Clinical Handbook of Mindfulness (108 page)

blood pressure is the best predictor of subsequent heart disease (Carlson

et al.,
2007).

Confirming this last finding in a much more methodologically rigorous

manner, preliminary results from a waitlist controlled trial conducted by

our group indicate a beneficial impact of MBSR on resting blood pressure

in women with cancer
(Van Wielingen, Carlson, & Campbell, 2007).
Twenty-nine women with a diagnosis of cancer (mostly breast) who had completed

treatment at least 1 month prior to study entry were either registered for

immediate MBSR participation, or were waiting for the next program. Resting

blood pressure was assessed weekly at home over the 8-week study period in

both groups. For participants with relatively high levels of baseline systolic

blood pressure at entry to the study, participation in the MBSR program was

associated with a significant decrease in resting systolic blood pressure over

the 8 weeks relative to the control group. In addition, MBSR participation

was associated with decreased self-reported symptoms of stress, depression,

rumination, and increased mindful attention awareness. This study confirms

our previous findings that the MBSR program may be efficacious in reduc-

ing resting blood pressure. The decrease in systolic blood pressure observed

(15.5 mmHg) is clinically meaningful, and is comparable to the drop seen

for antihypertensive medication or a 10 kg drop in body weight (The Tri-

als of Hypertension Prevention Collaborative Research Group,
1997;
Wua

et al.,
2005).
In the same study, when compared with waitlist controls, preliminary data suggests that MBSR participants appear to demonstrate greater

systolic blood pressure recovery following a public speaking stressor at post-

intervention
(Van Wielingen, Carlson, & Campbell, 2006).
It remains to be seen whether preliminary results from this ongoing trial hold up at study

completion. As blood pressure levels are predictive of the development of

cardiovascular morbidity and mortality, MBSR may have the potential to

Chapter 20 Mindfulness-Based Interventions in Oncology

391

improve health outcomes for cancer patients, many of who are already at

increased risk due to heart-related side effects of cancer treatments.

In another study which included biological outcomes,
Saxe et al. (2001)

evaluated the effects of combining a dietary intervention with MBSR on levels

of prostate specific antigen (PSA), an indicator of the level of tumor activity

in men with prostate cancer. Results suggested this 4-month combined pro-

gram resulted in a slowing of the rate of PSA increase in a pilot sample of 10

men
(Saxe et al., 2001).
Findings from the larger RCT may confirm whether this combined dietary and mindfulness-based intervention alters PSA levels

in prostate cancer patients.

Quantitative Findings – Positive Psychology Outcomes

The effects of the MBSR program on positive outcomes such as spiritual-

ity and PTG are in the early stages of investigation. Garland, Carlson, Cook,

Lansdell, & Speca
(2007),
compared the effects of an MBSR intervention and a creative arts-based (“Healing Arts”) program for facilitating PTG and

spirituality in cancer outpatients. Participants in the MBSR group demon-

strated significant increases in PTG and spirituality over the course of the

program; increases in spirituality as well as decreases in anger and over-

all stress symptoms were significantly greater for MBSR versus Healing Arts

program participants
(Garland et al., 2007).
This preliminary study indicates future research into the effects of MBSR on positive psychological outcomes

in cancer patients is warranted.

Quantitative Findings Summary

In general, MBSR is thought to have potential as a clinically valuable interven-

tion for cancer patients
(Mackenzie et al., 2005;
Ott et al., 2006; Smith et al.,

2005).
However, there is a need for replication of randomized controlled trials that include active control groups and long-term follow-up. In the future,

incorporating both positive (e.g., things we want to enhance such as PTG)

and negative (e.g., things we want to decrease such as depression) psycho-

logical outcomes alongside biological indices may foster greater breadth and

depth of understanding of changes incurred through the program. Studies

comparing MBSR to other psychosocial interventions developed for can-

cer patients (e.g., supportive-expressive therapy) and dismantling studies

will enable identification of the program’s key ingredients. Brown and Ryan

(Brown & Ryan, 2003)
reported that increased mindfulness over the course of the MBSR intervention predicted decreases in symptoms of stress and

mood disturbance, alluding to emerging research on the mediating role of

mindfulness in cancer-related outcomes
(Brown & Ryan, 2003;
Ott et al.,

2006).
According to
Ott et al. (2006),
“further work is needed to explicate the mediating factors and better understand the unique benefits of mindfulness meditation and MBSR (p. 107).”

Qualitative Findings and Case Conceptualization

A qualitative understanding of participants’ experiences may be used to tailor

MBSR programs to better assist patients during cancer diagnosis, treatment

and recovery. Findings from a recent qualitative study support and inform

quantitative findings indicating that the MBSR program has a positive impact

392

L.E. Carlson et al.

on psychological and emotional dimensions in cancer patients (Mackenzie,

Carlson, Munoz, & Speca,
2007).
Nine cancer patients who had participated in an 8-week TBCC MBSR program and who continued to attend weekly

drop-in MBSR sessions were interviewed for this study. Using a grounded

theory analytic approach, data from semi-structured interviews and a focus

group were analyzed to identify themes concerning the effects patients expe-

rienced by adding meditation to their lives. Five major themes emerged from

the data: (1) opening to change; (2) self-control; (3) shared experience; (4)

personal growth; (5) spirituality. This information was used to develop a the-

ory regarding mechanisms through which MBSR effects change for cancer

patients
(Mackenzie et al., 2007).

Case Study

The following case study was developed as part of a larger qualitative

research investigation conducted at the TBCC in Calgary, Alberta. Individ-

ual semi-structured interviews were conducted with cancer patients who

had recently completed an 8-week MBSR program. The aim of the interviews

was to explore items of interest that had been previously identified in ques-

tionnaires assessing positive and negative aspects of psychological function-

ing, which were administered before and after an MBSR program. Question-

naires included the Functional Assessment of Chronic Illness Therapy – Spir-

itual Well-Being Scale (FACIT-Sp), Posttraumatic Growth Inventory – revised

(PTGI-r), Symptoms of Stress Inventory (SOSI), and the Profile of Mood States

(POMS). Items that changed significantly for the sample as a whole on the

questionnaires were chosen as the focus for the interviews, and representa-

tive patients who demonstrated a change on those items were selected. All

participants provided informed consent, and the study was approved by the

Conjoint Health Research Ethics Board of the University of Calgary Faculty of

Medicine and Alberta Cancer Board. The case of Sylvia was chosen for pre-

sentation because it illustrates emerging themes common to the application

of MBSR in the context of cancer treatment and recovery.

Personal Background and Disease Context

Sylvia is a 50-year-old woman who lives with her common-law partner and

has no children. She has 13 years of education and has been employed as a

middle manager for 31 years. Sylvia was diagnosed with Stage I breast can-

cer in February 2006. She had two surgeries to remove affected tissue of the

left breast. She then received 25 radiation therapy treatments daily (M-F) for

a period of 5 weeks, beginning in August 2006. Radiation therapy, or radio-

therapy, is the use of ionizing radiation to control malignant cells. Radiother-

apy itself is painless, but can cause various acute and long-term side effects,

including skin reactions (e.g., redness, soreness) and reduced skin elastic-

ity due to scarring. Following surgery and radiation, Sylvia began a 5-year

course of Tamoxifen, an adjuvant therapy, which interferes with the activity

of the hormone estrogen, reducing the chance of recurrence of the disease.

Tamoxifen is commonly administered following primary treatment for early-

stage breast cancer. The side effects of Tamoxifen are similar to the symptoms

commonly associated with menopause, such as hot flashes and irregular men-

strual periods; the nature and degree of side effects varies across patients.

Chapter 20 Mindfulness-Based Interventions in Oncology

393

Sylvia began the 8-week MBSR program shortly after she finished radiation

in October 2006. When she began the program, she considered herself to be

very familiar with cancer-related stress, and hoped the program would help

her cope with the cancer experience. Sylvia described herself as “needy” for

support and stated she sought out the program because she did not know

where else to find help.

Findings

Common themes that emerged from the qualitative interviews related to

reduced symptoms of stress, improved mood, increased feelings of spiritual

connectedness, and perceived benefits from the cancer experience. These

themes that emerged included the importance of present-focused awareness

for identifying and dealing with stress, the development of self-efficacy for

coping with challenges, the importance of accepting things as they are, and

learning to let go of unknowable or uncontrollable outcomes.

In particular, participating in the MBSR program appeared to increase

Sylvia’s present-focused attention/awareness, influencing how she fets about

herself.

I never knew that we always thought about the past and the future. I just had

no idea that that was where our mind always went and it’s so true. I mean, it’s

kind of embarrassing to say that you didn’t know that before. But, you know,

we kept hearing that and it was when you are in the present you feel so much

different about yourself than when you think about the past, if you think about

the future. The present is a really good place to be.

It appeared that Sylvia developed greater
self-efficacy
with regard to cop-

ing with stress.

I learned that when you react to things when you’re under stress, you’re only

hurting yourself really. You know, because, I remember when I used to react to

things, you know, it would still fester and boil up in me. And now, when I sort

of let it go, when I have a stressful situation and I breathe and I think about it

[
. . .
] and then I deal with it, it’s not so bad.

Sylvia acknowledged that she had felt depressed for some time and felt that

the program was integral in
improving her mood
.

I think that I am better. I stand at better peace with myself. And it’s because

of the meditation by all means I know that. I know that because without that I

think I would’ve had the time, but nothing would have changed. It’s still minus

a body part and you still don’t know, you [are] still unsure
. . .
.I think you can

be depressed though for a long time. So, the fact that I had this [program] for

a couple of months and I feel a change. So, again I feel that I have to attribute

it to the meditation because I could still be the way I was going for so many

months.

She expressed a
reduction in fear
surrounding cancer recurrence, feeling

that if the cancer recurred she would be able to cope with it.

I was always thinking about [the cancer] and I was depressed
. . .
And I’m not

anymore
. . .
And if it recurs, I think I’m prepared for that. I sure wasn’t before

[the program]. [
. . .
] I realized that you can’t do anything about the cancer but

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L.E. Carlson et al.

you can do something about how you feel about it and how you react to it. I

do much better.

In particular, Sylvia described her change in attitude from needing to know

what caused her cancer to an attitude of
acceptance
of the cancer experience

after participation in the program. She finally felt able to
let go
of trying to

determine why she got cancer.

When I had cancer
. . .
what I questioned all the time was, “ok, what am I going

to learn from this”?
. . .
there’s a reason why I got this
. . .
I needed to know that because I thought I could deal with things differently and I was adamant to

know
. . .
.And for the longest time I thought that’s the only way I could deal

with it, so I was always thinking about that and I was depressed
. . .
And then it