Mindfulness | Cam-Cancer

Mindfulness

Abstract and key points

Mindfulness-based clinical interventions are mind-body modalities that may encompass multiple components: psycho-educational elements, mindfulness meditation exercises, cognitive-behavioral interventions and movement exercises. Core practices are sitting meditation (breath awareness, focused attention), body scan (awareness of sensations in the body, 45 minute exercise), Hatha Yoga (mindful movement), walking meditation and insight meditation. The two most used mindfulness-based clinical interventions in oncology are mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT), 8-week standardised group programs. MBCT further includes elements from cognitive behavioural therapy.

This summary is based on

  • a 2019 Cochrane review on mindfulness for breast cancer,
  • five further systematic reviews on breast cancer published since 2015,
  • two systematic reviews on all types of cancer published since 2015,
  • an overview of systematic reviews of mindfulness-based interventions in healthcare in general published before 2015, including one systematic review on breast cancer and five systematic reviews on any type of cancer
  • a further 21 randomized controlled trials (RCTs) published after the above reviews

All systematic reviews mentioned methodological shortcomings of the included studies and methodological shortcomings of the reviews themselves further limit their conclusions.

  • Depression: MBSR has positive short- and medium-term effects on depression in women with breast cancer. MBSR might also reduce depression in patients with thyroid cancer or leukaemia. Effects of MBCT on depression in mixed types of cancer were unclear.
  • Anxiety: MBSR has positive short-, medium-, and potentially long-term effects on anxiety in women with breast cancer. MBSR might also reduce anxiety in patients with thyroid cancer, melanoma or leukaemia; but perhaps not in patients with prostate cancer. Effects of MBCT on anxiety in mixed types of cancer were unclear.
  • Stress: MBSR seems to reduce stress in women with breast cancer in the short-term. It seems not to be superior to other psychological interventions. Effects of MBCT on stress in cancer patients have not been assessed.
  • Fatigue: MBSR seems to reduce fatigue in women with breast cancer in the short- and medium-term. There are also preliminary studies showing effects on fatigue in patients with thyroid cancer. Mindfulness apps were not shown to be effective in reducing fatigue. MBCT was effective in mixed types of cancer, although this is based on only few studies. Both, face-to-face and web-based interventions seem to be effective.
  • Quality of life: MBSR improves quality of life in women with breast cancer in the short- and probably in the medium-term. There are also preliminary studies showing effects of MBSR on quality of life in thyroid cancer, and of MBCT and of mindfulness apps in mixed cancer groups, which need to be replicated in future studies.

While MBSR and MBCT are generally considered to be safe in supportive cancer care, no rigorous assessment of the safety of mindfulness-based approaches in cancer patients is available. 

Document history

Summary fully updated and revised in October 2019 by Holger Cramer.
Summary fully revised and updated in August 2016 by Holger Cramer.
Updated in February 2016 by Ann-Christine Moenaert.
Summary first published in August 2012, authored by Ann-Christine Moenaert and Michaela Sieh.

Citation

Holger Cramer, Ann-Christine Moenaert, CAM-Cancer Consortium. Mindfulness [online document], http://cam-cancer.org/en/mindfulness-cam. October 2019

What is it?

Description

Mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT) are multi-component mind-body modalities, encompassing psycho-educational elements, mindfulness meditation exercises, cognitive-behavioral interventions and movement exercises. Core practices are: sitting meditation (focused attention, breath awareness), body scan (awareness of sensations in the body, 45 minute exercise), Hatha Yoga (mindful movement), walking meditation and insight meditation. The founder of MBSR, Jon Kabat-Zinn, uses the following operational definition for mindfulness: “the awareness that emerges through paying attention on purpose, in the present moment, and non-judgmentally to the unfolding of experience moment by moment”1The underlying ethical framework is built on the principles of non-harming.

The MBCT programme was designed specifically to help people who suffer repeated bouts of depression, and includes more psycho-educational elements than MBSR. MBCT also adds short formal meditation exercises to the program.

Background

MBSR and MBCT are based on the ancient Buddhist practice and concept of mindfulness. MBSR was first introduced as a clinical intervention for patients with chronic pain by Kabat-Zinn in 1979, in the Stress Reduction Clinic of the University of Massachusetts Medical Center. It has been widely adapted to settings independent of religious or cultural contexts. Mindfulness has also become increasingly popular as a practice in daily life. MBCT combines Mindfulness with Cognitive Behavioural Therapy and was developed by Zindel Segal, Mark Williams and John Teasdale, based on Jon Kabat-Zinn’s MBSR programme2.

In 2012, 2.5% of the general US adult population had used mindfulness meditation (including MBSR and MBCT but also Buddhist mindfulness meditation)63. Among cancer survivors, 2.4%, 2.6%, and 1.8% of those with less than 1 year, between 1 and 5 years, and 5 or more years of survivorship, respectively, had used mindfulness meditation28. In 2017, 4.3% of breast cancer survivors had used mindfulness meditation64.

Mechanisms of action

Complex psycho-physiological connections and interactions are regarded as basic foundations of the effects of mind-body modalities23. Mindfulness meditation is assumed to promote regulation of emotions, this leads to a down regulation of the sympathetic nervous system and to a reduction of stress hormone levels24-26. Psycho-neuro-immunology research on the effect of mindfulness-based interventions on brain structure and functions and immunological status is in its infancy. Shapiro et al. point out that research on mindfulness requires a variety of methodological and theoretical approaches to develop testable hypotheses27

Alleged indications/claims of efficacy

MBSR and MBCT are implemented mind-body modalities in supportive cancer care. They are used in oncology settings because they have been suggested to have beneficial effects on various symptoms connected to cancer: emotional distress, mood, anxiety, depression, sleeping disorders, fatigue, quality of life6-19. Some studies point to a possible effect on immunological parameters3,20-22

There are adaptations and modifications of the original program manuals of MBSR and MBCT for cancer patients5-11. A growing number of integrative oncology hospitals offer their patients mindfulness-based clinical interventions. Books on mindfulness for cancer patients have been published, leading to the use of mindfulness exercises as a self-help-technique.

 Application and providers

The standard MBSR program (as developed by Kabat-Zinn delivered in groups of 6 to 30 patients) encompasses 8 weekly class sessions with a duration of 2 ½ to 3 ½  hours, plus an additional retreat day of six hours between weeks 6 and 7 of the program (20 to 35 ½ hours class time). Shortened versions for cancer patients have been tested in clinical trials3. A review on the relationship between class contact hours and effect sizes for psychological outcomes4 did not find any evidence that reduction of class hours might lead to decreased reduction of psychological distress4. Programs with fewer contact hours may be able to engage more cancer patients, because disease and treatment-related symptoms (including fatigue) sometimes present a barrier to take part in longer sessions.

In order to integrate mindfulness into everyday life, patients are usually asked to practice mindfulness exercises 45 minutes per day, 6 days per week during the program. A higher amount of home practice seems to increase self-reported mindfulness; it has been suggested that this may lead to improvements in psychological outcome4. Some clinics provide day retreats and regular drop-in sessions for patients who completed the MBSR program5.

Online web-based versions of MBSR and MBCT have also been created; and an increasing number of health apps are also based on mindfulness.

Legal aspects

Training for MBSR and MBCT teachers is not legally regulated, however, the University of Massachusetts Medical School’s Center for Mindfulness in Medicine, Health Care, and Society requires prospective teachers to meet the Qualifications and Recommended Guidelines for MBSR Teachers29. The Oxford Mindfulness Centre, UK defines further requirements for different training routes of MBCT teachers65. These include a 6-course educational pathway over 36 months30. While other MBSR/MBCT associations have adopted comparable educational guidelines, required training hours for certification vary depending on the organization providing the training. Practical experience in meditation (previous own meditation practice, attendance of teacher-led silent retreats) is under discussion, ranging from virtually no requirements to prerequisites of at least 2 years prior mediation practice and attendance of at least 2 five-day retreats.

A mindfulness teacher needs a foundation of personal practice (having experienced the radical transformational essence of mindfulness, as Kabat-Zinn states1) and is required to embody the core concepts of mindfulness.

Cost

Fees for the 8 week-program (normally one weekly 2.5- to 3.5-hour class, often combined with a 6- to 7.5-hour full day retreat; a total of 20 to 35.5 class hours)66 of MBSR/MBCT range between € 200 and € 500, dependent on the setting. Partial or full reimbursement is available in some countries. Sometimes the programs are integrated into the general hospital services and are offered with reduced fees.

Does it work?

Supportive and palliative care

This summary is based on a 2019 Cochrane review on mindfulness for women with breast cancer36, five further systematic reviews on breast cancer published since 201532-34,38,39, two systematic reviews in mixed cancer populations35,37 published since 2015 as well as an overview of systematic reviews31 of mindfulness-based interventions in healthcare in general including six systematic reviews on cancer published before 2015. A further 21 randomized controlled trials (RCTs) published after the reviews are also included. Details of the included studies are presented in table 1 for the systematic reviews and table 2 for the RCTs.

The effect of mindfulness-based stress reduction (MBSR) has most commonly been investigated in female breast cancer patients. Five systematic reviews evaluate MBSR/MBCT in breast cancer patients and two in patients with various cancer diagnoses. There is some overlap in the systematic reviews in terms of the 63 individual RCTs, 9 non-randomized controlled trials, and 7 uncontrolled trials included (see table 1). One systematic review included one RCT on mindfulness-based cognitive therapy (MBCT). 

A common critique of these meta-analyses and systematic reviews is the lack of comparisons with other group-based psychosocial interventions. This does not allow for the identification of effects specifically attributed to specific mindfulness components rather than the attention and peer support associated with participation in psychosocial group based interventions. In addition, the focus of most reviews is on breast cancer patients and thus limits the generalization of the results of these studies towards the global cancer patient population. 

All systematic reviews mentioned methodological shortcomings of the included studies. Methodological shortcomings of the reviews themselves further limit their conclusions. These include small numbers of included trials32,34, inadequate search strategies32, inadequate methodology for meta-analysis (ie, the use of mean differences for analyses of different outcome measures)34, and lack of safety assessment in all but two reviews33,36. One systematic review did not formally assess methodological quality or risk of bias of the included studies35.For a description of the included systematic reviews please see table 1.

An additional 21 RCTs40-60 have been published since 2015: six RCTs including breast cancer patients49,50,51,52,56,58 published after the Cochrane review’s search period, seven RCTs including mixed cancer populations41,43,44,45,47,55,60, two RCTs of lung cancer46,54, two of prostate cancer57,42, and one each of colorectal cancer40, thyroid cancer48, melanoma53 and leukaemia59, respectively. For a description of included RCTs please see table 2.

  • Depression: MBSR has positive short- and medium-term effects on depression in women with breast cancer. MBSR might also reduce depression in patients with thyroid cancer or leukemia. Effects of MBCT on depression in mixed types of cancer were unclear.
  • Anxiety: MBSR has positive short-, medium-, and potentially long-term effects on anxiety in women with breast cancer. MBSR might also reduce anxiety in patients with thyroid cancer, melanoma or leukaemia; but perhaps not in patients with prostate cancer. Effects of MBCT on anxiety in mixed types of cancer were unclear.
  • Stress: MBSR seems to reduce stress in women with breast cancer in the short-term. It seems not to be superior to other psychological interventions. Effects of MBCT on stress in cancer patients have not been assessed.
  • Fatigue: MBSR seems to reduce fatigue in women with breast cancer in the short- and medium-term. There are also preliminary studies showing effects on fatigue in patients with thyroid cancer. Mindfulness apps were not shown to be effective in reducing fatigue. MBCT was effective in mixed types of cancer, although this is based on only few studies. Both, face-to-face and web-based interventions seem to be effective.
  • Quality of life: MBSR improves quality of life in women with breast cancer in the short- and probably in the medium-term. There are also preliminary studies showing effects of MBSR on quality of life in thyroid cancer, and of MBCT and of mindfulness apps in mixed cancer groups, which need to be replicated in future studies.

Effects of MBSR on depression

For breast cancer patients, the Cochrane Review by Schell et al. (2019)36 found high-quality evidence for short-term effects of MBSR compared to usual care on depression (effect size [ES]=-0.54, 95% confidence interval [CI]=-0.86 to -0.22), moderate-quality evidence for medium-term effects (ES=-0.32, 95%CI=-0.58 to -0.06) and no evidence for longer-term effects. Comparable effects were found in the meta-analyses by Haller et al. (2017)33 and by Huang et al. (2015)34. However, Huang et al. used inadequate methods which limit its conclusions. The meta-analyses by Castanhel et al. (2018)32, Zhang et al. (2016)38 and Zhang et al. (2019)39 also reported effects favouring MBSR over usual care. Haller et al. (2017)33 also reported effects favouring MBSR over other active interventions in reducing depression. Results from 3 RCTs in breast cancer patients were mixed52,57,59.

With regards to mixed cancer populations, the meta-analysis by Zhang et al. (2015)37 found large short-term effects but no medium-term effects favouring MBSR over usual care.

A subsequently published RCT assessed depression reported no difference between MBSR and a sleep hygiene intervention47 in mixed cancer populations; while others found positive effects of MBSR compared to usual care in patients with thyroid cancer48 or leukemia59. Rumination, a classical symptom of depression, was reduced in lung cancer patients compared to usual care54.

Effects of MBSR on anxiety

The Cochrane Review by Schell et al. (2019)36 found moderate-quality evidence for short- (ES=-0.29, 95% CI=-0.50 to -0.08) and medium-term effects (ES=-0.28, 95%CI=-0.49 to -0.07) of MBSR compared to usual care on anxiety in patients with breast cancer. Longer-term effects were not significant. The meta-analyses by Castanhel et al. (2018)32 and Zhang et al. (2019)39 also reported effects favouring MBSR over usual care. Zhang et al. (2016)38 found small short-term effects of MBSR compared to usual care on anxiety, but moderate short-term effects on cancer-specific fear of recurrence. Again, the effects reported by Huang et al. (2015)34 are limited by the inadequate methodology used. Haller et al. (2017)33 found short-, moderate- and long-term effects of MBSR compared to usual care; and also reported effects favouring MBSR over other active interventions.

For a mixed cancer population, the SR by Zhang et al. (2015)37 found moderate short-term effects of MBSR on anxiety when compared to usual care, but no medium-term effects.

Subsequently published RCTs found no effects favouring MBSR over usual care in prostate cancer patients42,57. RCTs in other cancer populations found reduced anxiety and fear of cancer recurrence43,48,51,53,59. A further RCT found no effects of a mindfulness app on anxiety45.

Effects of MBSR on stress

Four systematic reviews including breast cancer patients assessed stress. Haller et al. (2017)33, Huang et al. (2015)34, and Zhang et al. (2019)39 found short-term effects on stress. The meta-analysis by Zhang et al. (2016)38 found no effects of MBSR on stress in relation to usual care.

Stress was assessed in five of the subsequently published RCTs. Two RCTs reported positive effects of MBSR compared to usual care51,60, and one RCT of MBSR compared to an attention-control intervention58; while two found no group differences between MBSR and cognitive therapy44 and a sleep hygiene intervention47.

Effects of MBSR on fatigue

In the Cochrane Review by Schell et al. (2019)36, moderate-quality evidence for short-term effects of MBSR compared to usual care on fatigue in patients with breast cancer was found (ES=-0.50, 95%CI=-0.86 to -0.14). The meta-analyses by Haller et al. (2017)33 and Zhang et al. (2019)39 also reported effects favouring MBSR over usual care; while the meta-analysis by Castanhel et al. (2018)32 found no effects based on only 2 RCTs.

Further RCTs found effects favouring MBSR over usual care in women with breast cancer59 or thyroid cancer49, while no effects of a mindfulness app on fatigue were found46.

Effects of MBSR on quality of life

Based on RCTs on women with breast cancer, the Cochrane Review by Schell et al. (2019)36 found low- -quality evidence for short-term improvements of quality of life due to MBSR compared to usual care but did not perform a meta-analysis due to concerns about missing data. Haller et al. (2017)33 and Zhang et al. (2016)38 also found short-term effects. Zhang et al. (2019)39 found no effects on general quality of life but on emotional wellbeing, psychological and cognitive function.

Subsequent RCTs confirmed the effects of MBSR on quality of life of women with breast cancer52,53, but also in patients with thyroid cancer48 and lung cancer46,54. A further RCT found positive effects of a mindfulness app on quality of life of mixed cancer groups when compared to an untreated control group45.

Effects of MBSR on mindfulness

Based on the meta-analysis by Zhang et al. (2019)39 including patients with breast cancer, MBSR has short-term effects on mindfulness.

The RCTs published after the systematic reviews report mixed results43,45,47,49,52,54,57,58,60.

Effects of MBSR on other outcomes

For general distress, two RCTs found effects of MBSR beyond usual care54,60. One RCT found no effects of MBSR beyond other psychological interventions44. No effects of a mindfulness app beyond usual care was found45.

For sleep, the meta-analysis by Haller et al. (2017)33 found positive short-term effects of MBSR compared to usual care in breast cancer patients, while Zhang et al. (2019)39 did not. In a non-inferiority RCT, MBSR was inferior to cognitive therapy in the short-term but non-inferior in the medium term44. Cognitive therapy was superior regarding sleep quality and dysfunctional sleep beliefs; objective sleep measures did not differ. In further RCTs, MBSR did not differ from a Mind-body bridging program or a sleep hygiene education regarding sleep problems47, while MBSR was superior to an attention-control intervention58.

In one meta-analysis, no effects of MBSR on pain in women with breast cancer was found39.

The meta-analysis by Zhang et al. (2016)38 including breast cancer patients found no effects of MBSR beyond usual care on spirituality.

Single RCTs found positive effects on cancer-related symptoms46, body image50, life expectancy51, posttraumatic growth57, cortisol reactivity40, and immune parameters58.

Effects of MBCT

No SR separately assessed the effects of MBCT. The effects of MBCT in cancer will thus be reported separately for the available RCTs.

General distress in mixed cancer groups was decreased by MBCT compared to usual care in one RCT43; effects of web-based MBCT programs were mixed41,43. No effects on distress were found for telephone-based MBCT in men with prostate cancer42 and in face-to-face MBCT in women breast cancer56.

Both, face-to-face and web-based MBCT programs reduce fatigue severity in fatigued cancer survivors41,55.

Quality of life was increased by face-to-face and web-based MBCT programs in groups of patients with mixed cancer types reporting increased distress43, pain33 or fatigue55. No effects were found in patients with prostate cancer42.

MBCT effectively reduced pain33, and pain medication use33, and functional impairment55; and increased mindfulness43 in one RCT each. No effects on posttraumatic growth were found in patients with prostate cancer42, and on emotion regulation in women with breast cancer56.

Is it safe?

The safety of meditation-based interventions in general has not been well studied.

Adverse events

Rare cases of adverse effects in people with underlying mental illnesses, including episodes of mania or depersonalization, have been reported61 There have been rare reports that meditation could cause or worsen symptoms in people who have certain psychiatric problems, but this question has not been fully researched62. Of the systematic reviews and studies analyzed for this summary, only two reported safety-related data. Haller et al. (2017) found 2 RCTs reporting on safety; however, these RCTs only reported that no serious adverse events occurred33.  In the Cochrane Review, adverse events were assessed, but none of the included RCTs reported the occurrence or non-occurrence of adverse events36. None of the remaining reviews planned to assess safety-related data. In the subsequent RCTs, Witek-Janusek (2019) reported that no adverse events occurred58; the remaining RCTs on MBSR did not report the occurrence or non-occurrence of adverse events. Compen et al. (2018) report that 6 out of 77 patients in the MBCT, 9 out of 90 patients in the web-based MBCT and 6 out of 78 patients in the usual care group experienced severe adverse events, which were considered unrelated to MBCT43.

Contraindications

None known. Individuals with existing mental or physical health conditions should speak with their health care providers prior to starting a meditative practice and make their meditation instructor aware of their condition63.

Other safety issues and warnings

People with physical limitations may not be able to participate in certain meditative practices involving physical movement63.

References
  1. Kabat-Zinn J. Mindfulness-Based Interventions in Context: Past, Present, and Future. Clin Psychol Sci Prac. 2003;10(2):144-56.
  2. Campbell TS, Labelle LE, Bacon SL, Faris P, Carlson LE. Impact of Mindfulness-Based Stress Reduction (MBSR) on attention, rumination and resting blood pressure in women with cancer: a waitlist-controlled study. Journal of behavioral medicine. 2012;35(3):262-71. 
  3. Carlson LE, Speca M, Patel KD, Goodey E. Mindfulness-based stress reduction in relation to quality of life, mood, symptoms of stress, and immune parameters in breast and prostate cancer outpatients. Psychosomatic medicine. 2003;65(4):571-81. 
  4. Carmody J, Baer RA. How long does a mindfulness-based stress reduction program need to be? A review of class contact hours and effect sizes for psychological distress. Journal of clinical psychology. 2009;65(6):627-38. 
  5. Carlson LE, Speca M. Mindfulness-based Cancer Recovery. 1 ed. Oakland, CA: New Harbinger Publications, Inc.; 2010.
  6. Altschuler A, Rosenbaum E, Gordon P, Canales S, Avins AL. Audio recordings of mindfulness-based stress reduction training to improve cancer patients' mood and quality of life--a pilot feasibility study. Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer. 2012;20(6):1291-7. 
  7. Foley E, Baillie A, Huxter M, Price M, Sinclair E. Mindfulness-based cognitive therapy for individuals whose lives have been affected by cancer: a randomized controlled trial. Journal of consulting and clinical psychology. 2010;78(1):72-9. 
  8. Lengacher CA, Johnson-Mallard V, Post-White J, Moscoso MS, Jacobsen PB, Klein TW, et al. Randomized controlled trial of mindfulness-based stress reduction (MBSR) for survivors of breast cancer. Psycho-oncology. 2009;18(12):1261-72.
  9. Lengacher CA, Johnson-Mallard V, Barta M, Fitzgerald S, Moscoso MS, Post-White J, et al. Feasibility of a mindfulness-based stress reduction program for early-stage breast cancer survivors. Journal of holistic nursing : official journal of the American Holistic Nurses' Association. 2011;29(2):107-17. 
  10. Lengacher CA, Reich RR, Post-White J, Moscoso M, Shelton MM, Barta M, et al. Mindfulness based stress reduction in post-treatment breast cancer patients: an examination of symptoms and symptom clusters. Journal of behavioral medicine. 2012;35(1):86-94. 
  11. Rosenbaum E. Here For Now: Living Well with Cancer Through Mindfulness. 2 ed. Hardwick, Massachusetts: Satya House Publications; 2005.
  12. Birnie K, Garland SN, Carlson LE. Psychological benefits for cancer patients and their partners participating in mindfulness-based stress reduction (MBSR). Psycho-oncology. 2010;19(9):1004-9.
  13. Branstrom R, Kvillemo P, Brandberg Y, Moskowitz JT. Self-report mindfulness as a mediator of psychological well-being in a stress reduction intervention for cancer patients--a randomized study. Annals of behavioral medicine. 2010;39(2):151-61. 
  14. Carlson LE, Garland SN. Impact of mindfulness-based stress reduction (MBSR) on sleep, mood, stress and fatigue symptoms in cancer outpatients. International journal of behavioral medicine. 2005;12(4):278-85. 
  15. Carlson LE, Ursuliak Z, Goodey E, Angen M, Speca M. The effects of a mindfulness meditation-based stress reduction program on mood and symptoms of stress in cancer outpatients: 6-month follow-up. Supportive care in cancer. 2001;9(2):112-23. 
  16. Kieviet-Stijnen A, Visser A, Garssen B, Hudig W. Mindfulness-based stress reduction training for oncology patients: patients' appraisal and changes in well-being. Patient education and counseling. 2008;72(3):436-42.
  17. Kvillemo P, Branstrom R. Experiences of a mindfulness-based stress-reduction intervention among patients with cancer. Cancer nursing. 2011;34(1):24-31. 
  18. Matousek RH, Dobkin PL. Weathering storms: a cohort study of how participation in a mindfulness-based stress reduction program benefits women after breast cancer treatment. Current oncology (Toronto, Ont). 2010;17(4):62-70. 
  19. Tacon AM, McComb J. Mindful exercise, quality of life, and survival: a mindfulness-based exercise program for women with breast cancer. Journal of alternative and complementary medicine (New York, NY). 2009;15(1):41-6.
  20. Carlson LE, Speca M, Faris P, Patel KD. One year pre-post intervention follow-up of psychological, immune, endocrine and blood pressure outcomes of mindfulness-based stress reduction (MBSR) in breast and prostate cancer outpatients. Brain, behavior, and immunity. 2007;21(8):1038-49. 
  21. Jacobs TL, Epel ES, Lin J, Blackburn EH, Wolkowitz OM, Bridwell DA, et al. Intensive meditation training, immune cell telomerase activity, and psychological mediators. Psychoneuroendocrinology. 2011;36(5):664-81. 
  22. Witek-Janusek L, Albuquerque K, Chroniak KR, Chroniak C, Durazo-Arvizu R, Mathews HL. Effect of mindfulness based stress reduction on immune function, quality of life and coping in women newly diagnosed with early stage breast cancer. Brain, behavior, and immunity. 2008;22(6):969-81. 
  23. Grossman P, Niemann L, Schmidt S, Walach H. Mindfulness-based stress reduction and health benefits. A meta-analysis. Journal of psychosomatic research. 2004;57(1):35-43. 
  24. Carlson LE, Speca M, Patel KD, Goodey E. Mindfulness-based stress reduction in relation to quality of life, mood, symptoms of stress and levels of cortisol, dehydroepiandrosterone sulfate (DHEAS) and melatonin in breast and prostate cancer outpatients. Psychoneuroendocrinology. 2004;29(4):448-74. 
  25. Garland E, Gaylord S. Envisioning a Future Contemplative Science of Mindfulness: Fruitful Methods and New Content for the Next Wave of Research. Complementary health practice review. 2009;14(1):3-9. 
  26. Matousek RH, Pruessner JC, Dobkin PL. Changes in the cortisol awakening response (CAR) following participation in mindfulness-based stress reduction in women who completed treatment for breast cancer. Complementary therapies in clinical practice. 2011;17(2):65-70.
  27. Shapiro SL, Carlson LE, Astin JA, Freedman B. Mechanisms of mindfulness. Journal of clinical psychology. 2006;62(3):373-86.
  28. Campo RA, Leniek KL, Gaylord-Scott N, Faurot KR, Smith S, Asher G, et al. Weathering the seasons of cancer survivorship: mind-body therapy use and reported reasons and outcomes by stages of cancer survivorship. Supportive care in cancer. 2016;24(9):3783-91. 
  29. Santorelli SF. Mindfulness-based Stress Reduction (MBSR): standards of practice. Shrewsbury, MA: Center for Mindfulness in Medicine, Health Care & Society Department of Medicine Division of Preventive and Behavioral Medicine 2014. Available as PDF online, accessed 6 September 2019.
  30. Center for Mindfulness. Mindfulness-based professional education 2014. Available online, accessed 01 August 2019.
  31. Gotink RA, Chu P, Busschbach JJ, Benson H, Fricchione GL, Hunink MG. Standardised mindfulness-based interventions in healthcare: an overview of systematic reviews and meta-analyses of RCTs. PloS one. 2015;10(4):e0124344. 
  32. Castahel FD, Liberali R. Mindfulness-Based Stress Reduction on breast cancer symptoms: systematic review and meta-analysis. Einstein (Sao Paulo). 2018;16(4):eRW4383.
  33. Haller H, Winkler MM, Klose P, Dobos G, Kümmel S, Cramer H. Mindfulness-based interventions for women with breast cancer: an updated systematic review and meta-analysis. Acta Oncol. 2017;56(12):1665-1676.
  34. Huang HP, He M, Wang HY, Zhou M. A meta-analysis of the benefits of mindfulness-based stress reduction (MBSR) on psychological function among breast cancer (BC) survivors. Breast cancer (Tokyo, Japan). 2016;23(4):568-76.
  35. Rush SE, Sharma M. Mindfulness-Based Stress Reduction as a Stress Management Intervention for Cancer Care: A Systematic Review.  Journal of evidence-based complementary & alternative medicine. J Evid Based Complementary Altern Med. 2017;22(2):348-360
  36. Schell LK, Monsef I, Wöckel A, Skoetz N. Mindfulness-based stress reduction for women diagnosed with breast cancer. Cochrane Database Syst Rev. 2019;3:CD011518.
  37. Zhang MF, Wen YS, Liu WY, Peng LF, Wu XD, Liu QW. Effectiveness of Mindfulness-based Therapy for Reducing Anxiety and Depression in Patients With Cancer: A Meta-analysis. Medicine. 2015;94(45):e0897-0. 
  38. Zhang J, Xu R, Wang B, Wang J. Effects of mindfulness-based therapy for patients with breast cancer: A systematic review and meta-analysis. Complement Ther Med. 2016;26:1-10.
  39. Zhang Q, Zhao H, Zheng Y. Effectiveness of mindfulness-based stress reduction (MBSR) on symptom variables and health-related quality of life in breast cancer patients-a systematic review and meta-analysis. Support Care Cancer. 2019;27(3):771-781.
  40. Black DS, Peng C, Sleight AG, Nguyen N, Lenz HJ, Figueiredo JC. Mindfulness practice reduces cortisol blunting during chemotherapy: A randomized controlled study of colorectal cancer patients. Cancer. 2017;123(16):3088-3096.
  41. Bruggeman-Everts FZ, Wolvers MDJ, van de Schoot R, Vollenbroek-Hutten MMR, Van der Lee ML. Effectiveness of Two Web-Based Interventions for Chronic Cancer-Related Fatigue Compared to an Active Control Condition: Results of the "Fitter na kanker" Randomized Controlled Trial. J Med Internet Res. 2017;19(10):e336.
  42. Chambers SK, Occhipinti S, Foley E, Clutton S, Legg M, Berry M, Stockler MR, Frydenberg M, Gardiner RA, Lepore SJ, Davis ID, Smith DP. Mindfulness-Based Cognitive Therapy in advanced prostate cancer: a randomized controlled trial. J Clin Oncol. 2017;35 (3):291-297.
  43. Compen F, Bisseling E, Schellekens M, Donders R, Carlson L, van der Lee M, Speckens A. Face-to-Face and Internet-Based Mindfulness-Based Cognitive Therapy Compared With Treatment as Usual in Reducing Psychological Distress in Patients With Cancer: A Multicenter Randomized Controlled Trial. J Clin Oncol. 2018;36(23):2413-2421.
  44. Garland SN, Carlson LE, Stephens AJ, Antle MC, Samuels C, Campbell TS. Mindfulness-based stress reduction compared with cognitive behavioral therapy for the treatment of insomnia comorbid with cancer: a randomized, partially blinded, noninferiority trial. Journal of clinical oncology : official journal of the American Society of Clinical Oncology. 2014;32(5):449-57. 
  45. Kubo A, Kurtovich E, McGinnis M, Aghaee S, Altschuler A, Quesenberry C Jr, Kolevska T, Avins AL. A Randomized Controlled Trial of mHealth Mindfulness Intervention for Cancer Patients and Informal Cancer Caregivers: A Feasibility Study Within an Integrated Health Care Delivery System. Integr Cancer Ther. 2019;18:1534735419850634.
  46. Lehto RH, Wyatt G, Sikorskii A, Tesnjak I, Kaufman VH. Home-based mindfulness therapy for lung cancer symptom management: a randomized feasibility trial. Psycho-oncology. 2015;24(9):1208-12. 
  47. Lipschitz DL, Kuhn R, Kinney AY, Grewen K, Donaldson GW, Nakamura Y. An Exploratory Study of the Effects of Mind-Body Interventions Targeting Sleep on Salivary Oxytocin Levels in Cancer Survivors. Integrative cancer therapies. 2015;14(4):366-80. 
  48. Liu T, Zhang W, Xiao S, Xu L, Wen Q, Bai L, Ma Q, Ji B. Mindfulness-based stress reduction in patients with differentiated thyroid cancer receiving radioactive iodine therapy: a randomized controlled trial. Cancer Manag Res. 2019;11:467-474.
  49. Mohammadi PK, Zargar NA, Shahidi MA. The efficacy of mindfulness therapy on mindfulness attention awareness and perception of disease in women with breast cancer. Indian journal of public health research and development. 2018;9(3):157-161.
  50. Pintado S, Andrade S. Randomized controlled trial of mindfulness program to enhance body image in patients with breast cancer. European journal of integrative medicine. 2017;12:147-152.
  51. Pouy S, Attari Peikani F, Nourmohammadi H, Sanei P, Tarjoman A, Borji M. Investigating the Effect of Mindfulness-Based Training on Psychological Status and Quality of Life in Patients with Breast Cancer. Asian Pac J Cancer Prev. 2018;19(7):1993-1998.
  52. Rosen KD, Paniagua SM, Kazanis W, Jones S, Potter JS. Quality of life among women diagnosed with breast Cancer: A randomized waitlist controlled trial of commercially available mobile app-delivered mindfulness training. Psychooncology. 2018;27(8):2023-2030.
  53. Russell L, Ugalde A, Orellana L, Milne D, Krishnasamy M, Chambers R, Austin DW, Livingston PM. A pilot randomised controlled trial of an online mindfulness-based program for people diagnosed with melanoma. Support Care Cancer. 2019;27(7):2735-2746.
  54. Schellekens MPJ, van den Hurk DGM, Prins JB, Donders ART, Molema J, Dekhuijzen R, van der Drift MA, Speckens AEM. Mindfulness-based stress reduction added to care as usual for lung cancer patients and/or their partners: A multicentre randomized controlled trial. Psychooncology. 2017;26(12):2118-2126.
  55. van der Lee ML, Garssen B. Mindfulness-based cognitive therapy reduces chronic cancer-related fatigue: a treatment study. Psycho-oncology. 2012;21(3):264-72. 
  56. Vaziri ZS, Mashhadi A, Shamloo ZS, Shahidsales S. Mindfulness-based cognitive therapy, cognitive emotion regulation and clinical symptoms in females with breast cancer. Iranian journal of psychiatry and behavioral sciences. 2017;11(4):e4158.
  57. Victorson D, Hankin V, Burns J, Weiland R, Maletich C, Sufrin N, et al. Feasibility, acceptability and preliminary psychological benefits of mindfulness meditation training in a sample of men diagnosed with prostate cancer on active surveillance: results from a randomized controlled pilot trial. Psychooncology. 2017;26(8):1155-1163.
  58. Witek-Janusek L, Tell D, Mathews HL. Mindfulness based stress reduction provides psychological benefit and restores immune function of women newly diagnosed with breast cancer: A randomized trial with active control. Brain Behav Immun. 2019;80:358-373.
  59. Zhang R, Yin J, Zhou Y. Effects of mindfulness-based psychological care on mood and sleep of leukemia patients in chemotherapy. International journal of nursing sciences. 2017;4(4):357-361.
  60. Zernicke KA, Campbell TS, Speca M, McCabe-Ruff K, Flowers S, Carlson LE. A randomized wait-list controlled trial of feasibility and efficacy of an online mindfulness-based cancer recovery program: the eTherapy for cancer applying mindfulness trial. Psychosomatic medicine. 2014;76(4):257-67.
  61. Castillo RJ. Depersonalization and meditation. Psychiatry. 1990;53(2):158-68.
  62. National Center for Complementary and Integrative Health. Meditation: in depth. Available online, accessed 01 August 2019.
  63. Cramer H, Hall H, Leach M, Frawley J, Zhang Y, Leung B, Adams J, Lauche R. Prevalence, patterns, and predictors of meditation use among US adults: a nationally representative survey. Sci Rep. 2016;6:36760.
  64. Voiß P, Höxtermann M, Dobos G, Cramer H. Mind-body medicine use by women diagnosed with breast cancer: results of a nationally representative survey. Support Care Cancer. 2019. doi: 10.1007/s00520-019-04914-x.
  65. Oxford Mindfulness Center. How to become a Mindfulness-Based cognitive Therapy teacher. Available online, accessed 28 October 2019.
  66. Santorelli SF (Ed.). Mindfulness-Based Stress reduction (MBSR): standards of practice. 2014. Available online, assessed 28 October 2019.

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