Context: Pre- and postoperative distress in breast cancer patients can cause complications and delay recovery from surgery.

Objective: The aim of our study was to evaluate the effects of yoga intervention on postoperative outcomes and wound healing in early operable breast cancer patients undergoing surgery.

Methods: Ninety-eight recently diagnosed stage II and III breast cancer patients were recruited in a randomized controlled trial comparing the effects of a yoga program with supportive therapy and exercise rehabilitation on postoperative outcomes and wound healing following surgery. Subjects were assessed at the baseline prior to surgery and four weeks later. Sociodemographic, clinical and investigative notes were ascertained in the beginning of the study. Blood samples were collected for estimation of plasma cytokines—soluble Interleukin (IL)-2 receptor (IL-2R), tumor necrosis factor (TNF)-alpha and interferon (IFN)-gamma. Postoperative outcomes such as the duration of hospital stay and drain retention, time of suture removal and postoperative complications were ascertained. We used independent samples t test and nonparametric Mann Whitney U tests to compare groups for postoperative outcomes and plasma cytokines. Regression analysis was done to determine predictors for postoperative outcomes.

Results: Sixty-nine patients contributed data to the current analysis (yoga: n = 33, control: n = 36). The results suggest a signifi cant decrease in the duration of hospital stay (P = 0.003), days of drain retention (P = 0.001) and days for suture removal (P = 0.03) in the yoga group as compared to the controls. There was also a signifi cant decrease in plasma TNF alpha levels following surgery in the yoga group (P < 0.001), as compared to the controls. Regression analysis on postoperative outcomes showed that the yoga intervention affected the duration of drain retention and hospital stay as well as TNF alpha levels.

Conclusion: The results suggest possible benefi ts of yoga in reducing postoperative complications in breast cancer patients.

After surgery, breast cancer patients experience particularly high levels of distress  manifested as anxiety, depression and anger due to the effects of surgery and the disease itself on life expectancy, physical appearance and sexual identity. Furthermore, concerns regarding one s physical condition, postoperative recovery, hospital admissions, anticipating painful procedures, image problems, confronting cancer diagnosis and worries about survival and recovery can contribute to the already prevailing  distress and psychological reactions. Numerous studies have shown that such preoperative distress is known to affect postoperative outcomes and delay recovery in both cancer and noncancer population.
In general, high preoperative stress or anxiety is predictive of greater pain intensity, longer hospital stays, more postoperative complications and poorer treatment compliance.
Apart from this, distress is also known to impede wound healing in early phases of wound repair through its effect on glucocorticoids and proinflammatory cytokines in blood such as TNF-alpha and IL-1. Wound healing is important in this current context of breast surgery as exaggerated inflammation, infections and collection of seroma at the wound site lengthen hospital stay, warrant more medical attention, cause distress  and lead to delayed wound closure.
 Although the use of anesthetics and opioids for effective postoperative pain management has been shown to reduce plasma cortisol levels  related to poorer wound healing, they nevertheless cause distressing side effects such as headache, nausea and gastrointestinal distress and are not cost-effective.  Evidence suggests that in clinical practice, interventions to reduce the patient s psychological stress level may improve both wound repair and recovery following surgery.
There is evidence to show that interventions that alter appraisal, coping and/or mood may also modulate immune and endocrine function, thereby enhancing surgical recovery.  Even modest interventions that have relatively small consequences for psychological distress such as educating the patient about surgery  and improving the ambience in the wards  are known to influence the recovery process. Several meta-analyses of presurgical intervention studies have argued that association between presurgical intervention and clinical outcome is clinically meaningful.  Depending on the meta-analysis, two thirds to three quarters of intervention patients had better outcomes than control subjects (patients who have undergone surgery but not intervention) with the size of improvement ranging from 20 28%.  These stress reduction and behavioral interventions apart from reducing distress, hospital stays and medication are also known to affect recovery from surgery and are cost-effective.
Yoga is one such psychotherapeutic intervention that has been used in numerous health care concerns where stress was believed to play a role. It consists of a series of breathing exercises or Pranayama (regulated nostril breathing), postures, relaxation and meditative techniques. These techniques are known to alter certain physiological functions that are known to reduce the effects of stress. These functional alterations include bringing about a stable autonomic balance,  improvement of physical efficiency, increase in cardiopulmonary functions, improved immunological tolerance, mproved neuro-endocronine functions, improved mood states and a tranquil state of mind to combat stress. This could be particularly useful in the current context where apart from reducing psychological distress, yoga could be used to alter endocrine and immune function to lower the risk of infections and enhance wound healing. Distress could also impede recovery by reducing compliance, for example, it is known that breathing exercises reduce the risk of pneumonia following surgery  and incorporating yoga interventions that use breathing, stretching and relaxation interventions could help hasten the recovery process following breast surgery. We hypothesize that yoga interventions would help improve postoperative outcomes and recovery and improve wound healing in early operable breast cancer patients undergoing surgery.