Clinical Handbook of Mindfulness (106 page)

456–466.

Villemure C., Bushnell M. C. (2002). Cognitive modulation of pain: how do attention

and emotion influence pain processing?
Pain, 95
, 195–199.

Ware J. E. Jr. (2000). SF-36 health survey update.
Spine, 25
, 3130–3139.

Zubieta J. –K., Heitzeg M. M., Smith Y. R., Bueller J. A., Xu K., Xu Y., Koeppe R. A.,

Stohler C. S., Goldman D. (2003). COMT genotype affects u-opioid neurotransmit-

ter responses to a pain stressor.
Science, 299
, 1240–1243.

Part 3

Mindfulness-Based Interventions

for Specific Disorders

20

Mindfulness-Based Interventions

in Oncology

Linda E. Carlson, Laura E. Labelle, Sheila N. Garland, Marion L. Hutchins, and

Kathryn Birnie

“I realized that you can’t do anything about the cancer, but you can

do something about how you feel about it and how you react to it.”

Sylvia (cancer patient)

The Impact of Cancer Diagnosis and Treatment

Negative Effects

Cancer is a leading cause of death worldwide, accounting for 7.6 million

(or 13%) of all deaths in 2005
(World Health Organization, 2005).
According to cancer prevalence statistics, as of January 1, 2004, it was estimated

that there were 10.7 million cancer survivors in the United States alone,

which represents approximately 3.6% of the country’s population (Surveil-

lance, Epidemiology, and End Results (SEER) Program,
2007).
These num-

bers will only grow as treatments for cancer become more successful and a

larger cohort of patients survive long-term. Regardless of increasingly promis-

ing survival statistics (up to 65% of all patients now survive beyond 5 years in

North America
(National Cancer Institute of Canada, 2007;
Ries et al., 2007)),

receiving a diagnosis of cancer and undergoing cancer treatment continues

to be a source of dread and fear for many.

Indeed, cancer diagnosis and treatment is routinely associated with high

levels of emotional distress
(Strain, 1998;
Zabora, BrintzenhofeSzoc, Curbow, Hooker, & Piantadosi,
2001).
Despite recent development of targeted therapies and biologic treatments offering effective treatment with fewer side

effects
(Baselga & Hammond, 2002;
van der Poel, 2004),
cancer and its treatment are associated with a host of physical symptoms (e.g., nausea, fatigue,

pain, hair loss), and both temporary and permanent changes in physical

appearance. Emotional reactions of fear, confusion, anxiety and anger are

common given the prospect of debilitating and lengthy treatment protocols

and disruption of normal life trajectories
(Burgess et al., 2005;
Epping-Jordan et al.,
1999; Hughes, 1982;
Shapiro, 2001).
Hardship often extends beyond the patient, emotionally impacting family members and friends (Compas

et al.,
1994; Donnelly et al., 2000;
Pitceathly & Maguire 2003).
Unfortunately, this increase in stress occurs at a time when there may be an urgent need for

emotional and physical resources to help cope with the illness.

383

384

L.E. Carlson et al.

After completing primary treatments many patients continue to have

high levels of distress requiring psychosocial care (Carlson, Speca, Patel,

& Goodey,
2004).
Anxiety, depression
(Kissane et al., 2004;
Strain, 1998),

fatigue
(Carlson et al., 2004),
and sleep problems (Fortner, Stepanski, Wang, Kasprowicz, & Durrence,
2002)
are common among cancer survivors. Fear of recurrence, sexual problems, and concerns about body image are reported

by a large proportion of survivors
(Kornblith & Ligibel, 2003).
Threat of disease recurrence and alterations in future life plans can create considerable psychological stress
(Northouse, Laten, & Reddy, 1995).
Adjustment to cancer-related stress involves psychological and behavioral coping responses

(e.g., cognitive and emotional responses to receiving a diagnosis) that may

influence psychological functioning (e.g.,
Walker, Zona, & Fisher, 2006)
and the severity of cancer-related symptoms (e.g.,
Roscoe et al., 2002).
It follows that the potential benefits of psychosocial interventions designed to

enhance coping with stress and improve quality of life are substantial for

cancer patients and survivors.

Positive Effects

Clinicians and researchers in the field of psycho-oncology have often pri-

oritized the importance of identifying and reducing negative psychological

reactions following a cancer diagnosis. This is understandable as the focus

of effort has been to reduce the suffering of patients and families. However,

there has been a recent surge of interest in the perceived benefits of the

cancer experience. Being diagnosed with cancer can lead one to renegotiate

life priorities and search for purpose and meaning of one’s diagnosis and in

one’s life more generally. Research findings suggest that despite decreased

physical health and functioning, some cancer patients indicate positive psy-

chosocial change, including increased spirituality, a deeper appreciation of

life, and more positive perceptions of significant others (Andrykowski, Brady,

& Hunt,
1993;
Cordova, Cunningham, Carlson, & Andrykowski, 2001).

The experience of discovering or actively searching for benefits, or pos-

itive implications, of the cancer diagnosis and the life changes that fol-

low is termed posttraumatic growth (PTG). Research on PTG, while still

in early stages, indicates greater levels of PTG among cancer patients

when compared with age and education matched healthy controls (Cor-

dova et al.,
2001).
Patients have reported more compassion for others

and a willingness to express feelings more openly (Katz, Flasher, Caccia-

paglia, & Nelson,
2001).
Moreover, both patients and their partners report an increased sense of personal strengths and new possibilities for life

(Manne et al., 2004).

Spirituality may also play a significant role in the context of fighting

a life-threatening illness
(Cotton, Levine, Fitzpatrick, Dold, & Targ, 1999).

Despite lack of current consensus, definitions of spirituality generally high-

light the importance of providing a context in which people feel whole,

at peace and hopeful amid life’s most serious challenges (Brady, Peterman,

Fitchett, & Cella,
1999).
Definitions of religiosity are typically narrower and less inclusive, and emphasize adherence to institutionally sanctioned beliefs

and practices associated with a particular faith group. Alternatively, the

notion of spirituality refers more generally to the feelings and experiences

Chapter 20 Mindfulness-Based Interventions in Oncology

385

associated with the search for connection with a transcendent power

(Peterman, Fitchett, Brady, Hernandez, & Cella, 2002).
Research has confirmed the importance of spirituality to both patients and caregivers (Murray,

Kendall, Boyd, Worth, & Benton,
2004;
Taylor, 2003).

Spirituality and PTG have been linked with other positive outcomes, such

as increased quality of life, psychological adjustment, and positive affect,

as well as decreased physical discomfort and dysfunction following cancer

diagnosis
(Carver & Antoni, 2004; Cotton et al., 1999; Katz et al., 2001;
Krupski et al.,
2006).
Moreover, a need has been identified to provide interventions that may encourage the development of spirituality and posttraumatic

growth
(Lechner & Antoni, 2004; Linley & Joseph, 2004).
Psychosocial interventions which increase perceived benefits among cancer patients may help

individuals adapt and adjust to the disease and its consequences.

Hence, the need has been identified to focus both on alleviating some of

the more distressing negative symptoms associated with cancer diagnosis

and treatment, as well as working to enhance the ability of patients and fami-

lies to use the transition of the cancer experience as a catalyst to enhance

personal growth and spirituality. The Mindfulness-Based Stress Reduction

(MBSR) program has the potential to create an opportunity for both of these

aspects in cancer patients and families.

Mindfulness-Based Stress Reduction

General Description

Mindfulness meditation, a technique involving moment-to-moment nonjudg-

mental awareness of internal and external experience, including thoughts,

emotions, and body sensations, has become an increasingly popular stress

reduction tool used to improve symptoms associated with several clinical

illnesses, including cancer
(Baer, 2003).
Recent interest in the potential health benefits of mindfulness meditation has risen from the development

of treatment programs modeled after the MBSR program of Jon Kabat-Zinn

and colleagues (1990) at the Stress Reduction Clinic of the University of

Massachusetts Medical Center. MBSR is a group intervention consisting of

mindfulness meditation and gentle yoga that is designed to have applications

for stress, pain, and illness
(Kabat-Zinn, 1990).
The program is perceived as qualitatively distinct from other forms of meditation (e.g., mantra based),

and is not aimed at achieving a state of relaxation, but more at the culti-

vation of insight and understanding of self and self-in-relationship via the

practice of mindfulness
(Kabat-Zinn, 2003).
Within a framework of nonjudging, acceptance and patience, the individual is taught to focus attention on

the breath, body sensations, and eventually any objects (e.g., thoughts, feel-

ings) that enter his or her field of awareness. Although mindfulness med-

itation is formally practiced while seated, walking or lying down with eyes

closed, individuals may also practice mindfulness “informally” when engaged

in everyday activities. MBSR programs are being implemented and evaluated

in health-care settings across the globe to help address a need for effective

psychosocial care.

386

L.E. Carlson et al.

General Efficacy

Studies suggest that MBSR may be efficacious for treating some of the symp-

toms associated with a broad range of chronic medical and psychiatric prob-

lems. In a meta-analysis of the health benefits of MBSR, Grossman, Niemann,

Schmidt, and Walach
(2004)
identified 20 studies that met the criteria of acceptable quality or relevance to be included in their analyses. Ten of

the 20 studies had randomized controlled designs, while six investigations

employed forms of active control intervention to account for general or non-

specific effects of treatment. Overall, both controlled and uncontrolled stud-

ies assessing mental and/or physical health variables showed similar effect

sizes of approximately
d
= 0. 5. This indicates a relatively strong effect of

mindfulness interventions for improving physical symptoms (e.g., chronic

pain), and participants’ ability to cope with everyday distress and disability,

and with serious disorders or stress
(Grossman et al., 2004).
In general, treatment effects of one-half of a standard deviation (
d
= 0. 5) are considered to

represent clinically meaningful improvements in symptomatology (Norman,

Sloan, Wyrwich, & Norman,
2003).
Grossman et al. (2004)
conclude that although as a whole the current quality of evidence for the efficacy of MBSR

on physical correlates of disease suffers from serious methodological flaws

including a lack of randomized controlled studies, findings are generally sup-

portive for the hypothesis that mindfulness training has beneficial effects on

psychological and physical well-being.

Two other conceptual and empirical reviews of the general MBSR litera-

ture have been conducted independently
(Baer, 2003; Bishop, 2002),
each

examining mindfulness training as a clinical intervention and discussing con-

ceptual and methodological issues relevant to the research. The authors of

each review conclude that mindfulness-based interventions may be useful

in the treatment of several disorders. However,
Baer (2003)
emphasizes the need for methodologically sound investigations to clarify the utility of these

interventions, while
Bishop (2002)
expresses “cautious optimism” with his conclusion that there exists some preliminary evidence that supports the

need for further evaluation of the mindfulness-based approach.

Description of the Tom Baker Cancer Centre MBSR

Program

Given the high level of emotional distress experienced following a cancer

diagnosis
(Carlson et al., 2004),
and accumulating evidence of the efficacy of MBSR in other patient populations
(Baer, 2003; Bishop, 2002),
this intervention seemed well-suited for implementation at the Tom Baker Cancer Cen-

tre (TBCC). The TBCC’s MBSR program was modeled on the work of Jon

Kabat-Zinn and colleagues (1990), and is adapted and standardized to the

clinical context of the TBCC. As described by Speca, Carlson, Goodey, and