The Association Between Mindfulness and Postoperative Pain: A Prospective Cohort Study of Gynecologic Oncology Patients Undergoing Minimally Invasive Hysterectomy

STUDY OBJECTIVE

To describe the association between preoperative dispositional mindfulness (the personality trait of being mindful) and postoperative pain in gynecologic oncology patients undergoing minimally invasive hysterectomy.

DESIGN

Prospective cohort study.

SETTING

University-affiliated teaching hospital.

PATIENTS

Gynecologic oncology patients (n = 126) planning minimally invasive hysterectomy.

INTERVENTIONS

Minimally invasive hysterectomy.

MEASUREMENTS AND MAIN RESULTS

Baseline mindfulness was assessed at the preoperative visit using the Five Facet Mindfulness Questionnaire (FFMQ). Postoperative pain and opioid usage were evaluated via chart review and surveys at postoperative visits at 1 to 2 weeks and 4 to 6 weeks. Higher baseline mindfulness was correlated with lower postoperative pain as measured by both the average and highest numeric pain scores during the inpatient stay (r = -.23, p = .020; r = -.21, p = .034). At the initial postoperative visit, pain score was also inversely correlated with preoperative mindfulness score (r = -.26, p = .008). This relationship was not observed at the final postoperative visit (r = -.08, p = .406). Pre-operative mindfulness and opioid usage were also inversely associated, though this relationship did not reach statistical significance (r = -.18, p = .066).

CONCLUSION

Mindfulness was previously shown to be a promising intervention for chronic pain treatment. Our study demonstrates that higher preoperative dispositional mindfulness is associated with more favorable postoperative pain outcomes, including lower pain scores but not lower opioid consumption. This relationship provides an opportunity to target the modifiable personality characteristic of mindfulness, to reduce postoperative pain in patients following gynecologic surgery.

Effects of mindfulness-based interventions on quality of life of women with breast cancer: a systematic review

Aim: The systematic review assessed the effect of mindfulness-based interventions on the quality of life among women with breast cancer. Methods: PubMed, Cochrane library, EMBASE, Web of Science and CINAHL databases were searched for studies published. Our review assessed the effect of mindfulness-based interventions (Mindfulness-Based Stress Reduction [MBSR] intervention and Mindfulness-Based Cognitive Therapy [MBCT]) on quality of life for women with breast cancer. Two authors independently assessed the quality of all included studies using the Downs and Black Quality Index. Results: The search finally identified 15 studies. The MBSR intervention showed a significant effect between groups. The MBCT intervention also showed good effect on quality of life. Adverse events were inadequately reported. Conclusion: The MBSR intervention on quality of life among women with breast cancer was effective and safe. The effect of MBCT intervention on quality of life still needs more research.

Strategies of complementary and integrative therapies in cancer-related pain-attaining exhaustive cancer pain management

PURPOSE

Complementary integrative therapies (CITs) correspond to growing demand in patients with cancer-related pain. This demand needs to be considered alongside pharmaceutical and/or interventional therapies. CITs can be used to cover certain specific pain-related characteristics. The objective of this review is to present the options for CITs that could be used within dynamic, multidisciplinary, and personalized management, leading to an integrative oncology approach.

METHODS

Critical reflection based on literature analysis and clinical practice.

RESULTS

Most CITs only showed trends in efficacy as cancer pain was mainly a secondary endpoint, or populations were restricted. Physical therapy has demonstrated efficacy in motion and pain, in some specific cancers (head and neck or breast cancers) or in treatments sequelae (lymphedema). In cancer survivors, higher levels of physical activity decrease pain intensity. Due to the multimorphism of cancer pain, certain mind-body therapies acting on anxiety, stress, depression, or mood disturbances (such as massage, acupuncture, healing touch, hypnosis, and music therapy) are efficient on cancer pain. Other mind-body therapies have shown trends in reducing the severity of cancer pain and improving other parameters, and they include education (with coping skills training), yoga, tai chi/qigong, guided imagery, virtual reality, and cognitive-behavioral therapy alone or combined. The outcome sustainability of most CITs is still questioned.

CONCLUSIONS

High-quality clinical trials should be conducted with CITs, as their efficacy on pain is mainly based on efficacy trends in pain severity, professional judgment, and patient preferences. Finally, the implementation of CITs requires an interdisciplinary team approach to offer optimal, personalized, cancer pain management.

Evidence for the Role of Mindfulness in Cancer: Benefits and Techniques

Mindfulness is being used increasingly in various aspects of cancer management. Benefits of mindfulness practices are being observed to manage the adverse effects of treatment, symptoms from cancer progression, and the cost-effectiveness compared to conventional contemporary management strategies. In this review article, we present clinical trial data showing the benefits of mindfulness in various aspects of cancer management as well as techniques that have been commonly used in this practice.

Mind-Body Interventions in the Management of Chronic Cancer Pain

OBJECTIVES

To describe mind-body interventions used in the management of chronic cancer pain including their mechanisms of action, dosing, and delivery methods based on available evidence to date.

DATA SOURCES

Peer-reviewed publications.

CONCLUSION

Further high-quality research is needed to establish the effectiveness and mechanisms of actions for mind-body interventions in chronic cancer pain management.

IMPLICATIONS FOR NURSING PRACTICE

Mind-body interventions for chronic cancer pain management are generally safe and well-accepted by individuals with cancer. Nurses need to be knowledgeable about these interventions to explain their level of effectiveness and any safety issues with patients.

Mindfulness-based stress reduction for women diagnosed with breast cancer

BACKGROUND

Breast cancer is the most common cancer in women. Diagnosis and treatment may drastically affect quality of life, causing symptoms such as sleep disorders, depression and anxiety. Mindfulness-based stress reduction (MBSR) is a programme that aims to reduce stress by developing mindfulness, meaning a non-judgmental, accepting moment-by-moment awareness. MBSR seems to benefit patients with mood disorders and chronic pain, and it may also benefit women with breast cancer.

OBJECTIVES

To assess the effects of mindfulness-based stress reduction (MBSR) in women diagnosed with breast cancer.

SEARCH METHODS

In April 2018, we conducted a comprehensive electronic search for studies of MBSR in women with breast cancer, in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and two trial registries (World Health Organization's International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov). We also handsearched relevant conference proceedings.

SELECTION CRITERIA

Randomised clinical trials (RCTs) comparing MBSR versus no intervention in women with breast cancer.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Using a standardised data form, the review authors extracted data in duplicate on methodological quality, participants, interventions and outcomes of interest (quality of life, fatigue, depression, anxiety, quality of sleep, overall survival and adverse events). For outcomes assessed with the same instrument, we used the mean difference (MD) as a summary statistic for meta-analysis; for those assessed with different instruments, we used the standardised mean difference (SMD). The effect of MBSR was assessed in the short term (end of intervention), medium term (up to 6 months after intervention) and long term (up to 24 months after intervention).

MAIN RESULTS

Fourteen RCTs fulfilled our inclusion criteria, with most studies reporting that they included women with early breast cancer. Ten RCTs involving 1571 participants were eligible for meta-analysis, while four studies involving 185 participants did not report usable results. Queries to the authors of these four studies were unsuccessful. All studies were at high risk of performance and detection bias since participants could not be blinded, and only 3 of 14 studies were at low risk of selection bias. Eight of 10 studies included in the meta-analysis recruited participants with early breast cancer (the remaining 2 trials did not restrict inclusion to a certain cancer type). Most trials considered only women who had completed cancer treatment.MBSR may improve quality of life slightly at the end of the intervention (based on low-certainty evidence from three studies with a total of 339 participants) but may result in little to no difference up to 6 months (based on low-certainty evidence from three studies involving 428 participants). Long-term data on quality of life (up to two years after completing MBSR) were available for one study in 97 participants (MD 0.00 on questionnaire FACT-B, 95% CI -5.82 to 5.82; low-certainty evidence).In the short term, MBSR probably reduces fatigue (SMD -0.50, 95% CI -0.86 to -0.14; moderate-certainty evidence; 5 studies; 693 participants). It also probably slightly reduces anxiety (SMD -0.29, 95% CI -0.50 to -0.08; moderate-certainty evidence; 6 studies; 749 participants), and it reduces depression (SMD -0.54, 95% CI -0.86 to -0.22; high-certainty evidence; 6 studies; 745 participants). It probably slightly improves quality of sleep (SMD -0.38, 95% CI -0.79 to 0.04; moderate-certainty evidence; 4 studies; 475 participants). However, these confidence intervals (except for short-term depression) are compatible with both an improvement and little to no difference.In the medium term, MBSR probably results in little to no difference in medium-term fatigue (SMD -0.31, 95% CI -0.84 to 0.23; moderate-certainty evidence; 4 studies; 607 participants). The intervention probably slightly reduces anxiety (SMD -0.28, 95% CI -0.49 to -0.07; moderate-certainty evidence; 7 studies; 1094 participants), depression (SMD -0.32, 95% CI -0.58 to -0.06; moderate-certainty evidence; 7 studies; 1097 participants) and slightly improves quality of sleep (SMD -0.27, 95% CI -0.63 to 0.08; moderate-certainty evidence; 4 studies; 654 participants). However, these confidence intervals are compatible with both an improvement and little to no difference.In the long term, moderate-certainty evidence shows that MBSR probably results in little to no difference in anxiety (SMD -0.09, 95% CI -0.35 to 0.16; 2 studies; 360 participants) or depression (SMD -0.17, 95% CI -0.40 to 0.05; 2 studies; 352 participants). No long-term data were available for fatigue or quality of sleep.No study reported data on survival or adverse events.

AUTHORS' CONCLUSIONS

MBSR may improve quality of life slightly at the end of the intervention but may result in little to no difference later on. MBSR probably slightly reduces anxiety, depression and slightly improves quality of sleep at both the end of the intervention and up to six months later. A beneficial effect on fatigue was apparent at the end of the intervention but not up to six months later. Up to two years after the intervention, MBSR probably results in little to no difference in anxiety and depression; there were no data available for fatigue or quality of sleep.

Therapeutic alliance-not therapist competence or group cohesion-contributes to reduction of psychological distress in group-based mindfulness-based cognitive therapy for cancer patients

Mindfulness‐based cognitive therapy (MBCT) is an innovative evidence‐based intervention in mental and somatic health care. Gaining knowledge of therapeutic factors associated with treatment outcome can improve MBCT. This study focused on predictors of treatment outcome of MBCT for cancer patients and examined whether group cohesion, therapeutic alliance, and therapist competence predicted reduction of psychological distress after MBCT for cancer patients. Moreover, it was examined whether therapist competence facilitated therapeutic alliance or group cohesion. Multilevel analyses were conducted on a subsample of patients collected in a larger randomized controlled trial on individual internet‐based versus group‐based MBCT versus treatment as usual in distressed cancer patients. The current analyses included the 84 patients who completed group‐based MBCT out of 120 patients who were randomized to group‐based MBCT. Group cohesion and therapist competence did not predict reduction in psychological distress, whereas therapeutic alliance did. In addition, therapist competence did not predict therapeutic alliance but was associated with reduced group cohesion. Our findings revealed that therapeutic alliance significantly contributed to reduction of psychological distress in MBCT for cancer patients. Elaborating the clinical implications of the predictive significance of therapeutic alliance might be of added value to enhance the potential effect of MBCT.

Putting Integrative Oncology Into Practice: Concepts and Approaches

Unmet symptom needs and a desire for holistic health approaches or even cure are among the motivations patients have for seeking out complementary and alternative medicine. Using complementary and alternative medicine instead of conventional cancer treatment can have a negative impact on clinical outcomes and survival. Integrative oncology is a patient-centered, evidence-informed field of comprehensive cancer care that uses mind-body practices, natural products, and lifestyle modifications from different traditions alongside conventional cancer treatments. It prioritizes safety and best available evidence to offer appropriate therapeutic interventions along with conventional care. This review summarizes the underlying principles of integrative oncology and how it is distinct from alternative medicine, and it provides a practical guide for the effective application of evidence-based complementary and alternative medicine interventions in patient-centered care. In addition, we recommend resources for patients and clinicians and provide algorithms for appropriate integrative medicine referrals. Finally, we offer suggestions on developing and implementing an integrative oncology program and addressing current challenges in the field.

A Systematic Review: Mindfulness Intervention for Cancer-Related Pain

Moderate-to-severe pain is a common problem experienced by patients with cancer. Although analgesic drugs are effective, adverse side effects are common and some analgesic drugs are addictive. Nonpharmacological treatment may be a way to treat cancer pain without causing negative side effects. Mindfulness is used as an effective nonpharmacological treatment to improve quality of life (QoL) and to address psychological problems including distress, anxiety, stress, and depression. However, the effect of mindfulness on pain severity has not been sufficiently investigated. Therefore, a systematic review was undertaken to describe the effectiveness of mindfulness interventions for pain and its underlying pathophysiologic mechanisms. The search was conducted in PubMed, Ovid MEDLINE, and CINAHL and included only empirical studies published from 2008 to 2017. Search terms included mindfulness, mindfulness-based intervention, meditation, cancer, pain, and cancer-related pain. Six studies met the search criteria. These studies tested several types of intervention including mindfulness-based stress reduction, mindfulness-based cognitive therapy, meditation with massage, and mindful awareness practices. Study outcomes include improved pain severity, anxiety, stress, depression, and QoL. However, most studies reviewed were conducted in the United States and Denmark. Further research is needed to test culturally appropriate mindfulness interventions to reduce pain.

Consolidation and prediction of long-term treatment effect of group and online mindfulness-based cognitive therapy for distressed cancer patients

BACKGROUND

Group face-to-face and individual internet-based mindfulness-based cognitive therapy (MBCT and eMBCT) have been demonstrated to reduce psychological distress for distressed cancer patients in a randomized controlled trial (RCT). This study focused on the long-term effects of this RCT during the nine-month follow-up period, and on possible predictors, moderators and working mechanisms.

METHODS

Distressed cancer patients (n = 245) were randomized to MBCT or eMBCT. Data were collected at baseline, post-treatment, three- and nine-month follow-up. Data were analyzed with linear mixed effect models and (hierarchical) linear regressions.

RESULTS

Analyses revealed long-term reductions in psychological distress and rumination, and long-term increases in positive mental health and mental health-related quality of life (QoL) in both interventions over the course of the nine-month follow-up. Interestingly, patients reported less psychological distress in the follow-up period after eMBCT in comparison to MBCT. Less psychological distress, rumination and neuroticism, and more extraversion and agreeableness at baseline predicted less psychological distress at the nine-month follow-up after both interventions. Less mindful and conscientious patients at baseline benefited more from eMBCT than from MBCT. Regarding working mechanisms, changes in mindfulness skills, fear of cancer recurrence and rumination during both interventions predicted less psychological distress at follow-up.

CONCLUSIONS

Our findings suggest most improvements in cancer patients' increase over time after both interventions. Furthermore, patients seemed to benefit more from eMBCT than MBCT based on psychological distress levels, especially those patients with low levels of mindfulness skills and conscientiousness.

Rationale and design of technology assisted stepped collaborative care intervention to improve patient-centered outcomes in hemodialysis patients (TĀCcare trial)

Most hemodialysis (HD) patients experience symptoms of depression, pain and fatigue that impair their health-related quality of life (HRQOL) significantly. These symptoms are associated with increased hospitalization and mortality, mediated by behavioral factors (e.g. non-adherence to medication and dialysis) and biological factors (e.g. inflammatory cytokines). Prior interventions to alleviate symptoms and improve HRQOL showed limited effectiveness in HD patients and their effect on bio-behavioral mediators is lacking evidence. It is imperative to improve patient-centered dialysis care and to address call from Kidney Disease Improving Global Outcomes (KDIGO) guidelines for integration of symptom assessment and management in routine HD-care. Technology-Assisted stepped Collaborative Care (TĀCcare) is a multi-center randomized controlled trial (RCT) of 150 diverse HD patients from Pennsylvania and New Mexico, designed to compare the effectiveness of a 12-week stepped collaborative care intervention (cognitive behavioral therapy, CBT) with an attention control arm of technology-delivered health education. Collaborative care provides an integrated multi-disciplinary structured management plan. Furthermore, a stepped approach to pharmacotherapy and/or CBT allows for individualization of treatment according to patients' clinical status, preferences and treatment response. To simplify the delivery of CBT and to minimize patient and provider burden, we will use live video-conferencing with patients in dialysis units. We will examine the effect of these interventions on patient symptoms, HRQOL, treatment adherence and inflammatory biomarkers. This RCT tests a readily implementable intervention that can be integrated in routine HD-care and will generate novel and meaningful insights on strategies to alleviate common symptoms and improve HRQOL in HD.

Integrative Therapies During and After Breast Cancer Treatment: ASCO Endorsement of the SIO Clinical Practice Guideline

Purpose

The Society for Integrative Oncology (SIO) produced an evidence-based guideline on use of integrative therapies during and after breast cancer treatment that was determined to be relevant to the American Society of Clinical Oncology (ASCO) membership. ASCO considered the guideline for endorsement.

Methods

The SIO guideline addressed the use of integrative therapies for the management of symptoms and adverse effects, such as anxiety and stress, mood disorders, fatigue, quality of life, chemotherapy-induced nausea and vomiting, lymphedema, chemotherapy-induced peripheral neuropathy, pain, and sleep disturbance. Interventions of interest included mind and body practices, natural products, and lifestyle modifications. SIO systematic reviews focused on randomized controlled trials that were published from 1990 through 2015. The SIO guideline was reviewed by ASCO content experts for clinical accuracy and by ASCO methodologists for developmental rigor. On favorable review, an ASCO Expert Panel was convened to review the guideline contents and recommendations.

Results

The ASCO Expert Panel determined that the recommendations in the SIO guideline—published in 2017—are clear, thorough, and based on the most relevant scientific evidence. ASCO endorsed the guideline with a few added discussion points.

Recommendations

Key recommendations include the following: Music therapy, meditation, stress management, and yoga are recommended for anxiety/stress reduction. Meditation, relaxation, yoga, massage, and music therapy are recommended for depression/mood disorders. Meditation and yoga are recommended to improve quality of life. Acupressure and acupuncture are recommended for reducing chemotherapy-induced nausea and vomiting. Acetyl-l-carnitine is not recommended to prevent chemotherapy-induced peripheral neuropathy because of a possibility of harm. No strong evidence supports the use of ingested dietary supplements to manage breast cancer treatment–related adverse effects. Additional information is available at: www.asco.org/supportive-care-guidelines .

Patient involvement in the development of a psychosocial cancer rehabilitation intervention: evaluation of a shared working group with patients and researchers

PLAIN ENGLISH SUMMARY

The aim of this paper is to present our experiences from a shared working group (SWG) with patient representatives and researchers. The SWG collaborated on developing a psychosocial cancer rehabilitation intervention for women treated for breast cancer and men treated for prostate cancer and on the planning of an effect study of this intervention.The SWG included five patient representatives (three women treated for breast cancer and two men treated for prostate cancer), four researchers and a research assistant. The SWG met four times during the year where the intervention was developed. Data material for the present evaluation study comprises meeting documents, transcriptions of interviews with two patient representatives and three researchers from the SWG, and the primary investigator's field notes.The collaboration between patient representatives and researchers informed both the intervention and the research planning and was rewarding for the involved participants. The well-structured organization of the collaboration had a positive impact on the outcome. In addition, clear goals and clarification of expectations were important. Challenges were encountered in keeping continuity between meetings and carrying out homework as intended. It was crucial for the collaboration that patient representatives had specific knowledge, interest and motivation for the project.Involving patient representatives in the research process heightened the relevancy of the research and the quality of its contents. The SWG gave patient representatives and researchers a better mutual understanding. Overall, the conclusion is that the benefits obtained by involving patient representatives exceeds the additional costs this involves.

ABSTRACT

Background The aim of the paper is to present experiences of researchers collaborating with patients in a shared working group comprising patient representatives and researchers. Experiences are deduced from the evaluation of the work in the working group, which collaborated on developing a psychosocial cancer rehabilitation intervention for women treated for breast cancer and men treated for prostate cancer and the planning of a randomized controlled trial that investigates the effect of this intervention. Methods Five patient representatives (three women treated for breast cancer and two men treated for prostate cancer), four researchers and a research assistant participated in the shared working group. The shared working group met four times during the year the intervention was developed. Data material for the present evaluation study was collected from meeting documents, transcriptions of interviews with two patient representatives and three researchers from the shared working group, and the primary investigator's field notes. The data analysis was guided by Sandelowski's qualitative description strategy. Results The collaboration between patient representatives and researchers informed the intervention and the research planning and was rewarding for the involved participants. The well-structured organization of the collaboration had a positive impact on the outcome. Also, clear goals and clarification of expectations were important. Challenges were encountered in ensuring continuity between meetings and carrying out homework as intended. It was considered crucial for the collaboration to recruit patient representatives with specific knowledge, interest and motivation for the project. The direct costs related to the shared working group, including meals, transportation and salary for the research assistant, were small. However, the indirect costs in terms of time spent on planning patient-involving elements of, organizing meetings and evaluation were substantial and demanded a significant amount of extra work for the primary investigator. Conclusion Involving patients in the research process heightened the relevancy of the research and the quality of the research contents. The shared working group influenced both patient representatives and researchers and gave them a better mutual understanding. Overall, the conclusion is that the benefits obtained by involving patients exceed the additional costs related to patient involvement.

Being Present: A single-arm feasibility study of audio-based mindfulness meditation for colorectal cancer patients and caregivers

A metastatic cancer diagnosis is associated with high levels of distress in patients and caregivers. Mindfulness interventions can reduce distress and improve quality of life in cancer patients. However, standard mindfulness training relies on in-person instruction, which is often not practical for either patients receiving chemotherapy or their caregivers. In the Being Present single arm pilot study, we designed and tested an 8-week audio-based mindfulness meditation program for patients with metastatic colorectal cancer receiving chemotherapy with or without a participating caregiver. The study accrued 33 of 74 (45%) eligible patients consenting together with 20 family caregivers (53 participants total) within nine months. Forty-one participants were evaluable (77%); 10 of 12 cases of attrition were attributable to hospitalization or death. Median participant age was 51 (range 21-78 years); 38% were men. Baseline levels of distress were similar in patients and caregivers. The top reasons for participation cited in pre-intervention interviews were to increase relaxation/calm, improve mood/emotions, and reduce stress/anxiety. In measures of adherence, 59% of responses to weekly texts asking: "Have you practiced today?" were "Yes" and 59% of interviewees reported practicing >50% of the time. Compared to baseline, post-intervention surveys demonstrated significantly reduced distress (p = 0.01) and anxiety (p = 0.03); as well as increased non-reactivity (p<0.01), and feeling at peace (p<0.01). Post-intervention qualitative interviews, where 71% of participants reported benefit, were consistent with quantitative findings. In the interviews, participants spontaneously described reduced stress/anxiety and increased relaxation/calm. Benefits appeared to be accentuated in patient-caregiver pairs as compared to unpaired patients. Seventy-nine percent of participants reported plans for continued practice after study completion. We conclude that the Being Present audio-based mindfulness meditation program is of interest to, feasible, and acceptable for patients with metastatic colorectal cancer and caregivers, with initial evidence of efficacy. These results will guide plans for a follow-up study.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02423720.

Mindfulness-based Cognitive Therapy and Persistent Pain in Women Treated for Primary Breast Cancer: Exploring Possible Statistical Mediators: Results From a Randomized Controlled Trial

OBJECTIVES

The aim of this study was to investigate possible statistical mediators in a randomized controlled trial of mindfulness-based cognitive therapy (MBCT) on pain intensity in women treated for primary breast cancer.

MATERIALS AND METHODS

The sample consisted of 129 women treated for breast cancer, presenting with persistent pain, who were randomly assigned to MBCT or a wait-list control. We previously reported a statistically significant and robust effect of MBCT on pain intensity (11-point numeric rating scale), which was included as the primary outcome. The proposed mediators were mindfulness (the Five Facet Mindfulness Questionnaire), self-compassion (the Short-Form Self-Compassion Scale), and pain catastrophizing (the Pain Catastrophizing Scale). Measurement points included baseline (T1), postintervention (T2), and 3- (T3) and 6-month (T4) follow-ups. All indirect effects of the mediators were tested in separate Multilevel Models, using the product-of-coefficients approach with bias-corrected confidence intervals (95% BSCI). The statistically significant mediators were then included in a multiple mediator model.

RESULTS

Statistically significant indirect effects were found for mindfulness nonreactivity (B=-0.17, BSCI [-0.32 to -0.04]) and pain catastrophizing (B=-0.76, BSCI [-1.25 to -0.47]). No statistically significant indirect effect was found for self-compassion (B=-0.09, BSCI [-0.30 to 0.04]). In a multiple mediator model, including mindfulness nonreactivity and pain catastrophizing, only pain catastrophizing remained statistically significant (B=-0.72, BSCI [-1.19 to -0.33]), explaining 78% of the effect.

DISCUSSION

The results of the present study may have clinical implications. An increased focus on the proposed mediators may optimize the clinical use of MBCT for persistent pain in women treated for breast cancer.

Tele-delivered mindfulness-based cognitive therapy in chronic obstructive pulmonary disease: A mixed-methods feasibility study

INTRODUCTION

Mindfulness-based cognitive therapy has been shown to reduce psychological distress in chronic obstructive pulmonary disease, but uptake and attendance rates of hospital-based, face-to-face mindfulness-based cognitive therapy are low. The present mixed-methods study evaluates the clinical feasibility of home-based, tele-delivered mindfulness-based cognitive therapy in chronic obstructive pulmonary disease.

METHODS

Eight patients with chronic obstructive pulmonary disease (mean age: 72.6 years; 50% female) received a standardised eight-week mindfulness-based cognitive therapy programme delivered via home-based video-conferences in groups of four. Feasibility in relation to (a) clinical change, (b) attendance and (c) instructor-patient working alliance were evaluated with questionnaires and semi-structured interviews.

RESULTS

Statistically non-significant reductions in psychological distress (Cohen's d = 0.504; p = 0.399) and physical health status impairment (d = 0.743; p = 0.156) were observed from pre- to post-intervention. Participant narratives about clinical outcomes focused on changes in how to relate to unpleasant sensations, i.e. through attentional flexibility, taking a pause and acceptance. The average attendance rate was 7.5 (standard deviation = 0.8) out of eight sessions and no participants dropped out. The tele-based format appeared to accommodate participants' planning difficulties and promoted their ability and wish to participate. Although participant narratives suggested the tele-based format to be a barrier to developing a trusting and safe therapeutic environment, working alliance questionnaire scores were comparable to those found for face-to-face mindfulness-based cognitive therapy.

DISCUSSION

The preliminary results indicate that tele-delivered mindfulness-based cognitive therapy is a clinically feasible intervention in chronic obstructive pulmonary disease. Future large-scale, randomised controlled trials testing its efficacy on the outcomes of psychological distress and physical health status should include analyses of potential mediators and moderators of the effect as well as and careful monitoring of attendance and adverse events.

Being mindful of mindfulness interventions in cancer: A systematic review of intervention reporting and study methodology

OBJECTIVES

While mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT) have demonstrated efficacy in clinical populations, the potential therapeutic benefit of mindfulness in the context of cancer is less clear. The aim of this review was to critically appraise mindfulness intervention reporting and study methodology.

METHODS

Studies using randomized control trial design and/or a control arm were included. PubMed, Medline, PsycINFO, CINAHL, and Embase databases between January 1999 and April 2017 were searched. Studies were assessed on (1) reported theoretical framework, (2) intervention description, and (3) justification of modifications to standardized MBSR/MBCT. The overall quality of study design and research methodology were also assessed.

RESULTS

Of 30 studies identified, none adhered to MBSR. Modified versions of MBSR were reported in 19 studies. Five studies reported variants of MBCT, 1 used a combination of MBSR/MBCT, and 5 inadequately documented the intervention/ theoretical framework. Overall, component and timeline modifications were poorly documented and justified. Mean intervention contact time was less than standardized MBSR/MBCT protocols. Target outcomes were poorly justified, and 12 studies failed to identify a primary aim, reporting multiple outcomes. Only 9 of 15 studies recruiting clinical populations included clinical cutoffs, and an active therapeutic control was included in 4 studies.

CONCLUSIONS

Mindfulness is increasingly considered a standard therapy in psycho-oncology. While many studies proclaim benefits, considerable variability, modification to standardized protocols, and claims of benefit often reflect decreases in sub-clinical supportive care symptomology rather than therapeutic relief of clinically significant psychological disorders.

Pain and quality of life in breast cancer patients

OBJECTIVE

To evaluate the influence of pain on quality of life in breast cancer patients.

METHODS

A cross-sectional study of 400 patients, including 118 without metastasis, 160 with loco-regional metastasis and 122 with distant metastasis. The instruments used were the European Organization for Research and Treatment for Cancer Quality of Life Questionnaire-Core 30 and the Breast Cancer-specific 23 and short McGill Pain Questionnaire.

RESULTS

In total, 71.7% of patients reported pain. The most frequent sensory descriptor used by patients was 'jumping.' In the evaluative dimension, the main descriptor chosen was troublesome. The Global Health self-assessment showed pain to be inversely correlated with quality of life: the group without metastasis had a mean score of 55.3 (SD=24.8) for those in pain, which rose to 69.7 (SD=19.2) for those without pain (p=0.001). Subjects with loco-regional metastasis had score of 59.1 (SD=21.3) when in pain, and those without pain had a significantly higher score of 72.4 (SD=18.6) (p<0.001). Patients from the distant metastasis group showed similar results with a mean score of 48.6 (SD=23.1) for those in pain and 67.6 (SD=20.4) for those without pain (p=0.002). Regarding the association of pain intensity and quality of life, patients with distant metastasis and intense pain had the worst scores for quality of life with a functional scale mean of 49.9 (SD=17.3) (p<0.009), a Symptom Scale score of 50.0 (SD=20.1) (p<0.001) and a Global Health Scale score of 39.7 (SD=24.7) (p<0.006).

CONCLUSIONS

Pain compromises the quality of life of patients with breast cancer, particularly those with advanced stages of the disease.

Mindfulness-based interventions for women with breast cancer: an updated systematic review and meta-analysis

BACKGROUND

The aim of this meta-analysis was to systematically update the evidence for mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT) in women with breast cancer.

MATERIAL AND METHODS

In October 2016, PubMed, Scopus, and Central were searched for randomized controlled trials on MBSR/MBCT in breast cancer patients. The primary outcome was health-related quality of life. Secondary outcomes were fatigue, sleep stress, depression, anxiety, and safety. For each outcome, standardized mean differences (SMD/Hedges' g) and 95% confidence intervals (CI) were calculated. Risk of bias was assessed by the Cochrane risk of bias tool.

RESULTS

The Literature search identified 14 articles on 10 studies that included 1709 participants. The overall risk of bias was unclear, except for risk of low attrition bias and low other bias. Compared to usual care, significant post-intervention effects of MBSR/MBCT were found for health-related quality of life (SMD = .21; 95%CI = [.04-.39]), fatigue (SMD = -.28; 95%CI = [-.43 to -.14]), sleep (SMD = -.23; 95%CI = [-.40 to -.05]), stress (SMD = -.33; 95%CI = [-.61 to -.05]), anxiety (SMD = -.28; 95%CI = [-.39 to -.16]), and depression (SMD = -.34; 95%CI = [-.46 to -.21]). Up to 6 months after baseline effects were significant for: anxiety (SMD = -.28; 95%CI = [-.47 to -.09]) and depression (SMD = -.26; 95%CI = [-.47 to -.04]); and significant for anxiety (SMD = -.21; 95%CI = [-.40 to -.03]) up to 12 months after baseline. Compared to other active interventions, significant effects were only found post-intervention and only for anxiety (SMD = -.45; 95%CI = [-.71 to -.18]) and depression (SMD = -.39; 95%CI = [-.65 to -.14]). However, average effects were all below the threshold of minimal clinically important differences. Effects were robust against potential methodological bias. Adverse events were insufficiently reported.

CONCLUSIONS

This meta-analysis revealed evidence for the short-term effectiveness and safety of mindfulness-based interventions in women with breast cancer. However, their clinical relevance remains unclear. Further research is needed.

Pain, sensory disturbances and psychological distress are common sequelae after treatment of ductal carcinoma in situ: a cross-sectional study

Sequelae such as pain, sensory disturbances and psychological distress are well known after treatment for invasive breast cancer (IBC). Patients treated for ductal carcinoma in situ (DCIS) receive a similar treatment as low-risk IBC. The aim of this cross-sectional study was to describe prevalence of postoperative pain, sensory disturbances, psychological distress and rehabilitation needs among Danish women with DCIS.

METHODS

A total of 574 women treated for DCIS in Denmark in 2013 and 2014 were enrolled and 473 (82%) completed a detailed questionnaire on demographic factors, pain, sensory disturbances, psychological aspects and rehabilitation needs 1-3 years after surgery.

RESULTS

Median age was 60 years. A total of 33% of patients reported any pain and 12% reported moderate to severe pain in the area of surgery. Younger age (<50 years OR 4.7 (95% CI: 1.6-14.0, p = 0.006)), aged 50 to 65 years OR 2.8 (95% CI: 1.1-7.0, p = 0.02) and anxiety and depression (measured by HADS_total >15 OR of 3.1 (95% CI: 1.5-6.3, p = 0.003)) were significantly associated with moderate to severe pain. Approximately one-third of the patients reported sensory disturbances such as pins and needles (32%), numbness (37%) and painful itch (30%) and 94 women (20%) reported anxiety ≥8, 26 (6%) depression and 51 (11%) reported distress.

CONCLUSIONS

This cross-sectional study showed that women treated for DCIS suffered from pain, sensory disturbances and psychological impairment and had unmet rehabilitation needs. Further research is warranted, specifically addressing rehabilitation after diagnosis and treatment of DCIS.

Clinical and psychological moderators of the effect of mindfulness-based cognitive therapy on persistent pain in women treated for primary breast cancer - explorative analyses from a randomized controlled trial

BACKGROUND

Mindfulness-based intervention has been found efficacious in reducing persistent pain in women treated for breast cancer. Little, however, is known about possible moderators of the effect. We explored clinical and psychological moderators of the effect on pain intensity previously found in a randomized controlled trial of mindfulness-based cognitive therapy (MBCT) with women treated for breast cancer with persistent pain.

MATERIAL AND METHODS

A total of 129 women treated for breast cancer reporting persistent pain were randomized to MBCT or a wait-list control. The primary outcome of pain intensity (11-point numeric rating scale) was measured at baseline, post-intervention, three, and six months follow-up. Proposed clinical moderators included age, axillary lymph node dissection (ALND), radiotherapy, and endocrine treatment. Psychological moderators included psychological distress [the Hospital Anxiety and Depression Scale (HADS)], the adult attachment dimensions anxiety and avoidance [the Experiences in Close Relationships Short Form (the ECR-SF)], and alexithymia [the Toronto Alexithymia Scale (TAS-20)]. Multi-level models were used to test moderation effects over time, i.e. time × group × moderator.

RESULTS

Only attachment avoidance (p = 0.03, d = 0.36) emerged as a statistically significant moderator. Higher levels of attachment avoidance predicted a larger effect of MBCT in reducing pain intensity compared with lower levels attachment avoidance. None of the remaining psychological or clinical moderators reached statistical significance. However, based on the effect size, radiotherapy (p = 0.075, d = 0.49) was indicated as a possible clinical moderator of the effect, with radiotherapy being associated with a smaller effect of MBCT on pain intensity over time compared with no radiotherapy.

CONCLUSION

Attachment avoidance, and potentially radiotherapy, may be clinically relevant factors for identifying the patients who may benefit most from MBCT as a pain intervention. Due to the exploratory nature of the analyses, the results should be considered preliminary.

Complementary and Alternative Medicine Use and Latina Breast Cancer Survivors' Symptoms and Functioning

Complementary and alternative medicine (CAM) is used widely in cancer populations, particularly among women, and has shown promise for addressing symptom and functioning outcomes. Few studies to date have evaluated CAM use and associations over time with symptoms and function among Latina breast cancer survivors. We administered a baseline (N = 136) and follow-up (n = 58) telephone survey in Spanish or English assessing Latina breast cancer survivor demographics, physical function, anxiety, depression, fatigue, satisfaction with social roles, and both CAM activities and devotional and spiritual practices. About one-third of our sample (35% baseline; 36% follow-up) reported using CAM (yoga, meditation, massage, or herbal/dietary supplements). We assessed devotional and spiritual practices separately from CAM (church attendance, prayer, religious groups, and reading devotional and religious texts); the majority of Latina survivors reported devotional and spiritual practices (80% baseline; 81% follow-up). At baseline, CAM demonstrated a positive association with better physical functioning and lower depression. In contrast, CAM use at the time of follow-up appeared to be related to lower levels of satisfaction with social roles and physical function. In longitudinal analyses, devotional and spiritual practices at baseline significantly predicted lower anxiety, depression, and fatigue at follow-up. Findings suggest CAM plays a complex and not always linear role in symptoms and function outcomes for Latina breast cancer survivors. These findings contribute to the literature on longitudinal CAM use and associations with symptom and functioning outcomes among Latina breast cancer survivors.

Mindfulness-Based Cancer Recovery (MBCR) versus Supportive Expressive Group Therapy (SET) for distressed breast cancer survivors: evaluating mindfulness and social support as mediators

Despite growing evidence in support of mindfulness as an underlying mechanism of mindfulness-based interventions (MBIs), it has been suggested that nonspecific therapeutic factors, such as the experience of social support, may contribute to the positive effects of MBIs. In the present study, we examined whether change in mindfulness and/or social support mediated the effect of Mindfulness-Based Cancer Recovery (MBCR) compared to another active intervention (i.e. Supportive Expressive Group Therapy (SET)), on change in mood disturbance, stress symptoms and quality of life. A secondary analysis was conducted of a multi-site randomized clinical trial investigating the impacts of MBCR and SET on distressed breast cancer survivors (MINDSET). We applied the causal steps approach with bootstrapping to test mediation, using pre- and post-intervention questionnaire data of the participants who were randomised to MBCR (n = 69) or SET (n = 70). MBCR participants improved significantly more on mood disturbance, stress symptoms and social support, but not on quality of life or mindfulness, compared to SET participants. Increased social support partially mediated the impact of MBCR versus SET on mood disturbance and stress symptoms. Because no group differences on mindfulness and quality of life were observed, no mediation analyses were performed on these variables. Findings showed that increased social support was related to more improvement in mood and stress after MBCR compared to support groups, whereas changes in mindfulness were not. This suggests a more important role for social support in enhancing outcomes in MBCR than previously thought.

Psychological therapies for the management of chronic neuropathic pain in adults

BACKGROUND

Neuropathic pain is thought to arise from damage to the somatosensory nervous system. Its prevalence is increasing in line with many chronic disorders such as diabetes. All treatments have limited effectiveness. Given the evidence regarding psychological treatment for distress and disability in people with various chronic pain conditions, we were interested to investigate whether psychological treatments have any effects for those with chronic neuropathic pain.

OBJECTIVES

To assess the effects of psychological treatments on pain experience, disability, mood, and health-care use in adults with chronic neuropathic pain.

SEARCH METHODS

We searched for randomised controlled trials (RCTs) published in any language in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and PsycINFO, from database inception to March 2015.

SELECTION CRITERIA

Full publications of RCTs on psychological interventions for neuropathic pain. Trials had to have lasted at least three months, had at least 20 participants in each arm at the end of treatment, and compared a psychological intervention with any active or inactive intervention.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane.

MAIN RESULTS

Two small studies (enrolling a total of 105 participants) met the inclusion criteria. One was a standard cognitive behavioural treatment (CBT) programme for 61 people with pain from spinal cord injury, followed up for three months, and compared with a waiting list. The other was weekly group psychotherapy for 44 people with burning mouth syndrome, compared with a daily placebo tablet. The overall risk of bias was high in both trials.The CBT study assessed participants for pain, disability, mood, and quality of life, with improvement in treatment and control groups. However, there was no more improvement in the treatment group than in the control for any outcome, either post-treatment or at follow-up. The group psychotherapy study only assessed pain, classifying participants by pain severity. There is a lack of evidence on the efficacy and safety of psychological interventions for people with neuropathic pain.

AUTHORS' CONCLUSIONS

There is insufficient evidence of the efficacy and safety of psychological interventions for chronic neuropathic pain. The two available studies show no benefit of treatment over either waiting list or placebo control groups.