Description
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.
Efficacy
This summary is based on a 2019 Cochrane review on mindfulness for breast cancer, five further systematic reviews on adults with breast cancer published since 2015, six systematic reviews on adults with all types of cancer published since 2015, a systematic review on children and adolescents with 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, and a further 24 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. Positive short- and medium-term effects were also found in mixed cancer types but cannot be applied to specific types of cancer other than breast cancer. Positive effects in children and adolescents with mixed types of cancer are limited by methodological flaws of the included studies. MBCT might also improve depression in women with breast cancer.
Anxiety: MBSR has positive short-, medium-, and potentially long-term effects on anxiety in women with breast cancer. Positive short-, medium-, and long-term effects were also found in mixed cancer types but cannot be applied to specific types of cancer other than breast cancer. Positive effects in children and adolescents with mixed types of cancer are limited by methodological flaws of the included studies. MBCT might also improve anxiety in women with breast cancer.
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. Positive effects in children and adolescents with mixed types of cancer are limited by methodological flaws of the included studies. MBCT might also improve stress in women with breast cancer. Effects in other types of cancer are unclear
Fatigue: MBSR seems to reduce fatigue in women with breast cancer in the short- and medium-term. MBSR has short- and medium-term effects in mixed cancer types but cannot be applied to specific types of cancer other than breast cancer. Positive effects in children and adolescents with mixed types of cancer are limited by methodological flaws of the included studies. 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.
Quality of life: MBSR improves quality of life in women with breast cancer in the short- and probably in the medium-term. Positive short-, medium-, and long-term effects were also found in mixed cancer types but cannot be applied to specific types of cancer other than breast cancer. Positive effects in children and adolescents with mixed types of cancer are limited by methodological flaws of the included studies. There are also preliminary studies showing effects of MBCT and of mindfulness apps in mixed cancer groups, which need to be replicated in future studies.
Safety
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.
Citation
Cramer H, CAM Cancer Consortium. Mindfulness [online document], Mar 15, 2021.
Document history
Latest update: March 2021
Next update due: March 2024
Description and definition
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-behavioural 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” (Kabat-Zinn 2003). The 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 and prevalence
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 programme (Campbell 2012).
In 2012, 2.5% of the general US adult population had used mindfulness meditation (including MBSR and MBCT but also Buddhist mindfulness meditation) (Cramer 2016). 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 meditation (Campo 2016). In 2017, 4.3% and 8.8% of breast cancer and cervical cancer survivors, respectively, had used mindfulness meditation (Voiß 2019, Wong 2020).
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 life (Altschuler 2012, Foley 2010, Lengacher 2009, Lengacher 2011, Lengacher 2012, Rosenbaum 2005, Birnie 2010, Branstrom 2010, Carlson 2005, Carlson 2001, Kieviet-Stijnen 2008, Kvillemo 2011, Matousek 2010, Tacon 2009). Some studies point to a possible effect on immunological parameters (Carlson 2003, Carlson 2007, Jacobs 2011, Witek-Janusek 2008).
There are adaptations and modifications of the original program manuals of MBSR and MBCT for cancer patients (Carlson 2010, Altschuler 2012, Foley 2010, Lengacher 2009, Lengacher 2011, Lengacher 2012, Rosenbaum 2005). 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.
Mechanisms of action
Complex psycho-physiological connections and interactions are regarded as basic foundations of the effects of mind-body modalities (Grossman 2004). 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 levels (Carlson 2004, Garland 2009, Matousek 2011). 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 hypotheses (Shapiro 2006).
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 trials (Carlson 2003). A review on the relationship between class contact hours and effect sizes for psychological outcomes (Carmody 2009) did not find any evidence that reduction of class hours might lead to decreased reduction of psychological distress (Carmody 2009). 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 outcome (Carmody 2009). Some clinics provide day retreats and regular drop-in sessions for patients who completed the MBSR program (Carlson 2010).
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 Center for Mindfulness at the University of Massachusetts Memorial Medical Center requires prospective teachers to meet the Qualifications and Recommended Guidelines for MBSR Teachers (Santorelli 2014). The Oxford Mindfulness Centre, UK defines further requirements for different training routes of MBCT teachers (OMC 2019). These include a 6-course educational pathway over 36 months. 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 2003 states) and is required to embody the core concepts of mindfulness.
Supportive and palliative care
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 or mixed cancer populations, which also predominantly included female breast cancer patients. Five systematic reviews evaluate MBSR/MBCT in breast cancer patients and seven in patients with various cancer diagnoses. There is substantial overlap in the systematic reviews in terms of the 142 individual RCTs, 9 non-randomized controlled trials, and 79 uncontrolled trials included (see table 1). Four systematic reviews also included RCTs 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 studies in the 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 trials (Castahel 2018, Huang 2016, Tomlinson 2020) inadequate search strategies (Castahel 2018), inadequate methodology for meta-analysis (ie, the use of mean differences for analyses of different outcome measures or the pooling of studies with various control groups) (Huang 2016, He 2020, Oberoi 2020) and lack of safety assessment in all but two reviews (Haller 2017, Schell 2019). One systematic review did not formally assess methodological quality or risk of bias of the included studies (Rush 2017). For a description of the included systematic reviews please see table 1.
An additional 24 RCTs were not included in the reviews: 12 RCTs including breast cancer patients, published after the Cochrane review’s search period (Mohammadi 2018, Pintado 2017, Pouy 2018, Rosen 2018, Witek-Janusek 2019, Bagherzadeh 2020, Gok Metin 2019, Mirmamoodi 2018, Park 2020, Price-Blackshear 2020, van der Gucht 2020, Zhao 2019), nine RCTs including mixed cancer populations (Kubo 2019, Lipschitz 2015, van der Lee 2012, Ahmadiqaragezlou 2020, Hunter 2020, Kubo 2020, Nissen 2019, Victorson 2020, Wirth 2019), one RCT each of lung cancer (Lehto 2015), colorectal cancer (Black 2017), and cervical cancer (Zhang 2019b), respectively. For a description of included RCTs please see table 2.
Description of included studies
Effects of MBSR on depression
For breast cancer patients, the Cochrane Review (Schell 2019) 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 2017 and by Huang 20156. However, Huang et al. used inadequate methods which limit its conclusions. The meta-analyses by Castanhel 2018, Zhang 2016 and Zhang 2019 also reported effects favouring MBSR over usual care. Haller 2017 also reported effects favouring MBSR over other active interventions in reducing depression. Results from two RCTs in breast cancer patients were mixed (Rosen 2018, Zhang 20197b).
With regards to mixed cancer populations, the meta-analysis by Zhang 2015 (SMD −0.90, 95% CI −1.53, −0.26, P = 0.006)found large short-term effects but no medium-term effects favouring MBSR over usual care, the meta-analysis by Cillessen 2019 found small short-term but no longer-term effects, and the meta-analysis by Oberoi 2020 found short- and medium-term but no long-term effects.
Subsequently published RCT assessed depression and reported no effects of MBSR in breast cancer (Mirmamoodi 2018) or mixed cancer populations (Kubo 2020, Victorson 2020, Wirth 2019).
Effects of MBSR on anxiety
The Cochrane Review by (Schell 2019) 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 2018 and Zhang 2019a also reported effects favouring MBSR over usual care. Zhang 2016 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 2016 are limited by the inadequate methodology used. Haller 2017 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 systematic review by Zhang 2015 found moderate short-term effects of MBSR on anxiety when compared to usual care (SMD −0.75, 95% confidence interval −1.28, −0.22, P = 0.005), but no medium-term effects, the meta-analysis by Cillessen 2019 found small short-term and longer-term effects, and the meta-analysis by Oberoi 2020 found short- and medium-term but no long-term effects.
Subsequently published RCTs in breast cancer found reduced anxiety (Mirmahmoodi 2018), while effects in mixed cancer populations were inconclusive for both traditional live mindfulness-based programs (Pouy 2018, Ahmadiqaragezlou 2020, Victorson 2017) as well as for mindfulness apps (Kubo 2019, Kubo 2020).
Effects of MBSR on stress
Four systematic reviews including breast cancer patients assessed stress. Haller 2017, Huang 2016 and Zhang 2019a found short-term effects on stress. The meta-analysis by Zhang 2016 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 inconclusive effects of MBSR compared to usual care (Pouy 2018, Mirmahmoodi 2018). One RCT found positive effects of MBSR compared to an attention-control intervention (Witek-Janusek 2019); while two found no group differences between MBSR and a sleep hygiene intervention (Lipschitz 2015) or a breathing intervention (Wirth 2019).
Effects of MBSR on fatigue
In the Cochrane Review by Schell 2019, 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 2017 and Zhang 2019a also reported effects favouring MBSR over usual care; while the meta-analysis by Castanhel 2018 found no effects based on only 2 RCTs. In mixed cancer population, meta-analyses found positive short- and medium-term effects of MBSR compared to various control interventions (Cillessen 2020, He 2020, Xie 2019).
Further RCTs found effects favouring MBSR over usual care in women with breast cancer (Gok Metin, 2019, van der Gucht 2020), while no effects of a mindfulness app on fatigue were found (Lehto 2015).
Effects of MBSR on quality of life
Based on RCTs on women with breast cancer, the Cochrane Review by Schell 2019 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 2017 and Zhang 2016 also found short-term effects. Zhang 2019a found no effects on general quality of life but on emotional wellbeing, psychological and cognitive function. In mixed cancer populations, the meta-analysis by Oberoi 2020 found short- and medium but no longer-term effects on fatigue.
Subsequent RCTs found mixed effects of MBSR on quality of life of women with different types of cancer (Hunter 2020), breast cancer (Rosen 2018, Gok Metin 2019), or lung cancer (Lehto 2015). Two further RCTs found positive effects of a mindfulness app on quality of life of mixed cancer groups when compared to an untreated control group (Kubo 2019, Kubo 2020).
Effects of MBSR on mindfulness
Based on the meta-analysis by Zhang 2019a including patients with breast cancer, MBSR has short-term effects on mindfulness. The RCTs published after the systematic reviews report mixed results (Kubo 2019, Lipschitz 2015, Mohammadi 2018, Rosen2018, Witek-Janusek2019, Kubo 2020, Price-Blackshear 2020, Victorson 2020, Wirth 2019).
Effects of MBSR on sleep
For sleep, the meta-analysis by Haller 2017 found positive short-term effects of MBSR compared to usual care in breast cancer patients, while Zhang 2019a did not. In a subsequent RCT, MBSR was superior to an attention-control intervention (Zhang 2019b). In patients with cervical cancer, positive effects were found on subjective sleep measures, but not on actigraphy or polysomnography (Zhang 2019b).
Effects of MBSR on other outcomes
For general distress, the meta-analysis by Cillessen et al. (2019) found medium- and long-term effects of mindfulness-based interventions (g = 0.32; 95% CI 0.22‐0.41; P <0.001) and follow‐up (g = 0.19; 95%CI: 0.07‐0.30; P < .002). No effects of a mindfulness app beyond usual care was found in subsequent RCTs (Kubo 2020).
In one meta-analysis, no effects of MBSR on pain in women with breast cancer was found (Zhang 2019a). A subsequent RCT in mixed cancer found no effects on pain (Kubo 2019).
The meta-analysis by Zhang 2016 including breast cancer patients found no effects of MBSR beyond usual care on spirituality.
Single RCTs found positive effects on cancer-related symptoms (Lehto 2015), body image (Pintado 2017), life expectancy (Pouy 2018), cognitive function (van der Gucht 2020), and nausea (Hunter 2020) no effects were found on vomiting (Hunter 2020) sexual function (Bagherzadeh 2020), social isolation (Victorson 2020), self-compassion (Victorson 2020) or posttraumatic growth (Victorson 2020), and mixed effects on immune parameters and cortisol reactivity (Black 2017, Witek-Janusek 2019, Mirmahmoodi 2018, Wirth 2019).
Effects of MBSR in children and adolescents with cancer
In their systematic review, Tomlinson 2020 found positive effects on quality of life, distress, depression, anxiety, fear of cancer recurrence, stress, affect, analgesia use, mindfulness, and heart rate in children and adolescents with mixed types of cancer. These findings however are limited by the methodological flaws of the included studies, of which only 2 were RCTs.
Effects of MBCT
While RCTs of MBCT were included in some of the above SRs, no SRs specifically on MBCT are available. The effects of MBCT in cancer are thus reported for the available individual RCTs.
MBCT programs reduced fatigue severity in fatigued cancer survivors (van der Lee 2012), as well as depression, anxiety, quality of life, fatigue, and mindfulness in breast cancers patients (Park 2020). MBCT improved both subjective and objective sleep quality in cancer patients with insomnia, the latter assessed by actigraphy and polysomnography (Zhao 2019). Internet-based MBCT programs improved anxiety, depression, and stress but not quality of life and insomnia (Nissen 2019). MBCT effectively reduced pain and pain medication use (Johannsen 2016 included in Haller 2017) and functional impairment (van der Lee 2012) in one RCT each.
Quality of life was increased by face-to-face and web-based MBCT programs in groups of patients with mixed cancer types reporting increased pain (Johannsen 2016) or fatigue (van der Lee 2012).
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 reported (Castillo 1990). 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 researched (NCCIH 2019). Of the systematic reviews and studies analyzed for this summary, only two reported safety-related data. Haller 2017 found 2 RCTs reporting on safety; however, these RCTs only reported that no serious adverse events occurred (Haller 2017). In the Cochrane Review, adverse events were assessed, but none of the included RCTs reported the occurrence or non-occurrence of adverse events (Schell 2019). The systematic review by He 2020 reported that there were no adverse events in any of the included studies on mixed cancer populations, but it is unclear on whether really no adverse events occurred, or adverse events simply were not reported in some of the studies. In their systematic review on mixed cancer populations, Xie 2020 found only one RCT that reported on the occurrence or non-occurrence of adverse events. In the subsequent RCTs, Witek-Janusek 2019 reported that no adverse events occurred (Witek-Janusek 2019); the remaining RCTs on MBSR did not report the occurrence or non-occurrence of adverse events. Compen 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 MBCT (Compen 2018).
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 condition (Cramer 2016).
Other safety issues and warnings
People with physical limitations may not be able to participate in certain meditative practices involving physical movement (Cramer 2016)
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