Mindfulness Based Stress Reduction (MBSR) in breast cancer: research and practice

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Mindfulness Based Stress Reduction (MBSR) in
breast cancer research and practice

• Caroline Hoffman, PhD
• Clinical Director Research Co-ordinator
• The Haven
• Breast Cancer Support Centres
• London - Hereford - Leeds
• www.thehaven.org.uk
• caroline.hoffman_at_thehaven.org.uk

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The Haven (Breast Cancer Support Centres)

• Free programmes of emotional support and
  complementary therapies for breast cancer
• Also an outreach programme called The Haven at
  Home (2.5h DVD and 1h CD)

The Haven in London
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Mindfulness at The Haven

• MBSR has been taught to 500 people at the Haven.
• Mindful movement and meditation practice classes
  (drop-in) are also available twice a month

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What is mindfulness?

• Mindfulness means paying attention (being aware)
  in a particular wayon purpose,in the present
  moment,and non-judgmentally.
• Dr Jon Kabat-Zinn
• Founder
• Mindfulness-Based Stress Reduction Programme

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What is mindfulness?

• Mindfulness is about being fully awake in our
  lives. It is about perceiving the exquisite
  vividness of each moment. We feel more alive. We
  also gain immediate access to our own powerful
  inner resources for insight, transformation, and
  healing.
• Jon Kabat-Zinn

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Mindfulness training is worldwide

• Up to 3,000 health professionals among 18,000
  participants in the MBSR programme at the Center
  for Mindfulness, University of Massachusetts, USA
• www.bemindful.co.uk lists mindfulness courses
  available by area in Great Britain (GB)
• Mindfulness at Monash University, Melbourne,
  Australia

• Professional teacher training centres
• University of Massachusetts USA (MBSR)
• University of Oxford, G.B. (MBCT)
• University of Bangor, G.B. (MBSR and MBCT)

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Aim of MBSR study

• The aim of this randomised controlled trial was
  to determine if and how much MBSR affects mood,
  disease-related quality of life, including
  endocrine symptoms, and wellbeing in women with
  stages 0 to III breast cancer.

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Numbers of study participants

• 229 women who had attended the Haven
• Computer randomised into blocks of four
• 114 in intervention group
• 115 in wait-list control group
• Sample size calculated for 80 power from
  Profile of Mood States (Speca et al 2000)

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Age and socioeconomic status

• Mean age 49 years (Intervention Group)
• 50 years (Control Group)
• Socio-economic status
• AB (Higher and intermediate manager/
  administrator/ professional)
• Intervention Group 84 (73.7) Control Group 90
  (78.3)
• C1 (Supervisory clerical junior managerial/
  administrator/ professional)
• Intervention Group 20 (17.5) Control Group 16
  (13.9)

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Measurement tools

• Profile of Mood States (POMS) (65 item)
• Primary outcome measure
• Quality of Life measures
• FACT-B (Breast) (37 item)
• FACT-ES (Endocrine Symptoms) (19 item)
• WHO-5 Wellbeing questionnaire (5 item)

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MBSR Programme taught

• 8-week MBSR programme
• Week 1 and 8 2 and a quarter hours (Uni. Mass 3
  hrs)
• Week 2 to 6 2 hours per week (Uni.Mass 2.5 hrs)
• 6-hour day of mindfulness in week 6 on a
  Saturday
• 10am to 4pm (both groups together for this)
• Number of groups
• Pilot group
• 7 cycles of 8 week programmes (13 groups) in 2005
  -2006
• Regular clinical supervision for
  clinician-researcher

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Contents of MBSR programme

• Ways of seeing how we perceive our world
• Awareness of thoughts, emotions and body
  sensations
• Mindful body scan, mindful stretches, mindful
  sitting practice
• Understanding stress
• Awareness of habitual thought patterns and
  emotional reactions
• Mindfulness in everyday life

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MBSR spaces atThe Haven in London

• Group Room

• Reception area

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Home Practice

• Home Practice Manual included photos of
  stretching exercises, meditation sitting
  positions, information on stress, some stories,
  exercises, tips
• 4 x 45 minute CDs Mindful Body Scan, Mindful
  Lying Stretches, Mindful Sitting Meditation,
  Mindful Standing Stretches
• Home practice sheets
• Record of formal home mindfulness practice

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Profile of mood states (POMS) (primary outcome)

• Total Mood Disturbance
• Subscales Anxiety
• Depression
• Anger
• Vigour
• Fatigue
• Confusion

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POMS
Outcome measure mean (SD) Intervention (N103) Control (N111) Mean Difference p value CI (95) for difference
T1 Total Mood Disturbance 43.65 (34.73) 49.23 (39.37) N110 -5.58
T2 Total Mood Disturbance 30.02 (31.60) 47.81 (39.81) -17.79 -27.44, -8.14
T3 Total Mood Disturbance 29.83 (34.19) 45.43 (35.51) -15.60 -25.01, -6.20
T1 Tension-Anxiety 13.16 (7.21) 13.42 (7.24) -0.26
T2 Tension-Anxiety 10.32 (7.0) 13.36 (7.20) -3.04 -4.95, -1.18
T3 Tension-Anxiety 10.33 (7.02) 12.73 (6.59) -2.40 -4.24, -5.66
T1 Depression-Dejection 12.79 (10.76) 15.70 (12.79) -2.91
T2 Depression-Dejection 10.0 (9.95) 14.96 (13.23) -4.96 -8.11, -1.83
T3 Depression-Dejection 10.34 (10.32) 14.10 (11.60) -3.76 -6.72, -0.80
T1 Anger-Hostility 10.75 (8.08) 11.60 (8.62) -0.85
T2 Anger-Hostility 8.78 (7.57) 11.11 (8.88) -2.33 -4.57, -0.10
T3 Anger-Hostility 7.87 (6.72) 11.04 (8.95) -3.17 -5.29, -1.04
T1 weeks -2 to 0, T2 weeks 8 to 10, T3
weeks 12 to 14 plt0.05, plt0.01, plt0.001
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POMS
Outcome measure mean (SD) Intervention (N103) Control (N111) Mean difference and p value CI (95) for difference

T1 Vigour-Activity -14.31 (6.53) -14.06 (6.19) 0.25
T2 Vigour-Activity -15.91 (6.0) -13.57 (6.61) -2.34 -4.05, -0.64
T3 Vigour-Activity -16.23 (6.63) -13.47 (6.22) -2.76 -4.50, -1.03

T1 Fatigue-Inertia 11.17 (6.64) 11.75 (7.20) -0.58
T2 Fatigue-Inertia 8.71 (6.10) 11.62 (7.16) -2.91 -4.71, -1.11
T3 Fatigue-Inertia 9.27 (6.90) 11.39 (6.73) -2.12 -3.95, -0.28

T1 Confusion-Bewilderment 10.11 (5.58) 10.65 (5.57) N110 -0.54
T2 Confusion-Bewilderment 8.13 (4.71) 10.32 (5.28) -2.19 -3.54, -0.87
T3 Confusion-Bewilderment 8.24 (5.32) 9.64 (4.79) -1.4 -2.76, -0.40
T1 weeks -2 to 0, T2 weeks 8 to 10, T3
weeks 12 to 14 plt0.05, plt0.01, plt0.001
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FACT - quality of life measure

• FACT-B (breast) and FACT ES (endocrine symptoms)
• Subscales
• Physical wellbeing
• Social and family wellbeing
• Emotional wellbeing
• Functional wellbeing
• Breast-specific subscale (B)
• Endocrine-specific subscale (ES)

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FACT-B results
FACT scores mean (SD) Intervention Group (N102) Control Group (N111) Mean difference and p value CI (95) for difference
T1 FACT- ES 127.02 (18.84) 127.08 (23.20) -0.06
T2 FACT- ES 134.97 (19.25) 127.28 (23.48) N108 7.69 1.83, 13.55
T3 FACT- ES 135.34 (19.54) 127.46 (21.17) N110 7.88 2.33, 13.44
T1 FACT-ES TOI 92.51 (14.54) 92.20 (16.98) 0.31
T2 FACT-ES TOI 98.47 (14.37) 92.58 (17.67) N110 5.89 1.52, 10.28
T3 FACT-ES TOI 98.67 (14.63) 92.75 (16.75) N107 5.92 1.65, 10.19
T1 FACT-B 96.57 (17.22) 96.68 (12.05) -0.11
T2 FACT-B 103.56 (17.01) N101 96.87 (21.05) , N107 6.69 1.33, 12.05
T3 FACT-B 103.78 (17.85) N101 96.36 (19.39) , N107 7.42 2.32, 12.52
T1 FACT-B TOI 62.04 (12.01) 61.92 (14.03) 0.12
T2 FACT-B TOI 67.02 (11.96) N101 62.10 (14.38) N109 4.92 1.31, 8.54
T3 FACT-B TOI 67.11 (12.30) N101 61.67 (13.67) N109 5.44 1.89, 8.98
T1 weeks -2 to 0, T2 weeks 8 to 10, T3
weeks 12 to 14 plt0.05, plt0.01, plt0.001
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FACT subscales
FACT scores mean (SD) Intervention Group (N102) Control Group (N111) Mean difference p value CI (95) for difference
T1 PWB (physical) 21.88 (4.29) 21.89 (4.35) -0.01
T2 PWB 22.86 (4.22) 21.84 (4.54) 1.02 -0.16, 2.21
T3 PWB 22.96 (4.34) 21.67 (4.87) 1.29 0.05, 2.54
T1 SWB (social) 17.59 (5.91) 18.78 (6.01) -1.19
T2 SWB 18.36 (5.65) 18.26 (5.88) N109 0.1 -1.46, 1.67
T3 SWB 18.08 (5.81) 18.30 (5.75) N109 -0.22 -1.78, 1.35
T1 EWB (emotional) 16.91 (3.84) 15.97 (4.58) 0.94.
T2 EWB 18.13 (3.82) 16.53 (4.42) N110 1.6 0.48, 2.73
T3 EWB 18.58 (3.75) 16.28 (4.40) N110 2.3 1.19, 3.41
T1 FWB (functional) 17.83 (5.03) 17.65 (5.82) -0.18
T2 FWB 19.46 (5.27) 17.41 (6.06) N110 2.05 0.50, 3.59
T3 FWB 19.45 (5.32) 17.53 (5.37) N110 1.92 0.47, 3.37
T1 weeks -2 to 0, T2 weeks 8 to 10, T3
weeks 12 to 14 plt0.05, plt0.01, plt0.001
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Minimally important differences scores (MIDs) for
FACT
Scales MIDs score Reference Clinically significant range for MIDs
T2 FACT-B 7 7-8
T3 FACT-B 8
T2 FACT-B TOI 5 5-6
T3 FACT-B TOI 5
T2 Breast subscale 0 2-3
T3 Breast subscale 0
denotes significant values T1 weeks -2 to 0,
T2 weeks 8 to 10, T3 weeks 12 to 14
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WHO 5-item wellbeing questionnaire
For each of the five statements below, please put
a circle round one number, which is closest to
how you have been feeling over the last week.
Notice that the higher numbers mean better
well-being.
Over the last week All the time Most of the time More than half of the time Less than half of the time Some of the time At no time
I feel cheerful and in good spirits 5 4 3 2 1 0
I feel calm and relaxed 5 4 3 2 1 0
I feel active and vigorous 5 4 3 2 1 0
I wake up feeling fresh and rested 5 4 3 2 1 0
My daily life is filled with things that interest me 5 4 3 2 1 0
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Scores for WHO-5 wellbeing questionnaire
WHO 5-item wellbeing questionnaire mean (SD) score Intervention (N102) Control (N110) Mean difference and p value CI (95) for difference
T1 WHO-5 13.04 (4.48) 52.2 12.53 (4.68) 50.1 0.09
T2 WHO-5 14.91 (4.23) 59.6 12.59 (4.92) 50.4 2.32 1.06, 3.56
T3 WHO-5 15.08 (4.61) 60.3 12.64 (4.30) 50.6 2.44 1.23, 3.64
T1 weeks -2 to 0, T2
weeks 8 to 10, T3 weeks 12 to 14 plt0.05,
plt0.01, plt0.001
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Clinical significance for WHO-5
WHO-5 mean (SD) score Intervention (N102) Control (N110) Level of clinical significance in (changes of 10 are significant)
T1 WHO-5 52.2 50.1 1.1
T2 WHO-5 59.6 50.4 9.2
T3 WHO-5 60.3 50.6 9.7
T1 weeks -2 to 0, T2 weeks 8 to 10, T3
weeks 12 to 14
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Measurements of illness stress and life stress

• How difficult or stressful is your illness for
  you at the moment?
• Apart from your illness, have you had any recent
  events in your life which has affected you
  strongly or been particularly stressful?

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Perceptions of difficulty or stress caused by
breast cancer(independent sample t-tests)
Intervention Group Means (SD) Control Group Means (SD) Mean difference and p value CI 95 for difference
T1 4.20 (2.03) (N105) 4.11 (2.24) (N110) 0.09 -0.48, 0.67
T2 3.28 (2.20) (N92) 3.98 (2.24) (N104) -0.7 -1.32, -0.07
T3 2.63 (1.94) (N86) 3.64 (2.24) (N94) -1.01 -1.63, -0.40
plt0.05, plt0.01, plt0.001 T1 weeks -2 to
0, T2 weeks 8 to 10, T3 weeks 12 to
14 Perceptions of difficulty or stress from
other live events did not give significant
results.
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Themes from qualitative data (intervention group
only)
Main themes (N 92) ()
More mindful 92 (100)
Being calmer, centred, at peace, connected and more confident 30 (32.6)
The value and challenges of mindfulness practice 28 (30.4)
Being more aware 27 (29.3)
Coping with stress, anxiety and panic 27 (29.3)
Accepting things as they are, being less judgemental of myself and others 18 (19.6)
Improved communication and personal relationships 16 (17.4)
Making time and creating space for myself 15 (16.3)
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• Great to be supported through a difficult time
  and this (MBSR) has truly been a gift that I will
  always have and I think not only support me, but
  my family and friends because I will be in a
  better place

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How mindfulness helped with pain, stress and
anxiety

• I at first wondered if the programme was for me.
  After the first session, I was in tears, but
  Caroline convinced me to continue with the body
  scan and I did. It has helped me greatly with my
  pain (peripheral neuropathy for 18 months). Other
  practices have helped me with daily stress and
  remaining calm
• More aware now of anxious thoughts and their
  effects on the body. Aware of when I am reacting
  to thoughts in a stressed and anxious manner.

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Köszönöm