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Original article

Mindfulness-based Cancer Stress Management: impact of


a mindfulness-based programme on psychological distress
and quality of life
J.A. FISH, BPSYCH (HONS), RESEARCH AND EVALUATION ASSISTANT, Cancer Council SA, Eastwood, SA, K. ETTRIDGE, BPSYCH
(HONS), PHD, SENIOR RESEARCH OFFICER, Cancer Council SA, Eastwood, SA, G.R. SHARPLIN, BHSC (HONS), RESEARCH AND
EVALUATION OFFICER, Cancer Council SA, Eastwood, SA, B. HANCOCK, DIPNURS, DIPCOUNS&COMM, COUNSELLOR, Cancer
Council SA, Eastwood, SA, & V.E. KNOTT, BA (HONS), PHD, ASSISTANT PROFESSOR, Centre for Applied Psychology,
Faculty of Health, University of Canberra, Bruce, ACT, Australia
FISH J.A., ETTRIDGE K., SHARPLIN G.R., HANCOCK B. & KNOTT V.E. (2014) European Journal of Cancer
Care 23, 413421
Mindfulness-based Cancer Stress Management: impact of a mindfulness-based programme on psychological
distress and quality of life
Within the area of cancer care, mindfulness-based therapeutic interventions have been found to be efficacious
in reducing psychological distress related to a cancer diagnosis; however, the impact of mindfulness-based
interventions on quality of life is unclear. This study explores the impact of a Mindfulness-Based Cancer Stress
Management programme on psychological distress and quality of life. Research methodology included a
single-group quasi-experimental study of 26 participants experiencing distress related to a cancer diagnosis,
including carers, who completed an MBCSM programme and all assessments. Participants completed the
Functional Assessment of Cancer Therapy General version 4 (FACT-G) and its associated spirituality index
(FACIT-Sp-Ex), Hospital Anxiety and Depression Scale (HADS), Freiburg Mindfulness Inventory (FMI), and the
Distress Thermometer at baseline, post-intervention, and three months after programme completion. Significant improvements were observed on all measures (ranges: P 0.001 to 0.008, r = 0.53 to 0.79) following the
intervention, which were maintained at 3-month follow-up. Mindfulness was significantly correlated with
all main outcome measures at post-intervention (range: r = 0.41 to 0.67) and 3-month follow-up (range: r = 0.49
to 0.73), providing evidence for the internal validity of the study. Our findings indicate that the MBCSM
programme is effective in reducing psychological distress and improving quality of life, including spiritual
well-being.

Keywords: cancer, oncology, mindfulness, quality of life, anxiety, depression.

INTRODUCTION
Across different stages of the cancer trajectory many
cancer patients and carers experience cancer-related

Correspondence address: Jennifer A. Fish, Cancer Council SA, 202 Greenhill


Road, Eastwood, SA 5063, Australia (e-mail: jfish@cancersa.org.au).

Accepted 23 August 2013


DOI: 10.1111/ecc.12136
European Journal of Cancer Care, 2014, 23, 413421

2013 John Wiley & Sons Ltd

psychological distress, including anxiety, depression,


and/or global psychological distress (Zabora et al. 2001;
Chambers et al. 2012b). It is estimated that approximately
one-third of cancer survivors experience clinically significant anxiety or depression, with varied prevalence rates
across different cancer diagnoses (Zabora et al. 2001;
Brintzenhofe-Szoc et al. 2009; Boyes et al. 2011). While for
some cancer survivors there is a reduction in cancerrelated psychological distress over time, for others it may
be ongoing (Carlson et al. 2013).

FISH ET AL.

Within the area of cancer care, psychological distress


has been proposed as the sixth vital sign for well-being
(Bultz & Carlson 2006) and increased psychological distress has been significantly associated with reduced
quality of life (Skarstein et al. 2000). Quality of life is a
subjective and multidimensional construct, commonly
incorporating emotional, physical, functional and global
well-being. Cella and Cherin (cited in Cella & Tulsky
1993, p. 329) define quality of life as patients appraisal of
and satisfaction with their current level of functioning
compared to what they perceive to be possible or ideal.
A number of psychosocial interventions have been
found to positively impact on psychological distress and
quality of life in adult cancer patients (Rehse & Pukrop
2003; Osborn et al. 2006), with mindfulness-based therapy
recently experiencing an increase in popularity within
cancer care (Piet et al. 2012). Mindfulness-based therapy is
centred upon mindful awareness and meditation practice,
which entails bringing regular awareness to internal sensations, emotions, and thoughts in a watchful, accepting,
and non-judgemental way (Baer 2007; Shapiro & Carlson
2009). It has been speculated that mindfulness practice
may reduce cancer-related psychological distress through
the focus on the present moment, reducing rumination
over the disease and fears for the future (Piet et al. 2012).
The two most widely used mindfulness interventions
are Mindfulness Based Stress Reduction (MBSR) developed
by Kabat-Zinn (1990), and Mindfulness Based Cognitive
Therapy (MBCT), developed by Segal et al.(2002). The
MBSR programme utilises mindfulness techniques to
manage pain, reduce psychological stress and increase
overall well-being in people living with a chronic disease,
including cancer (Kabat-Zinn 1990). MBCT is an adaptation of MBSR that includes a greater focus on recurrent
depression and relapse prevention, using a combination of
mindfulness meditation practice and cognitive therapy to
reduce rumination and fusion with negative thoughts
(Segal et al. 2002). Both MBSR and MBCT have been found
to have a positive impact on psychological distress in
cancer patients (Ott et al. 2006; Ledesma & Kumano 2009;
Shennan et al. 2011; Piet et al. 2012); however, the effectiveness of these interventions to improve quality of life is
unclear.
A number of recent studies have evaluated the impact
of MBSR on global quality of life and various well-being
subdomains with conflicting results. A series of papers
by Carlson and colleagues (Carlson et al. 2003, 2004,
2007) found a significant improvement in global quality of
life directly following an MBSR programme, however, no
improvements were observed in the specific domains of
physical, emotional, or cognitive functioning. Lengacher
414

et al. (2009) also failed to observe a significant difference


in emotional well-being between treatment groups at
post-intervention, but noted significantly greater improvements in physical functioning, physical role limitations,
and energy scores in comparison to usual care. Yet in a later
study, Lengacher et al. (2011) found a reversed pattern of
results, with significant improvements in emotional wellbeing and general health observed directly following an
MBSR programme, but no significant changes in physical
functioning, physical role limitations, or energy. MBSR has
also been found to increase spiritual well-being in comparison to usual care and a nutritional education programme
(Henderson et al. 2012, 2013).
Several controlled studies have observed greater
improvements in quality of life for mindfulness-based
groups in comparison to groups receiving usual care.
Lerman et al. (2012) found a significant improvement on
global quality of life from baseline to post-intervention
for MBSR participants, which was not observed for the
control group. Witek-Janusek et al. (2008) reported significantly greater global quality of life for MBSR participants
in comparison to participants in the control group. Similarly, Foley et al. (2010) also reported a trend for an MBCT
treatment group to improve more than the waitlist control
group on global quality of life from baseline to postintervention. However, among all of these studies interaction effects between time and treatment group were not
significant suggesting that there was non-equivalence
between treatment and control groups on the global
quality of life measure.
Research regarding the impact of MBCT on quality
of life has also been mixed. In a pilot study sampling
advanced prostate cancer patients, Chambers et al. (2012a)
found no significant improvement on global quality of life
or well-being subscales from baseline to post-intervention or 3-month follow-up. In contrast, van der Lee and
Garssen (2012) found that, controlling for baseline level
of well-being, cancer patients in a treatment group had
significantly higher well-being in comparison to those
in a waiting-list control group following a modified
MBCT programme, which further improved at 6-month
follow-up.
Discrepant evidence across mindfulness-based studies
may have occurred for a number of reasons, including
variations in research design, sampling, measures used,
or programme specifications. For instance, quality of
life outcome measures were largely heterogeneous across
studies, including a variety of subscales. Thus, studies
conceptually defined quality of life in different ways and
are difficult to compare (Pukrop et al. 2000). Furthermore,
observed effects in uncontrolled studies may be due to
2013 John Wiley & Sons Ltd

Mindfulness-based Cancer Stress Management

an unmeasured variable rather than the intervention,


which cannot be determined without a control condition.
Overall, research indicates that mindfulness-based
therapy has the potential to improve quality of life and
well-being; however, additional studies are necessary to
confirm the impact of mindfulness-based therapy on such
constructs.
This article presents a follow-up study to pilot research
conducted by Sharplin et al. (2010), which assessed the
impact of an 8-week MBCT programme on psychological
distress with individuals experiencing cancer-related psychological distress, including carers. The study found a
significant reduction in anxiety across all clinical levels,
and a clinically significant change in depression for those
with moderate to severe depression. Feedback also
revealed that a selection of participants did not relate to
the session focussed upon depression (e.g. the cognitive
therapy element of the programme). Accordingly, the
MBCT programme was modified by reducing the focus
on depression, and incorporating a greater focus on stress
management and cancer survivorship.
The aim of the present study was to evaluate the impact
of a unique Mindfulness-based Cancer Stress Management
(MBCSM) programme on depression, anxiety and stress
for individuals affected by cancer. A secondary aim was to
evaluate the impact of the MBCSM programme on quality
of life and spiritual well-being.

METHODOLOGY
The present study utilised similar methodology to the
pilot study (Sharplin et al. 2010), such that it was a singlegroup quasi-experimental study of participants directly
(i.e. cancer patients and survivors) and indirectly affected
by cancer (i.e. carers), recruited through Cancer Council
SAs Cancer Helpline. Participants were assessed for
global psychological distress, anxiety, depression, and
quality of life before and after an MBCSM programme.

Sample
Between June 2010 and July 2011 clients experiencing
psychological distress (i.e. anxiety, depression, or global
psychological distress) related to a cancer diagnosis,
including carers, were recruited into the MBCSM programme evaluation study. Promotional fliers were distributed at oncology treatment centres in South Australia in
conjunction with promotion through the CCSA Progress
newsletter, Cancer Council SAs support programmes and
Cancer Helpline, and through a psychologist based at an
Adelaide Breast Cancer Centre.
2013 John Wiley & Sons Ltd

Registration of interest in the study occurred through


the Cancer Council Helpline. The programme facilitator
contacted the client via mail and telephone to provide
further detail regarding the study and to establish the
suitability of the programme for the client. Clients were
eligible to participate if they: (1) were over the age of 18,
(2) had either completed treatment or having treatment
with few side effects), (3) were not currently experiencing
psychosis, (4) had no active alcohol or drug dependency, (5)
were willing to undertake practice at home, and (6) saw no
foreseeable barrier to attending at least six sessions.
Procedure
Ethics approval was gained from Cancer Council SAs
Human Research Ethics Committee. All participants
provided consent to participate in the research prior to
programme commencement.
Prior to programme commencement participants
received a final confirmation letter, consent form, and
baseline questionnaire in the mail. Baseline questionnaires
and consent forms were returned at the first session.
Post-intervention questionnaires were distributed at the
final session (session 8) for postal return. A reminder postintervention pack was mailed to participants who had not
returned their questionnaire 2 weeks following the programme. Three months following the final session, a
follow-up questionnaire was mailed to participants who
had completed both baseline and post-intervention questionnaires for postal return. A reminder follow-up pack was
mailed to participants 2 weeks after if the follow-up questionnaire had not yet been returned.
Mindfulness-Based Cancer Stress
Management programme
Across 2010 and 2011, four MBCSM programmes were run
for clients experiencing psychological distress related
to a cancer diagnosis, including carers. Each group had
between nine and thirteen clients.
The MBCSM programme is a modified version of MBCT
as developed by Segal et al. (2002). Modifications were
actioned in response to findings from a pilot study by
Sharplin et al. (2010). The programme, which was originally structured to assist those with depression and
anxiety following a history of cancer, was altered to incorporate elements of MBSR as developed by Kabat-Zinn
(1990). Specifically, session four was altered from that
delivered in the pilot study to include education concerning the psycho neuroimmunology of stress, and an exploration of the cancer survivorship experience within the
context of anxiety, depression and stress.
415

FISH ET AL.

The programme involved eight, 2-h weekly sessions,


each providing instruction in mindfulness exercises by
an experienced counsellor trained in MBCT. Clients were
also asked to complete approximately 40 min of meditation a day with the aid of notes, practice CDs, and homework sheets. In addition, a 3-h follow-up session was
offered to clients 6 weeks after completion of the programme to revisit skills learnt in the programme, and
encourage clients to share their experiences of their own
mindfulness-based practice.

Measures
Psychological distress
Global psychological distress was measured using a visual
analogue Distress Thermometer (DT) scale. Participants
were asked to indicate how much distress they had experienced in the past week on a scale of 0 (no distress) to 10
(extreme distress). The DT has been shown to be a psychometrically sound measure of global psychological distress with cancer patients and carers, with a score of four
or above signifying clinically significant distress (Ransom
et al. 2006; Gessler et al. 2008; Zwahlen et al. 2008).
Levels of anxiety and depression were measured with
the self-administered Hospital Anxiety and Depression
Scale (HADS). The HADS contains two interwoven sevenitem subscales designed to measure possible cases of
depression (HADS-D) and anxiety (HADS-A). Items are
scored on a four-point scale (03), with subscale scores
ranging from 0 to 21 on both the HADS-A and HADS-D.
For HADS-A, a score of 9 or above indicates a possible or
probable case of anxiety, while for HADS-D the optimal
cut-off score for caseness is 8 or above (Bjelland et al.
2002). The HADS has demonstrated validity and reliability in various medical populations, including cancer
(Zigmond & Snaith 1983; Herrmann 1997; Bjelland et al.
2002).

Quality of life and spiritual well-being


For participants directly affected by cancer, quality of life
was measured with The Functional Assessment of Cancer
Therapy General version 4 (FACT-G). The FACT-G is a
27-item multidimensional questionnaire assessing four
domains: physical well-being (score range 028), social/
family well-being (score range 028), emotional well-being
(score range 024), and functional well-being (score range
028). Subscale scores are summed to reach a total FACT-G
score (score range 0108). It has demonstrated reliability
and validity with cancer patients (Cella et al. 1993).
416

For carers, quality of life was measured using the Functional Assessment of Cancer Therapy General Population version 4 (FACT-GP). The FACT-GP is a 21-item
questionnaire, which is identical to the FACT-G, except
for the removal of six illness-related items. Adjustments
to the scoring procedure were made in order for scores to
be comparable to FACT-G scores.
For all participants spiritual well-being was measured
with The Functional Assessment of Chronic Illness
Therapy Spiritual Well-being version 4 (FACIT-Sp-Ex), a
23-item questionnaire (score range 092) that addresses
religious/spiritual aspects of quality of life. The 12-item
FACIT-Sp-12, which is embedded within the expanded
FACIT-Sp, has demonstrated validity and reliability with
cancer patients (Peterman et al. 2002). While psychometric
testing of the expanded FACIT-Sp is currently underway
(Peterman et al. 2002), in this study the FACIT-Sp-Ex had
high internal consistency reliability at each time point ( =
0.950.97) and was considered to have good face validity.

Mindfulness
Mindfulness was measured with the short-form Freiburg
Mindfulness Inventory (FMI), a 14-item psychometrically
sound self-report measure of mindfulness qualities such as
awareness of the present moment, non-judgmental accepting attitude, and openness to negative states (Walach et al.
2006). Items are scored on a four-point scale (14), with a
score range of 1456.

Statistical analysis
Significance values were set at P < 0.05 unless otherwise
stated. Analyses were conducted using PASW Statistics
17.0 (SPSS, Chicago, Illinois, USA, 2009).
Exploratory tests revealed non-normally distributed
data for a number of measures, which was observed when
using both raw and adjusted univariate outlier scores
(Tabachnick & Fidell 2007). Furthermore, results were
comparable for statistical analyses conducted with both
raw and adjusted outlier scores. As such, all subsequent
non-parametric analyses use raw scores, including unadjusted univariate outlier scores.
Due to the distribution of the data, to assess the impact
of the MBCSM programme over time, a series of
Friedmans anovas were run with post-hoc analyses conducted with the Wilcoxon Signed Rank Test. A Bonferroni
correction was applied; therefore, post-hoc analyses were
considered significant at P < 0.017. Pearsons r effect sizes
for non-parametric tests were calculated, with 0.10, 0.30
and 0.50 considered small, medium, and large effect sizes
2013 John Wiley & Sons Ltd

Mindfulness-based Cancer Stress Management

respectively (Cohen 2009). To assess the internal validity


of the intervention a series of correlations were conducted
with Spearmans Rank Order Coefficients and a coefficient of determination was calculated for each time point.

RESULTS
Participants
Fifty-three clients were recruited into four MBCSM programmes, of which 47 completed a baseline questionnaire
and 26 (55%) completed all three stages of the study. Of
the 26 participants who completed all stages of the evaluation, all attended at least five sessions, with 24 (92%)
attending at least six of the eight sessions.
Twenty-one participants were directly affected by
cancer (81%) and five were carers (19%). The majority of
participants were female (n = 20; 77%), married or in de
facto relationships (n = 21; 81%), and had completed tertiary education (n = 19; 73%). The most predominant
cancer type reported was breast cancer (n = 11; 42%).
Participant ages ranged from 38 to 79 years, with a mean
age of 56 (SD = 11). Time since diagnosis ranged from 2
months to 84 months (M = 25 months, SD = 29 months).
Exploratory analyses indicated that there were no significant differences between baseline scores across sociodemographic groups. Specifically, global psychological
distress, anxiety, depression, quality of life and mindfulness scores did not vary significantly according to gender
(P > 0.06), client type (P > 0.23), educational level (P >
0.05), or relationship status (P > 0.39).

Psychological distress
A series of Friedmans anovas indicated that there were
significant differences in levels of global psychological
distress [2(2) = 11.49, P = 0.003], anxiety [2(2) = 22.33, P <
0.001], and depression [2(2) = 9.58, P = 0.008; see Table 1]
over time. Post-hoc analyses revealed that scores were
significantly higher at baseline than at post-intervention
for levels of global distress (P = 0.004), anxiety (P < 0.001),
and depression (P = 0.008), with levels maintained from
baseline to follow-up assessment for global distress (P =
0.004), anxiety (P = 0.001), and depression (P = 0.008).

Quality of life and spiritual well-being


Global quality of life [2(2) = 19.44, P < 0.001] and spiritual
well-being [2(2) = 16.95, P < 0.001] significantly improved
over time (see Table 1). Post-intervention scores were significantly higher than baseline scores for both quality of
life (P < 0.001) and spiritual well-being (P = 0.001), which
was maintained from baseline to follow-up assessment
(P < 0.001 and P = 0.003 respectively).
In addition, significant differences were found over time
on subscales of emotional well-being [2(2) = 21.78, P <
0.001], physical well-being [2(2) = 6.20, P = 0.045], and
functional well-being [2(2) = 18.06, P < 0.001]. Both emotional well-being (P < 0.001) and functional well-being
scores (P = 0.002) were significantly higher at postintervention than at baseline assessment, which was
maintained from baseline to follow-up assessment (P <
0.001 and P = 0.001 respectively). There was a trend for

Table 1. Results of Friedmans anovas and effect sizes for measures of psychological distress, quality of life, and mindfulness

DT (n = 22)
HADS-A (n = 25)
HADS-D (n = 25)
FACT-G (n = 25)
Emotional well-being
subscale (n = 25)
Social well-being
subscale (n = 26)
Physical well-being
subscale (n = 26)
Functional well-being
subscale (n = 26)
FACIT-Sp-Ex (n = 20)
FMI (n = 25)

Pre-treatment

Post-treatment

Follow-up

Mdn (IQR)

Mdn (IQR)

Pre-post
z-score

Pre-post
r

Mdn (IQR)

Pre-fu
z-score

Pre-fu
r

5.50 (2.757.00)
10.00 (7.0011.50)
6.00 (3.009.50)
74.00 (63.0085.00)
15.00 (11.0019.00)

2.00 (1.004.00)
5.00 (3.008.00)
4.00 (1.007.00)
87.42 (72.5093.04)
19.50 (17.4021.00)

2.89
3.97
2.65
3.70
3.98

0.62
0.79
0.53
0.74
0.80

2.00 (1.004.00)
6.00 (5.008.00)
2.00 (1.006.50)
87.87 (71.8395.50)
19.50 (15.5021.00)

2.89
3.31
2.67
3.51
3.66

0.62
0.66
0.53
0.70
0.73

19.00 (16.1924.00)

23.40 (16.7526.25)

1.92

0.38

21.00 (16.6026.00)

1.36

0.27

21.50 (18.7526.00)

24.00 (21.0025.67)

2.03

0.40

24.75 (18.5026.88)

2.52

0.49

17.50 (14.0021.75)

20.50 (16.7523.25)

3.15

0.62

22.00 (16.8326.25)

3.23

0.63

61.50 (47.8373.57)
35.00 (27.0041.00)

76.00 (52.2584.51)
39.00 (36.5044.00)

3.44
3.78

0.77
0.76

71.07 (59.6678.00)
40.00 (36.5046.00)

2.97
3.58

0.66
0.72

Note. Mdn = Median, z-score = Standardised value, r = Pearsons r effect size for non-parametric tests; IQR = interquartile range.
DT, Distress Thermometer; FACIT-Sp-Ex, The Functional Assessment of Chronic Illness Therapy Spiritual Well-being version 4;
FACT-G, the Functional Assessment of Cancer Therapy General version 4; FMI, Freiburg Mindfulness Inventory; HADS-A, Hospital
Anxiety and Depression Scale-Anxiety; HADS-D, Hospital Anxiety and Depression Scale-Depression.

2013 John Wiley & Sons Ltd

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FISH ET AL.

improvement in physical well-being from baseline to postintervention (P = 0.042), which reached significance at
follow-up (P = 0.012). Social well-being did not significantly change over time (P = 0.096).

Mindfulness
Mindfulness scores changed significantly over time [2(2)
= 16.33, P < 0.001; see Table 1]. Level of mindfulness was
significantly lower at baseline assessment than at postintervention (P < 0.001), which was maintained from
baseline to follow-up assessment (P < 0.001). To assess the
internal validity of the intervention a series of Spearmans
Rho correlations were conducted. Additionally, coefficients of determination were calculated to examine the
proportion of variance in ranks accounted for by level of
mindfulness across measures of psychological distress and
quality of life.
There were significant negative correlations for level of
mindfulness with levels of global distress and anxiety at
post-intervention and follow-up, and with level of depression at all time points (see Table 2). For levels of anxiety
and depression, the proportion of variance in ranks
accounted for by level of mindfulness increased at each
time point from baseline to follow-up. For level of global
psychological distress, the proportion of variance in ranks
accounted for by level of mindfulness increased from baseline to post-intervention, with a slight decrease from postintervention to follow-up.

Mindfulness was significantly positively correlated


with global quality of life at all time points, and with
spiritual well-being at post-intervention and follow-up.
For both global quality of life and spiritual well-being the
proportion of variance in ranks accounted for by level of
mindfulness increased from baseline to follow-up, with
5053% shared variance in ranks at follow-up.

DISCUSSION
The primary aim of the present study was to evaluate the
impact of an MBCSM programme on cancer-related psychological distress. Overall, the results of this study were
positive with significant improvement observed in levels
of global distress, anxiety, and depression from baseline to
post-intervention. Moreover, improvements in psychological distress were sustained up until three months after
the intervention. This supports preliminary research by
Sharplin et al. (2010), who found a significant and sustained improvement in depression and anxiety levels
following an MBCT programme. Thus, in line with the
growing body of research, this study provides further
support for the effectiveness of mindfulness-based therapeutic approaches in the treatment of cancer-related psychological distress (Ott et al. 2006; Ledesma & Kumano
2009; Shennan et al. 2011; Piet et al. 2012).
A secondary aim of the study was to evaluate the impact
of the MBCSM programme on quality of life, including
spiritual well-being. Results indicated that there was a

Table 2. Results of Spearmans Rank Order Coefficients for mindfulness and all other measures at pre-intervention, post-intervention and
3-month follow-up
FMI scores
DT scores

HADS-A scores

HADS-D scores

FACT-G scores

FACIT-Sp-Ex scores

Pre-intervention
Post-intervention
Follow-up
Pre-intervention
Post-intervention
Follow-up
Pre-intervention
Post-intervention
Follow-up
Pre-intervention
Post-intervention
Follow-up
Pre-intervention
Post-intervention
Follow-up

rs

Rs2 (%)

P-value*

0.36
0.61
0.53
0.22
0.41
0.49
0.46
0.52
0.58
0.62
0.67
0.73
0.40
0.60
0.71

13
37
28
5
17
24
21
27
34
38
45
53
16
36
50

0.084
0.002
0.008
0.302
0.043
0.011
0.020
0.008
0.002
0.001
<0.001
<0.001
0.075
0.005
<0.001

Note. rs = Spearmans Rank Order Coefficient. Rs2 = proportion of shared variance between ranks.
*Probability of the observed values occurring assuming that the null hypothesis is true.
DT, Distress Thermometer; FACIT-Sp-Ex, The Functional Assessment of Chronic Illness Therapy Spiritual Well-being version 4;
FACT-G, the Functional Assessment of Cancer Therapy General version 4; FMI, Freiburg Mindfulness Inventory; HADS-A, Hospital
Anxiety and Depression Scale-Anxiety; HADS-D, Hospital Anxiety and Depression Scale-Depression.

418

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Mindfulness-based Cancer Stress Management

significant improvement in global quality of life, emotional well-being, functional well-being, and spiritual
well-being from baseline to post-intervention, with
improvements maintained at follow-up assessment.
Improvement in physical well-being approached significance post-intervention and was significant at follow-up
compared to baseline data. Our results are consistent with
studies that found improved global quality of life (Carlson
et al. 2003, 2004, 2007; van der Lee & Garssen 2012) and
well-being across various subdomains (Lengacher et al.
2009, 2011; Henderson et al. 2012, 2013), thus providing
support for the proposal that mindfulness-based therapy is
effective in improving quality of life for individuals experiencing cancer-related psychological distress.
Our findings, however, are inconsistent with a number
of previous studies that found limited evidence for
improved quality of life following a mindfulness-based
programme. Chambers et al. (2012a) reported a nonsignificant change in quality of life following a MBCT
programme for advanced prostate cancer patients. Further,
several controlled trials (Witek-Janusek et al. 2008; Foley
et al. 2010; Lerman et al. 2012) reported a non-significant
interaction between time and treatment group on global
quality of life. Inconsistent results may be due to numerous methodological differences across studies, including
variations in specific types of cancer targeted, research
design, measures used, and particular elements including
the programme utilised. For instance, quality of life measures varied across studies and thus, was conceptualised in
different ways across the literature. It could be speculated
that the improved quality of life outcomes observed
in this study were attributable to the use of a unique
MBCSM programme, which was specifically designed to
address issues of relevance to living with and surviving
cancer. As noted previously, the programme drew upon
elements of both MBCT (e.g. ruminative thought cycle)
and MBSR (e.g. psycho-neuroimmunology of stress), and
was adapted based on feedback (Sharplin et al. 2010) and
with the intention of best meeting the needs of clients. In
the absence of a control condition, however, it is difficult
to draw conclusions regarding the effects of particular
elements of the programme.
Mindfulness significantly improved from baseline to
post-intervention and this improvement was maintained
at follow-up. Results also indicated that as level of mindfulness increased at post-intervention and follow-up,
levels of global distress, anxiety, and depression decreased,
with a substantial proportion (2434%) of variation in
these constructs (as indicated by rank) explained by level
of mindfulness at follow-up. Moreover, mindfulness was
positively associated with quality of life and spirituality
2013 John Wiley & Sons Ltd

at post-intervention and follow-up, such that as level of


mindfulness improved, quality of life and spirituality also
improved, with mindfulness explaining over half (50
53%) of the variation observed in these constructs (as
indicated by rank) at follow-up.
The present study had several limitations that are
important to take into consideration when interpreting
results. First, a control group was not included in the
study design due to ethical and practical considerations.
There were insufficient enrolment numbers to warrant a
concurrent waiting-list group, and, therefore, to employ a
waiting-list control group, clients on a waiting list would
have had to wait a considerable length of time to receive
intervention. Withholding care from individuals experiencing psychological distress for a prolonged period was
considered unethical, particularly in light of the positive
results achieved in the pilot study (Sharplin et al. 2010). It
is therefore possible that the effects observed in this study,
especially in relation to psychological distress, are due to
the passing of time or an unmeasured variable.
Nevertheless, there appeared to be an increasingly
strong link between mindfulness and psychosocial functioning over the course of the study, as demonstrated by
significant correlations. These associations provide strong
support for the internal validity of the intervention, that
is, the intervention systematically increased participants
levels of mindfulness across the intervention and the benefits of this were evident in the improvements in wellbeing and quality of life observed. There was a slight drop
in the extent of variance accounted for in global distress
scores, which may underscore the need for ongoing
booster sessions in mindfulness training. Conversely, the
drop in variance accounted for may have occurred due to
changes in experiences of the participants, such that some
may have experienced increased global distress as a result
of factors external to the intervention.
Second, a significant dropout rate was also observed
over the duration of the study, with 45% of participants
who completed a baseline questionnaire not completing
the evaluation. The socio-demographic characteristics and
baseline scores on psychological and well-being measures
did not significantly differ between participants who completed the study and those who did not. Lastly, few carers
participated in the programme, thus the ability to generalise the results regarding the effectiveness of the programme to improve psychosocial functioning in carers is
unclear. Due to the high levels of cancer-related psychological distress experienced by some carers (Pitceathly &
Maguire 2003; Hodges et al. 2005), further research is
needed to determine the effectiveness of mindfulnessbased therapy for this group.
419

FISH ET AL.

Despite these limitations, the results of this study indicate that the MBCSM programme is effective in improving psychosocial functioning for individuals experiencing
cancer-related psychological distress. Levels of anxiety,
depression, and global distress were significantly reduced
following the MBCSM programme, which were maintained at follow-up. Additionally, significant and sustained improvements were observed in global quality
of life, emotional well-being, functional well-being, and
spiritual well-being. A modest improvement in physical
well-being was also observed over the course of the study.

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