Mindfulness Meditation and Oncology

Mindfulness Meditation for Oncology Patients: A Discussion and Critical Review Mary Jane Ott, MN, MA, APRN, BC, Rebecca L. Norris, BA, and Susan M. Bauer-Wu, DNSc, RN

The purpose of this article is to (1) provide a comprehensive overview and discussion of mindfulness meditation and its clinical applicability in oncology and (2) report and critically evaluate the existing and emerging research on mindfulness meditation as an intervention for cancer patients. Using relevant keywords, a comprehensive search of MEDLINE, PsycInfo, and Ovid was completed along with a review of published abstracts from the annual conferences sponsored by the Center for Mindfulness in Medicine, Health Care, and Society and the American Psychosocial Oncology Society. Each article and abstract was critiqued and systematically assessed for purpose statement or research questions, study design, sample size, characteristics of subjects, characteristics of mindfulness intervention, outcomes, and results. The search produced 9 research articles published in the past 5 years and 5 conference abstracts published in 2004. Most studies were conducted with breast and prostate cancer patients, and the mindfulness intervention was done in a clinic-based group setting. Consistent benefits— improved psychological functioning, reduction of stress symptoms, enhanced coping and well-being in cancer outpatients—were found. More research in this area is warranted: using randomized, controlled designs, rigorous methods, and different cancer diagnoses and treatment settings; expanding outcomes to include quality of life, physiological, health care use, and health-related outcomes; exploring mediating factors; and discerning dose effects and optimal frequency and length of home practice. Mindfulness meditation has clinically relevant implications to alleviate psychological and physical suffering of persons living with cancer. Use of this behavioral intervention for oncology patients is an area of burgeoning interest to clinicians and researchers. Keywords: cancer; chronic illness; integrative therapies; meditation; mindfulness; Mindfulness-Based Stress Reduction (MBSR)

Introduction: Cancer as a Stressful Experience

life-threatening implications and the potentially serious side effects of treatment. Cancer is the second leading cause of death in the United States, exceeded only by heart disease. In 2005, nearly 1.4 million Americans will be newly diagnosed with cancer, and 65% are estimated to be alive in 5 years.1 Thus, cancer is generally considered a chronic illness for the 10 million people with a history of the disease who are living in the United States. The diagnosis of a serious illness such as cancer is traumatizing to both the patient and to the rest of his or her family and may lead to significant immediate and long-term emotional sequelae for all.2,3 In their seminal article, Weisman and Worden first described the “existential plight” experienced by cancer patients as occurring during the first 100 days after the diagnosis of cancer.4 This common experience involves predominant concerns of life and death that surpass worries about medical details and physical symptoms. Potentially every aspect of life is affected by cancerrelated emotional distress, including changes in social relationships, body image, and functioning, as well as physical symptoms associated with the disease and treatment. The experience of cancer can be so emotionally distressing for some patients that they may meet diagnostic criteria for a mental illness such as anxiety and depression5 or post-traumatic stress disorder.6-8 Myriad physical symptoms may result from cancer treatments or the disease itself. Common acute symptoms may include nausea, vomiting, diarrhea, and mouth sores. Cancer patients are especially vulnerable to chronic symptoms such as fatigue and pain. In addition, over time, cancer survivors may also experience fear of recurrence as well as physical health concerns such as infertility, cardiac or pulmonary damage, or increased risk for secondary cancers.

Cancer is a profoundly stressful experience. A cancer diagnosis is feared by most people because of its

MJO, RLN, and SMB-W are at the Dana-Farber Cancer Institute, Boston, Massachusetts. SMB-W is at Harvard Medical School, Boston, Massachusetts.

DOI: 10.1177/1534735406288083

Correspondence: Mary Jane Ott, MN, MA, APRN, BC, Nursing and Patient Care Services, Dana-Farber Cancer Institute, Boston, MA 02115. E-mail: [email protected].

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Mindfulness Meditation and Oncology Given the chronicity of cancer and its ongoing complex emotional and physical stressors, those living with and beyond cancer are challenged to overcome many crises and cope with symptoms, life changes, and uncertainty about the future. Interventions designed to enhance coping with stress and symptoms and to promote relaxation are therefore warranted. Mind-body therapies have become more popular within cancer populations as methods to treat physical and psychiatric symptoms in conjunction with conventional allopathic care. Interventions such as support groups, educational programs, guided imagery, and expressive writing have been studied and are now frequently incorporated into plans of care.9-11 Mindfulness meditation is another mind-body therapy that is gaining credibility and interest for use in oncology patients. The purpose of this article is (1) to provide a comprehensive overview and discussion of mindfulness meditation and its clinical applicability in oncology and (2) to report and critically evaluate the existing and emerging research on mindfulness meditation as an intervention for cancer patients.

Mindfulness Meditation The primary emphasis of mindfulness meditation is experiencing life fully and being in touch with the full range of human emotions and sensory experiences. Rather than a technique to control or change unpleasant or unwanted emotions, thoughts, or sensations, mindfulness is a way of being engaged in the pure experience of what is happening in the present moment without getting entangled in ruminations about previous experience or an anticipated future.12 By paying attention to present-moment experience nonjudgmentally, one begins to cultivate a stable and nonreactive awareness even to stressful situations.13 Mindfulness meditation does not require a great deal of physical effort on the part of the novice. The student is instructed not to struggle with or manipulate thoughts in any way but merely to notice the presence of thoughts and return full attention to the physical experience of breathing or other body sensations. Mindfulness meditation is primarily concerned with acceptance, the directing of attention, and the development of skillful control of responses to stressful psychological and environmental cues.12 Mindfulness will often elicit relaxation; however, relaxation is actually a side benefit of mindfulness and not the aim. Unlike cognitive-behavioral therapy, mindfulness encourages nonstriving and makes no attempt to distract or to reframe. As a result, mindfulness offers individuals a way to alleviate suffering that often accompanies pain or emotional discomfort. Mindfulness meditation practice can cultivate a INTEGRATIVE CANCER THERAPIES 5(2); 2006

stable, nonreactive awareness for use in everyday life, not just during emotionally distressing situations; in doing so, mindfulness becomes “a way of life.”14 Mindfulness-Based Stress Reduction (MBSR) is a well-defined, systematic, educational, patient-focused intervention with formal training in mindfulness meditation and its applications in everyday life, which includes managing physical and emotional pain.12 Developed more than 25 years ago by Jon Kabat-Zinn and colleagues at the University of Massachusetts in Worcester, MBSR programs are now offered in health care settings around the world and generally consist of 7 to 10 weekly group sessions. Each session lasts for 1 to 1.5 hours; in addition, there is one silent retreat. Classes are structured to include both a didactic and an experiential component. In addition, students are given a homework assignment each week. During class, participants are taught meditation fundamentals and practice sitting meditation, body scan, and hatha yoga (also known as mindful body movement), which they are expected to practice for 45 minutes on a daily basis. During the first class, students receive an audiotape or CD that can be used to support their home practice sessions. Class sessions include information about the psychophysiology of stress, experiential mindfulness practice, discussions about how participants are progressing with their home practice, and challenges they are experiencing in this process. Participants are encouraged from the beginning to bring informal mindfulness into day-to-day activities.12,15 Much of the research done in mindfulness meditation as a therapeutic intervention over the past 2 decades has used the original MBSR program or modifications of it. Mindfulness-based therapies have been used to treat a wide range of stress and pain disorders and chronic diseases,16 such as psoriasis,17 chronic pain,18 fibromyalgia,19 HIV/AIDS,20 anxiety,21,22 and depression.23-25

Mindfulness as an Intervention for Persons Living With Cancer Mindfulness meditation can be helpful to cancer patients across the continuum of care from diagnosis through procedures, treatments, cure, and survival as well as at the end of life. It is a useful skill that can be practiced by patients to reduce and cope with stress, promote relaxation, and alleviate physical discomfort and emotional distress. Patients with cancer often experience a loss of control and feelings of helplessness. Mindfulness provides an internal locus of attention, empowering them to take a proactive stance by consciously directing their attention to present-moment experiences. Patients can be taught 4 forms of mindfulness practice: awareness of sensations, sitting meditation, body scan, and mindful movement. Patients are initially 99

Ott et al taught to focus attention on different sensory experiences, such as sounds, sights, or taste. Bringing attention to the senses is generally unthreatening and easy to experience for those who are new to mindfulness practice. Another common mindfulness technique is to focus on the physical sensation of breathing during sitting meditation. When doing so, patients are often surprised to discover they are not breathing fully but rather limiting inspiration to the upper part of the chest, thereby losing the benefit of full abdominal breathing. As they continue to focus awareness on breathing, they are often able to breathe more easily and fully, often eliciting the relaxation response. With practice, the breath becomes a familiar focal point, a trusted place of refuge and stillness in the midst of uncertainty, rigorous treatments, and intense emotions. After learning to focus on breath awareness, patients are taught to focus awareness on physical sensation during sitting meditation. Initially judged as counterintuitive, when patients direct complete attention on a strong physical sensation with a sense of curiosity without labeling or judging, the physical sensation frequently becomes less frightening, which peels away one layer of suffering. Strong physical sensations, such as pain, may become less overwhelming and less intense when experienced as sensations that change from moment to moment. Rather than getting caught up in abstract thoughts, such as what the pain might represent (eg, cancer progression), the cancer patient can pay attention to the actual physical sensations, such as aching, burning, or throbbing. The effect can be a realization that these feelings are not constant. The same can be true of thoughts and emotions, each of which can be a focal point during sitting meditation. By becoming a compassionate witness to thoughts and emotional responses, patients can begin to understand more about what triggers and fuels them. Plus, they learn from careful observation that thoughts and emotions arise, manifest, and then pass away, just as each breath and physical sensation does. The body scan is the third form of mindful meditation that enables one to develop a focused, concentrated awareness of the body, moving attention methodically from the toes to the head. In doing so, it is possible to develop an awareness of subtle changes that are continuously happening moment to moment. This often makes unpleasant sensations more tolerable and simultaneously enhances awareness of physical needs. When done with an attitude of gentleness and loving kindness, one can often begin to experience a new relationship with one’s body—a reconnection and appreciation for one’s physical being. The fourth form of meditation is mindful movement, such as hatha yoga, which invites a compassionate, ongoing awareness of the body in motion. Each of these practices can lead 100

to a gradual transformation that can empower and enhance the life of the person living with cancer.

Critical Review of Literature Method Sample Articles published between 1987 and 2004 were retrieved using the search engines MEDLINE, PsycInfo, and Ovid. The inclusion criteria consisted of original research investigating the effects of mindfulness-based interventions within cancer populations. Relevant keywords mindfulness, Mindfulness-Based Stress Reduction (MBSR), and mindfulness meditation were combined with cancer and chronic illness to yield 9 articles. To report and review emerging research in the field, we also reviewed the 3 unpublished abstracts from the First and Second Annual Conference for Clinicians, Researchers and Educators (Integrating Mindfulness-Based Interventions Into Medicine, Health Care, and Society) in 2003 and 2004, sponsored by the Center for Mindfulness in Medicine, Health Care, and Society, and 2 published abstracts from the first annual conference of the American Psychosocial Oncology Society in 2004. Procedure Each article and abstract was read and critiqued by 3 reviewers: 1 clinician, 1 researcher, and 1 research coordinator. Each article and abstract was systematically assessed for study design and methods, sample size and characteristics, specifics of mindfulness intervention, study measures, and results. Findings of the review are summarized in Table 1. Description of Research In 2002, Bishop provided a critical evaluation of the state of knowledge regarding MBSR and made suggestions for future research.26 At that time, there was only 1 randomized, controlled, clinical trial with cancer patients.27 Bishop concluded there were significant limitations with research to that point and emphasized the need to operationalize mindfulness, test its construct validity, and develop a solid method of assessment to investigate its mediating role and health outcomes. His article undoubtedly catalyzed the efforts of researchers. The result has been an increase in the number and quality of recently funded and published investigations of mindfulness as an intervention for patients with a variety of medical diagnoses including cancer. Published Studies Psychological Adjustment and Symptom Control Speca et al conducted a prospective study with a convenience sample (N = 90) of patients heterogeneous in INTEGRATIVE CANCER THERAPIES 5(2); 2006

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Mindfulness Intervention 7 weekly 90-min group sessions

Same as Speca et al27

15 sessions of MBSR

Combined nutrition and MBSR intervention; 12 weekly 3- to 4-h classes 8 weekly 90-min MBSR sessions, 3-h retreat between weeks 6 and 7 8 weekly 90-min MBSR sessions, 3-h retreat between weeks 6 and 7

6 weekly 120-min MBSR sessions, one 6-h retreat

Design Randomized, treatmentcontrol trial, pre-/posttest design

Same as Speca et al27

Randomized, controlled trial of a dietary intervention NEP, in comparison to SRC and UC One-group pretest-posttest design

One-group pretest-posttest design One-group pretest-posttest design

Part of a larger, randomized, controlled study of MBSR compared to FC for women with breast cancer

Participants

90 cancer outpatients heterogeneous in stage and type of cancer

Participants from Speca et al,27 combined with the waitlist control group who completed the MBSR, and then both groups were followed up at 6 mo

Women diagnosed with stage I or II breast cancer within the past 2 years (157 preintervention, 149 postintervention, 146 followed up at 6 mo)

10 men with prostate cancer and their partners

32 early-stage breast and 9 prostate cancer patients

42 early-stage breast and prostate cancer patients

Women with stage II breast cancer; 2 y posttreatment (54 postintervention, 41 at 3-mo follow-up, and 49 at 9mo follow-up)

Speca et al (2000)27

Carlson et al (2001)30

Hebert et al (2001)38

Saxe et al (2001)39

Brown and Ryan (2003)32

Carlson et al (2003)48

Shapiro et al (2003)31

Mindfulness Meditation and Oncology: Review of the Research Literature

Study

Table 1.

POMS, BDI, PENN, STAI, FACT-B, SOC, SCI, sleep diary

EORTC-QLQ, POMS, SOSI, immune measures, health behavior form, weekly meditation form

EORTC-QLQ, POMS, SOSI, MAAS

Immulite PSA test, 7-d dietary recall

Dietary fat, complex carbohydrates, fiber, and body mass

Same as Speca et al27

POMS and SOSI

Measures

(continued)

Significant improvement on daily diary sleep quality measures for both MBSR and FC groups, while neither showed significant improvement in sleep efficiency.

Significant improvements in quality of life, cytokine production, health behaviors, and stress symptoms associated with MBSR. No significant changes were observed for lymphocyte counts or distress.

Higher levels of mindfulness were related to lower levels of mood and stress both before and after the MBSR intervention.

Significant decrease in PSA observed in 8 of 10 men. Dietary changes include reduction in intake of total fat and saturated fat, BMI, weight. Fiber intake and physical activity increased.

NEP group had reduction in body mass at 4 mo vs no change in SRC and UC groups. NEP had larger reduction in fat consumption at 4 mo, and much of this reduction was preserved at 1 y.

Significant decreases in distress and stress scores after treatment. Scores were maintained after 6 mo, but no significant improvements were observed. Total minutes of home practice significantly predicted improvements in distress from pre- to postintervention.

Significant decrease in distress and stress symptoms in the treatment group postintervention. Number of minutes practiced significantly predicted decreased distress, and number of sessions attended significantly predicted stress symptoms.

Selected Findings

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27 self-selected breast cancer patients heterogeneous in type, stage, length of time since diagnosis, and treatment regimen

Tacon et al (2004)34

Same as Carlson et al

8 weekly 90-min group sessions; adapted to the specific patient needs (eg, use during radiation and chemo treatments)

One-group pretest-posttest design

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Mindfulness Intervention

Same as Carlson et al48

Design

Basic measure of stress (single-item question asked participants to rate current level of stress on a 10-point scale ranging from low to high), STAI, MAC, MHLC

Same as Carlson et al48

Measures

Significant reduction in stress and state anxiety scores. Helplessness-hopelessness and anxious preoccupation coping styles showed significant decreases from pre- to postintervention; internal and chance health locus of control significantly decreased from pre to posttreatment.

Same results as Carlson et al.48 In addition, no significant changes in hormone levels were observed.

Selected Findings

POMS = Profile of Mood States; SOSI = Symptoms of Stress Inventory; MBSR = Mindfulness-Based Stress Reduction; NEP = nutrition education program; SRC = stress reduction group; UC = usual care group; PSA = prostate-specific antigen; BMI = body mass index; EORTC-QLQ = European Organization for Research and Treatment of Cancer Quality of Life Questionnaire; MAAS = Mindfulness Attention Awareness Scale; FC = free-choice group; BDI = Beck Depression Inventory; PENN = PENN State Worry Questionnaire; STAI = State Trait Anxiety Index; FACT-B = Functional Assessment of Cancer Treatment–Breast; SOC = Sense of Coherence; SCI = Shapiro Control Index; MAC = Mental Adjustment to Cancer; MHLC = Multidimensional Health Locus of Control.

Same as Carlson et al

Carlson et al (2004)49

48

Participants

Study

Table 1 (continued)

Mindfulness Meditation and Oncology type and stage of cancer.27 Participants were randomized into either a 7-week MBSR intervention group or a wait-list control group. The investigators reported significant improvements in mood disturbance and stress symptoms after participation in the MBSR intervention, with a 65% overall reduction (P < .001) in total mood disturbance using the Profile of Mood States (POMS)28 and a 31% reduction (P < .01) in symptoms of stress using the Symptoms of Stress Inventory (SOSI).29 The control group results were not significant, with only a 12% overall reduction in total mood disturbance and an 11% reduction in symptoms of stress. The best predictor of improvement in total mood disturbance was the average time meditating, and the best predictor of stress reduction was the number of sessions attended. This study was an important initial step in the use of mindfulness with cancer patients. Carlson and colleagues continued to study the participants from the previous study,27 with the waitlist control group subsequently completing the MBSR intervention.30 The data from all participants were combined, and both groups were followed 6 months after the completion of the MBSR intervention. This longitudinal, repeated-measures design demonstrated that mood disturbance and stress symptoms decreased significantly (P < .001) from pre- to postintervention. The mean POMS Total Mood Disturbance (TMD) score showed a significant reduction (t = 5.04, P < .001), while the POMS subscale results were significant for decreases in anger (t = 6.24, P < .001), anxiety (t = 6.19, P < .001), depression (t = 5.52, P < .001), confusion (t = 4.14, P < .001), and fatigue (t = 2.38, P < .05). There was also a statistically significant increase in vigor (t = –3.30, P < .001). Those with greater initial mood disturbance demonstrated the most improvement postintervention (P < .001). As with the earlier findings by Speca et al,27 total minutes of home practice also predicted improvements (P < .05) in mood disturbance from pre to postintervention. The mean SOSI total score demonstrated a significant reduction in stress symptoms (t = 3.63, P < .001) at postintervention as well. The SOSI post intervention subscale scores were significant in the following areas: emotional irritability (t = 5.62, P < .001), habitual patterns (t = 5.26, P< .001), depression (t = 4.95, P < .001), anxiety (t = 4.32, P < .001), cardiopulmonary (t = 4.13, P < .001), muscle tension (t = 4.02, P < .001), peripheral manifestations (t = 3.13, P < .01), cognitive disorganization (t = 3.05, P < .005), and gastrointestinal (t = 2.57, P < .012). In this sample (n = 89), all scores showed shifts toward improvement at 6 months; however, the changes were not statistically significant. In a larger exploratory study using a randomized, controlled design, Shapiro et al reported on the efficacy

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of MBSR in the treatment of sleep disturbance in women with breast cancer (N = 63).31 This reported outcome was one component of a larger study. The study sample consisted of women with a history of stage II breast cancer in remission who continued to experience high levels of cancer-related anxiety. Participants were randomized into 2 groups: the control group was allowed “free choice” (FC) to pick their own stress management technique, and the experimental group participated in a MBSR intervention that met for 6 weekly 2-hour sessions and one 6-hour silent retreat. The MBSR interventions included sitting meditation, body scan, hatha yoga, and a loving kindness meditation. The study was innovative in that the FC participants were allowed to freely choose their own unstructured, unguided method of stress reduction, such as taking a bath or talking to a friend. The investigators first found that sleep functioning was associated with psychological distress, although the study hypothesis that MBSR would more greatly enhance sleep quality in anxious breast cancer patients compared to the control condition was not supported. In both the MBSR and FC groups, those who had greater baseline distress also had significantly poorer sleep quality (β = –.327) and felt less refreshed after sleep (β = –.447). Both the MBSR and FC groups showed significant improvements in sleep quality from before to after the intervention period, indicating that both methods of stress reduction were helpful to participants. However, neither intervention showed significant improvement on sleep efficiency. For the MBSR participants, the amount of time in informal mindfulness practice at home predicted the sense of feeling refreshed upon awakening (β = .339). This finding is consistent with that of Carlson and colleagues who found that total minutes of home mindfulness practice predicted improvements in mood disturbance.30 The authors conclude not only that MBSR is a promising intervention for breast cancer patients who have stressrelated sleep disturbance but also that other selfselected stress-reducing activities can be helpful since the activities may be more personalized and suitable to the individual and thus more likely to encourage adherence. Consistent with Bishop’s recommendation to operationalize and better understand the mediating role of mindfulness, Brown and Ryan conducted a series of studies in the development of the Mindful Attention Awareness Scale (MAAS).32 One study included early-stage breast and prostate cancer patients (N = 41) to determine if changes on the MAAS related to changes in adjustment and wellbeing after participation in an MBSR program. A heterogeneous group of breast cancer and prostate cancer patients were enrolled in an 8-week MBSR

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Ott et al program, meeting for 90 minutes per week with a 3-hour retreat between weeks 6 and 7. The MAAS, POMS, SOSI, and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC-QLQ)33 were completed pre- and postintervention. There were no significant differences in changes in the measures from pre- to postintervention. However, an increase in MAAS from the pre- to postintervention was found be significantly predictive of a drop in the POMS (P < .01) and SOSI (P < .01) scores, suggesting that becoming more mindful is associated with less distress and fewer stress symptoms. The authors note the study limitations of nonrandomized design and small sample size. However, they propose that the MAAS might be of use in future studies to determine whether the experience of cancer increases one’s attention to present-moment concerns and experiences. More recently, a single-arm pilot study (N = 27) using a pre/post design investigated the effectiveness of an MBSR program in a heterogeneous sample of women with cancer.34 The outcomes were stress (measured by a visual analog scale), state anxiety (measured by the State scores of the State-Trait Anxiety Inventory),35 mental adjustment to cancer (measured by the Mental Adjustment to Cancer Scale),36 and health locus of control (measured by the Multidimensional Health Locus of Control Scale).37 The intervention followed the typical MBSR activities of didactic, inductive, and experiential learning about the stress response and mindfulness techniques of sitting meditation, body scan, and hatha yoga, which were conducted over 1.5-hour sessions held once a week for 8 weeks. Significant reductions were documented at the end of the intervention period in the following areas: stress (t = 7.54, P < .001), anxiety (t = 4.95, P < .001), helplessness-hopelessness (t = 2.66, P < .01), anxious preoccupation (t = 2.54, P < .01), internal locus of control (t = 2.30, P < .05), and chance locus of control (t = 4.64, P < .001). At the completion of the 8-week program, more than half of the participants indicated their preference for yoga, 42% preferred the body scan, and 7% preferred sitting meditation. At the 3-month follow-up, 88% still practiced some form of mindfulness with the following preferences: 50% yoga, 29% body scan, and 21% sitting meditation. At that time, more than half practiced at least 5 days per week, one third practiced at least 3 days per week, and less than one fifth practiced fewer than 3 days per week. Many reported a preference for yoga because it improved their upper body/arm flexibility and increased their physical comfort (ie, relieving symptoms of lymphedema), especially on the side of the body affected by cancer surgery.

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Nutrition-Related Outcomes Two published studies investigated the efficacy of MBSR in relation to nutritional outcomes with cancer patients, using MBSR in comparison with or in combination with dietary interventions.38,39 Evidence indicates that nutrition is associated with an increased risk of both breast and prostate cancer40-45 and, conversely, that plantbased diets are associated with decreased risk.40,46,47 While it is important to identify effective interventions that positively effect nutritional outcomes in cancer patients, the use of MSBR for this purpose is not well described. Nonetheless, we have included the following studies since MBSR was used and the study samples were limited to patients with cancer. In a clinical trial (N = 172) using repeated-measures (preintervention, immediately postintervention, 4 months later, and 12 months later) by Herbert and colleagues, women with stage I or II breast cancer were randomized to 1 of 3 groups: usual supportive care (UC); a group-based, 15-week, dietitian-led nutrition education program (NEP); or a Mindfulness-Based Stress Reduction clinic program (SRC).38 The SRC group received instruction in yoga and mindfulness meditation as well as having sessions specifically addressing issues of coping with breast cancer. The SRC group did not receive formal instruction in nutrition or instruction in cooking. Primary outcome measures included dietary fat, complex carbohydrates, fiber, and body mass. The SRC group experienced no significant improvement in any of the outcome variables. At 4 months postintervention, when compared to the SRC or UC group, the NEP group experienced a significant reduction in total fat (P < .05) and body mass (P < .05) and a significant increase in consumption of fiber (P < .05). At 4 months, the NEP group also had a significant increase in complex carbohydrate consumption (P < .05) when compared to the UC or SRC groups. The significant reduction (P < .05) in total fat consumption was sustained by the NEP group at 12 months.38 It is not surprising that the NEP group demonstrated significant dietary changes given the intense education and relational model used. Unlike the SRC group, they were taught new ways of preparing food to reach the desired goal. Of note, while measures of psychological functioning (anxiety, depression, distress, and self-esteem) were also administered, these findings were not reported in the article. In a similar pilot study using a descriptive, prospective design in men with prostate cancer (N = 10), participants served as their own control to determine the effects of participation in a 12-week group (3 to 4 hours each week) that combined an MBSR program with consumption of a plant-based diet that was low in saturated fat and high in fiber.39 It is important to note that

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Mindfulness Meditation and Oncology neither MBSR practice adherence nor psychological outcomes were described in the article. The investigators found that the rate of increase in prostate-specific antigen (PSA) decreased in 8 of 10 men (P = .01). The PSA estimated median doubling time increased from 6.5 months (95% confidence interval [CI], 3.7 to 10.1) prior to the intervention to 17.7 months (95% CI, 7.8 to infinity) after the intervention. Additional findings included weight loss by all 10 men, with a mean decrease in body mass index of 7%. The mean caloric intake decreased an average 530 kcal daily in 8 of the 10 participants, total fat decreased by a mean of 6 g daily in 6 of the 10 participants, saturated fat intake decreased by an average of 4.14 g daily in 9 of the 10 participants, and fiber intake increased by an average of 5.5 g per day (40% increase from baseline) in 4 of the participants. Eight of the 10 participants increased their intentional daily physical activity by an average of 21 to 33 minutes daily (a 57% increase). The rate of increase of the PSA slope was significantly associated with 3 dietary and lifestyle factors: inversely associated with dietary fiber intake (Spearman’s ρ = –0.73, P = .02) and number of minutes exercised (Spearman’s ρ = –0.60, P = .04) and positively associated with change in body mass index (Spearman’s ρ = 0.60, P = .04). The findings of this pilot study are interesting, although external validity is limited by the very small sample size and lack of randomization. Because the study combined MBSR with a new diet in a single sample, one cannot determine if the observed findings were the result of unique or complementary effects of the mindfulness and dietary interventions. It is possible that MBSR may prove to be an effective method to help men cope with a drastic change in diet.

Immune and Neuroendocrine Outcomes There are 2 articles published by Carlson and colleagues that evaluated immune and neuroendocrine outcomes.48,49 Both are nonrandomized, convenience samples with repeated-measures design (pretest and posttest intervention). In 2003, Carlson et al reported on the effects of an 8-week MBSR with early-stage breast cancer (n = 49) and prostate cancer (n = 10) patients. The outcomes reported with this nonrandomized study were lymphocyte counts and cytokine production, quality of life, mood, and stress symptoms. Forty-two participants (33 with breast cancer; 9 with prostate cancer) were available for postintervention assessment. Seven participants did not complete the study; the reasons for attrition were work demands (n = 4), scheduling difficulties (n = 2), and lack of interest (n = 1). While there were no significant changes noted in lymphocytes counts, there were statistically significant changes in some of the cytokines assessed: T-cell production of interferon-γ INTEGRATIVE CANCER THERAPIES 5(2); 2006

(t = 2.18, P < .01) and interleukin-4 (t = –3.84, P < .001), and natural killer cell production of interleukin-10 (t = 2.22, P < .05). These results are suggestive of a shift toward an anti-inflammatory response and away from a proinflammatory one. This study was the first of its kind to demonstrate positive effects of MBSR on the immune system of cancer patients. In addition to immune outcomes, the authors reported on quality of life, mood disturbance, stress symptoms, and health behaviors. They identified significant improvements in quality of life (measured by EORTC-QLQ; P < .05). TMD scores on the POMS decreased by 13%; however, this was not statistically significant, most likely because the initial scores were already low. The mean SOSI total score was significantly lower after the intervention (19.3%, P < .01). Changes in health behaviors, specifically reduction in caffeine intake, increased physical exercise, and improved sleep quality, were also statistically significant, which could also contribute to the observed anti-inflammatory immune response. Additional results were subsequently published from the same sample of breast and prostate cancer patients (n = 42).48,49 This later publication focused on the neuroendocrine outcomes of salivary cortisol, plasma dehydroepiandrosterone sulfate, and salivary melatonin. There were no significant changes in hormone levels observed in the patients studied. While not statistically significant, there were interesting observations related to neuroendocrine function. Melatonin levels were higher immediately after meditation practice, and baseline peak nighttime levels were higher. Diurnal cortisol secretion patterns demonstrated attenuation of more extreme levels, indicating a shift toward a healthier hypothalamicpituitary-adrenal (HPA) axis functioning. While not generalizable because of the small sample size and nonrandomized design, the study provides valuable information related to MBSR’s potential effects on HPA axis functioning and stress hormone functioning in cancer patients.

Conference Abstracts The use of mindfulness interventions with cancer patients is of growing interest, and emerging research in this area is quite promising. In a relatively new field of study such as this one, getting a glimpse of new studies that have yet to be published is enlightening. Therefore, descriptions and findings from recent conference abstracts are provided. In 2004 at the first annual conference of the American Psychosocial Oncology Society, there were 2 published research abstracts related to mindfulness and cancer. Bauer-Wu and colleagues presented data on the use of mindfulness meditation with cancer patients undergoing a stem cell/autologous bone 105

Ott et al marrow transplant (SC/ABMT; N = 20).50 The primary aim of this single-arm, exploratory study was to examine the feasibility of a mindfulness meditation intervention in a sample of highly symptomatic cancer patients who experience a lengthy hospitalization (3-4 weeks) for SC/ABMT. The authors found that the intervention, consisting of twice-weekly individual sessions with a trained mindfulness meditation instructor and daily listening to a 17-minute mindfulness meditation CD, was feasible: there was an 87% recruitment rate, 95% of the participants completed the intervention, and there were 4 longitudinal data collection points. Visual analog scales administered before and after individual sessions revealed a statistically significant decrease in pain (P = .0002 to .031) and increases in the levels of relaxation (P < .0001 to .031), happiness (P = .0001 to .036), and comfort (P = .0003 to .002). Reduced heart rate (P = .001 to .039) and respiratory rate (P = .008 to .031) were also observed. Qualitative data obtained through structured interviews during hospitalization and up to 3 months after discharge from the hospital revealed a consistent overall positive experience with learning mindfulness and using it to cope with the transplant. Many participants also described using the mindfulness techniques up to 3 months after going home from the hospital. This is the first known mindfulness study conducted in acutely ill, hospitalized persons with cancer. Based on the results of this pilot study, a large randomized clinical trial is under way. In another preliminary study (N = 34) using pre- and postintervention questionnaires, Moscoso et al reported on the effectiveness of a brief mindfulness meditation intervention in decreasing anxiety, depression, anger, demoralization, and symptoms of somatic fatigue in male and female cancer patients. Type and stage of cancer were not specified. Seventeen cancer patients self-selected to participate in four 1-hour-weekly classes; the other 17 served as controls.51 The authors indicated that they found statistically significant test-retest differences for the Cancer Emotional Distress Inventory (CEDI) total scale and a significant test-retest interaction by group effects on the Hospital Anxiety and Depression Scale (HADS) total scale, the HADS Anxiety subscale, and the CEDI Anxiety subscale. No significant changes were observed with fatigue scores. While limited because of self-selection bias, the results indicate that the brief mindfulness intervention had a positive effect on anxiety and that improvements in anxiety were evident 3 months after participation in the intervention. There were 3 abstracts published in the conference proceedings of poster presentations from the Second Annual Conference for Clinicians, Researchers and Educators: Integrating MindfulnessBased Interventions Into Medicine, Health Care, and 106

Society, sponsored by the University of Massachusetts Center for Mindfulness in Medicine, Health Care, and Society. In the first abstract, Carlson et al reported on the use of MBSR as an intervention to improve sleep quality in cancer patients (n = 44) and their spouses (n = 12). The patient participants varied in stage and type of cancer. In this prospective study using pre- and posttest measures on both patient and spouse participants, significant improvements in sleep quality (P < .001), sleep duration (P < .01), and sleep efficiency (P < .01) and decrease in sleep disturbances (P < .05) were identified, in addition to decreases in stress symptoms (using SOSI; P < .001) and improvement in mood measured by the POMS (P < .001). The second abstract by Carlson and Brown reported on the validation of the MAAS initially described by Brown and Ryan.52 Cancer outpatients (n = 122) who participated in an MBSR program were matched to local community members (n = 122) as controls. The single-factor structure of the MAAS was found to be invariant across the groups. They also found that higher MAAS scores were associated with lower POMS and SOSI scores in both samples; however, no specific data or statistical results were reported in the abstract. Using qualitative research methods, the third abstract by Mackenzie et al explored self-perceived effects of participation in an MBSR drop-in class in 10 cancer patients.53 Identified themes reported include the importance of group practice, meditation as a form of healing and a source of control, and the desire to share the meditation practice with significant others.

Summary of Results In summary, from 2000 to 2005, there have been 9 research articles published in peer-reviewed journals that investigated the use of mindfulness meditation interventions in adults living with cancer. These were the first studies on mindfulness that have focused on the oncology population. All of these studies used convenience samples of cancer outpatients, mostly with early-stage breast cancer, and used clinic-based mindfulness interventions conducted in a group setting. Three of the 9 published studies used a randomized controlled design. Improvements in psychological and physical symptoms were consistently reported across studies, and while preliminary, mindfulness interventions seem to have a positive effect on health behaviors and physiological outcomes (ie, immunological and neuroendocrine functioning) in cancer patients. Conference abstracts provide insight into emerging research on mindfulness and cancer, which includes the use of mindfulness with more symptomatic and hospitalized cancer patients as well as the mediating role of mindfulness in cancer-related outcomes. INTEGRATIVE CANCER THERAPIES 5(2); 2006

Mindfulness Meditation and Oncology Given the limitations identified, there is clearly a need for multisite, randomized, controlled clinical trials using rigorous design and large samples. It would be helpful to widen the study populations to include other cancer diagnoses and stratify according to staging and to expand studies to include the pediatric oncology population. Further work is needed to explicate the mediating factors and better understand the unique benefits of mindfulness meditation and MBSR (eg, controlling for attention, group effect, and nutrition education). Furthermore, it would be valuable to objectively monitor dose effects of mindfulness practice. Previous work demonstrates a positive association between study outcomes and the amount of time patients use or practice the mindfulness techniques. However, this information is limited by self-report, and little is known about the optimal frequency and length of practice (ie, listening to meditation CDs) to achieve desired clinical outcomes.

Conclusion Cancer diagnosis, treatment, and survivorship are all associated with a multitude of psychological and physical consequences. Stress-reducing techniques can be incorporated into the care of cancer patients to promote effective coping, decrease symptoms, and enhance health outcomes. Mindfulness meditation interventions are one type of mind-body therapy becoming increasingly popular and gaining credibility for use in the oncology population. While this field is just beginning to emerge, with the first published study in 2000, research to date demonstrates remarkable benefits of mindfulness-based interventions to enhance the wellbeing of persons living with cancer.

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