Nirupa Raghunathan, MD
Jyothirmai Gubili, MS
Guest Editor’s Note: Mindfulness has gained immense popularity in recent years. Growing evidence suggests the benefits of mindfulness-based practices, which include concentration meditation and guided imagery, for managing symptoms associated with cancer and its treatments. In this article, Nirupa Raghunathan, MD, and Jyothirmai Gubili, MS, summarize the current evidence surrounding these practices in pediatric and adolescent patients with cancer and highlight the challenges of conducting mindfulness research in this population.
Both mindfulness and its close sister meditation have been growing in popularity, culturally and as therapeutic techniques. Mindfulness can be described as self-regulation of attention and a state of consciousness that is associated with awareness of thoughts, feelings, and sensation, observed without judgment.1 There are many types of mindfulness practices. Here we will review mindfulness meditation, concentration meditation and guided imagery, as well as their use in pediatric and adolescent populations with cancer.
Mindfulness meditation is based on having increased awareness of present-moment emotional, cognitive, and sensory experiences. Breathing methods and other practices are used to support this awareness.1,2 Most commonly, mindfulness-based stress reduction has been adapted to younger populations, with benefits to mental health and coping.
In a study of 102 adolescent psychiatric patients treated at an outpatient facility, those randomly assigned to mindfulness-based stress reduction reported reductions in anxiety and depression along with increases in self-esteem and sleep quality (P < .05). Over the 5-month study period, the mindfulness-based stress reduction group also experienced improvements in global functioning scores as well as mental health compared with the usual-treatment group.3
Jun J. Mao, MD, MSCE
Integrative Oncology is guest edited by Jun J. Mao, MD, MSCE, Laurance S. Rockefeller Chair in Integrative Medicine and Chief of Integrative Medicine Service at Memorial Sloan Kettering Cancer Center, New York.
Preliminary studies in oncology settings have shown acceptability and feasibility of mindfulness-based stress reduction in adolescents and young adults with sarcoma, their caregivers and health-care professionals,4 and young adults with various cancers.5
Also, a meta-analysis of 11 randomized trials (n = 1,454 children and adolescents with mental health problems) found benefits of mindfulness-based interventions, including mindfulness-based stress reduction, mindfulness-based cognitive therapy, and acceptance commitment therapy. Researchers reported improvements in stress, anxiety, depressive symptoms, and quality of life.6 However, several studies in this analysis had limitations, including heterogeneity in participant age groups and rating scales as well as a lack of blinding.
“Mindfulness practices have enormous potential for easing the symptoms and side effects of cancer and cancer treatments.”— Nirupa Raghunathan, MD
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Given the need for further research and more robust data, it is important to note that the ease of use and minimal side effects associated with mindfulness have led to incorporating this practice into clinical practice guidelines for reducing fatigue in pediatric patients with cancer and recipients of hematopoietic stem cell transplants.7
Concentration meditation involves focusing attention on one specific thing, such as a word, phrase, or an object.8 The most common forms of this practice are transcendental meditation and relaxation response with an intent to have focused attention without distraction, leading to a one-minded state.9
In a trial involving 50 high school sophomores, a relaxation response–based curriculum was found to result in statistically significant changes in self-esteem (P < .05) compared with the control curriculum. These findings suggest that incorporating relaxation response into school curricula may augment positive psychological attitudes.10
As defined by the National Center for Complementary and Integrative Health, guided imagery involves a series of relaxation techniques followed by the visualization of detailed images, usually calm and peaceful in nature, used for healing or health maintenance.11 Guided imagery is particularly helpful because it can be implemented in younger children, who may have trouble concentrating on a specific instruction.
A small feasibility study of 12 pediatric patients with cancer found that guided imagery, relaxation techniques, and biofeedback were well received by participants to cope with preprocedural distress.12
Guided imagery may also be effective in managing pain. In a randomized trial involving 22 children, those who learned guided imagery along with progressive muscle relaxation experienced significant reduction in the number of days with pain compared with children who used breathing exercises alone (after 1 month, 67% vs 21%, P = .05; after 2 months, 82% vs 45%, P < .01). Researchers also reported a significant decrease in the number of days with missed activities (at 1 month, 85% vs 15%, P = .02; at 2 months, 95% vs 77%, P = .05).13
Another study reported benefits of a 10-session mind-body skills program that included meditation; guided imagery; breathing techniques; autogenic training; biofeedback; genograms; and self-expression through words, drawings, and movement. Data were analyzed from 129 children and adolescents who met the criteria for posttraumatic stress disorder. Improvements were observed in posttraumatic stress disorder and depressive symptoms along with a decrease in the sense of hopelessness immediately following participation in the program. Furthermore, improvements in total posttraumatic stress disorder and depression scores were largely maintained at the 7-month follow-up.14
Guided imagery has also been reported to reduce salivary cortisol and support beneficial immune function in adults with cancer.15,16 Research is needed to determine whether pediatric patients can experience similar benefits.
Mindfulness for Caregivers
Caregiver assistance is crucial to the pediatric and adolescent oncologic experience, and preliminary findings suggest benefits of mindfulness practices in this cohort. Case studies showed an eight-session mindfulness-based cognitive therapy program to effect improvements in depression and anxiety in mothers of children with cancer. Posttreatment interviews revealed improved relationships of subjects with self and family as well as improved social functions.17
In another small study of professional caregivers, a mindfulness-based stress reduction program was found to result in improvement in perspective taking, identification of one’s own emotions and emotional acceptance. These findings suggest mindfulness may be a useful tool for improving empathy in caregivers.18
Limitations of mindfulness practices include variability in training and no clear overseeing certification body. Extra caution should be used for those with a history of physical, verbal, or emotional abuse or those with posttraumatic stress disorder, with support from a mental health professional.
Challenges Surrounding Mindfulness Research
Current data on the effectiveness of mindfulness practices in pediatric settings are limited. Research efforts are complicated by the possible heterogeneity of the interventions, which are often tailored to the patient’s needs, as well as the heterogeneity of the treatment populations, since response to a therapy may vary based on age and developmental stage. Additionally, the lack of a certification body for mindfulness in general, and for pediatric populations specifically, challenges the production of a broadly applicable intervention.
Mindfulness practices have enormous potential for easing the symptoms and side effects of cancer and cancer treatments. As research progresses, there will be more guidance to implementation as well as “dosing” and appropriate selection of modality based on indication.
Dr. Raghunathan is a Pediatric Integrative Medicine Specialist and Ms. Gubili is Editor, both at the Integrative Medicine Service, Memorial Sloan Kettering Cancer Center, New York.
DISCLOSURE: Dr. Raghunathan and Ms. Gubili reported no conflicts of interest.
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