as balance, compared to usual care controls\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. Vadiraja et al.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e demonstrated that a 6-week integrated yoga program during radiotherapy led to significant improvements in positive affect, emotional function, and cognitive function and decreases in negative affect compared to supportive therapy controls.\u003c/p\u003e\n \u003cp\u003eFour of the 16 studies investigated the effects of qigong-based interventions that included a breathwork component (50\u0026ndash;100% or \u0026le;\u0026thinsp;50% breathwork; Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e. In a randomized controlled trial of 96 women receiving radiotherapy, those who practiced qigong reported significantly fewer depressive symptoms than controls, with particularly strong benefits observed in women who had elevated depressive symptoms at baseline\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. A 15-week program of Chan-Chuang qigong with breathing meditation improved emotional function and self-regulation in women undergoing chemotherapy\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e. However, the intervention did not significantly influence physical symptoms or the overall quality of life\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e. Another study of Chan-Chuang qigong in patients receiving chemotherapy for breast cancer showed that the practice helped reduce certain physical symptoms, including pain, numbness, heartburn, and dizziness, and showed some benefits for psychological distress related to hopelessness and unwillingness to live. However, the overall psychological distress scores were not significantly different between the groups\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eA previous systematic review\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e suggested that studies should investigate the effects of different yoga interventions and clarify which components of yoga (physical exercise, breath control, and meditation) are essential for their effects on quality of life in women with breast cancer. The present review broadens the scope of inquiry by comparing the effects of various levels of breath components in yoga and qigong interventions in patients with breast cancer. Despite the heterogeneity in intervention types and components, ten of 16 studies we reviewed showed significant improvements in emotional well-being\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e,\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e, quality of life\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e, and cancer or treatment-related symptomology, such as pain\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e and nausea\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e. The overall risk of bias among the studies in which breathwork was a major component of the intervention was low. However, for some self-reported outcomes, some bias may be present in the reporting by the participants, as well as by researchers who knew the treatment assignment of participants. Given the nature of the interventions, participants were aware of their group assignment. Future studies should aim to limit measurement or analysis bias by blinding outcome assessors and statisticians to the group assignments. Furthermore, our ability to assess true compliance or determine the standard frequency and duration of breathwork among the included studies is limited. It is unknown whether a participant\u0026rsquo;s change in studied outcomes from baseline or if a certain threshold of duration and frequency of practice is needed to detect intervention effects.\u003c/p\u003e \u003cp\u003eInteroceptive awareness is the capacity to detect, interpret, and consciously integrate signals related to the physiological condition of the body, and is central to emotion experience and regulation. Interoceptive ability can be trained and improved through mind-body intervention\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e. One recent study examined interoceptive awareness as an effect of qigong, and several self-reported items, such as self-regulation, emotional awareness, attention regulation, and body listening, improved among participants in the qigong group.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e Two of the included studies investigated hot flashes and night sweats, and both reported non-significant improvements\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. A pilot study of the Yoga of Awareness program reported no significant change in hot flashes in breast cancer survivors post-intervention when compared to waitlist controls; however, the study noted several confounding factors, such as treatment with antidepressants, tamoxifen, or aromatase inhibitors, which may have contrasting effects on hot flashes\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. Although paced respiration has been shown to have no effect on vasomotor symptoms, such as hot flashes and night sweats\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e, other types of breathwork may improve menopausal symptoms and should be explored in future studies on breathwork interventions in studies with high adherence rates.\u003c/p\u003e \u003cp\u003eParticipant recruitment challenges are commonly reported in studies of neoadjuvant chemotherapy, as treatment typically begins immediately after diagnosis when patients are busy scheduling appointments for imaging, surgery, and consultation with physicians\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. In one of the included studies\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e, researchers were able to recruit only 83 patients undergoing neoadjuvant chemotherapy over four years and had to modify their protocol to include post-surgery patients undergoing chemotherapy. Several studies have shown that breathwork improves the quality of life in patients with breast cancer, suggesting that breathwork interventions can be used for patient rehabilitation, reducing the time needed for patients to return to work. However, more research is required to verify the benefits of breathwork at each phase of cancer care with larger sample sizes and consistent intervention lengths.\u003c/p\u003e \u003cp\u003eAdherence rates were not reported in many of the included studies because adherence may be difficult to track. Two studies reported non-significant findings, and low adherence may have contributed to the limited efficacy of the interventions\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. Using telemedicine to implement the interventions or guide the practice might increase access for patients living in rural areas. When designing studies, social support and rigorous follow-up are important factors for improving adherence to overcome cultural or communication gaps; higher adherence to interventions will strengthen confidence in any findings. Very few studies have used active comparators to delineate the benefits of the different aspects of breathwork interventions\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eEvidence supporting the benefits of breathwork for physical functioning is limited. Larkey et al.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e demonstrated that qigong/Tai Chi Easy significantly reduced cancer-related fatigue among breast cancer survivors, suggesting that these practices may enhance physical resilience during and after treatment. Similarly, Aybar et al.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e reported improvements in functional status and reductions in nausea and vomiting among patients undergoing chemotherapy when engaging in breathing exercises. The findings of these studies underscore the potential of breathwork to alleviate cancer- and treatment-related physical challenges.\u003c/p\u003e \u003cp\u003eEvidence supporting the benefits of breathwork on inflammatory biomarkers is also limited. Kumar et al.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e found that Sudarshan Kriya and Pranayama breathing techniques significantly reduced serum cortisol levels, a stress marker linked to inflammation. This reduction in cortisol levels may correlate with improved immune function. In addition, Khedmati Zare et al.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e reported that yoga training combined with high-dose vitamin D supplementation resulted in significant changes in the expression of genes involved in immune cell survival (p53 and Bcl2). The study also demonstrated that participants assigned to yoga combined with vitamin D supplementation led to downregulation of NF-κB, an inflammation-related transcription factor, although this effect was not statistically significant.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e This study has a higher risk of bias due to randomization and unclear reasons for excluding some data.\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eClinical Implications\u003c/h2\u003e \u003cp\u003eThe reviewed studies suggest that breathwork interventions can have multifaceted benefits for women with breast cancer. The outcomes assessed in these studies included physical functioning, inflammatory biomarkers, and psychosocial outcomes. Several studies have shown the positive effects of breathwork on various psychosocial outcomes, including symptom distress, quality of life, sleep quality, mood, anxiety, depression, and stress levels\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. These psychosocial benefits are critical as they can lead to -improved adherence to cancer treatment and improved health outcomes. Evaluation of complementary interventions in clinical studies involving long-term follow-up of thousands of patients is challenging. Projects such as REBECCA (REsearch on BrEast Cancer induced chronic conditions supported by Causal Analysis of multi-source data), which collect real-world data across breast cancer survivors in Europe, could help shape future guidelines and practices for post-cancer treatment\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e. Long-term studies that track real-world data may reveal new trends in cancer treatment outcomes in patients receiving complementary care (e.g., breathwork) along with cancer treatment, and could enable researchers to assess the effects of lifestyle changes that are difficult to capture in the control settings of RCTs.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eA key limitation of this review is that, unlike breathwork studies included in other systematic reviews that were not restricted to any particular disease population\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e, we could not exclude yoga-based or qigong practices that have other components, such as movement, postures, visualization, or meditation. The number of studies that met the inclusion criteria was limited when the breast cancer population was considered, resulting in the inclusion of many heterogeneous studies. The few breathwork trials conducted are heterogeneous in terms of patient demographics (e.g., cancer stage and treatment type) and the type of intervention. The included studies involved various breathwork practices that could not be categorized as slow- or fast-paced breathing, cyclic breathing, rhythmic breathing, or hyperventilation. Although the RCTs discussed in this article met our inclusion criteria for breathwork, the findings should be interpreted with caution. The duration of interventions in the included studies ranged from 7 days to 6 months, which is an extremely wide range when comparing and synthesizing the results. The sample sizes for these studies also varied widely (ranging from 30 to 240 participants), with most studies having between 62 and 160 participants. Maintaining a larger sample size and longer intervention length will help with population validity. The high heterogeneity among the studies precludes the conduction of a meta-analysis; therefore, we cannot draw definitive conclusions on which type of breathwork is associated with statistically and clinically significant improvements.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAs studies delineate the effects of different types of breathwork, specific modules could be developed according to the needs of patients with breast cancer across the care continuum, as patients face differing challenges during each phase of treatment. In healthy individuals, breathwork improves vagal tone and regulates the nervous system to handle physiological stress\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. Breathwork practices such as Sudarshan Kriya Yoga have been shown to improve anxiety, immune status, and social connectedness, as well as reduce burnout\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e. These findings may be relevant to patients with breast cancer and should be further studied both in health care settings as well as during survivorship for rehabilitation.\u003c/p\u003e \u003cp\u003eSome evidence points to breathwork interventions causing an improvement in inflammatory biomarkers\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e. Nevertheless, this is a gap that we have identified in the landscape presented here, with few studies examining blood-based markers. The effects of breathwork interventions on the immune system have yet to be studied in patients with breast cancer. There is also a lack of studies that focus on specific breast cancer subtypes. With the accumulation of data from more heterogeneous studies of breathwork interventions, it may be possible to conduct a meta-analysis to determine the characteristics of breathwork interventions that are more suitable for specific breast cancer subtypes, which are associated with unique cancer- and treatment-related symptoms. Recently, immunotherapy has become the standard of care for TNBC\u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e; thus, we can hypothesize that improving patients\u0026rsquo; general immune responses may play a vital role in their treatment outcomes, aiming for a truly integrative therapy. Breathwork is safe and widely accessible, and a better understanding of its molecular effects is required to leverage breathwork interventions to enhance patient outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"700\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 191px;\"\u003e\n \u003cp\u003eData availability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 809px;\"\u003e\n \u003cp\u003eSee protocol registration or request to the corresponding author\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 191px;\"\u003e\n \u003cp\u003eCode availability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 809px;\"\u003e\n \u003cp\u003eNot applicable\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFunding for some team members (VG, AA, AP, DKW, and JK) was provided by UAB Institutional startup funds awarded to Ritu Aneja, PI. Funding for some team members (KAK and MM) was provided in part by the UAB Center for Outcomes and Effectiveness Research (COERE). Editorial assistance was provided by Christos Evangelou, PhD.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization: RA, KAK, and VG; data curation: KAK; formal analysis: VG, KAK, AA, and AP; funding acquisition: KAK and RA; investigation: KAK, VG, AA, AP, DKW, MM, AM, JK, and HG; methodology: MB, KAK, and VG; project administration: VG and KAK; resources: KAK and RA; supervision: KAK, VG, and RA; visualization: KAK, VG, and AP; writing: VG, KAK, and AA. All authors reviewed and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors declare no competing financial or non-financial interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData sharing is not applicable to this article as no datasets were generated or analyzed during the current study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMiller KD et al (2022) Cancer treatment and survivorship statistics, 2022. CA Cancer J Clin 72:409\u0026ndash;436. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.3322/caac.21731\u003c/span\u003e\u003cspan address=\"https://doi.org:10.3322/caac.21731\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e(NCCN) (2024) N. C. C. N. \u003cem\u003eNCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines): Breast Cancer, Version 4.2023\u003c/em\u003e, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.nccn.org/professionals/physician_gls/pdf/breast.pdf\u003c/span\u003e\u003cspan address=\"https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (Nov\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen Z et al (2013) Qigong improves quality of life in women undergoing radiotherapy for breast cancer: results of a randomized controlled trial. Cancer 119:1690\u0026ndash;1698. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.1002/cncr.27904\u003c/span\u003e\u003cspan address=\"https://doi.org:10.1002/cncr.27904\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarreira H et al (2018) Associations Between Breast Cancer Survivorship and Adverse Mental Health Outcomes: A Systematic Review. JNCI: J Natl Cancer Inst 110:1311\u0026ndash;1327. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.1093/jnci/djy177\u003c/span\u003e\u003cspan address=\"https://doi.org:10.1093/jnci/djy177\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVenditti S et al (2020) Molecules of Silence: Effects of Meditation on Gene Expression and Epigenetics. Front Psychol 11:1767. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.3389/fpsyg.2020.01767\u003c/span\u003e\u003cspan address=\"https://doi.org:10.3389/fpsyg.2020.01767\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFincham GW, Strauss C, Montero-Marin J, Cavanagh K (2023) Effect of breathwork on stress and mental health: A meta-analysis of randomised-controlled trials. Sci Rep 13:432. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.1038/s41598-022-27247-y\u003c/span\u003e\u003cspan address=\"https://doi.org:10.1038/s41598-022-27247-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBalban MY et al (2023) Brief structured respiration practices enhance mood and reduce physiological arousal. Cell Rep Med 4:100895. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.1016/j.xcrm.2022.100895\u003c/span\u003e\u003cspan address=\"https://doi.org:10.1016/j.xcrm.2022.100895\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBanushi B et al (2023) Breathwork Interventions for Adults with Clinically Diagnosed Anxiety Disorders: A Scoping Review. Brain Sci 13. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.3390/brainsci13020256\u003c/span\u003e\u003cspan address=\"https://doi.org:10.3390/brainsci13020256\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZaccaro A et al (2018) How Breath-Control Can Change Your Life: A Systematic Review on Psycho-Physiological Correlates of Slow Breathing. Front Hum Neurosci 12:353. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.3389/fnhum.2018.00353\u003c/span\u003e\u003cspan address=\"https://doi.org:10.3389/fnhum.2018.00353\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKorkmaz A et al (2024) Sudarshan Kriya Yoga Breathing and a Meditation Program for Burnout Among Physicians: A Randomized Clinical Trial. JAMA Netw Open 7:e2353978. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.1001/jamanetworkopen.2023.53978\u003c/span\u003e\u003cspan address=\"https://doi.org:10.1001/jamanetworkopen.2023.53978\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaiser K, Ganesan V, Aneja R (2024), February 14. Systematic Scoping Review of Breathwork Intervention Trials in Women with Breast Cancer. Retrieved from osf.io/jgzsx ()\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTricco AC et al (2018) PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Ann Intern Med 169:467\u0026ndash;473. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.7326/m18-0850\u003c/span\u003e\u003cspan address=\"https://doi.org:10.7326/m18-0850\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCovidence systematic review software (2023)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSterne JA et al (2019) RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ 366\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAybar DO, Kılıc SP, \u0026Ccedil;ınkır HY (2020) The effect of breathing exercise on nausea, vomiting and functional status in breast cancer patients undergoing chemotherapy. Complement Ther Clin Pract 40:101213. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.1016/j.ctcp.2020.101213\u003c/span\u003e\u003cspan address=\"https://doi.org:10.1016/j.ctcp.2020.101213\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHoogland AI et al (2018) Efficacy of a Spanish-Language Self-Administered Stress Management Training intervention for Latinas undergoing chemotherapy. Psychooncology 27:1305\u0026ndash;1311. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.1002/pon.4673\u003c/span\u003e\u003cspan address=\"https://doi.org:10.1002/pon.4673\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChakrabarty J et al (2013) Effectiveness of pranayama on the levels of serum protein thiols and glutathione in breast cancer patients undergoing radiation therapy: a randomized controlled trial. Indian J Physiol Pharmacol 57:225\u0026ndash;232\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKumar N et al (2013) Randomized Controlled Trial in Advance Stage Breast Cancer Patients for the Effectiveness on Stress Marker and Pain through Sudarshan Kriya and Pranayam. Indian J Palliat Care 19:180\u0026ndash;185. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.4103/0973-1075.121537\u003c/span\u003e\u003cspan address=\"https://doi.org:10.4103/0973-1075.121537\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLarkey LK et al (2015) Randomized controlled trial of Qigong/Tai Chi Easy on cancer-related fatigue in breast cancer survivors. Ann Behav Med 49:165\u0026ndash;176. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.1007/s12160-014-9645-4\u003c/span\u003e\u003cspan address=\"https://doi.org:10.1007/s12160-014-9645-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarpenter JS et al (2013) Paced respiration for vasomotor and other menopausal symptoms: a randomized, controlled trial. J Gen Intern Med 28:193\u0026ndash;200. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.1007/s11606-012-2202-6\u003c/span\u003e\u003cspan address=\"https://doi.org:10.1007/s11606-012-2202-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBao T et al (2020) Yoga for chemotherapy-induced peripheral neuropathy and fall risk: a randomized controlled trial. JNCI Cancer Spectr 4:pkaa048. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.1093/JNCICS/PKAA048\u003c/span\u003e\u003cspan address=\"https://doi.org:10.1093/JNCICS/PKAA048\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVadiraja SH et al (2009) Effects of yoga on symptom management in breast cancer patients: A randomized controlled trial. Int J Yoga 2:73\u0026ndash;79. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.4103/0973-6131.60048\u003c/span\u003e\u003cspan address=\"https://doi.org:10.4103/0973-6131.60048\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarson JW, Carson KM, Porter LS, Keefe FJ, Seewaldt VL (2009) Yoga of Awareness program for menopausal symptoms in breast cancer survivors: results from a randomized trial. Support Care Cancer 17:1301\u0026ndash;1309. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.1007/s00520-009-0587-5\u003c/span\u003e\u003cspan address=\"https://doi.org:10.1007/s00520-009-0587-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJong MC et al (2018) A Randomized Study of Yoga for Fatigue and Quality of Life in Women with Breast Cancer Undergoing (Neo) Adjuvant Chemotherapy. J Altern Complement Med 24:942\u0026ndash;953. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.1089/acm.2018.0191\u003c/span\u003e\u003cspan address=\"https://doi.org:10.1089/acm.2018.0191\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGreaney SK et al (2022) Yoga Therapy During Chemotherapy for Early-Stage and Locally Advanced Breast Cancer. Integr Cancer Ther 21:15347354221137285. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.1177/15347354221137285\u003c/span\u003e\u003cspan address=\"https://doi.org:10.1177/15347354221137285\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoadel AB et al (2007) Randomized controlled trial of yoga among a multiethnic sample of breast cancer patients: effects on quality of life. J Clin Oncol 25:4387\u0026ndash;4395. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.1200/jco.2006.06.6027\u003c/span\u003e\u003cspan address=\"https://doi.org:10.1200/jco.2006.06.6027\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhedmati Zare V, Javadi M, Amani-shalamzari S, Kaviani M (2021) The high dose of vitamin D supplementation combined with yoga training improve the leukocytes cell survival-related gene expression in breast cancer survivors. Nutr Metabolism 18. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.1186/s12986-021-00607-7\u003c/span\u003e\u003cspan address=\"https://doi.org:10.1186/s12986-021-00607-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChang CI, Yeh ML, Liao J (2023) Chan-Chuang qigong with breathing meditation improves quality of life and interoceptive awareness in patients with breast cancer: a randomised controlled trial. Support Care Cancer 31:140. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.1007/s00520-023-07578-w\u003c/span\u003e\u003cspan address=\"https://doi.org:10.1007/s00520-023-07578-w\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee TI, Chen HH, Yeh ML (2006) Effects of chan-chuang qigong on improving symptom and psychological distress in chemotherapy patients. Am J Chin Med 34:37\u0026ndash;46. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.1142/s0192415x06003618\u003c/span\u003e\u003cspan address=\"https://doi.org:10.1142/s0192415x06003618\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCramer H et al (2017) Yoga for improving health-related quality of life, mental health and cancer‐related symptoms in women diagnosed with breast cancer. Cochrane Database Syst Reviews. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.1002/14651858.CD010802.pub2\u003c/span\u003e\u003cspan address=\"https://doi.org:10.1002/14651858.CD010802.pub2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLazzarelli A et al (2024) Interoceptive Ability and Emotion Regulation in Mind-Body Interventions: An Integrative Review. Behav Sci (Basel) 14. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.3390/bs14111107\u003c/span\u003e\u003cspan address=\"https://doi.org:10.3390/bs14111107\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLarkey L, Huberty J, Pedersen M, Weihs K (2016) Qigong/Tai Chi Easy for fatigue in breast cancer survivors: Rationale and design of a randomized clinical trial. Contemp Clin Trials 50:222\u0026ndash;228. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.1016/j.cct.2016.08.002\u003c/span\u003e\u003cspan address=\"https://doi.org:10.1016/j.cct.2016.08.002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e\u0026lt;\u0026thinsp;https:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e//rebeccaproject.eu/about-the-project/\u003c/span\u003e\u003cspan address=\"http:////rebeccaproject.eu/about-the-project/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSeppala EM et al (2020) Promoting Mental Health and Psychological Thriving in University Students: A Randomized Controlled Trial of Three Well-Being Interventions. Front Psychiatry 11:590. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.3389/fpsyt.2020.00590\u003c/span\u003e\u003cspan address=\"https://doi.org:10.3389/fpsyt.2020.00590\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eO'Rourke H, Hart C, De Boer RH (2024) Current usage of pembrolizumab in triple negative breast cancer (TNBC). Expert Rev Anticancer Ther 24:253\u0026ndash;261. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.1080/14737140.2024.2341729\u003c/span\u003e\u003cspan address=\"https://doi.org:10.1080/14737140.2024.2341729\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcGuinness LA, Higgins JPT (2021) Risk-of-bias VISualization (robvis): An R package and Shiny web app for visualizing risk-of-bias assessments. Res Synth Methods 12:55\u0026ndash;61. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.1002/jrsm.1411\u003c/span\u003e\u003cspan address=\"https://doi.org:10.1002/jrsm.1411\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"University of Alabama at Birmingham","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"breast cancer, cancer survivorship, quality of life, breathwork interventions, yoga, pranayama, qi, qi gong, paced breathing","lastPublishedDoi":"10.21203/rs.3.rs-5921372/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5921372/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Patients with breast cancer experience distress, treatment-related discomfort, and fear of recurrence, from initial diagnosis through survivorship.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAims:\u003c/strong\u003e This study aimed to assess the effects of breathwork interventions on the mental health and quality of life of breast cancer patients and survivors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e We searched multiple databases for randomized controlled trials involving breathwork interventions in patients with breast cancer.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Of the 5,909 items screened, 16 studies involving 1,726 participants met the inclusion criteria. Breathing interventions included yoga (n=9), qigong (n=4), and other breathing techniques (n=3). We found that the highest average risk of bias was in the randomization process, with challenges in accurately evaluating deviations from intended interventions due to unquantified adherence to at-home practices, although overall bias in the included studies was generally low. Interventions were prescribed daily or weekly, lasting from one week to two years. Outcomes included treatment side effects, fatigue, sleep, quality of life, biomarkers (e.g., inflammatory markers), psychosocial factors, anxiety, and depression.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e Although positive outcomes were reported in domains of quality of life and emotional wellbeing, null findings were reported for vasomotor symptoms such as hot flashes for breathing interventions. The wide range of interventions and outcomes administered to patients in various phases of the breast cancer care continuum complicates firm conclusions. Recruitment and adherence issues were noted in multiple studies. Future research should standardize outcome measures, increase accessibility of the intervention (ie via Telehealth) to improve adherence, and include longer follow-up periods to evaluate survival and recurrence.\u003c/p\u003e","manuscriptTitle":"A scoping review on randomized controlled trials investigating effects of breathwork in women with breast cancer","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-01-30 10:24:31","doi":"10.21203/rs.3.rs-5921372/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6846866a-5b11-4dfb-8314-6f9f776a1989","owner":[],"postedDate":"January 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":43546061,"name":"Psychology"}],"tags":[],"updatedAt":"2025-07-30T18:40:28+00:00","versionOfRecord":{"articleIdentity":"rs-5921372","link":"https://doi.org/10.1002/lim2.70033","journal":{"identity":"lifestyle-medicine","isVorOnly":true,"title":"Lifestyle Medicine"},"publishedOn":"2025-07-08 00:00:00","publishedOnDateReadable":"July 8th, 2025"},"versionCreatedAt":"2025-01-30 10:24:31","video":"","vorDoi":"10.1002/lim2.70033","vorDoiUrl":"https://doi.org/10.1002/lim2.70033","workflowStages":[]},"version":"v1","identity":"rs-5921372","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5921372","identity":"rs-5921372","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}