Running head: BREAST CANCER STRESS REDUCTION

Breast Cancer Stress Reduction

Paige Stevens
University of South Florida

BREAST CANCER STRESS REDUCTION

Abstract
Many women diagnosed with stages 0, I, or, II of breast cancer are not guided toward how to
deal with this new life-changing diagnosis. Being diagnosed with cancer can cause an individual
to become depressed, stressed, and sleep deprived. Mindfulness based stress reduction (MBSR)
techniques have been used in random controlled trials and were proven to clinically reduce
depression and increase quality of life related to a breast cancer diagnosis. The aim of the study
is to determine the efficacy of Mindfulness based stress reduction on quality of life and
depression over a 1-year time-span. PubMed was used to collect random controlled trials
relevant to MBSR. In the study called Mindfulness meditation for younger breast cancer
survivors there was a significant decrease in perceived stress (P=.004) and a decline in
depressive symptoms (P=.094) (Bower et al., 2015). Another study presented with a significant
effect on the MBSR group of women reporting a total increase of quality of life in respect to the
non-MBSR group (p=0.023) (Sarenmalm et al., 2013). These studies exemplify the positivity of
implementing mindfulness based stress reduction into routine breast cancer diagnosis follow-up.
If this were to be provided to all women diagnosed with breast cancer, there would be less
statement of fatigue, depression, and increased quality of life in breast cancer patients
participating in chemotherapy and/or radiation.
Keywords: Mindfulness-based stress reduction program, Quality of life, Psychosocial
factors, Breast cancer, Random controlled trials

Breast Cancer Stress Reduction

For clients recently diagnosed with breast cancer, increased distress can conflict health
decisions and create further medical issues. The pressure that a breast cancer finding and its

BREAST CANCER STRESS REDUCTION

diagnosis can generate an assortment of psychosocial concerns including fatigue, depression, and
impaired immune responses. A structured program named Mindfulness Based Stress Reduction
(MBSR) has been studied with its effect of breast cancer diagnosis and treatment. MBSR
integrates yoga and meditation with mind-body exercises. Even though there is hopeful evidence
currently accessible on the matter, there is still a need for randomized controlled trials to prove
the efficacy of MBSR. By incorporating MBSR into routine treatment of breast cancer, clients
would have reduced risks of developing depression, sleep disorders due to fatigue, and impaired
immunologic disorders. In a meta-analysis, studies were aimed to examine the evidence of the
efficacy of mindfulness-based stress reduction in improving stress, depression and anxiety
in breast cancer patients. Nine published studies were used that fulfilled the inclusion criteria and
were analyzed. The pooled effect size (95% CI) for MBSR onstress was 0.710 (0.511-0.909), on
depression was 0.575 (0.429-0.722) and on anxiety was 0.733 (0.450-1.017) (Zainal, Booth, &
Huppert, 2013). During these studies, it was proven that MBSR does help to reduce depressive
symptoms, stress, and anxiety related to breast cancer diagnosis. These numbers exemplify that
MBSR does play a significant role in cancer diagnosis. With these studies and numbers in mind,
the following question is asked. In women ages 40 to 65 diagnosed with stage 0, I, and II breast
cancer, how does Mindfulness Based Stress Reduction compared with supportive care affect the
rate of depression and quality of life over 1 year?
Literature Search
The only search engine used to find random controlled trials to support the PICOT
question was PubMed. Key words used to search PubMed consisted of Mindfulness-based stress
reduction program, Quality of life, Psychosocial factors, Breast cancer, and Random controlled
trials.

BREAST CANCER STRESS REDUCTION

Literature Review
A longitudinal study of 93 patients undergoing chemotherapy revealed that a symptom
cluster consisting of pain, depression, fatigue, and sleep disturbance adversely and
synergistically affected patient functional status (Roscoe et al., 2007). The pain symptomatic of
chemotherapy and radiation is often thought to cause these disturbances of quality of life.
Guidelines for breast cancer diagnosis in the hospital consist of treating the cancer and avoiding
a reoccurrence of breast cancer in the future. Most patients diagnosed are less worried about the
side effects of chemotherapy and radiation, but mainly focus on curing the cancer. What they
later realize is that the therapy used to cure their disease results in a lowered quality of life.
Mindfulness based stress reduction helps clients work past their pain and improve their
depressive symptoms. By applying mindfulness therapy, clients are less likely to be fatigued and
sleep better at night.
The first study was written by Bower (Bower et al., 2015). The aim of this trial was to
provide the first evaluation of a brief, mindfulness-based intervention for younger breast cancer
survivors targeting to reduce stress, depression, and inflammatory activity. This study was a
single-center, 2-armed randomized controlled trial measuring perceived stress, depression,
inflammation, and fatigue related to breast cancer diagnosis. To be included in this study, clients
had to meet criteria including diagnosis with stage 0, I, II, or III breast cancer at or before age 50
years and completion of local and/or adjuvant cancer therapy, except hormone therapy, at least 3
months previously. The study also included women up to 10 years after cancer treatment. The
women were assigned to a 6-week MAPS intervention group (n = 39) or to a control group (n =
32). Following the therapy there were significant decrease in perceived stress (P=.004) and a
decline in depressive symptoms (P=.094), as well as a drop in proinflammatory gene expression

BREAST CANCER STRESS REDUCTION

(P=.009) and inflammatory signaling (P=.001) at postintervention. Improvements in secondary

outcomes included reduced fatigue, sleep disturbance, and vasomotor symptoms and increased
peace and meaning and positive affect (P<.05 for all) (Bower et al., 2015). A strength of this
study is that all the measures of the trial ended up as the hypothesis aimed for. The study
included more than just depressive symptoms and stress, but it included fatigue and
inflammatory process, which gives the study a well-rounded conclusive outcome. A weakness of
this study is that is showed short-term efficacy. Though it lasted 6 weeks with a 3-month followup, the study did not show how mindfulness would effect a clients depression long-term (Bower
et al., 2015).
The next randomized controlled trial used was done by Henderson (Henderson et al.,
2012). The purpose of this study was to determine the efficacy of a mindfulness-based stressreduction (MBSR) program on quality of life and psychosocial outcomes. MBSR was compared
to a nutrition education program (NEP) and usual supportive care (UC). The design of this trial
was a three-arm randomized controlled trial. Standardized, self-administered questionnaires were
approved to assess psychosocial variables. Measurements used included quality of life,
depressive symptoms, anxiety, general distress, and psychosocial outcomes. The study was done
on 172 women aged 20 to 65 with stage I or II breast cancer. Usual care (n=58), NEP (n=52),
and MBSR (n=53). Nine participants dropped out. The differences between the ITT and post-hoc
analyses were a significant variance between MBSR and NEP at the 2-year point (P = 0.04) on
active cognitive coping and the difference between MBSR and NEP at the 4-month point on
SCL-90-R-Depression became marginally significant (P = 0.06 as opposed to P = 0.05 in the
multivariable model). At 4 months, patients in the MBSR intervention group had significantly
greater improvement, including spirituality and active cognitive coping, with trends toward

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active behavioral coping and less avoidance coping. Other categories that were marginally or
significantly better included depression and unhappiness, anger, and hostility, anxiety, and
emotional control (Henderson et al., 2012). A strength of this trial is the timeline. The study is
done over a greater amount of time showing how MBSR can effect a patient over an extended
period. Another benefit is that it is compared to a nutrition education program as well, showing
the efficacy of mindfulness on quality of life and psychosocial symptoms. A weakness of this
study is that it only includes clients with stage I or II breast cancer. Since this is a small ratio of
patients with breast cancer, this study is not useful to compare to clients with breast cancer stages
beyond stage II (Henderson et al., 2012).
The final trial used was written by Sarenmalm (Sarenmalm et al., 2013). The Sarenmalm
randomized controlled trial used patients diagnosed with early stage breast cancer. These clients
were enrolled in this three-armed randomized controlled trial to prove the efficiency of MBSR.
The study measured anxiety, depression, coping mechanisms, and overall quality of life. Clients
were randomized into three groups including MBSR Intervention I (weekly group sessions+
self-instructing program), MBSR Intervention II (self-instructing program), and Controls (nonMBSR). A total of 150 participants were used, Intervention group I (n=50), Intervention group II
(n=50), and Controlled group (n=50). Whether the patient was in a self-instructing group or if it
was joined with group sessions, the MBSR program proved positive outcomes by reducing
cortisol levels, improving quality of life and immune function, and increasing coping efficiency.
The results presented with a significant effect on the MBSR group of women reporting a total
increase of quality of life in respect to the non-MBSR group (p=0.023) (Sarenmalm et al., 2013).
A strength of this study is the extended timeline of up to 5 years. Allowing for this amount of
time can give a well-rounded result on the efficacy of MBSR. Another benefit was that the study

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was broken up into three parts including weekly group sessions, self-instructing, and non-MBSR
groups. The differences in these groups can show if group therapy is more or less effective than
self-instruction. A weakness of the study is that they have looked at many secondary outcomes
that have significant change in the MBSR groups, but since there are so many, the study is less
specific on how they are measured. Secondary outcomes include: symptom experience, coping
capacity, personal growth, quality of life, level of mindfulness, health status, and many more
(Sarenmalm et al., 2013).
Synthesis
The trial done by Bower measured perceived stress, depressive symptoms, and
inflammatory signaling (Bower et al., 2015). The study also included reduced fatigue and sleep
disturbances. The PICOT question directly applies to stress, fatigue, and sleep disturbances
because they are related to quality of life. In the Bower trial there was a substantial decrease in
perceived stress (P=.004), depressive symptoms (P=.094), and fatigue and sleep disturbances
(P<.05 for both). Depression is also directly associated with the PICOT question. The
Henderson trial measured active cognitive coping, depression, hostility, and anxiety (Henderson
et al., 2012). The Henderson trial had moderately significant drop in depression and anxiety (P =
0.06). Depression and anxiety are linked to the question, but coping mechanisms and hostility are
not directly related. In the Sarenmalm trial cortisol levels, immune function, coping
effectiveness, and quality of life were all measured (Sarenmalm et al., 2013). For this study,
quality of life was concentrated on most. The Sarenmalm trial reported an increase of quality of
life (p=0.023). The two studies done by Henderson and Bower both looked into depressive
symptoms and perceived anxiety or stress. The Bower trial does not candidly measure quality of
life, but it contains many variables that are part of quality of life including quality of sleep and

BREAST CANCER STRESS REDUCTION

feeling alert during the day. Since the Bower and Henderson trials did not measure quality of life,
the Sarenmalm trial is used to exemplify the change of quality of life through MBSR. In all three
trials, all of the measurements were positively effected by MBSR. Two things that were missing
from the research were how quality of life was measured and that it was not gauged in the first
two trials. Even though it is missing, other variables that benefit quality of life were measured.
With all positive outcomes, the trials have shown to improve patient outcome with MBSR.
Clinical Recommendations
Clients diagnosed with breast cancer are often flooded with stress and emotion. After the
diagnosis they will have to start treatment, if they so choose. Now with radiation and
chemotherapy in the mix, these newly diagnosed clients will start to show signs of fatigue,
depression, and a general decrease in quality of life. With all of these symptoms in mind,
mindfulness based stress reduction should be offered concurrently with a breast cancer diagnosis.
Since multiple random controlled trials have proven the efficacy of MBSR, clinical settings
should be prepared with information and locations of where MBSR takes place. As said above,
clients may be overwhelmed when first diagnosed, so MBSR should be brought up after the
client has a chance to understand their diagnosis and speak with their doctor about treatment
plans. After the client has had a chance to comb over information pertaining to the diagnosis,
protocol should require, minimally, a handout be given to the client on the outcomes and process
of MBSR. Speaking to the patient directly about the therapy would be most beneficial to the
client and the nurse because the client will be better informed and able to ask question while the
nurse is present in the room. It should be explained that clients who choose to participate in the
MBSR group will partake in weekly meetings and activities related to mindfulness such as yoga,
meditation, or group therapy. By implementing this evidence-based therapy, breast cancer
patients would have fewer complications related to depression, fatigue, and quality of life.

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Clients recently diagnosed with cancer should receive a trial period giving the client a chance to
experience MBSR before committing to the group. After the trial is finished, clients will
hopefully want to remain participating in activities pertaining to MBSR. By remaining in these
stress relief programs, clients will be able to maintain low stress levels and continue to increase
their quality of life. If the classes are not accessible to the clients after the study concludes,
worksheets explaining how to do mindful activities alone will be provided at the end of each day.

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10

References
Bower, J .E., Crosswell, A. D., Stanton, A. L., Crespi, C. M., Winston, D., Arevalo, J., Ganz,
P. A. (2015). Mindfulness meditation for younger breast cancer survivors: A randomized
controlled trial. Cancer, 121(8), 1231-1240. doi: 10.1002/cncr.29194
Henderson, V. P., Clemow, L., Massion, A. O., Hurley, T. G., Druker, S., & Hbert, J. R. (2012).
The effects of mindfulness-based stress reduction on psychosocial outcomes and quality
of life in early-stage breast cancer patients: A randomized trial. Breast Cancer Research
and Treatment, 131(1), 99109. doi:10.1007/s10549-011-1738-1
Roscoe, J. A., Kaufman, M. E., Matteson-Rusby, S. E., Palesh, O. G., Ryan, J. L., Kohli, S.,
Morrow, G. R. (2007). Cancer-Related Fatigue and Sleep Disorders. The Oncologist, 12,
35-42. doi:10.1634/theoncologist.12-S1-35
Sarenmalm, E. K., Mrtensson, L. B., Holmberg, S. B., Andersson, B. A., Odn, A., & Bergh, I.
(2013). Mindfulness based stress reduction study design of a longitudinal randomized
controlled complementary intervention in women with breast cancer. BMC
Complementary and Alternative Medicine, 13, 248-256. doi: 10.1186/1472-6882-13-248
Zainal, N. Z., Booth, S. & Huppert, F. A. (2013). The efficacy of mindfulness-based stress
reduction on mental health of breast cancer patients: A meta-analysis. Psycho-Oncology,
22, 14571465. doi: 10.1002/pon.3171