Mindfulness-Based Stress Reduction

To conduct a preliminary exploration of mindfulness-based stress reduction (MBSR) participation of couples affected by cancer, particularly as participation affects symptoms of stress, mood disturbance, and mindfulness for patients with cancer and their partners

A convenience sample of 41 couples already enrolled in an MBSR program at a cancer outpatient center agreed to participate by completing the three study measures before the program started and two weeks following program completion. Weekly 90-minute classes held over an eight-week period, plus one weekend retreat lasting three to six hours, comprised the intervention. Of the 41 couples, only 21 completed post-test measures and at least six of eight MBSR classes.

• The sample was comprised of 21 couples (95% married).
• The sample was 52.4% female and 47.6% male.
• Mean patient age was 62.9 years (SD = 7.37); mean partner age was 62.8 years (SD = 9.34).
• The most common patient diagnoses were prostate cancer (28.6%), breast cancer (19%), and colorectal cancer (14.3%).
• Mean time since primary diagnosis for all patients was 2.03 years.
• Mean educational level for couples was 14.6 years.

• Single site
• Outpatient setting
• Cancer center in Calgary, Alberta, Canada

• Multiple phases of care
• Late effects and survivorship

A pretest/post-test design was used.

• Profile of Mood States (POMS): Measures identified mood and change in mood or affective states using a Likert scale with well-established reliability (Kuder-Richardson of six POMS subscales ranged from 0.84 to 0.95.)    
• Calgary Symptoms of Stress Inventory (C-SOSI): Uses a Likert scale to measure physical and psychologic responses to stress and consists of eight subscales (depression, anger, muscle tension, cardiopulmonary arousal, sympathetic arousal, neurologic/gastrointenstinal, cognitive disorganization, and upper respiratory symptoms). The tool has been validated in the oncology population with convergent and divergent validity (Cronbach's alpha = 0.95).
• Mindfulness Attention Awareness Scale (MAAS): Uses a Likert scale to  assess individual differences in mindfulness over time and measures the presence or absence of attention and awareness to the present moment. The scale has been validated with patients with cancer (Cronbach's alpha = 0.87).

Of the couples, 21 provided POMS data, 19 provided C-SOSI data, and 16 provided MAAS data for baseline and postintervention measures. Before MBSR intervention, patients reported significantly higher scores on the POMS fatigue subscale (p = 0.05), while partners reported significantly higher scores on the C-SOSI sympathetic arousal subscale (p < 0.05) than did patients according to t-test analysis. Patients with only baseline data reported significantly higher levels of total mood disturbance before MBSR classes than those who provided complete data (p < 0.05). After program completion, both patients and partners experienced significant reduction in mood disturbance (p < 0.05) and the C-SOSI subscales of muscle tension (p < 0.01), fatigue (p < 0.05), neurologic/GI (p < 0.05), and upper respiratory symptoms (p < 0.01). Both groups significantly increased their mindfulness (p < 0.05) as a result of the intervention. After the MBSR intervention, couples’ scores on the POMS and C-SOSI were more highly correlated with one another. Partners’ mood disturbance scores were positively correlated (p < 0.05) with patients’ symptoms of stress and negatively correlated with patients’ levels of mindfulness (p < 0.05).

As one of the first studies using a sample of patients with cancer and partners, the MBSR program benefited both patients and their partners by reducing mood disturbance and physical symptoms of stress, psychologically aligning patients and partners during the cancer journey, and increasing levels of mindfulness. Moderate effect sizes were found for both patients and partners on these variables.

• The sample was small and underpowered, with less than 30 participants.
• The study had no comparison group.
• The study had 51% attrition following collection of baseline data from 41 couples.

MBSR programs for patients with cancer and their partners may buffer physical and psychological challenges during their cancer journey. Nurses, as members of the healthcare team, may suggest these increasingly evidence-based programs as a complementary intervention for patients and partners who seek additional nonmedical ways to cope with the cancer illness. Validation of MBSR will enhance couples’ willingness to seek out MBSR that may respond to psychosocial gaps in care of patients with cancer and their partners who struggle with predominant high-technology approaches to oncology care. Further examination is also needed to identify cost-effective ways of meeting healthcare system goals for person-centered care in diverse populations of families facing cancer.

To evaluate the applicability and effectiveness of existential behavioral therapy (EBT)  to informal caregivers of palliative care patients with regards to psychological distress and quality of life when compared with treatment as usual

The intervention was six group sessions totaling 22 hours. The sessions focused on introductions and mindfulness, death, bereavement and mindfulness, activating resources, finding meaning, self-care and stress management, personal values for (re-)orientation, and moving forward. Sessions were administered in small (10 participants or fewer), closed groups by a trained behavioral therapist following a study manual. Evaluations occurred at baseline, pre- and post-intervention, and at 3- and 12-month follow-up (five time points).

• N = 133  
• MEAN AGE = 54.5 years (13.2 years)
• MALES: 30.1%, FEMALES: 69.9%
• KEY DISEASE CHARACTERISTICS: Primarily (92.7%) various cancer diagnoses and neurological diseases; six months or less to live; currently in an inpatient palliative care unit
• OTHER KEY SAMPLE CHARACTERISTICS: German speaking; 61.7% identified as partners, 26.3% as parents, 4% as children, and 12% as other

• SITE: Multi-site    
• SETTING TYPE: Inpatient  
• LOCATION: Munich, Germany

• PHASE OF CARE: End-of-life care
• APPLICATIONS: Palliative care 

• RCT

• Brief Symptom Inventory (BSI) subscales—somatization, anxiety, and depression
• Quality of life
  • Satisfaction With Life Scale (SWLS)—cognitive aspects
  • World Health Organization Quality of Life (WHOQOL)-BREF
  • Numeric rating scale for quality of life—QOL-NRS (single-item, scale of 1–10)
• Positive and Negative Affect Scale (PANAS)

EBT showed medium effects at the pre-/immediate post-test evaluation with improvement in anxiety (p 0.006) and on all measures of quality of life (p 0.009, 0.007, < 0.001). At the three-month evaluation, EBT showed no significant effects, with only small effect sizes on one-third of the quality-of-life measure SWLS (p 0.04). However, at the 12-month evaluation, EBT demonstrated medium effects on depression (p 0.04) and QOL-NRS (p 0.002). Interestingly, similar patterns resulted when examining secondary outcomes of affect, with significantly less negative affect demonstrated at post-test (p 0.003), which then was not noted at the three-month evaluation, and at 12 months, significantly less negative affect was measured again (p 0.003). Positive affect, although never significant, always was trending more positive than when compared with controls. High level of satisfaction existed with the group, the therapist, information, mindfulness, and values.

EBT shows promise as an intervention to improve psychological distress and quality of life for carers of patients with cancer at end of life. The effect is greatest immediately following the intervention. Additional work is required with attentional control groups and outpatient patient populations to further support the benefits of this intervention.

• Risk of bias (no appropriate attentional control condition)  
• Risk of bias (sample characteristics)
• Intervention expensive, impractical, or training needs
• Other limitations/explanation: Heterogeneous sample—variety of care types, partners versus relatives and carers of living and dead patients were included in the same groups, meaning that for some, they already were in the grieving process at the start of the intervention. When compared to treatment as usual, which is no intervention, whether EBT or just being part of a group, or having attention of the therapist accounted for the improved outcomes is unclear. Intervention included specially trained behavioral therapist, not nurses.

Interventions such as EBT that target informal carers of patients with cancer have the potential to relieve distress and improve quality of life for the carer and the patient.

To assess the feasibility of a ​mindfulness-based stress reduction (MBSR) intervention for patients with lung cancer and their partners, and to determine whether MBSR decreases distress in the same population

Participants received eight weekly sessions (two and a half hours each) of an MBSR course with an additional psychoeducational component of coping with grief taught by health professionals and qualified mindfulness trainers. Assessments were made at baseline, postintervention, and three months later.

• N = 19 patients and 16 partners  
• MEAN AGE: Patients 61.7 years (range = 54–77 years), partners 60 years (range = 30–76 years)
• MALES: 53% (patients); 64% (partners), FEMALES: 47% (patients); 56% (partners)
• KEY DISEASE CHARACTERISTICS: Patients with lung cancer and their partners
• OTHER KEY SAMPLE CHARACTERISTICS: Dutch; 79% advanced stage lung cancer

• SITE: Single site    
• SETTING TYPE: Not specified    
• LOCATION: Holland

• PHASE OF CARE: Mutliple phases of care
• APPLICATIONS: Palliative care 

Pre- and post-test, single-arm feasibility study

• Hospital Anxiety and Depression Scale (HADS)
• European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-LC14)
• Impact of Events Scale (IES)
• Penn State Worry Questionnaire (PSWQ)
• Mindful Attention and Awareness Scale (MAAS)
• The Self-Perceived Pressure Form Informal Care (SPPIC)
• The Care Derived Self Esteem of the Caregiver Reaction Assessment (CRA-SE)
• Semistructured interview

An MBSR intervention for patients with lung cancer and their partners was feasible. No statistically significant change in anxiety and depression or mindfulness and worry were observed in patients or partners. Caregiver burden decreased after the MBSR training post-treatment (p < 0.05), and at the three month follow-up (p < 0.01). Six patients and five partners were able to report on facilitators (participating with partner and in group) and barriers (physical function) to participating as well as themes of process of change (standing still, being aware, insight, letting go, and changing behavior and acceptance).

MBSR is feasible for patients with lung cancer and their partners.

• Small sample (< 30)
• Risk of bias (no control group)
• Findings not generalizable

MBSR may be an effective intervention for decreasing caregiver burden in the lung cancer population. Additional research is needed in larger randomized, controlled trials.