Clinical Handbook of Mindfulness (107 page)

Angen
(2000),
the MBSR program offered through the TBCC aims to provide

an opportunity to become aware of one’s personal responses to stress and

to learn and practice meditation techniques that will bring about healthier

stress responses. The core of the program consists of the practice of mindful-

ness meditation. Attitudes of nonjudging of personal experience, seeing and

accepting situations as they are, patience during the practice and in daily life,

Chapter 20 Mindfulness-Based Interventions in Oncology

387

non-striving and loosening of goal-oriented stances, and letting go of uncon-

trollable outcomes are suggested and modeled by group leaders
(Speca et al.,

2000).
Group members are encouraged to take an active role in their healing process, and are taught options for self-care that promote feelings of competence in terms of managing stress. The core of the program consists of the

practice of mindfulness meditation. The two instructors provide a safe and

supportive group environment in which self-disclosure regarding the experi-

ence of cancer can serve to enhance skill acquisition
(Speca et al., 2000).

The intervention is provided over the course of eight weekly, 90-minute

group sessions, as well as one 6-hour intensive session on a Saturday between

weeks six and seven. The program consists of three components: didactic

instruction, experiential practice, and group process. Topic areas covered

didactically in-session and in a participant manual are: (a) the impact of stress

on one’s physical and psychological health, including the psychological and

physical symptoms of stress, (b) emotional, cognitive, and behavioral pat-

terns and how they may influence our stress responses, and (c) concepts

fundamental to mindfulness meditation and mindful living. Participants learn

to apply the principles taught didactically, through experiential practice of

mindfulness meditation at home and during group sessions. In group ses-

sions, instructors guide participants through experiential activities including

various types of mindfulness meditation (e.g., sitting, walking) and gentle

hatha yoga. When the yoga component is taught, it is framed as a modal-

ity for practicing mindfulness (moving meditation), rather than a physical

exercise. Participants are encouraged to practice the prescribed meditation

and yoga techniques daily, for 45 minutes. Guided meditation CDs are pro-

vided to support home practice. During each session, group discussions are

facilitated to encourage self-disclosure regarding experiences and challenges

encountered through the practice of mindfulness meditation. Instructors and

other program participants offer constructive feedback and support to help

problem solve when there are impediments to effective practice. Supportive

interaction between group members is encouraged.

Several specific issues involved in therapy for cancer patients are consid-

ered in the delivery of MBSR at the TBCC. Sensitivity to the physical and men-

tal implications associated with the various types and stages of disease, and

medical treatments received, is critical. It follows that the timing of a can-

cer patient’s enrollment is an important factor to consider. The program’s

format and scheduling requirements are discussed with patients at a pre-

intervention interview, at which time concerns regarding pain, fatigue, nau-

sea, immobility and other factors influencing motivation to participate are

discussed. Patients are encouraged to discuss any concerns regarding partic-

ipating in MBSR with their treating physician. Some patients find that partic-

ipating in MBSR during the course of a demanding treatment regime is diffi-

cult or impossible, while other patients find they can engage fully in the pro-

gram while undergoing treatment. Appropriate management of expectations

and concern for safety often permits debilitated patients to fully engage in the

program. For example, consideration of physical limitations is emphasized

with regards to the yoga component of the program; instructors provide

modifications of standard yoga
asanas
(i.e., postures) as necessary, to ensure

individual comfort and safety. Many patients find the program useful for cop-

ing with day-to-day demands of treatment such as waiting for appointments,

388

L.E. Carlson et al.

tolerating venipuncture and chemotherapy or radiation therapy administra-

tion and coping with uncomfortable tests and scans. Others find that the

program is particularly helpful after treatment completion when they some-

times feel “abandoned” by the treatment team and are often struggling with

fears of recurrence and issues around how to live a genuine and authentic

life moving forward, but still re-integrate into mainstream society.

Review of Empirical Support for MBSR in Oncology

Settings

Quantitative Findings – Symptom Reduction Outcomes

MBSR is gaining credibility and interest for use in oncology settings (Ott,

Norris, & Bauer-Wu,
2006).
Several independent reviews of the literature of MBSR in oncology settings indicate that although the research is still at an

early stage, MBSR may be efficacious as an adjunct treatment for improving

psychological functioning of cancer patients
(Lamanque & Daneault, 2006;

Mackenzie, Carlson, & Speca, 2005; Matchim & Armer, 2007;
Ott et al., 2006;

Smith, Richardson, Hoffman, & Pilkington, 2005).
The first published study in this area was our randomized controlled trial of the effects of MBSR on

symptoms of stress and mood disturbance in a diverse population of cancer

outpatients
(Speca et al., 2000).
When compared to a waitlist control group, MBSR participants indicated significantly less total mood disturbance, tension, depression, anger, and more vigor following the intervention. Program

participants also reported reduced symptoms of stress, including peripheral

manifestations of stress, cardiopulmonary symptoms of arousal, central neu-

rological symptoms, gastrointestinal symptoms, habitual stress behavioral

patterns, anxiety/fear, and emotional instability, when compared with con-

trols. In addition, more home meditation practice over the course of the

program was associated with fewer reported stress symptoms and decreased

total mood disturbance. Results of a 6-month follow-up study which included

intervention and control group participants together revealed that psycho-

logical benefits were maintained at the follow-up assessment (Carlson, Ursu-

liak, Goodey, Angen, & Speca,
2001).
The largest improvements were seen on subscales of anxiety, depression, anger and irritability.

Evaluations of the efficacy of MBSR for improving sleep quality among

cancer outpatients also offer promising results. Sleep disturbance in cancer

patients has been found to range from 40 to 85% across studies, clearly indi-

cating that sleep is a problem for this clinical population
(Carlson et al., 2004;

Engstrom, Strohl, Rose, Lewandowski, & Stefanek, 1999;
Koopman et al.,

2002;
Savard & Morin, 2001).
In a study of the effects of an MBSR program on sleep quality in a heterogeneous cancer patient population, results indicated

significant reductions in overall sleep disturbance and improved subjective

sleep quality, as assessed by the Pittsburgh Sleep Quality Index (Carlson &

Garland,
2005).
When using a conservative cutoff on this measure, sleep

disturbance was reduced in the entire sample by 11%. After the program,

participants reported they were sleeping a mean of 1 hour more per night,

which is considered clinically significant. Reductions in symptoms of stress,

mood disturbance, and fatigue were also observed; changes in symptoms of

Chapter 20 Mindfulness-Based Interventions in Oncology

389

stress and fatigue correlated in expected ways with improvement in sleep

quality.

In an earlier study of the effects of MBSR on sleep, Shapiro, Bootzin,

Figueredo, Lopez, & Schwartz
(2003)
compared an MBSR and a “free choice”

active control condition on sleep complaints in a group of breast can-

cer patients. Both MBSR and control participants demonstrated significant

improvement on daily diary sleep quality measures. Participants in the MBSR

group who reported greater mindfulness practice improved significantly

more on the sleep quality measure most strongly associated with distress

(i.e., feeling rested after sleep)
(Shapiro et al., 2003).

Observations of other research groups who are applying modifications of

MBSR in oncology settings complement the above-described findings. Monti

et al.
(2006)
conducted a randomized waitlist-controlled trial to evaluate the efficacy of a mindfulness-based art therapy (MBAT) program designed for cancer patients. MBAT incorporates mindfulness meditation and art therapy with

the goal of decreasing distress and improving quality of life. Participants in

the study were women with a variety of cancer diagnoses. MBAT participants

demonstrated significant decreases in emotional distress, and improvements

in general health, mental health, vitality, and social functioning, when com-

pared with waitlist controls. Gains associated with MBAT participation were

maintained at a 2-month follow-up assessment
(Monti et al., 2006).
Another research group has presented pilot qualitative data attesting to the potential benefits of integrating mindfulness techniques into psychoeducational

programs for sexual problems subsequent to gynecological cancer (Brotto &

Heiman, 2007). Finally, studies evaluating modifications of MBSR have been

presented at scientific meetings, representing ongoing clinical application of

MBSR in oncology populations (e.g.,
Bauer-Wu & Rosenbaum, 2004;
Baum & Gessert,
2004;
Lengacher et al., 2007; Moscoso, Reheiser, & Hann, 2004).

Quantitative Findings – Biological Outcomes

In addition to improving psychological functioning, MBSR is hypothesized to

impact biological systems in cancer patients, who may exhibit dysregulation

of these systems
(Abercrombie et al., 2004;
Sephton, Sapolsky, Kraemer, & Spiegel,
2000; Touitou, Bogdan, Levi, Benavides, & Auzeby, 1996;
van der Pompe, Antoni, & Heijnen,
1996).
Our group evaluated the effects of MBSR

on immune, neuroendocrine, and autonomic function in early stage breast

and prostate cancer patients who were at least 3 months posttreatment

(Carlson, Speca, Patel, & Goodey, 2003;
Carlson et al., 2004).
Participants completed self-report measures to assess quality of life, mood states, and

stress symptoms, and provided blood samples to measure immune cell num-

bers and function. Salivary cortisol (assessed three times/day), plasma dehy-

droepiandrosterone sulfate (DHEAS, a steroid product of the adrenal glands),

and salivary melatonin were also measured pre- and post-intervention (Carl-

son et al.,
2004).
Significant improvements were observed in overall quality of life, symptoms of stress, and sleep quality. Although there were no significant changes in the overall number of lymphocytes or cell subsets, T cell

production of cytokines interleukin (IL)-4 increased and interferon gamma

decreased, whereas natural killer cell production of IL-10 decreased. These

changes in patients’ immune profiles were behaviorally associated with a

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L.E. Carlson et al.

shift away from a depressive pattern to one more consistent with healthy

immune function. In addition, approximately 40% of patients shifted from

an abnormal “inverted V-shaped” pattern of diurnal cortisol secretion, to a

healthier “V-shaped” pattern. This change was driven by a decrease in after-

noon and evening cortisol levels in some participants. Improvements in qual-

ity of life were associated with decreases in afternoon cortisol levels. In sum,

although the lack of a control group limits interpretation, findings suggest

that the MBSR program alters immunological and neuroendocrine profiles

of cancer patients in a direction more consistent with healthy functioning

(Carlson et al., 2003,
2004).

More recently a 1-year follow-up paper of this same group of breast and

prostate cancer patients has been published
(Carlson, Speca, Patel, & Faris,

2007).
We found that improvements in stress symptoms and quality of life were maintained over the full year of follow-up. In addition, cortisol levels

continued to drop over the year, and salivary cortisol levels at 1-year follow-

up were associated with stress symptoms, such that those patients with less

stress also had lower cortisol values. Continued regulation in immune sys-

tem values, particularly pro-inflammatory cytokines, was also seen. This is

usually interpreted as a sign of stabilization of the immune system, which

may have been producing a maladaptive inflammatory response to the can-

cer. Finally, systolic blood pressure values decreased over the course of the

MBSR program. Any decreases in blood pressure are desirable, as elevated