The acceptability and potential benefits of mindfulness-based interventions in improving psychological well-being for adults with advanced cancer: A systematic review

Highlights

• This article describes, evaluates and synthesises the acceptability and potential benefits of MBIs for advanced cancer patients.

• The number of studies identified was notably small, and logistical problems and limitations were reported.

• Adaptations to the MBIs must be considered to allow patients to participate in this kind of treatment.

• The ethical and methodological obstacles identified provide insights of what kind of MBIs may appropriately address this population needs.

Abstract

Objective

In spite of supportive care for people affected by cancer being well recognized as a priority for research, there is little solid evidence of the effectiveness of psychological interventions using mindfulness for those with advanced cancer. This systematic review aims to describe, evaluate and synthesize the acceptability and potential benefits of mindfulness-based interventions (MBIs) for the psychological well-being of people with advanced cancers.

Methods

Eight databases were searched and terms related to advanced stages of cancer and mindfulness were combined systematically to identify relevant published literature. Inclusion criteria were studies with adults only and all types of cancer at stages III and IV. There was considerable variety in the MBI treatment packages including in the extent and centrality of mindfulness in the interventions.

Results

Of 312 identified studies, only 8 included MBIs for people with advanced cancer rather than their families or carers. Results from these studies suggests that MBIs are acceptable and beneficial to the advanced cancer population, improving quality of life, use of mindfulness skills, acceptance of their cancer situation and reduction in depression and anxiety. Some adaptations were recommended however regarding delivery, simplified briefer MBIs, abbreviated session time, flexibility concerning locality of treatment and a minimized questionnaire burden for this group.

Conclusions

MBI packages reviewed in this study had evidence of acceptability and of effectiveness, indicating potential benefit for this population. Individualized, including home-based interventions may be optimal to allow critically ill patients to participate in treatment. In future, MBIs adapted to the needs of various advanced cancer patients are recommended to address the gap in the field and improve health care.

Introduction

Mindfulness meditation was initially developed and applied to those with significant medical conditions by Jon Kabat-Zinn in 1979, with the results published in 1982 [1]. Numerous subsequent studies have shown considerable evidence about the benefits of practicing mindfulness meditation for those who face a range of health problems [2], [3], [4]. Cancer is one of these conditions that often leads to mental distress, worries, fear for the future, shock, hopelessness, anger, a sense of unfairness, and sometimes denial [5]. For some people, avoidance of the implications of their diagnosis is the only way they see to keep living.

Denying the diagnosis does not change the fact that the cancer is present at an advanced stage so moving to a position of acceptance can be an important element of an active coping process. With an attitude of acceptance, the person can embrace all kinds of experiences, including the negative ones, though the concept of acceptance in this sense should not be confused with pessimism, giving-up or resignation [6].

Advanced cancer is by definition unlikely to be cured [7], [8], and the diagnosis of a life-threatening illness has a significant impact on an individual's life. Apart from the physical suffering during the processes of surgery, chemotherapy and radiotherapy, emotional suffering is great, affecting not only the patient but their families, caregivers, partners, friends and community. Being diagnosed with advanced cancer is a very frightening experience; for some it may be a slowly progressing illness, for others it is more rapid [8]. Emotional reactions and existential questions arise when the patient becomes aware of the disease's progression. At the end of life, patients usually experience many physical changes, but in addition to that, a sense of loss, altered roles, difficulty in achieving goals, and awareness of the distress of loved ones, all compounding the levels of distress and suffering [9].

These symptoms and effects of the disease course, however, may be moderated by the use of adaptive coping strategies, the best outcome being a positive adjustment that allows for personal growth and resilient coping with a difficult situations [10]. In order to cope with stressful situations, mindfulness is increasingly being used for stress reduction. Mindfulness is “the awareness that emerges through paying attention on purpose, in the present moment, and non-judgmentally to the unfolding of experience moment by moment” ([11] p145).

Through mindfulness practice a decentered perspective is reinforced, where a shift is made from perceiving negative thoughts as distressing or dangerous to being seen as impersonal and part of a process [12]. Mindfulness meditation also cultivates the ability to be in the present moment, in an accepting and non-judgmental way [13]. The formal Mindfulness-Based Stress Reduction (MBSR) program, devised in the 1990s, has been widely adopted in clinical settings [14], [15], [16], [17], [18]. The program is an eight week course of 2.5 h of mindfulness sessions per week usually delivered in groups, and an 8-h retreat day of silent mindful practice, usually delivered in groups [19].

There are numerous studies of mindfulness-based interventions (MBIs) used for patients with different types of cancer, mostly in the early stages of the illness [16], [17], [18], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29]. Very few of these studies, however, have involved patients with advanced stages of cancer, despite the fact that these patients are facing the greatest challenge in coping with incurable, end-stage cancer [30]. The complexity of undertaking research with this specific group has meant that until recently there has been little solid evidence of the effectiveness of psychological treatments for those affected by advanced stages of cancer [31].

Patients with advanced or incurable cancer have higher levels of need for support than patients whose cancer has stopped growing, therefore it is advantageous if psychological interventions are tailored to those patients who require them the most. In the United Kingdom, psychological adjustment to a diagnosis of incurable cancer has long been identified by the National Health Services research strategists as a priority area for research [32].

There is now an emerging body of research trials on the delivery of psychological interventions to advanced cancer populations. These include Dignity Therapy [33], Meaning and Purpose Therapy (MaP) [34] Meaning-Centered Psychotherapy Palliative Care version (MCP-PC) [35], Managing Cancer and Living Meaningfully (CALM) [36], Meaning-Centered Group Psychotherapy (MCGP) [37], Individual Meaning-Centered Psychotherapy (IMCP) [38], [39]. None of these trials included mindfulness components.

The practice of mindfulness involves nonjudgmental observation of the constantly changing stream of stimuli as they arise, including thoughts, memories, bodily sensations, and emotions. That is, people learn to notice all of these events as they occur, without making judgments about their relative worth or importance [40].

Advanced cancer patients commonly appear to oscillate between their present life situation and the reality of their future [41]. Some sources of stress for cancer patients however relate to concerns about the past: these might include attributions about cancer causation or regrets about past decisions or weighing life priorities; other worries are related to the future. A fundamental aspect of mindfulness meditation that may have particular salience for cancer patients is the ‘here-and-now’ orientation, that is, the “radical insistence” on paying attention to present-moment reality [15]. Regarding the fear that life could end at any moment, a study reported that cancer patients cope better with their situation by refraining from forming expectations and choosing to live one day at a time to avoid disappointment [5]. This ability to live one day at a time is consistent with cultivating the present moment practiced in MBIs. Other relevant mindful coping skills of potential benefit to the cancer population may include awareness of the present moment, constructive self-distraction and a non-judgemental acceptance of situation [42].

This systematic review aims to describe, evaluate and synthesize the peer-reviewed literature on the acceptability and potential benefits of MBIs on the psychological well-being of those with advanced stages of cancer, in order to contribute insights for further improvement in delivering psychological interventions to this group.