Giuseppe Marano, Ida Paris, M. Mazza
INTRODUCTION AND EPIDEMIOLOGY In 2025, cancer diagnosis rates varied significantly across different countries. In the United States (US), 2,041,910 new cancer cases and 618,120 cancer deaths were projected.[1] In Japan, there were around 350,000 new cancer cases.[2] The World Health Organization reported that in 2022, there were 20 million new cancer cases globally, with 9.7 million deaths.[3] Over 4 million cancer deaths have been averted since 1991, thanks to continued declines in mortality through 2021.[4] Key factors contributing to this success include decreased tobacco use, improved early detection for some cancers, and better treatment strategies for both early-stage and advanced disease. Progress in the early detection and effective treatment of cancer has resulted in a growing population of individuals living beyond a cancer diagnosis. It is estimated that the number of cancer survivors in the US surpassed 16.9 million in January 2019 and is projected to reach as high as 22.1 million by the year 2030.[5] The diagnosis of cancer is a life-altering event that can trigger a cascade of psychological challenges.[6] Anxiety, depression, fear, and diminished quality of life are common experiences for individuals navigating the complexities of cancer treatment and survivorship.[7] Psychological burden The diagnosis of cancer often serves as a significant traumatic event, not only for the individual directly affected but also for their entire family system.[8] The emotional burden of cancer can be substantial, affecting not only the patient’s mental health but also their physical well-being and overall treatment outcomes.[9] While conventional medical care focuses on the physical aspects of the disease, addressing the psychological well-being of cancer patients is equally crucial for holistic and patient-centered care. Rationale for Tai Chi and Qigong Mind–body interventions such as Tai Chi and Qigong (TCQ) have shown promise in reducing psychological distress, improving mood, and enhancing overall well‑being in cancer patients.[10] These practices emphasize the interconnectedness of the mind and body,[11] utilizing gentle movements, deep breathing techniques, and focused attention to cultivate a sense of calm, enhance self-awareness, and promote emotional regulation. A growing body of research indicates that mind–body practices offer valuable support alongside standard cancer treatments, effectively addressing the diverse needs of individuals facing cancer.[12,13] These interventions are frequently employed by patients to lessen symptom burden and improve coping strategies for both the disease itself and its associated treatments.[14] As cancer survival rates improve globally, there is increasing recognition of the need to address not only physical but also psychological and emotional dimensions of the cancer experience. Given the rising number of cancer survivors and the high prevalence of psychological distress during and after cancer treatment, there is a pressing need for accessible, non-pharmacological interventions that can enhance patients’ emotional well-being. Traditional mind–body practices such as TCQ are gaining attention as integrative strategies capable of addressing both mental and physical aspects of cancer survivorship. Despite growing evidence of their benefits, TCQ remains underutilized in mainstream oncology care, underscoring the need for greater awareness and synthesis of existing data. The objective of this commentary is to critically reflect on the effects of TCQ in alleviating anxiety and depression in cancer patients. We aim to contextualize these findings within the broader literature on integrative oncology, explore the mechanisms underlying TCQ’s psychological effects, and discuss implications for future research and clinical application. PHYSICAL AND PSYCHOLOGICAL EFFECTS OF TAI CHI AND QIGONG Definition and principles TCQ are traditional Chinese exercises that integrate physical movement, meditation, and breathing regulation. Tai Chi, often described as “meditation in motion,” involves slow, flowing movements performed in a relaxed and mindful state. These movements are characterized by their grace, fluidity, and emphasis on balance and coordination. Tai Chi promotes relaxation, reduces stress, and improves physical function through its gentle yet effective approach. Qigong encompasses a broader range of practices, including static postures, dynamic movements, and guided imagery, all aimed at cultivating and balancing vital energy (“Qi”). Qigong practices vary widely in their focus and intensity, but they all share the common goal of enhancing the flow of Qi throughout the body, promoting healing, and improving overall well-being. Accessibility and settings Both TCQ emphasize the connection between the mind and body, recognizing that mental and emotional states can significantly influence physical health, and vice versa. While Tai Chi can be considered a subset of Qigong, for practical purposes, they are often treated as equivalent and will be referred to collectively as TCQ and have demonstrated a range of health advantages.[15] TCQ exercises can be performed in various settings, indoors or outdoors, and require no specialized equipment. Regular practice can modulate stress responses by activating the parasympathetic nervous system, leading to reductions in stress hormones, blood pressure, and heart rate.[16] A substantial body of research, spanning diverse adult populations, indicates that TCQ practice can positively influence various aspects of physical and mental well-being. These include mood regulation (e.g., reductions in depression[17] and anxiety[18]), improved sleep quality,[19] enhanced musculoskeletal strength,[20] better balance during daily activities,[19] pain management,[21] and modulation of fundamental physiological processes like inflammation.[22] Furthermore, TCQ has been linked to decreased overall distress and improved long-term outlook, reflected in enhancements to quality of life[17] and self-efficacy.[23] Specifically in cancer patients, numerous clinical trials have demonstrated the benefits of TCQ, particularly in improving fatigue, cognition, and immune function.[24,25] Mind–body connection The mechanisms through which TCQ exert their psychological benefits are likely complex and involve multiple interacting pathways. These practices may influence the nervous system by modulating the autonomic nervous system, reducing sympathetic activity (the “fight-or-flight” response) and promoting parasympathetic activation (the “rest-and-digest” response). By shifting the balance towards parasympathetic activity, TCQ can help to reduce levels of stress hormones, such as cortisol, and promote a greater sense of calm and relaxation. TCQ may modulate the stress response by acting on the hypothalamic–pituitary–adrenal (HPA) axis, contributing to cortisol regulation and endocrine balance in contexts of chronic stress.[26] In a randomized trial, Chen et al.[13] observed reductions in salivary cortisol levels among breast cancer patients practicing Qigong during radiotherapy, suggesting decreased chronic stress activation. These physiological changes are in line with observed reductions in anxiety, depression, and fatigue in oncology populations. For example, Lee et al.[16] found that regular TCQ practice improved heart rate variability (HRV) in cancer survivors, indicating enhanced vagal tone and reduced physiological stress responses. Furthermore, the mindful and meditative aspects of TCQ can enhance self-awareness, emotional regulation, and coping skills. By focusing attention on the present moment and cultivating a sense of inner peace, individuals may become more attuned to their emotions and develop greater resilience in the face of challenges. Through movement, breathing, and mindful awareness, TCQ practices promote the release of endorphins and neurotransmitters associated with well-being, improving mood and reducing the perception of stress.[16] Social support The social support and sense of community that can be fostered through group TCQ classes should not be overlooked. Participating in these practices with others who share similar experiences can reduce feelings of isolation and provide a sense of belonging, which can be particularly beneficial for cancer patients who may be experiencing social challenges. The shared experience of engaging in these practices can create a supportive and encouraging environment where individuals can connect with others, share their experiences, and receive emotional support. Lo et al.[27] explored the evidence for TCQ in alleviating depressive and anxiety symptoms in cancer patients. Notably, the improvement in depressive symptoms was reported in 56% of the SRs, while 75% of the SRs reported improvements in anxiety symptoms. This lends substantial support to the potential efficacy of TCQ in enhancing mental health outcomes for cancer patients.[27] These findings are consistent with earlier reviews by Zou et al.,[19] who demonstrated benefits of Qigong across multiple psychological domains, and Chan et al.,[18] who observed reductions in fatigue, anxiety, and depression in individuals with chronic fatigue syndrome-like symptoms. Chen et al.[13] also reported improvements in quality of life and mood during radiotherapy in breast cancer patients. Collectively, these studies support the potential of TCQ as a mind–body intervention for psychological distress in oncology settings. TCQ in care plans for cancer patients The positive effects of TCQ on depressive and anxiety symptoms suggest that healthcare providers should consider incorporating TCQ into comprehensive care plans for cancer patients. TCQ’s potential to enhance mental health outcomes could improve patients’ quality of life and adherence to treatment regimens. Lo et al.[27] also highlighted the importance of culturally tailored interventions. TCQ, rooted in traditional Chinese medicine, may be particularly effective for Chinese patients due to cultural familiarity and higher expectations. However, more research is needed to determine TCQ’s effectiveness across different ethnic populations to ensure its universal applicability. However, the meta-analysis is limited by several important factors. First, the number of included reviews was relatively small, and the methodological quality of some of the primary studies was modest. Many lacked blinding or standardized outcome measures, reducing the overall strength of the evidence. Second, there was notable heterogeneity across included studies in terms of patient populations, intervention protocols, and outcome assessments. This limits the ability to generalize the findings across diverse cancer subgroups or stages. Third, the meta-analysis largely included trials from Asian populations, raising questions about cultural specificity and applicability to other settings. Despite these limitations, the meta-analysis contributes to the growing recognition of TCQ as a potentially effective component of integrative cancer care. By identifying promising but underexplored avenues, it highlights the need for higher-quality randomized controlled trials with standardized methodologies and broader population sampling. Cost considerations and broader clinical applications From a practical standpoint, TCQ interventions are typically delivered 2 to 3 times per week, with session durations ranging from 30 to 60 minutes, either in individual or group formats. Instruction is ideally provided by certified mind-body practitioners with training in oncology care or clinical supervision by integrative medicine professionals. Programs can be implemented in hospital wellness units, cancer support centers, or remotely via online platforms. Safety profiles are favorable, but providers should adapt movements to patients’ functional status, treatment stage, and fatigue levels, ensuring accessibility and comfort.[13,14] The affordability and accessibility of TCQ make it a practical option for diverse populations. TCQ interventions are relatively low-cost and accessible. Group-based sessions led by certified instructors typically cost between $10 and $30 per class, depending on setting and location. Programs usually consist of 8 to 12 weekly sessions lasting 45–60 minutes. With increasing digital access, online and video-based TCQ programs have become widely available, some offered at no cost through hospital platforms or public health agencies, thus minimizing financial and logistical barriers. Although in-person instruction may offer additional benefits through direct feedback and group support, virtual formats present a scalable alternative, particularly for immunocompromised patients or those in rural settings. Beyond oncology, TCQ has been found to support physical and mental well-being in a variety of medical conditions, including Parkinson’s disease, chronic pain syndromes, fibromyalgia, chronic fatigue syndrome, and cardiopulmonary diseases.[20-22] These cross-cutting applications further support TCQ’s relevance as an integrative modality in cancer care. FUTURE RESEARCH This commentary briefly synthesizes existing knowledge on the psychological mechanisms of TCQ and tries to offer guidance for the development of more personalized and feasible implementation strategies in oncology settings. Barriers to implementation and strategies to improve access Despite its promising benefits, the real-world implementation of TCQ in oncology care presents several challenges that must be addressed. Access to qualified instructors can be limited, as there is no universally standardized certification process for TCQ practitioners, particularly within healthcare systems. Moreover, training programs for healthcare providers often lack structured modules on TCQ, limiting their ability to recommend or integrate these practices confidently. Insurance coverage for TCQ remains inconsistent, with many programs categorized as non-essential or alternative therapies, thereby requiring out-of-pocket expenses for patients. Additionally, socioeconomic and geographic disparities may restrict access, particularly for patients in rural or underserved areas.[15] To overcome these barriers, several strategies can be considered. Community-based programs and hospital-affiliated wellness centers can serve as accessible platforms for guided TCQ practice. Online or app-based delivery formats may offer scalable and cost-effective options for patients unable to attend in-person sessions. Integrating TCQ into psycho-oncology support groups, physical rehabilitation, or survivorship care plans may enhance uptake. Finally, promoting policy change for reimbursement inclusion and supporting research on cost-effectiveness could help legitimize TCQ as a reimbursable adjunct in integrative oncology.[17,23] Methodological limitations in current literature While the existing literature is generally supportive of TCQ’s benefits, several gaps and inconsistencies remain. Many studies vary widely in terms of intervention length, frequency, and style, making it difficult to standardize protocols or draw direct comparisons. Furthermore, some randomized controlled trials report non-significant or marginal effects, particularly when TCQ is used as a standalone intervention rather than part of a multimodal care plan. Methodological limitations, such as small sample sizes, lack of blinding, or short follow-up durations, are frequent. These issues highlight the need for greater methodological rigor and replication in future studies to substantiate TCQ’s place in evidence-based integrative oncology. Research priorities proposed physiological markers for mechanistic studies Future research should prioritize several key areas to strengthen the evidence base for TCQ in cancer care. Larger, more diverse randomized controlled trials are needed, employing rigorous methodologies including blinding to minimize bias and enhance generalizability. While full participant blinding in TCQ trials is often unfeasible, partial blinding can be achieved through the use of attention control interventions, waitlist groups, or sham movement conditions that mimic the physical structure of TCQ without incorporating its key meditative or intentional components. These strategies help reduce expectancy bias and enhance internal validity in mind-body randomized controlled trials. These trials should prioritize depressive and anxiety symptoms as primary outcomes, utilizing validated psychological assessment tools to ensure consistent and accurate measurement across studies. Furthermore, studies should focus on specific cancer types and stages, ensuring applicability of TCQ benefits across diverse patient populations. Longer follow-up periods are essential for assessing the sustainability of observed mental health improvements. Delving deeper into the mechanisms by which TCQ influences psychological well-being, including exploration of physiological markers such as changes in brain activity and hormonal levels, is crucial. This mechanistic understanding will inform the development of personalized TCQ interventions, tailored to individual patient needs and preferences, taking into account factors like cancer type, treatment stage, and physical limitations. Finally, future systematic reviews should adhere to rigorous protocols, including protocol registration and comprehensive literature searches, to ensure the reliability and transparency of findings. Besides, ongoing research should adopt multimodal physiological assessments to better understand the mechanisms by which TCQ exerts its psychological effects. For example, functional magnetic resonance imaging and electroencephalography can be used to investigate changes in brain activity associated with emotional regulation, attentional control, and mindfulness, key components targeted by TCQ. Similarly, salivary or plasma cortisol assays can provide insight into the modulation of the HPA axis, an important biomarker of chronic stress. Monitoring HRV offers a reliable, non-invasive measure of autonomic nervous system balance, particularly vagal tone. Additional markers, such as pro-inflammatory cytokines (e.g., interleukin-6, tumor necrosis factor-alpha) and C-reactive protein, could further clarify TCQ’s impact on inflammation-related pathways. Including these measures in randomized controlled trials would help establish a clearer causal framework and support the development of personalized TCQ interventions in integrative oncology. In conclusion, TCQ offers promising avenues for managing psychological distress and enhancing well-being in cancer patients. While existing evidence suggests positive effects on anxiety, depression, stress, and quality of life, further research is crucial to definitively establish efficacy and optimize implementation within integrative cancer care models. Integrating mind–body practices like TCQ into comprehensive cancer care allows healthcare providers to address the holistic needs of their patients, promoting both physical and psychological well-being throughout the cancer journey. Future research should prioritize individualized approaches, adapting TCQ practices to patients’ physical conditions, abilities, and preferences to ensure safety and comfort. Critically, TCQ should be viewed not as a replacement for conventional medical care, but rather as a complementary and integrative approach. By incorporating TCQ alongside standard cancer treatments, such as surgery, chemotherapy, and radiation therapy, healthcare providers can deliver more holistic care that addresses both the physical and emotional dimensions of the disease, ultimately empowering patients to actively manage their well-being and enhance their overall quality of life. As research continues to explore the full potential of these ancient practices, TCQ may become increasingly recognized as an integral component of comprehensive and patient-centered cancer care. To facilitate the development of high-quality evidence, key research priorities are proposed in Table 1.Table 1: Research priorities for TCQ in cancer careAuthor contributions The conceptualization of the study was carried out by Giuseppe Marano and Marianna Mazza. Resources were provided by Giuseppe Marano, Ida Paris, and Marianna Mazza. The original draft of the manuscript was written by Giuseppe Marano, Ida Paris, and Marianna Mazza. The review and editing process was conducted by Giuseppe Marano and Marianna Mazza. Supervision was provided by Giuseppe Marano and Marianna Mazza. All authors have read and agreed to the published version of the manuscript. Ethical statement Ethical statement is not applicable for this article. of patient is not applicable for this article. statement new was for this support and of Marianna and Giuseppe Marano are of and The was to the standard with review of Marianna and Giuseppe Marano and the research are no of