Shelly Latte-Naor, MD
Jyothirmai Gubili, MS
The ASCO Post’s Integrative Oncology series is intended to facilitate the availability of evidence-based information on integrative and complementary therapies commonly used by patients with cancer. In this installment, authors Shelly Latte-Naor, MD, and Jyothirmai Gubili, MS, present the case study of a man diagnosed with colorectal cancer who exhibits signs of anxiety, and they discuss the use of mindfulness-based stress reduction in patients being treated for cancer.
Peter is a 44-year-old man, who was healthy and active prior to his recent diagnosis with colorectal cancer. He is currently undergoing chemotherapy and is tolerating the treatments with few adverse effects. Peter presents with anxiety about his health, resulting in difficulty sleeping. Despite showing a good response to his treatments, he describes relentless worry about the future of his family and fears loss of physical independence due to his disease. He is overwhelmed with the stress of his diagnosis and ongoing treatment in addition to managing his family and professional life. He is followed by a psychiatrist for adjustment reaction with anxiety but is currently reluctant to initiate anxiolytic or antidepressant medications. He is interested in self-help tools for stress management and ways to maintain his quality of life, despite the challenges of his diagnosis.
Defined as “a wakeful hypometabolic physiologic state,”1 meditation is a mind-body modality that has been practiced for thousands of years around the world. It involves focused attention, regulated breathing, and developing a nonjudgmental awareness of one’s thoughts and feelings to increase calmness and improve overall well-being. Nearly 18 million adults and 927,000 children have practiced meditation, according to data from the 2012 National Health Interview Survey.2
Meditation involves a variety of approaches, which include repeating words with phonetic significance as in mantram meditation; paying attention or continually returning to the present moment as in mindfulness meditation; or tai chi and qigong, movement meditative practices that are components of traditional Chinese medicine.
Several studies have been conducted to determine the effects of meditative practices on health. Over the past 30 years, research has particularly focused on mindfulness-based stress reduction, which consists of a well defined 8-week curriculum. The course content focuses on sitting meditation and mindful movement practice, which reorients the mind to sense the connection with body and breath. Mindfulness-based stress reduction also offers participants insights into the nature of their own stress reactivity and increasing awareness toward their coping mechanisms. The practice and framework of the group process in the mindfulness-based stress reduction class encourage re-examining habits and practice of alternative patterns of skillful stress response. Its value in the management of chronic pain, insomnia, depression and anxiety, coronary heart disease, diabetes, and irritable bowel syndrome is well documented.3
Does Meditation Benefit Patients With Cancer?
The potential of mindfulness-based stress reduction in alleviating the often disabling symptoms associated with cancer and its treatments has also been evaluated in many randomized trials. Data show that it affects reductions in psychological distress in patients with lung cancer,4 improves mood and general well-being in patients across several cancer diagnoses,5 as well as enhances psychological functioning and mindfulness in partners of cancer patients.6 In studies involving breast cancer patients, mindfulness-based stress reduction was found effective in alleviating anxiety and depression, decreasing long-term emotional and physical adverse effects associated with medical and endocrine treatments,7 and improving the quality of sleep.8 Furthermore, Reich et al recently reported that the favorable effects produced by mindfulness-based stress reduction are sustained over several weeks following practice.9
Several studies have documented the value of meditation in managing both psychological and physical symptoms associated with cancer and its treatments. But it is important for patients considering meditation to note that regular, ongoing practice is essential for sustained benefits.
And mindfulness-based stress reduction not only benefits patients undergoing active treatments but also survivors posttreatment. Reductions in anxiety, fear of recurrence, as well as physical symptoms of fatigue severity and fatigue interference were observed in a randomized trial of breast cancer survivors following mindfulness-based stress reduction practice.10 Those with cancer-related cognitive impairment, a fatigue-related symptom that negatively impacts quality of life, also experienced durable improvements with mindfulness-based stress reduction practice.11
Meditation has been evaluated in pediatric cancer patients as well. In a trial of children with neuroblastoma undergoing anti-GD2 monoclonal antibody therapy, guided mantram meditation was reported effective in alleviating acute pain.12 And a review of mind-body therapy studies that included mindfulness-based stress reduction revealed greater self-confidence and optimism in coping with illness in a pediatric oncologic population.13
Although the mechanisms underlying the salutary effects of meditation are yet unknown, emerging data suggest that it may influence changes in the structural and functional aspects of the brain, which are involved in regulating attention, emotion, and self-awareness.14 A randomized study reported a greater “decentering” from internal experiences and abatement in reactivity to repetitive thoughts following mindful breathing exercise compared with progressive muscle relaxation or loving-kindness meditation.15 In addition, mindfulness-based stress reduction practice may modulate the immune system evidenced by a reduction in the ratio of T1 proinflammatory to T2 anti-inflammatory lymphocytes,16 and increase cellular longevity by increasing telomerase activity, which is a known marker of cellular aging and psychological risk.17
Learning to Meditate and Safety Concerns
Meditation classes are increasingly available in many communities, and cancer centers across the country offer programs that are led by experienced teachers. Practitioners who teach mindfulness-based stress reduction go through a certification process. But it is important for patients considering meditation to note that regular, ongoing practice is essential for sustained benefits.
Meditation is generally considered a safe practice, with the exception of a few reports of psychosis, which occurred in concert with sleep loss, drug withdrawal, or preexisting psychotic disorders18-20; epilepsy21; and qigong deviation syndrome, involving changes in heart rate, illusions, and pseudohallucination, in patients following inappropriate qigong training.22
Individuals with physical limitations should speak to their health-care provider before beginning meditative practices that involve movement.
The continuing rise in the rates of cancer rates and longer survivorship underscores the need for effective symptom management across the disease continuum. Based on current evidence, meditation appears to be a promising modality for the relief of both psychological and physical symptoms associated with cancer and its treatments. It is recommended by the Society of Integrative Oncology as part of a multidisciplinary approach to improve the quality of life of patients with breast cancer.23
Mindfulness-based stress reduction, the most researched form, is not only feasible and noninvasive, but has also been shown to be a cost-effective strategy when compared with other interventions in a study of breast cancer survivors.24 However, meditation research overall is limited by poor methodology. Future trials should be based on a robust design, involving larger sample sizes and active control groups. Also worthy of consideration may be a shorter mindfulness-based stress reduction program for patients who have difficulty engaging in the full 8-week practice, especially those with newly diagnosed disease.25 Finally, meditation studies should include patients with all types of cancers, because the majority of trials to date have been conducted in the breast cancer population. ■
Dr. Latte-Naor is Director of Mind-Body Medicine, Assistant Attending Physician, Integrative Medicine Service, Memorial Sloan Kettering Cancer Center, New York. Ms. Gubili is Editor, Integrative Medicine, Memorial Sloan Kettering Cancer Center, New York.
Disclosure: Dr. Latte-Naor and Ms. Gubili reported no conflicts of interest.
4. Schellekens MPJ, van den Hurk DGM, Prins JB, et al: Mindfulness-based stress reduction added to care as usual for lung cancer patients and/or their partners: A multicentre randomized controlled trial. Psychooncology. March 23, 2017 (early release online).
5. Garland SN, Tamagawa R, Todd SC, et al: Increased mindfulness is related to improved stress and mood following participation in a mindfulness-based stress reduction program in individuals with cancer. Integr Cancer Ther 12:31-40, 2013.
7. Hoffman CJ, Ersser SJ, Hopkinson JB, et al: 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. J Clin Oncol 30:1335-1342, 2012.
8. Würtzen H, Dalton SO, Elsass P, et al: Mindfulness significantly reduces self-reported levels of anxiety and depression: Results of a randomised controlled trial among 336 Danish women treated for stage I-III breast cancer. Eur J Cancer 49:1365-1373, 2013.
9. Reich RR, Lengacher CA, Alinat CB, et al: Mindfulness-based stress reduction in post-treatment breast cancer patients: Immediate and sustained effects across multiple symptom clusters. J Pain Symptom Manage 53:85-95, 2017.
10. Lengacher CA, Reich RR, Paterson CL, et al: Examination of broad symptom improvement resulting from mindfulness-based stress reduction in breast cancer survivors: A randomized controlled trial. J Clin Oncol 34:2827-2834, 2016.
11. Johns SA, Von Ah D, Brown LF, et al: Randomized controlled pilot trial of mindfulness-based stress reduction for breast and colorectal cancer survivors: Effects on cancer-related cognitive impairment. J Cancer Surviv 10:437-448, 2016.
15. Feldman G, Greeson J, Senville J: Differential effects of mindful breathing, progressive muscle relaxation, and loving-kindness meditation on decentering and negative reactions to repetitive thoughts. Behav Res Ther 48:1002-1011, 2010.
16. Carlson LE, Speca M, Patel KD, et al: Mindfulness-based stress reduction in relation to quality of life, mood, symptoms of stress, and immune parameters in breast and prostate cancer outpatients. Psychosom Med 65:571-581, 2003.
23. Greenlee H, Balneaves LG, Carlson LE, et al: Clinical practice guidelines on the use of integrative therapies as supportive care in patients treated for breast cancer. J Natl Cancer Inst Monogr 2014:346-358, 2014.
25. Carmody J, Baer RA: How long does a mindfulness-based stress reduction program need to be? A review of class contact hours and effect sizes for psychological distress. J Clin Psychol 65:627-638, 2009.