Mindfulness Meditation and Coping with Cancer
Mindfulness Meditation and Coping with Cancer
By Howell Sasser, PhD. Dr. Sasser is Director, Research Epidemiology, R. Stuart Dickson Institute for Health Studies, Carolinas HealthCare System, Charlotte, NC; he reports no consultant, stockholder, speaker's bureau, research, or other financial relationships with companies having ties to this field of study.
For many patients, a diagnosis of cancer is the beginning of a series of stressful events. Uncertainty about long-term prognosis, changes in work and personal relationships, and the basic unpredictability of the disease compound the anxiety and discomfort associated with treatment. Considerable physical and emotional resources often must be expended simply to maintain day-to-day functioning, let alone to maintain peace of mind and optimism about the future.1
The role of stress in prognosis and disease progression after cancer diagnosis remains controversial.2,3 Yet, coping skills and resilience play a large part in the quality of life of cancer patients and cancer survivors. In recognition of this, various forms of psychosocial support support groups are the most familiar are among the services available at nearly all cancer treatment centers.
Meditative practice is another modality for the control of psychosocial disturbance that has received critical, scientific investigation. Interestingly, it likely began as an activity sought out independently by patients, that only later came to be recognized and studied by organized medicine. There are many varieties of meditative practice that originate from many different traditions. Meditation for mindfulness has a very long history in Asian religion. In Buddhism, it is the seventh part of the Noble Eightfold Path to enlightenment. Mindfulness, being present in the moment, is used as a way of detaching from futile repetition of past events or worry about events that have not yet happened and that may not (yet) be susceptible to alteration.4 The appeal of this approach, when used with cancer patients, is considerable.
A Basic Pattern
Nearly all studies of mindfulness meditation with cancer patients refer directly or indirectly to the work of Jon Kabat-Zinn, PhD, now an emeritus professor at the University of Massachusetts School of Medicine. Beginning in the early 1980s, in a series of journal articles and books, he described the elements that have come to be standard in many clinical mindfulness meditation programs.5 Because most of the studies reviewed in this article patterned their interventions on this model, it is worth reviewing briefly the essential components of mindfulness meditation:
"Sweeping" or Body Scan
The meditator directs his or her attention to each area of the body, focusing non-judgmentally on sensations and feelings. Attention is brought back periodically to breathing and relaxation.
The meditator focuses on the moment, awareness of breathing, and other perceptions. When the consciousness drifts to other thoughts, it is brought back gently to the present moment. Strong feelings or emotions are observed in a detached manner, and then consciousness is again brought to the present moment. All thoughts and feelings are treated as equal, and are neither pursued nor rejected.
Yoga postures are used to help develop mindfulness during movement, but also to reduce and reverse disuse atrophy and enhance joint range of motion. Although, as Kabat-Zinn notes, yoga is not a traditional part of mindfulness practice, the inclusion of a physical component in a program for those whose illnesses have significant physical effects seems intuitively appealing.
Other factors considered to be important include the group format for weekly sessions, an explicitly stated expectation that the program will bring relief of symptoms, a philosophy of "non-striving" (ie, the deliberate avoidance of long-term goals to maximize present benefit), a variety of techniques offered to suit varying individual needs and styles, and individual responsibility for gains through sustained work. Since the practice is one of experiencing the moment, patients need not worry about failure to do meditation "right."
Kabat-Zinn developed a 10-week course of weekly two-hour sessions. Later programs have reduced the length of the course to six to eight weeks, and the duration of the individual sessions to 60 to 90 minutes.
A small study (n = 27) of women with breast cancer at all stages of disease compared measures of stress, anxiety, and adjustment to living with cancer before and after a meditation intervention.6 The program lasted eight weeks, and was as described above. After eight weeks, participants reported statistically significant improvements in feelings of stress and anxiety and in adjustment to life with cancer. In interpreting these findings, the authors emphasize that the study had no comparison group, and that the participants were heterogeneous as to disease stage the range was less than one year to five years since diagnosis and that patients with both in situ and metastatic disease were included.
A somewhat larger, but also single-sample, study by Brown and Ryan enrolled 58 men and women in the early stages of breast or prostate cancer.7 Although various stages of disease were permitted, at least three months had to have passed since definitive surgical treatment. Psychological distress was measured with the Profile of Mood States (POMS) and the Symptoms of Stress Inventory (SOSI), and with a new instrument developed by the investigators, the Mindful Attention Awareness Scale (MAAS). The intervention was again adapted from the model of Kabat-Zinn. Forty-one participants completed the program and were included in the results. Comparison of before and after change scores showed statistically significant improvements in symptoms of stress, as measured by the SOSI, but not in the measures of mood disturbance (POMS) or mindfulness (MAAS).
A group in Alberta, Canada, has contributed much of the available controlled clinical research in the field. Their published work began with a randomized study published in 2000.8 A convenience sample of 90 men and women, with cancer of all types and all stages, were randomly assigned to a seven-week course of meditation or put on a wait-list control status. The active arm of the study was again based on the Kabat-Zinn model. It is not clear whether those in the control arm were instructed to avoid meditation or other purposeful relaxation practices. The outcomes of interest were the intervention's impact on mood disturbance and symptoms of stress, as measured by the POMS and SOSI.
At the end of seven weeks, those in the active arm scored lower on measures of depression, anger, confusion, and a summary mood disturbance score, as well as on symptoms of stress. These changes were statistically significant both when the end-of-study values were compared between the study arms, as well as when baseline-to-study-completion change scores were calculated. The authors note that both groups showed improvement over the course of the study. Also, when the last available scores for participants who dropped out were carried forward, the significance of the observed improvements in mood disturbance no longer held, although those for stress did remain significant.
A second article by many of the same authors carried the follow-up from their earlier study out to six months.9 Because those who had been in the control group in the original study were offered the meditation program at the end, as many as 90 potential participants were available for the follow-up study. Of these, 54 participants (60%) were included in the follow-up report. They completed the POMS and SOSI and returned them by mail. Change scores were calculated from the end of the original study to the six-month survey. All measures of mood disturbance and stress showed continued small, but statistically non-significant, improvement. The authors note that the lack of a comparison group further limits the strength of their conclusions.
In a subset of patients from the same study, the Calgary group reported on assessments of the impact of meditation on immune measures.10 Forty-nine women with breast cancer and ten men with prostate cancer were included. Although the participants' cancer diagnoses could be "at any time in the past," the cancer had to have been in the early stages when diagnosed. In addition to the psychological measures described above, blood samples were taken at baseline and study completion. These were assessed for changes in cell counts and for specific cell types' expression of pro- and anti-inflammatory cytokines. As already described, significant improvements were noted in measures of mood disturbance and stress. Favorable changes in interleukin-4 (IL-4), interferon-gamma (IFN-y), and interleukin-10 were also noted. However, correlations between the psychological and cytological change scores were not statistically significant.
The most recent study from this group considered the potential benefit of meditative practices on sleep, as well as the psychological measures included in their prior work.11 Sixty-three men and women with cancers of all types (59% were women with breast cancer) were enrolled in an eight-week program using the standard model. In addition to the psychological questionnaires used in the other studies by this group, the participants' sleep experience was assessed with the Pittsburgh Sleep Quality Index (PSQI). This included a variety of dimensions, including sleep latency, duration, subjective quality, and use of sleep medications. Participants showed statistically significant improvements in all sleep dimensions from baseline to study completion. Significant improvements also were noted in measures of mood disturbance and stress. Correlations of the stress and sleep measures were statistically significant, but no significant correlation could be shown between measures of mood disturbance and sleep quality.
A group in Arizona also considered the relationship of meditative practice with measures of sleep quality.12 A sample of 63 women, all with a history of Stage II breast cancer, were randomly assigned to a six-week course of organized meditation sessions and home practice, or to a "free" comparison group in which participants were permitted to choose any relaxation technique. Participants in the comparison group kept track of their activities in a diary, but did not receive any formal instruction or other guidance. Psychological distress was measured with the POMS, the Beck Depression Inventory (BDI), and standardized questionnaires for worry and anxiety. Details about sleep, including latency, awakenings, and duration were recorded by the participants in a diary. After the six-week intervention, no statistically significant benefit of meditation could be shown. Those who had higher levels of psychological distress at baseline reported poorer sleep over the entire course of the study, regardless of random assignment. No statistically significant improvement from baseline to study completion could be demonstrated in the intervention group. Interestingly, there was a significant and positive change in feeling rested in the free control group.
The bulk of the available evidence shows some benefit from meditative practice in managing the symptoms of stress. Although the effect appears to be small, it is fairly consistent. The evidence for benefit in other dimensions, such as emotional disturbance and sleep patterns, is more equivocal. Even where the findings appear solid, several limitations of the available clinical studies should weigh in the assessment of what they report. First, the majority of the articles reviewed above did not report any ante hoc power calculations, so there is no basis for determining whether their findings, and particularly the negative ones, should be viewed as reliable. Second, all of the study populations were heterogeneous in one or more respects. The outlook and emotions of cancer patients can be expected to vary considerably by the type of cancer, time since diagnosis, experiences with treatment, and non-medical factors such as social support. Third, although the meditation intervention seems to be well-developed and relatively standard, the control conditions to which it has been compared often leave open the possibility of unknown, or at least unmeasured, effects in the control group patients. These issues, combined with mixed study findings, argue for caution in ascribing a clinically significant effect to meditative practice.
While the evidence may not paint a clear picture of meditation as medically efficacious, it plainly can have benefit for patients who are receptive to it. If nothing else, it can foster a sense of self-efficacy, of "doing something," of taking control of some aspect of wellbeing in those patients who find inaction in the face of a crisis to be unpalatable. In a situation where confronting an uncertain future can be as debilitating as coping with present reality, meditation can be a helpful reminder that the present is the only segment of time over which we have meaningful influence. It also can help to nourish a sense that life events good or bad can be experienced in an immediate way, but without becoming overwhelming. In all of these respects, the best advice to the patient begins with the clinician's awareness of the patient's coping style and mental construction of his or her disease. Discussion of these and related topics can help both to guide the choice of suggested psychosocial support techniques and to give both patient and clinician a sense of what sort of results to expect from them.
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12. Shapiro SL, et al. The efficacy of mindfulness-based stress reduction in the treatment of sleep disturbance in women with breast cancer: An exploratory study. J Psychosom Res 2003;54:85-91.For many patients, a diagnosis of cancer is the beginning of a series of stressful events. Uncertainty about long-term prognosis, changes in work and personal relationships, and the basic unpredictability of the disease compound the anxiety and discomfort associated with treatment.
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