Mindfulness Interventions for Cancer Survivors: Moving Beyond Wait-List Control Groups

Abstract

There is considerable interest in mind-body therapies for reducing symptoms and enhancing well-being in patients with cancer and survivors, including mindfulness-based therapies. Mindfulness involves bringing attention to an individual’s presentmoment experiences, including thoughts, feelings, and physical sensations, with openness, curiosity, and acceptance. Interventions have been developed to cultivate mindfulness through formal meditation and informal practice, and randomized controlled trials have documented beneficial effects on psychological and behavioral outcomes in post-treatment survivors, particularly depressive symptoms and fatigue. The study by Johannsen et al is one of the first trials to specifically target post-treatment pain in breast cancer survivors using a mindfulness-based approach. Pain is one of the most common symptoms experienced by women with breast cancer and causes serious disruption in quality of life, making it an important target for intervention. This study recruited 129 women who had completed surgery, radiation therapy, and/or chemotherapy for nonmetastatic breast cancer and reported elevated pain. Women were randomly assigned to an 8-week, manualized mindfulness-based intervention or a wait-list control group and completed assessments at baseline, postintervention, and at 3and 6-month follow-ups. The focus onwomenwith elevated pain and the examination of persistent effects of the intervention are notable strengths of this study. The specific intervention used in this trial was mindfulnessbased cognitive therapy (MBCT), which was originally developed to treat recurrent depression and incorporates elements of cognitive therapy along with mindfulness. In the context of depression, MBCTeducates patients about the role of dysfunctional thoughts in depression recurrence and helps patients to recognize and disengage from these dysfunctional thoughts when they occur. The focus on dysfunctional thoughts may also be useful in the context of pain because cognitive processes such as pain catastrophizing (ie, negative thoughts about one’s ability to tolerate or manage pain) are known to play a role in the onset and persistence of pain symptoms. What were the results of this intervention? The authors reported results for eight measures of pain, all described as primary outcomes. In analyses controlling for multiple comparisons,MBCT led to significantly greater reductions in a single-item measure of pain intensity than seen in the wait-list control group, with a medium effect size. In analyses that did not control for multiple comparisons, significant intervention effects were also seen for another measure of pain intensity, for neuropathic pain, and for the Short FormMcGill PainQuestionnaire 2 total score, with small effect sizes. Importantly, these effects seemed to be relatively stable over the follow-up period. In terms of non–pain-related outcomes, mindfulness led to significant improvements in overall quality of life relative to wait-list control but did not reduce psychological distress. How do these results compare with the broader literature on mindfulness? A recent meta-analysis concluded that mindfulness interventions demonstrated moderate evidence of improved pain, anxiety, and depression in diverse adult clinical populations. Among individuals with chronic pain conditions (not related to cancer), mindfulness-based approaches including MBCT have also shown beneficial effects on pain outcomes, with small to medium effect sizes. Interestingly, these trials have typically shown stronger intervention effects on pain interference rather than pain intensity, which is consistent with the goal of mindfulness-based interventions to accept rather than reduce pain sensations. Pain interference was not specifically assessed in the Johannsen et al study, although the intervention did not reduce perceived pain burden. Only a few mindfulness trials in cancer survivors have examined effects on pain, and they have generally not found positive effects. In contrast to the Johannsen et al study (and studies with patients experiencing chronic pain), these trials have not specifically targeted pain, which may have limited their ability to improve pain-related outcomes. On the basis of this growing body of evidence, should we be prescribing mindfulness for breast cancer survivors with posttreatment pain? What conclusions and treatment recommendations can we draw from the existing literature? At this point, the main conclusionmay be thatmindfulness leads tomodest benefits in certain aspects of psychological and physical functioning, relative to wait-list control. This is because a majority of mindfulness trials conducted with cancer populations have used wait-list control groups rather than active control or comparison conditions (including studies conducted by our group). This design is reasonable during early intervention development and preliminary evaluation of efficacy. However, the field ofmindfulness research has now progressed, and experts are calling for use of more rigorous control and comparison conditions. So, what is the most appropriate control or comparison condition for mindfulness interventions? Of course, this depends on the goal of the trial. In some trials, the primary goal is to determine whether mindfulness is the so-called active ingredient of the intervention. Mindfulness and other behavioral interventions