Abstract PURPOSE:To compare the efficacy of the following two empirically supported group interventions to help distressed survivors of breast cancer cope: mindfulness-based cancer recovery (MBCR) and supportive-expressive group therapy (SET).
PATIENTS AND METHODS:This multisite, randomized controlled trial assigned 271 distressed survivors of stage I to III breast cancer to MBCR, SET, or a 1-day stress management control condition. MBCR focused on training in mindfulness meditation and gentle yoga, whereas SET focused on emotional expression and group support. Both intervention groups included 18 hours of professional contact. Measures were collected at baseline and after intervention by assessors blind to study condition. Primary outcome measures were mood and diurnal salivary cortisol slopes. Secondary outcomes were stress symptoms, quality of life, and social support.
RESULTS:Using linear mixed-effects models, in intent-to-treat analyses, cortisol slopes were maintained over time in both SET (P = .002) and MBCR (P = .011) groups relative to the control group, whose cortisol slopes became flatter. Women in MBCR improved more over time on stress symptoms compared with women in both the SET (P = .009) and control (P = .024) groups. Per-protocol analyses showed greater improvements in the MBCR group in quality of life compared with the control group (P = .005) and in social support compared with the SET group (P = .012).
CONCLUSION:In the largest trial to date, MBCR was superior for improving a range of psychological outcomes for distressed survivors of breast cancer. Both SET and MBCR also resulted in more normative diurnal cortisol profiles than the control condition. The clinical implications of this finding require further investigation.
The term “complementary and alternative medicine” (CAM) refers to the broad range of health systems, modalities, and practices that are not part of the conventional and politically dominant health system.1, 2 Functionally defined, CAM refers to those interventions that are neither taught widely in medical schools nor generally available in US hospitals. Several practices that are considered CAM in the United States include complex traditional health systems from other cultures, such as traditional Chinese medicine (TCM), as well as components of these systems that are practiced as distinct entities, such as acupuncture.3 The National Center for Complementary and Alternative Medicine (NCCAM) categorizes CAM into the following domains, entire medical systems, such as homeopathy and ayurveda; mind-body medicine, such as meditation and art therapy; biologically based practices, such as herbal and dietary supplements; manipulative and body-based practices, such as chiropractic and massage; and energy medicine, such as biofield therapies and magnets.4 The use of CAM treatments in the United States is substantial, especially among those with chronic medical problems, including cancer. Eisenberg et al. published the first national survey on the use of CAM in 1993, which revealed that 1 in 3 respondents had used an unconventional or CAM treatment in the previous year.2 Follow-up studies confirmed CAM use rates at least that high,5, 6 and most studies suggested that people use these treatments in addition to conventional medical care. Recent data confirm that CAM use continues to be particularly high among those with chronic diseases, such as cancer.7 Studies have indicated that patients tend not to disclose their use of CAM treatments to their conventional physicians, with many patients reporting that they perceive their physicians as unreceptive to the issue.6 One possible explanation for the patient-physician communication gap on this topic is the limited information most physicians have about CAM, especially given its historical absence as a covered subject in conventional Western medical training. In addition, despite a recent surge of interest in CAM from the medical community, including some form of CAM curriculum at a growing number of medical schools,8 evidence-based information on the topic is currently limited.
The field of cancer survivorship research has been steadily growing along with the number of cancer survivors in the United States. When the National Cancer Act was passed in 1971, there were 3 million cancer survivors. Since that time, the number of cancer survivors has more than tripled, with approximately 10.8 million survivors currently in the United States.
One of the arenas in which there has been substantial interest in the use of CAM modalities is in the field of oncology, both during active treatment and in the post-treatment survivorship phase.10–15 The majority of published studies have either focused on the treatment phase or have included both patients and survivors without making a distinction between these phases.
This article is concerned primarily with CAM and cancer survivorship. The use of CAM interventions is a growing area of interest in cancer survivorship research. CAM can be a challenging issue for oncologists, primary care physicians, and other mainstream medical professionals caring for cancer survivors, especially given that survivors are exposed to reams of information on the Internet and in the media that can cause them to stray into territory that may trigger discomfort and concern from their physicians.
Motivations for CAM use are multidimensional, including a desire to improve quality of life,16 enhance immune function,17 cope with pain,18, 19 and decrease anxiety or other psychological symptoms.15, 20 Although a large number of cancer survivors have high stress levels21 and unmet psychosocial needs,22, 23 uptake of conventional supportive programs often is low.24 For myriad reasons, CAM modalities may be seen as desirable options for some survivor groups to address unmet needs.25 Issues related to CAM use may be particularly relevant to diverse groups with culturally based health beliefs, the underserved, and those who experience health disparities in the mainstream healthcare system.26 As the number of cancer survivors increases, it includes more diverse groups who may be using CAM, making it even more important to understand why particular subgroups of survivors are using CAM, what forms of CAM they are using, and whether this use is being integrated into the rest of their care.27 Although, at this point, there has been little formal assessment of patterns and predictors of CAM use among cancer survivors from diverse ethnic groups, some data suggest that CAM use is overall similarly high across ethnic groups, with subgroup variations in patterns of use.25, 28 For example, although use of mind-body therapies is consistently high on the list of commonly used CAM modalities overall, it is particularly high in some minority subgroups such as African Americans.25
There are potential advantages for practitioners to be able to discuss CAM with their patients and, in some cases, to integrate it with conventional care.26 One way of facilitating meaningful discussion would be for oncologists to have a positive platform from which to establish some “common ground” with the CAM-oriented patient. We posit that particular evidence-based mind-body therapies could provide such a platform and serve as a bridge to connect potentially beneficial supportive interventions to patients, while also opening a general dialogue about CAM and the needs that particular patients may be attempting to address with CAM approaches. The results could be an improved physician-patient relationship and an overall improved patient care.26 Mind-body therapies are a chosen platform because several of these therapies have at least some positive supportive data, and many target stress reduction, which is a tangible endpoint that is associated with improved quality of life and better health outcomes. Moreover, such interventions generally are not practiced as an “alternative” to regular oncological care; hence, they can be integrated into the overall cancer survivorship treatment plan with relatively low risk.29
In this article, we review a few mind-body therapies relevant to cancer survivors and provide a rationale for considering these therapies as possible complementary interventions on the basis of presence of supportive data (albeit inconclusive), an applicable theoretical framework, and relative safety. It is often stated in publications that because CAM modalities lack conclusive evidence, they should not be recommended.30 Despite a lack of absolute certainty about efficacy and mechanism of action, we propose a modified perspective that considers potential benefits of supporting the use of certain mind-body therapies in cancer survivor subgroups,.
Psychosocial Stress and Cancer
A recent report of cancer incident rates between 1992 and 2004 showed increases in some cancer types and decreases in others, with an overall slight decline of cancer incidence in both sexes.31 At the same time, mortality rates continued to decline.9, 31 Thus, for increasing numbers of patients, the diagnosis of cancer means coping with a chronic illness that has a variable course for an undetermined amount of time. Given the numerous stressful challenges involved with having a cancer diagnosis,32 it is not surprising that as many as one-third of cancer survivors report high stress levels.33, 34 Stress can manifest in a variety of psychological symptoms, such as anxiety and depression,35–40 intrusive cancer-related thoughts (ie, traumatic stress symptoms),41–44 or physical symptoms, such as fatigue,34, 44 increased pain,45 and impaired sleep.46–48 Amplified stress in cancer patients has been associated with increased morbidity and mortality,29, 49–50 decreased immune function,51–54 increased relapse,53 and decreased health-related quality of life.55, 56 Given the known negative impact of stress on cancer patients, stress has become a priority issue in cancer treatment and research.56, 57 Targeting stress-related variables with psychosocial interventions has been an important emphasis in cancer-care models.58–66
Although the conventional approach to addressing high stress levels in cancer survivors has largely been through supportive group programs, there are significant challenges in recruiting participants to these programs, despite availability, particularly in hard-to-reach populations.24 Hence, high levels of unmet psychosocial needs continue to persist among cancer survivors. It has been well established and recognized that there are widespread health disparities that impact on cancer prevention, treatment, survivorship, and palliative care.67 In the field of cancer survivorship research, an emerging body of literature acknowledges the existence of disparities and supports the development of interventions that are sensitive to social, cultural, and economic differences, particularly as these factors influence quality of life.68–70 Some of the selected findings from this research suggest that the survivorship experience varies by ethnicity, sex, and age.71–73 For example, population studies suggest that the ethnic groups that are low users of conventional supportive group interventions may be relatively high users of CAM.25, 28
As the fields of cancer survivorship and health disparities grow, it will be important to access hard-to-reach and underserved populations. Therefore, we need to continue exploring novel interventions and options for support for the growing and diverse population of cancer survivors. Although evidence for most CAM treatments is not clearly established, many of the mind-body therapies that have been used to support cancer patients are generally regarded as safe. We focus our discussion on a few modalities that have a promising basis in evidence to serve as adjunctive interventions for supporting the psychosocial needs of cancer survivors.
Conceptual FrameworkSeveral theoretical models are available to help understand the concepts of stress, distress, coping, and stress reduction. Self-regulation is one such construct that appears to be applicable to a wide variety of psychosocial interventions, whether they are conventional or CAM. Measuring self-regulation has been shown to be reliable and may be a useful predictor of cancer patients' ability to find benefits in their cancer experience.74 In a broader context, self-regulation theory is a framework for conceptualizing psychosocial stress and provides an explanation for observed therapeutic effects. Although this framework cannot be seen as complete for any intervention, we propose self-regulation theory as a common ground for considering the effects of the mind-body interventions to be discussed.
Self-regulation theory75, 76 provides a foundation for understanding reactions to perceptions of physical and emotional well-being. Functionally defined, self-regulation theory explains how people cope with and adapt to stressful situations, such as health problems or threats (eg, a cancer diagnosis). The theory reflects 2 aspects of information processing: 1) the objective data, such as a laboratory result or tumor stage, and 2) subjective appraisal of that data, such as fear or anger. An essential component to this theory is the personal schema that is formed from the combined objective and subjective aspects of the health threat. The schema can be characterized as the lens through which all subsequent health-related information and cues are perceived and, as such, the determining factor for coping behaviors. The schema and resultant coping behaviors form a feedback loop, where one impacts the other. Hence, techniques that affect subjective appraisal of health-related information will affect coping behaviors related to that information. Likewise, techniques that modulate coping responses can affect the schema itself. Both the ability to negotiate subjective appraisals of health threats and resulting coping responses directly affect stress levels.77, 78
Mind-body therapies may affect self-regulation by either targeting the schema, the coping response(s), or both. For example, some therapies teach techniques that may modify appraisals of health-related data (eg, mindfulness), others may provide methods to dampen or alter physiological responses to data (eg, meditation practices), whereas others may directly alter perception of the data itself (eg, hypnosis).
Complementary Mind-Body TherapiesThe term “Mind-body Therapies” is a somewhat ambiguous categorization that generally refers to a collection of treatments that recognize the bidirectional nature of psyche and soma. Many of these modalities are classified as CAM, primarily because they are not currently part of a dominant conventional therapeutic paradigm. Alleviating stress through various mental and physical exercises tends to be a focus of these interventions. Numerous mind-body techniques are in use. We briefly describe below a few of those classified as CAM that may have particular relevance to cancer survivors based on available supportive data and relative safety.
HypnosisFranz Anton Mesmer (1734–1815) captivated the public in the 18th century when he introduced a form of hypnosis, which he called “animal magnetism.”79 Mesmer made such an impact that his technique came to be known as “mesmerism,”, a word that is still sometimes used to describe a hypnotic-like trance. The word “hypnosis” (from the Greek root hypnos, meaning sleep) is misleading in some ways, because the phenomenon to which it refers is not a form of sleep; rather, it is a complex process of attentive, receptive concentration. This state, also called a “trance,” is characterized by a modified sensorium, an altered psychological state, and characteristically minimal motor functioning. In addition to achieving deep relaxation, the hypnotic treatment may include direct suggestions for specific changes in physiology and cognition.80 Guided imagery is often an integral part of hypnotic technique.
Some data suggest that hypnosis may be efficacious for a variety of mental health problems81, 82 and physical disorders that are exacerbated by stress, including pain.82 A National Institutes of Health Technology Assessment Panel18 concluded that there was strong evidence for the use of hypnosis in alleviating chronic pain conditions, including pain associated with cancer. Hypnosis has been shown to be particularly helpful for a variety of acute and chronic cancer pain issues in children,83, 84 and some evidence suggest that children may have better responsiveness to hypnosis than adults.85 Studies have demonstrated that hypnosis can be an effective means for some cancer patients to alleviate nausea and vomiting associated with chemotherapy.86 Hypnotic effects are thought to occur through 3 primary mechanisms, muscle relaxation, perceptual alteration, and cognitive distraction.87 Hence. learning new ways of perceiving an experience and developing coping strategies to negotiate the experience are important self-regulatory aspects of hypnosis.
Meditation PracticesMany common forms of meditation are extracted from traditional Eastern systems that encompass lifestyle issues beyond meditative techniques. For example, yoga is an ancient South Asian system of health that prescribes a multiphasic approach to living, including proper diet, behavior, physical exercise, and sleep hygiene. Likewise, qigong meditation practices often are derived from complex traditional Chinese medicine practices. A recently released report from the Agency for Healthcare Research and Quality, Department of Health and Human Services,30 comprehensively reviewed and synthesized the state of research on a variety of meditation practices. Although cancer was not the focus, the report reviewed encouraging data that suggest therapeutic benefits from several meditation practices for a variety of health conditions, but the authors were unable to translate that data into firm conclusions because of the poor quality of many of the studies. We focus below on a few meditation-based practices that are commonly used by cancer survivors and have at least some substantive supportive evidence for use.
Mindfulness-based stress reduction (MBSR)MBSR is a standardized, 8-week intervention that incorporates mindfulness meditation, Hatha yoga practices, and other techniques for the purposes of stress reduction and improvement of quality of life.88 MBSR is the most studied meditation intervention, with suggested therapeutic benefits in several illness populations, including cancer.89–92 Speca and colleagues published the first randomized, controlled study of MBSR in a mixed group of cancer patients, and their study demonstrated significant improvements in mood disturbances and decreased stress compared with wait-list controls.93 These improvements were maintained at 6-month follow-up.94 Another report showed that breast cancer (n = 33) and prostate cancer (n = 9) patients who received the 8-week MBSR program had shifts in their immune profiles (reduction in Th1 proinflammatory to Th2 anti-inflammatory environment) associated with decreased depressive symptomology.95 These trends continued at 1-year follow-up.96
A primary goal of MBSR is to develop the capacity to be relaxed and aware in each moment, while maintaining a nonjudgmental attitude.88 In this regard, thoughts and emotions are not viewed as wrong or faulty but rather as events. Together, this allows for conscious observation of both the actual experience (objective data) and the emotional response to it (subjective appraisal), which may facilitate improved self-regulation and more healthful coping strategies.
QigongQigong practices involve slow body movements and meditation, with or without imagery and breathing techniques. Common forms of qigong emphasize self-regulation of emotion (eg, maintaining a peaceful, calm mood) and focused attention. In China, a huge resurgence in qigong followed their Great Cultural Revolution during the mid-1970s. This increased interest has since extended to the western world, including the United States,19 although the majority of studies on the topic have been performed in China. A review of 50 Chinese studies on the use of qigong in cancer patients showed that although there was some indication that qigong had a positive impact on several parameters of cancer survivorship, the results cannot be considered conclusive because of the poor design of most studies.97 Outside China, the majority of studies have been done on healthy volunteers. One study showed that qigong practice lowered cortisol levels with concomitant changes in numbers of cytokine-secreting peripheral blood cells in a group of 19 healthy volunteers.98 These biological indicators suggest stress reduction, which was not directly measured. Positive results from a well-designed study in patients with late-stage complex regional pain syndrome provide potential support for consideration of qigong as a complementary intervention for management of stress-related symptoms in cancer patients. This randomized, placebo-controlled clinical trial found that qigong training was associated with short-term pain reduction and long-term anxiety reduction.99
Tai chiTai chi is characterized by a set of exercises that emphasize a series of postures and movements along with controlled breathing. Also derived from TCM, the exercises are designed to balance chi, which refers to the body's energy or life force. Tai chi is sometimes referred to as “moving meditation,” because the exercises are paired with training the mind to be calm and relaxed. The variety and patterning of the movements are slow, gentle, and light, requiring focused concentration. The movements may facilitate self-regulation by their intention to foster a sense of inner and outer harmony as the movements become more fluid, yet controlled, and the mind more alert, yet peaceful.100
Some data suggest cardiovascular benefits from tai chi, such as lowered blood pressure and heart rate,101 indirectly suggesting stress reduction and improved self-regulation. A Japanese study of older adults found significantly higher scores in health-related quality of life in older adults who practiced tai chi as compared with age-matched national standards, particularly in the domains of physical functioning and vitality.102 Although tai chi is in common use, data on its use in cancer populations is limited. A recent systematic review of controlled clinical trials of tai chi as a supportive therapy for cancer patients searched the literature, without language restrictions, by using 19 databases from their respective inceptions through October 2006.103 Of 27 potentially relevant studies, only 4 met the criterion of “controlled clinical trial,” and all 4 assessed patients with breast cancer. Two of these were considered well designed, and they both reported significant differences in psychological and physiological symptoms when compared with a psychosocial support control.104 Hence, data to support the use of tai chi is encouraging but limited and inconclusive.
Art TherapyArt therapy facilitates self-regulation by providing concrete tasks for expressing representations in a tangible and personally meaningful manner. A recent qualitative study of women with breast cancer suggests that the processes of art creation and art therapy provide unique opportunities to address psychosocial needs.105 Research with cancer survivors and with other populations supports the use of tasks that allow focused expression of unpleasant emotions, which can lead to a reduction in medical symptoms, such as pain, and an increased sense of well-being.106–109 Although numerous case and qualitative studies from the field of art therapy have been published, including the widely reported and beneficial use of art therapy with cancer populations in both individual and group formats,110–113 few controlled studies exist. One particularly well performed clinical trial of an art therapy intervention with hospitalized children with post-traumatic stress disorder demonstrated that the use of specific art tasks was associated with stress reduction.114 Recent reports in the cancer literature include the use of art therapy in a largely qualitative study of children with cancer, which resulted in enhanced communication and expression of emotional appraisals of the cancer experience.115 In addition, significant reductions of anxiety were reported in a pre-postassessment of caregivers of persons with cancer (n = 69) who received a brief art therapy intervention.116 Most recently, a controlled trial of art therapy demonstrated improved depression scores and fatigue levels in a group of cancer patients who were undergoing active chemotherapy.117
Mindfulness-based art therapyMindfulness-based art therapy (MBAT) was developed to engender health-promoting skills and behaviors in a heterogeneous group format that can include patients with a variety of cancer types.118 The 2 main components of MBAT, art therapy and MBSR, are paired with the purpose of facilitating both verbal and nonverbal information processing. Art therapy tasks are designed to meaningfully complement the MBSR curriculum, which may enhance the nonverbal process of negotiating subjective appraisals of health-related information and advance more adaptive coping. This combined intervention is new, with limited data available. In a recently published randomized clinical trial (RCT) of MBAT,118 111 women with a variety of cancer diagnoses were paired by age and randomized to either an 8-week MBAT intervention group or a wait-list control group. Compared with controls, the MBAT group demonstrated significant decreases in symptoms of distress and significant improvements in key aspects of health-related quality of life. Another report of a group of prostate survivors showed improvements from the MBAT intervention consistent with the RCT of women.119
Multimodal interventions have gained popularity, likely because of the potential for an additive therapeutic effect. A recent study of women with breast cancer, which used a multimodal format that included several of the elements of the MBAT intervention, showed increased emotional regulation and psychological adjustment.120 From a research viewpoint, the disadvantage of multimodal interventions is their inability to distinguish the relative contribution of each component to observed effects.
Music TherapyMusic therapy is an increasingly popular adjunctive intervention for supporting the psychosocial needs of cancer survivors. Music therapy may facilitate self-regulation and enhanced coping by providing a soothing stimulus to counter distressing ones, using either music alone or music combined with guided imagery. The usefulness of music therapy to evoke relaxation was assessed in a meta-analysis of 22 music therapy trials that had quantitative outcomes, with overall findings suggesting decreased stress-based arousal.121 Although specific data in cancer populations are quite limited, a recent report surveyed the coping strategies of 192 cancer outpatients; 43% reported using music as a coping strategy, second in frequency only to prayer.122 In a group of autologous stem-cell transplant recipients (n = 62), those who received music therapy had significantly lower mood disturbance compared with controls.123 In a randomized trial of cancer patients who were receiving radiation therapy (n = 63), nonsignificant trends in stress reduction were observed in the music condition when compared with controls who did not receive music.124 Significant results were seen in a randomized clinical trial (n = 80) where terminally ill cancer patients who were receiving hospice care in their homes were assigned either to a music therapy intervention or to usual hospice care.125 In that study, those who received repeated sessions of music therapy showed significant improvement in quality- of-life scores, whereas those not receiving music therapy showed decreased quality-of-life scores.
Neuroemotional TechniqueA relative newcomer to the cancer survivorship literature, the neuroemotional technique (NET) pairs standard psychological approaches, such as addressing cognitive distortions and desensitization procedures (eg, relaxed breathing while visualizing distressing cues), with elements of traditional Chinese medicine, such as using acupuncture pulse points.19 This is mainly accomplished by having the patient touch particular pulse points while visualizing emotionally distressing experiences. Although data are limited, NET may be appropriate as an intervention for cancer survivors to alleviate traumatic stress symptoms.79 Full post-traumatic stress disorder is rather uncommon in cancer survivors, but subsyndromal traumatic stress symptoms causing significant impairment and distress related to the cancer illness experience can be seen in as many as one-third of survivors.21, 42 A recently published pilot study of NET involving 7 female cancer survivors with cancer-related traumatic stress symptoms compared pre-intervention to post-intervention changes in response to recalling a distressing cancer-related event. Results showed encouraging decreases in physiologic reactivity to the distressing event and decreases in subjective ratings of distress related to the event.126 A few other small studies suggest an antianxiety effect of the intervention.19 Although no evidence has demonstrated yet that the CAM component (acupressure) of NET adds to the effectiveness of the psychological aspects of the technique, the combination may appeal to survivor subpopulations that are attracted to CAM treatments. Improved self-regulation from NET may occur from modulating the character and intensity of subjective appraisals.
In the past decade or more, both the overall number of cancer survivors and the percentage of cancer survivors who use CAM treatments has been increasing. Despite the importance of oncology providers being aware of CAM modalities that their patients are using, patient disclosure and communication on the topic remains problematic. Mind-body therapies categorized as CAM could potentially serve as a positive platform from which providers could discuss CAM and even link survivor subgroups to services that may, at least, partly address unmet psychosocial needs. This would be especially relevant for survivor subgroups that have a cultural bias toward CAM. The mind-body therapies reviewed in this article have some supportive evidence and a rationale for use in cancer survivors. Although data on efficacy and mechanisms of action of mind-body therapies are incomplete and inconclusive, the potential benefits of using these therapies in survivor care plans warrant consideration.
Future DirectionsGiven the growing field of survivorship and known challenges of recruiting to cancer support programs, it is important to identify interventions that are both effective and can appeal to a broad range of cancer survivors. Mind-body therapies categorized as CAM may be suitable for survivorship care when they offer tangible therapeutic endpoints, such as stress reduction, have a plausible mechanism of action, and can target needs that may not otherwise be addressed. Future research should focus on expanding a database on novel modes of psychosocial support, particularly in regard to vulnerable survivor populations, and increasing the understanding of survivor subgroup preferences for psychosocial support.
Source : Cancer 21 APR 2008 DOI: 10.1002/cncr.23443
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