Running head: MEDITATION FOR BREAST

Meditation for Breast Cancer Patients

Katherine Rivas
University of South Florida

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2
Abstract

Clinical Problem: Patients diagnosed with breast cancer experience the same feelings of stress
like any patient with cancer. Although overall levels of stress tend to decrease as time progresses
some women report high levels of stress throughout their diagnosis. These consistently high
levels of stress are associated with higher mortality and higher incidence of cancer.
Objective: To determine if meditation, specifically mindfulness based stress reduction or MBSR,
can reduce stress in women diagnosed with breast cancer. PubMed was accessed to obtain
randomized control trials (RCT) and clinical guidelines describing how the use of meditation can
reduce stress in patients with breast cancer. The key search terms used were breast cancer,
neoplasm, stress, meditation, complementary therapy, alternative therapy, carcinoma,
mindfulness, and stress reduction.
Results: Hoffman et al. (2012) found in their research that participants that practiced MBSR for
at least two hours weekly reported decreased levels of stress compared to women who did not
practice MBSR.
Conclusion: Patients with breast cancer who practice mindfulness based stress reduction a few
hours a week, have a reduced level of stress compared to patients that just follow a
pharmacological approach for treatment. Further research is needed to confirm how long these
results last.

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Meditation for Breast Cancer Patients

When a patient learns that they have cancer, it can be an overwhelming experience.
According to Cramer et al. (2012), the second most common cancer worldwide is breast cancer.
In 2008 alone, an estimate of 1.5 million new cases of breast cancer were diagnosed. Although,
survival rates are increasing in patients with breast cancer, it still has the highest mortality rate of
all cancers in women (Cramer et al, 2012). Cancer comes without warning and the diagnosis can
cause many emotions at once. Cancer treatment is also linked to many psychosocial and physical
ailments that can interfere with activities of daily living. One of the most common complaints in
patients with breast cancer is stress. Therefore, in the last 20 years, breast cancer patients have
turned to alternative medicine to treat the mind, body and soul instead of pharmacological
approaches that only treat the body. An approach that is becoming increasingly popular among
cancer patients worldwide to treat stress is the use of meditation, specifically mindfulness.
Mindfulness is defined as being aware of each moment in a non-judgmental way. This type of
meditation focuses on being accepting and open towards ones own experiences (Hoffman et al.,
2012). The most common systematic approach that involves mindfulness is known as
mindfulness-based stress reduction or MBSR (Hoffman et al., 2012). This approach consists of
practicing MBSR for 2.5 to 3.5 hours a week for a few weeks. Meditation, specifically MBSR
has shown to be effective in reducing a range of psychosocial cancer symptoms that reduce
patients quality of life. An evaluation of evidence about this topic was guided by the following
PICOT question: in patients with breast cancer, how does meditation versus patients who dont
meditate, affect their stress levels over the course of eight weeks?
Literature Search

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PubMed was accessed to obtain three randomized controlled trials that explained the use
of meditation for patients with breast cancer. These clinical trials explained their findings
between breast cancer patients who practiced meditation for eight weeks verses patients who did
not. The key search terms used were, breast cancer, neoplasm, stress, meditation, complementary
therapies, alternative therapy, carcinoma, mindfulness and stress reduction.
Literature Review
One clinical guideline and three randomized control trials were used to assess the
connection between MBSR and levels of stress in patients with breast cancer (see Table 1).
Henderson et al. (2013) designed a randomized, controlled intervention study to determine how
efficient is the use of Mindfulness Based Stress Reduction (MBSR) in reducing stress and
improving quality of life in patients with breast cancer, versus patients who just receive usual
care (UC) with nutrition education. 172 patients were recruited and randomly assigned to the
experimental and control groups. The participants were in stage I or stage II breast cancer and
were randomized to these two groups for a total of 8 weeks, with a follow up in four months,
twelve months and then again at 24 months. In the MBSR group, women were paired up with
instructors with a Masters or doctorate degree and with long term meditation practice. The
women were then asked to participate in two to three hour meditation practice sessions weekly.
The primary outcome resulted in that the women in the experimental group, the MBSR program,
experienced a significant improvement, P < .05, in psychosocial variables compared to the
women in the UC group. The results indicated that women in the MBSR were using more active
coping and less avoidance coping than the group with UC. Results were obtained using The
Functional Assessment of Cancer Therapy and the Dealing with Illness questionnaire. Secondary
measurements included the Beck Anxiety Inventory, Becks Depression Inventory, and Mini

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Mental adjustment to Cancer Scale. Stress levels measured using the Sense of Coherence scale.
The results demonstrated a statistically significant decrease in the levels of stress .By increasing
their coping mechanisms and helping patients focus on activities that are meaningful, versus
denial of negative results, it improves their global orientation. One weakness of the study was
that the demographic of the participants was limited. Most participants were white, married,
employed, well-educated and on average 50 years old. This can affect the studys validity to the
rest of the population. Another weakness of this study is that, it did not consider side effects from
radiotherapy. Strengths of the study include, the use of two control groups, variety in stages of
cancer and a 2 month follow up. The recommendation grade for this study is an (B), due to its
statistically significant evidence found in the MBSR group and its minimal to no adverse effects
to participants in both groups. However, the limited demographic and the use of participants with
only stages I to II, make it difficult to apply this study to the general population.
Hoffman et al. (2012) conducted a randomized, wait listed, controlled study design on
229 women after radiotherapy and chemotherapy for breast cancer. The study was designed to
compare the difference in stress and sleep quality between women who use mindfulness versus
women who do not. The women were randomly assigned to one program that included eight
weeks of MBSR, or a control group that received standard care. The women varied in stages of
breast cancer from 0 to III. The MBSR program consisted of eight weekly classes, 40 to 45
minutes in length. The classes consisted of sitting meditation and discussions. Home practice was
conveyed with a manual and a compact disc of mindfulness practices. The wait listed controls
did not have any interventions besides their standard care. Participants were given various
assessments at weeks zero, eight and twelve. Primary outcomes were assessed using the Profile
of Mood States (POMS). Other assessments used were the Functional Assessment of Cancer

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Therapy-Endocrine symptoms (FACT-ES), Functional Assessment of Cancer Therapy-Breast

(FACT-B), and the WHO five item well-being survey. The results presented that increased hours
of formal mindfulness decreased stress, anxiety among other emotional issues compared with
those in the control group who did not sue these techniques. The treatment group main effect was
p= <.001, which is statistically significant improvement when comparing the MBSR group to the
control. Limitations to this study include the use of self-reporting. This can be a biased measure
of reporting and can affect results. Other limitations included, clinician-researcher role and
during the follow up period between weeks 9 to 12 there wasnt a record kept of the time spent
practicing meditation. There was limited generalizability to women with stage 0 to III breast
cancer, patients less inclined to join the study included people with stage III disease and patients
who received more chemotherapy. Strengths of the study are the large sample size and the range
of participants stages of breast cancer including those with stages 0. The recommendation grade
for this study is an (A), due to its statistically significant evidence found in the MBSR group,
minimal to no adverse effects to participants in both groups, wide range of cancer patients and
large sample size.
Lerman et al. (2012) conducted a randomized controlled trial using standardized
measures for evaluating MBSR. The purpose of this study was to evaluate the effect of eight
weeks of MBSR and looking at how this can improve quality of life in cancer patients and
survivors. Sixty-eight female cancer patients were randomized into two groups. In one group
they utilized the MBSR intervention and the other group was the wait listed control group. A
variety of measures were used to accurately obtain this information; The Symptoms Checklist,
the European Organization for Research, Treatment of Cancer Quality of Life questionnaire and
the Symptoms of Stress Inventory (SOSI). Treatment groups were taught meditation, mindful

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communication skills and mindful breast self-exam in weekly two hour classes. Patients also
recorded daily logs that were used to verify compliance with the program. The control groups
(n=20) scores did not differ significantly after the eight weeks. (P = 0.94). On the other hand, the
intervention group (n=48) improved significantly (p = 0.005) based on the SOSI questionnaire.
In conclusion, there were statistically significant improvements in the group that practiced
MBSR. Limitations to the study are that patients in the waitlist control group were planning to
start the program and their positive anticipation might have influenced their responses. Another
weakness of the study is that an average of four years to twenty nine years had passed since the
cancer diagnosis for some patients. Long-term survivors may respond differently to the
interventions. A strength of the study is that it included other cancers in women and categorized
the results based on the type of cancer. However all cancers demonstrated statistically significant
results. Although there was statistically significant evidence found in breast cancer patients in the
the MBSR group, we dont know the specific stages of breast cancer that the participants had and
this is important to know. The recommendation grade for this study is an (C).
The guidelines for the use of mindfulness based stress reduction by the Society for
Integrative Oncology retrieved from the National Institute of Health (2014) incorporates
evidence that suggests that mind and body approaches help cope with symptoms of cancer and
effects of its treatment. The Society for Integrative Oncology recommends weekly stress
management, yoga, energy conservation and meditation for stress reduction and quality of life.
This recommendation received a Grade (B), which indicates that there is a high certainty that the
benefit is moderate.
Synthesis

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Henderson et al. (2013) demonstrated that women that underwent radiotherapy while
participating in MBSR experienced a significant improvement, in psychosocial variables
compared with UC group at eight weeks (p < .05). Hoffman et al. (2012) reported that increased
hours of formal mindfulness decreased stress, anxiety among other emotional issues in patients
with breast cancer (p= .001). Additionally, Lerman et al. (2012) found statistically significant
improvements in the group that practiced MBSR compared to the group that received standard
care (p = 0.005). Although the connection between MBSR and a decrease in stress levels in
patients with breast cancer is significant there is still gaps in the research. Additional research is
needed for patients with a range of stages and for a longer period of time. The time spent
meditating should also be taken into consideration.
Clinical Recommendations
The Society for Integrative Oncology (2012) recommends that meditation including
MBSR is recommended to reduce long term anxiety and stress before and after treatment. Many
trials available for review shared common limitations such as lack of standardized outcome
measures, small sample sizes and poorly reported outcomes. Future studies need to address these
problems so future studies can be more conclusive and complete.

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References
Cramer, H., Lauche, R., Paul, A. & Dobos, G. (2012). Mindfulness-based stress reduction for
breast cancer-a systematic review and meta-analysis. Current Oncology, 19(5): e343
e352. doi:10.3747/co.19.1016.
Greenlee, H., Balneaves, L.G., Carlson, L.E., Cohen, M., Deng, G., Hershman, D., Mumber, M.,
Perlmutter, J., Seely, D., Sen, A., Zick, S.M., & Tripathy, D. (2014). Clinical Practice
Guidelines on the Use of Integrative Therapies as Supportive Care in Patients Treated for
Breast Cancer. Society for Integrative Oncology. DOI:10.1093/jncimonographs/lgu041.
Henderson, V.P., Massion, A.O., Clemow, L., Hurley, T.G., Druker, S. & Hbert, J.R. (2013). A
randomized controlled trial of mindfulness-based stress reduction for women with earlystage breast cancer receiving radiotherapy. Integrative Cancer Therapies, 12(5):404-13.
doi: 10.1177/1534735412473640.
Hoffman, C.J., Ersser, S.J., Hopkinson, J.B., Nicholls, P.G., Harrington, J.E. & Thomas, P.W.
(2012). Effectiveness of Mindfulness-Based Stress Reduction in Mood, Breast- and
Endocrine-Related Quality of Life, and Well-Being in Stage 0 to III Breast Cancer: A
Randomized, Controlled Trial. Journal of Clinical Oncology, 30(12):1335-42. doi:
10.1200/JCO.2010.34.0331.
Lerman, R., Jarski, R., Rea, H., Gellish, R., & Vicini, F. (2012). Improving symptoms and
quality of life of female cancer survivors: a randomized controlled study. Annals of
Surgical Oncology, (2):373-8. doi: 10.1245/s10434-011-2051-2.

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Table 1
Literature Review
Reference
Henderson, V.P., Massion, A.O.,
Clemow, L., Hurley, T.G.,
Druker, S. & Hbert, J.R. (2013).
A randomized controlled trial of
mindfulness-based stress
reduction for women with earlystage breast cancer receiving
radiotherapy. Integrative Cancer
Therapies, 12(5):404-13.doi:
10.1177/1534735412473640.

Aims

Design and
Measures
To test the
RCT: Study
effectivenes was a
s of a
randomized
mindfulness clinical trial
based stress of 172 women
reduction
with
program
diagnosed
compared
with breast
with a
cancer in the
group
last two year
receiving
from from
nutritional
four sites: The
education
University
intervention and Memorial
and usual
Hospital
care in
Campuses of
women with the University
breast
of
cancer.
Massachusetts
Memorial
Health care,
Worcester,
Mass; and
Miriam
Hospital
Measures:
Data from the
report was
obtained by
selfassessment
questionnaires
,

Sample

Outcomes /
statistics
N= 172
At 4
women.
months,
199 women patients in
were
the MBSR
eligible for group had a
the study.
significantly
180
greater
enrolled
overall
and were
improvemen
randomized t than the
. Before
UC controls
collection
(p=0.05)
of data, 8
women
left. N=58
received
UC N= 52
received
nutrition
education
and N=53
received
MBSR.

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Hoffman, C.J., Ersser, S.J.,

Hopkinson, J.B., Nicholls, P.G.,
Harrington, J.E. & Thomas, P.W.
(2012). Effectiveness of
Mindfulness-Based Stress
Reduction in mood, breast- and
endocrine-related quality of life,
and well-being in stage 0 to III
breast cancer: A randomized,
controlled trial. Journal of
Clinical Oncology, 30(12):133542.doi:10.1200/JCO.2010.34.033
1.

Lerman, R., Jarski, R., Rea, H.,

11

To assess
the
effectivenes
s of MBSR
for mood,
breast and
endocrine
specific
quality of
life after
hospital
treatment in
patients
with stage 0
to III breast
cancer.

The

anthropometri
c
measurements
and medical
chart reviews.
Randomized
controlled
trial design
recruited
patients over
15 months
from The
Haven.
Eligibility was
strictly
restricted to
women
diagnosed
with stage 0 to
III breast
cancer
between the
ages of 18 to
80 years old.

Began with
N= 643
participants
contacted
by letter,
n= 290
were
eligible,
n=242 were
randomly
assigned,
n=114
received
interventio
n with
MBSR and
n=115 in
control
group.

The results
were
statistically
significant
outcomes in
the
experimenta
l group
compared
with the
control
group.
There was
an
improvemen
t in overall
emotions of
p=0.04.

Measures:
The primary
outcome was
mood and
measured by
using the
POMS, 65
items.
Secondary
outcomes
were
measured
using FACTB, FACT-ES,
a functional
well-being 19
item subscale
and the WHO
5 item
questionnaire.
RCT: Sixty

N=77 were

The major

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Gellish, R., & Vicini, F. (2012).
Improving symptoms and quality
of life of female cancer
survivors: a randomized
controlled study. Annals of
Surgical Oncology, (2):373-8.
doi: 10.1245/s10434-011-2051-2.

12
objective of
this study
was to
evaluate
using
reliable
measures to
effects of
eight week
MBSR
program in
female
cancer
patients.

eight female
cancer
patients were
recruited from
the oncology
department of
a major MidWestern
University
teaching
hospital from
September
2009 through
August 2010.
Measures:
Patients were
evaluated
using the
Symptoms
Checklist
(SCL-90-R),
the European
Organization
for Research
and Treatment
of Cancer
Quality of
Life
questionnaire
and the
Symptoms of
Stress
Inventory
(SOSI)

randomized
, n=53 were
assigned to
MBSR and
24 were
assigned to
control. In
the analysis
MBSR
group, lost
5 so
included
n=48
participants
. In the
control
group, lost
4, ended
with n= 20
in analysis.

cancer type
represented
was breast
cancer. The
intervention
group
improved
significantly
in
decreasing
stress,
p=0.005 on
both SCL90 R
subscales,
while the
control
group,
p=>0.2, did
not improve
in these
measures.