Ann. N.Y. Acad. Sci.

ISSN 0077-8923

A N N A L S O F T H E N E W Y O R K A C A D E M Y O F SC I E N C E S
Issue: Meditation

Mindfulness-based interventions for coping with cancer

Linda E. Carlson
Division of Psychosocial Oncology, Department of Oncology, Cumming School of Medicine, University of Calgary, and
Department of Psychosocial Resources, Tom Baker Cancer Centre, Alberta Health Services CancerControl, Calgary, Alberta,
Canada

Address for correspondence: Dr. Linda E. Carlson, Department of Psychosocial Resources, Holy Cross Site, 2202 2nd St.
S.W., Calgary, Alberta, Canada T2S 3C1. l.carlson@ucalgary.ca

Work in the development and evaluation of mindfulness-based interventions (MBIs) for cancer care has been
underway for the last 20 years, and a growing body of literature now supports their efficacy. MBIs are particularly
helpful in dealing with common experiences related to cancer diagnosis, treatment, and survivorship, including loss
of control, uncertainty about the future, and fears of recurrence, as well as a range of physical and psychological
symptoms, including depression, anxiety, insomnia, and fatigue. Our adaptation, mindfulness-based cancer recovery
(MBCR), has resulted in improvements across a range of psychological and biological outcomes, including cortisol
slopes, blood pressure, and telomere length, in various groups of cancer survivors. In this paper, I review the rationale
for MBIs in cancer care and provide an overview of the state of the current literature, with a focus on results from three
recent clinical trials conducted by our research group. These include a comparative efficacy trial comparing MBCR
to supportive–expressive therapy in distressed breast cancer survivors, a non-inferiority trial comparing MBCR to
cognitive behavioral therapy for insomnia in cancer survivors with clinical insomnia, and an online adaptation of
MBCR for rural and remote cancer survivors without access to in-person groups. I conclude by outlining work in
progress and future directions for MBI research and applications in cancer care.

Keywords: meditation; mindfulness; cancer; stress; anxiety; depression

Introduction and behavioral flexibility, exposure to challenging

stimuli, and clarification of key life values and
Mindfulness is often defined as paying attention in
priorities.1,2
the present moment, with nonjudgmental accep-
Within the realm of cancer care, my group and
tance of experience. Shapiro and I have defined
others have been applying principles of mind-
mindfulness as consisting of three key axioms:
fulness, explicitly training people diagnosed with
intention, attention, and attitude.1 Intention lightly
cancer in mindfulness meditation, and assessing
directs the focus of practice, while attentional
the effects of such training since the mid-1990s. We
skills are trained through sustained practice of
have learned much about the feasibility and efficacy
directing and redirecting attention to aspects of the
of these interventions across a wide range patients
present moment. All of this is done with attitudes
and outcomes, including psychological, behavioral,
of kindness and curiosity. Mindfulness is thought
physiological, and biological markers of health. In
of both as a way of being in the world (one can be
this paper, I review the rationale for the application
mindful) and as a concrete practice (mindfulness
of mindfulness-based interventions (MBIs) for
meditation). One objective of the wide variety of
people living with cancer and review some of the key
mindfulness meditation practices is to enhance
studies and outcomes, especially newer, larger, and
the quality of being mindful in everyday life. The
well-designed studies, with a focus on work from
effects of systematically practicing mindfulness are
our research group evaluating the mindfulness-
thought to arise through a variety of mechanisms,
based cancer recovery3 (MBCR) program.
including improved emotion regulation, cognitive

doi: 10.1111/nyas.13029
Ann. N.Y. Acad. Sci. xxxx (2016) 1–8 
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Mindfulness and cancer Carlson

Why mindfulness? repetitive and consistent application of awareness

of present-moment experience, with a kind, curi-
There are several characteristics of a cancer experi-
ous, and nonjudgmental attitude. This typically
ence, and of illness experience in general, that are
begins with training in focused attention on the
especially amenable to a mindfulness approach. A
breath or bodily sensation through body scanning,
diagnosis often challenges the commonly held world
sitting meditation, and mindful movement. Once
view that life is predictable and controllable. On an
stability of attention has been established through
existential level, people are forced to confront their
ongoing practice, a broadening of attention (“bare
own mortality in a real way, often for the first time.
awareness”) is applied, which allows an individual
Substantial and potentially permanent changes in
to directly experience one’s own mind for what it
functional abilities, appearance, and lifestyle may
is: transient, impersonal, and constantly changing.
follow, as well as having to face the possibility of
Through observation, participants can also directly
ongoing pain and dysfunction. Life plans are neces-
experience how grasping at certain outcomes or
sarily altered, and the future is premised on whether
states of being causes suffering, and through that
the illness comes back or gets worse. Most people
insight, learn to let go of clinging and personaliza-
experience significant fear, anxiety, and depression.
tion of experience. Repetitive practice of alternative
After treatment, no matter how positive the progno-
responses to difficult emotions or thoughts dur-
sis may be, for most people, there is a lingering fear
ing meditation helps retrain the brain to respond
of recurrence or progression, which turns every ache
in ways that are supportive of more positive
and pain into a potential life threat and can result
emotions.
in constant anxious monitoring. Mindfulness prac-
A mindfulness approach is eminently adaptable
tices allow a short-circuiting of this process to pre-
to a wide array of circumstances, including living
vent such escalation. Indeed, many of these common
with cancer. Simply absorbing the general under-
cancer-related problems are amenable to treatment
standing that the only certainty in life is change, and
through mindfulness training, which is especially
that sometimes the best thing to do to solve a prob-
helpful in dealing with uncontrollable, unpre-
lem is accept it, can be extremely relieving and even
dictable, and emotionally charged life stressors.
liberating to people who are desperately and often
Psychologists often classify problems as either
frantically trying to fix things. Acceptance in this
those that can be solved with problem-focused
context does not equate to “giving up” or not trying
coping techniques or those that require emotion-
to treat one’s illness; rather, it acknowledges the facts
focused coping. Problem-focused coping is useful
and allows a turning away from blame toward accep-
when there are tasks to be done to solve the prob-
tance of the reality of loss and grief. Realizing that,
lem. People therefore embrace their treatment reg-
in fact, one can slow down and see things as they
imens, attend their appointments, and do whatever
are, without blinders, and learn ways to hold strong
they can to ensure a positive outcome. In response to
emotions and sensations even in the face of can-
feeling a loss of control, many people try even harder
cer, can be transformative. The further realization
to control some aspects of their lives and solve the
that, although specific symptoms may be unpleas-
problems, but this is often a losing battle. Much
ant, they are tolerable and constantly in flux can
of the illness experience requires emotion-focused
provide alleviation of suffering. Stepping back and
coping, rather than problem solving, which can be
seeing the racing thoughts, worries, and self-blame
difficult for many people who are not well trained
as just thoughts, and not necessarily the truth, pro-
in that area. MBIs offer a form of emotion-focused
vides further relief. Hence, change occurs not only
coping, which allow people to actually embrace
by training the mind through formal mindfulness
uncertainty. Learning how to accept our fundamen-
practice, but through a shift in attitude and perspec-
tal inability to control or change the course of ill-
tive that allows people to see their illness in a new
ness progression (and ultimately death) is where
light, without allowing fear to consume them and
emotion-focused approaches, such as MBIs, can
drive behavior. This approach can provide energy
be especially helpful for people facing a cancer
and motivation for moving forward in life’s jour-
diagnosis.
ney, whatever the future holds.
The core training in MBIs involves the develop-
Hence, mindfulness training offers a venue
ment of stable and kind mindful attention, through
for coping with these often uncomfortable and
2 Ann. N.Y. Acad. Sci. xxxx (2016) 1–8 
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Carlson
difficult emotions elicited by a cancer diagnosis, in a
safe and controlled container of one’s own making.
By adopting a stance of observer to overwhelming
thoughts and emotions, patients can take a step back
and allow themselves to process these experiences at
their own pace, seeing their experience as constantly
changing and their distressing thoughts as simply
mind events that are often untrue. Ultimately, they
begin to see that they are more than a cancer patient;
they are connected to, and supported by, everyone
who shares this human condition.
Mindfulness-based interventions
Over the past three decades, there has been a grow-
ing clinical and research interest in the practice of
mindfulness meditation, owing in large part to the
pioneering work of Jon Kabat-Zinn at the University
of Massachusetts Medical Center. The mindfulness-
based stress reduction (MBSR)4 program that he
devised in the late 1970s, based on intensive secu-
lar training in mindfulness meditation techniques,
has since been adapted for treating many differ-
ent conditions, and thousands of studies have been
conducted investigating its efficacy. The original
impetus for developing MBSR was to help patients
who seemed to be falling through the cracks of the
system, suffering from unrelieved complex medi-
cal conditions and symptoms that often involved
untreated pain and anxiety. In the first stud-
ies of MBSR, Kabat-Zinn documented improve-
ments in pain and anxiety that proved to be long
lasting.4
The MBSR program is structured as an 8-week
group program of 2.5-h weekly sessions that incor-
porate intensive training in mindfulness medita-
tion with group reflection and mindful Hatha yoga
practice. In weekly sessions participants learn fun-
damentals of the mind–body connection and how
their interpretations of the world can cause both
physical and mental suffering. The primary medita-
tion techniques used to cultivate mindfulness in the
MBSR program are the body scan, sitting medita-
tion, walking meditation, and loving-kindness med-
itation, in conjunction with mindful yoga postures,
with new material building upon previous weeks’
training and practice. Participants are instructed to
practice at home daily for 45 min, 6 days per week.
Instructors are highly trained in meditation, group
process, and didactic instruction.
Ann. N.Y. Acad. Sci. xxxx (2016) 1–8 
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Mindfulness and cancer
Our program for people living with cancer,
MBCR, is an adaptation of MBSR. Structurally, we
still have 8 sessions with a weekend retreat and
require similar daily home practice, but the sessions
are shorter—1.5 to 2 h—in recognition of the lim-
ited energy of many of our participants. The core
principles and practices are essentially the same.
We have included specific material on coping with
cancer; further focus on symptoms, such as sleep
problems, pain, and fear of cancer recurrence; and
some cognitive coping strategies based on cognitive
behavioral therapy principles. We include helpful
imagery, such as the mountain meditation, and also
emphasize loving-kindness practice toward the self
and others. There is a strong component of mindful
movement through yoga postures and emphasis on
group process and group support.
Summary of the literature
There is now a large body of work investigating the
efficacy of MBIs for patients with various types of
cancer, which has been reviewed repeatedly over the
last decade.5–18 A 2009 meta-analysis of 10 stud-
ies found a medium-sized effect on psychosocial
outcome variables (d = 0.48), but only a small
effect on the handful of physical biomarker vari-
ables measured up to that point (d = 0.18).5 A more
recent meta-analysis of 19 studies reported similar
effect sizes on mood (d = 0.42) and distress (d =
0.48), but did not look at biological outcomes.7 Two
other recent meta-analyses focused on breast can-
cer patients exclusively, reporting large effect sizes
on stress (d = 0.71) and anxiety (d = 0.73) across
nine studies with various designs,15 as well as small
effects on depression (d = 0.37) and medium effects
on anxiety (d = 0.51) in three randomized con-
trolled trials (RCTs).16 Piet et al. examined 22 ran-
domized and nonrandomized studies and reported
moderate effect sizes on anxiety and depression in
nonrandomized studies (d = 0.60 and 0.42, respec-
tively) and slightly smaller effects for RCTs.18 I also
reviewed MBI studies for all medical illnesses, apply-
ing the criteria for assigning levels of evidence, and
concluded there is level 1 (highest) evidence for the
efficacy of MBIs in oncology.17
Looking at individual studies, the first publica-
tion of an MBI in cancer was from our research
group, in which we randomized 89 patients with a
variety of cancer diagnoses to MBCR or a waitlist
control condition.19 Patients in the MBCR program
3
Mindfulness and cancer Carlson

improved significantly more on mood states and Recent trials

symptoms of stress than those in the control
More recently, we conducted two comparative effec-
condition, with large improvements of approxi-
tiveness RCTs of the MBCR program, the MINDSET
mately 65% on mood and 35% on stress symptoms.
and I-CAN Sleep trials, and developed an online
These patients, as well as the control group, were
adaptation of the program tested in the eCALM
followed up 6 months after treatment completion,
trial, each of which is described below.
and similar benefits were maintained over the
The MINDSET trial directly compared MBCR
follow-up period.20 In the combined group the
to another active group intervention for cancer
greatest improvements were seen on anxiety,
support in over 270 distressed breast cancer
depression, and irritability.
patients, supportive–expressive therapy (SET),27
Since that time, many pre–post observa-
and a minimal-intervention control condition (a
tional studies without comparison groups, quasi-
1-day stress management seminar). This trial was
experimental studies, and RCTs with usual-care or
unique in a number of ways: (1) we included only
waitlist control groups have been published, cit-
distressed breast cancer survivors, in order to avoid
ing improvements in a range of outcomes, includ-
floor or ceiling effects on outcomes wherein par-
ing quality of life (QOL) domains, such as emo-
ticipants do not improve because they are already
tional, social, role and physical functioning, and
doing quite well; (2) outcomes were both psycho-
psychological improvements on measures includ-
logical and biological; (3) psychological outcomes
ing stress symptoms, anxiety, depression, fear, and
included measures of both symptom reduction
avoidance (for reviews, see Refs. 5–18). Other out-
(mood disturbance, anxiety, stress symptoms),
comes assessed include cancer-related symptoms,
as well as enhancement of positive psychological
such as fatigue, pain, and sleep, and existential pos-
constructs (posttraumatic growth, spirituality);
itive psychology outcomes, including spirituality,
(4) we included a third group who participated
posttraumatic growth, loss, and grief.14
in only a 1-day stress management seminar, as a
While some RCTs comparing MBIs to waitlist or
minimal-intervention control, who after the active
usual-care controls have large sample sizes,21–25 still
intervention period were re-randomized into one
only a few studies have included randomized active
of the two longer interventions; (5) we followed
comparison groups. Henderson et al.26 randomized
all participants for a full year post-program to
172 early-stage breast cancer patients into an 8-week
determine long-term outcomes; and (6) the study
MBSR program, a nutrition education program
included moderator analyses to determine if
matched on time, or a usual-care control condition,
outcomes differed across groups for people with
and included follow-up assessments post-program,
different baseline characteristics, personalities, and
1 and 2 years later. The MBSR group improved more
preferences.
than the other two groups on many measures post-
Overall, women in the MBCR group showed
program, including QOL, active behavioral and
more improvement on stress symptoms compared
cognitive coping, and avoidance and spirituality, as
with women in both the SET and control groups, on
well as depression, hostility, anxiety, unhappiness,
QOL compared with the control group, and in social
meaningfulness, and several measures of emotional
support compared with the SET group,28 but both
control. These group differences eroded over time,
active-intervention groups’ cortisol slopes (a marker
however, as participants in the other two groups
of stress responding) were maintained over time
continued to improve more slowly: by 24 months the
relative to the control group, whose cortisol slopes
only group differences were on measures of anxiety,
became flatter. Steeper slopes are generally consid-
unhappiness, and emotional control, still favoring
ered to be healthier. The two intervention groups
MBSR over usual care, but not over the educational
also maintained their telomere length, a potentially
group. It seems that MBSR may have helped to speed
important marker of cell aging, over time compared
up the natural course of cancer recovery across
to controls.29 Over the longer-term follow-up of
many domains, but also added a more lasting and
1 year, the MBCR participants maintained all of
distinct shift in perspective and skills in emotion
the benefits received in the group, while the SET
regulation.
participants still had higher levels of stress, mood

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Carlson
disturbance, and lower QOL.30 This suggests that
the 8-week group provided longer-term protection
from distress for these women compared to those
who did not participate.
The most preferred treatment (by over half of
participants) was MBCR, and those who received
their preferred treatment (regardless of what it was)
improved more on QOL and spirituality over time.31
Preference seemed to be a more powerful predic-
tor of outcome than individual personality traits.
Indeed, while we measured baseline levels of neu-
roticism, extraversion, conscientiousness, openness
to experience, and agreeableness (the “big 5” per-
sonality traits), as well as emotional suppression
and repression, contrary to our original hypothe-
ses, none of these traits had significant effects on
most outcomes. This begins to indicate something
beyond what can be learned from classic RCT
designs—preference matters more than individual
differences in personality or coping styles. Treat-
ment credibility and expectancy for benefit are likely
important components in harnessing the power of
the individual to produce meaningful change.
In another head-to-head comparative effective-
ness trial (I-CAN Sleep), we also tried something
relatively novel for behavioral interventions—
blinding participants to treatment. We did this
by advertising the study simply as “I-CAN Sleep:
non-drug treatments for insomnia in cancer
survivors,” and did not tell participants what the
treatments were until they were already enrolled.
Even then, they only knew about the treatment that
they received, not what the other treatment was.32
They were randomly assigned to either MBCR or
cognitive behavioral therapy for insomnia (CBT-I),
the gold-standard treatment for insomnia. This is
a very tough test of efficacy for MBCR and was
designed as a non-inferiority trial to test whether
the novel treatment for sleep (MBCR) was as
effective as the gold standard.
In total, 111 patients with a variety of cancer types
were randomly assigned to either an 8-week CBT-
I program (n = 47) or the 8-week MBCR group
(n = 64).33 Immediately post-program, MBCR was
found to be inferior to CBT-I in improving the
primary outcome of insomnia severity, but MBCR
was noninferior at follow-up 3 months later. The
time to fall asleep was reduced by 22 min in the
CBT-I group and by 14 min in the MBCR group
at follow-up. Similar reductions in wake time after
Ann. N.Y. Acad. Sci. xxxx (2016) 1–8 
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Mindfulness and cancer
sleep onset were observed for both groups. Total
sleep time increased by 0.6 h for CBT-I and 0.75 h for
MBCR. CBT-I improved sleep quality and dysfunc-
tional sleep beliefs, and both programs resulted in
reduced stress and mood disturbance. The percent-
age of patients reporting severe insomnia dropped
to 0% in both groups, while moderate insomnia in
the MBCR group dropped from 41% at baseline to
19% post-program and continued to drop to 15% at
follow-up, whereas moderate insomnia in the CBT-I
group dropped from 50% to 10% post-program,
but then increased to 17% at follow-up. Rates of
mild insomnia increased in both groups, as peo-
ple shifted from the moderate and severe categories
when they improved. At the follow-up assessment,
22% of patients in MBCR and 50% of patients in
CBT-I no longer had clinically significant insomnia
in any range; however, these categorical differences
between groups were not statistically significant.34
Overall, these findings indicated that while MBCR
was slower to take effect, it could be as effective as
the gold-standard treatment for insomnia in cancer
survivors over time.
One final example of stretching the boundaries
of traditional service delivery is a study by our
research group of an online adaptation of MBCR,35
which included a broad range of both men and
women who could either be on active treatment or
have completed treatment within the past 3 years,
with any type of cancer. They all were experiencing
at least moderate levels of distress. Because it was
offered to people living in rural and remote areas
and who otherwise didn’t have access to face-to-
face MBCR groups, we couldn’t directly compare
in-person to online versions. Instead, we conducted
a waitlist RCT comparing those in the online pro-
gram to a group randomly assigned to wait for the
next online program. Our primary interest was fea-
sibility: whether people would sign up, complete the
program, and receive much benefit. The program
was offered through a website called emindful.com,
which already offered online MBSR and had a plat-
form where people used webcams and microphones
to connect to live online groups. The participants
attended each week for 8 weeks at a set time, as in a
face-to-face group, and could see and interact with
the instructor and the other participants in the
online classroom. We enrolled 62 people, 83% of
whom completed the program, which is a similar
completion rate as for in-person programs. All
5
Mindfulness and cancer Carlson

participants said the program either met (40%) or
exceeded (60%) their expectations, and all said they
would recommend the program to other cancer
patients. There were significant improvements
and medium effect sizes in the online MBCR
group, relative to controls, for scores of total mood
disturbance, stress symptoms, and spirituality,36
again of similar magnitude to in-person groups.
Future directions
Following the eCALM trial, our next steps to fur-
ther enhance the reach of these interventions are
to develop and test home-study self-managed ver-
sions of the online intervention. The idea is to
record online sessions and allow participants to fol-
low along at their own pace, still doing the daily
home practice, with an opportunity for questions
and answers in a nonsynchronous format from an
instructor. This would improve the scalability and
sustainability of such programs as costs would be
minimal. Currently, we have yet to investigate the
feasibility of this approach and whether outcomes
would be similar in type and magnitude. I sug-
gest caution in adapting MBIs to self-study pro-
grams without first rigorously evaluating outcomes,
knowing from clinical experience the value of both
group interaction and facilitator expertise and sup-
port. Whether participants can benefit similarly on
their own with minimal interaction or support is
an empirical question but one of significant interest
because of the potential to reach so many more peo-
ple. However, proceeding carefully and thoughtfully
is necessary to avoid diluting or adapting interven-
tions to the point where harm is possible or benefit
is minimal.
One final study that has recently been funded,
and will be conducted in Calgary and Toronto
from 2016 to 2021, is a preference-based compar-
ative effectiveness trial comparing MBCR to Tai
Chi/Qigong in cancer survivors. It is a four-arm

Figure 1. Preference-based trial design. Depicted is a standard pragmatic preference-based clinical trial. Participants with a
preference are assigned to either treatment 1-P or 2-P, whichever they prefer. Without a preference, they are randomized to either
1-R or 2-R. The comparison of 1-P versus 2-P looks at real-world comparative effectiveness of interventions (Box A). 1R versus 2R
is a standard RCT assessing efficacy (Box B). 1-P versus 1-R looks at the same treatment but compares those who preferred it to
those without a preference; hence, isolating the effect of preference on outcome in intervention 1 (Box C). The same is done for
intervention 2 (Box D). Finally the combination of all participants in each intervention can be summed and the two interventions
compared with greater power to allow correlational and subgroup analyses (Box E).

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Carlson
trial in which distressed participants with a pref-
erence receive the intervention of their preference
in a pragmatic design, while those without any
preference are randomized to one or the other
intervention, in the manner of a traditional RCT
(see Fig. 1 for trial design). Outcomes include psy-
chological self-reported measures and symptoms,
as well as a range of biomarkers, including cytokine
production, telomere length, salivary cortisol, gene
expression, and blood pressure, as well as health
economic outcomes. Using this design, we can
isolate the effect of each intervention in the RCT
portion and begin to understand the nuances of
how each intervention affects specific symptoms
and outcomes, and also see the impact of preference
and expectancy on outcomes in a real-world
scenario. This design has similar advantages to
the MINDSET study, but with the addition of the
ability to isolate the effects of preference.
Other pressing research questions revolve around
potential mechanisms of action, which is currently
an active area of study and debate. The role of
home practice, including how much is necessary
and whether dose–response relationships with out-
comes exist, is also of interest. Similarly, we do not
yet know the optimal length of MBSR programs
to maximize outcomes, or the shortest interven-
tion that can still derive benefit. The issue of nec-
essary and/or sufficient training of facilitators has
also been raised, but rarely studied. These and many
other questions will be provocative research areas for
future investigation.
Conclusions
In summary, the evidence for efficacy of MBIs
in cancer care is unequivocal. We know now that
this type of approach can help improve a wide
range of psychological and biological outcomes in
people with cancer, particularly when compared to
usual-care or minimal-intervention controls. More
research comparing MBIs to other active interven-
tions is still necessary to determine specificity of
effects. Most of the evidence to date comes from
studies of traditional in-person programs modeled
on the MBSR curriculum. In the future, more
online adaptations, shorter programs, self-study,
or mobile-supported applications will likely be
developed and require careful and rigorous testing.
The future of mindfulness training for people living
with cancer holds great potential for much more
Ann. N.Y. Acad. Sci. xxxx (2016) 1–8 
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Mindfulness and cancer
widespread dissemination of these approaches,
with the potential to benefit many more people, but
I also behoove those who promote and study such
approaches to proceed carefully and document
outcomes including both benefits and potential
limitations.
Acknowledgments
Dr. Linda E. Carlson holds the Enbridge Research
Chair in Psychosocial Oncology, co-funded by the
Alberta Cancer Foundation and the Canadian Can-
cer Society Alberta/North West Territories Division.
She is also an Alberta Innovates–Health Solutions
Health Scholar. Research discussed in this paper was
funded by the Canadian Breast Cancer Research
Alliance, Canadian Cancer Society Research Insti-
tute, Mind and Life Institute (Varela Award), and
the John and Lotte Hecht Foundation.
Conflicts of interest
The author declares no conflicts of interest.
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