Mindfulness-Based Stress Reduction on breast cancer symptoms: systematic review and meta-analysis

Castanhel, Flavia Del; Liberali, Rafaela

doi:10.31744/einstein_journal/2018RW4383

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Review • EINSEinstein (São Paulo) 16 (4) • 2018 • https://doi.org/10.31744/einstein_journal/2018RW4383 copy

Mindfulness-Based Stress Reduction on breast cancer symptoms: systematic review and meta-analysis

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Mindfulness-Based Stress Reduction practices increase the capacity for concentration and attention, and these practices are particularly effective for people with breast cancer. To analyze the effects of the application of Mindfulness-Based Stress Reduction on breast cancer symptoms. Systematic review and meta-analysis were carried out. To find suitable studies, the PubMed/ MEDLINE database was searched using the keywords “breast cancer” and “Mindfulness-Based Stress Reduction”. Studies included were published between 2013 and 2017, written in English and showed methodological quality through the PEDro scale (score greater than 3). They also presented empirical evidence, had an experimental study design (randomized or non-randomized), and had full text available. For the meta-analysis, we used a random-effects model, with standardized mean differences and 95% confidence intervals. Seven studies were included, one non-randomized and containing only an intervention group of Mindfulness-Based Stress Reduction, and six randomized including samples of two or three groups. The non-randomized study showed 6 points on the PEDro scale, the randomized studies of two groups 6 to 7 points and studies with three groups showed 7 points. In the meta-analysis of the two randomized studies, the results, although not significant, revealed a moderate effect for Mindfulness-Based Stress Reduction on the outcome of fatigue, with a mean difference of −0.42 (95%CI −0.92- −0.07; p=0.09). Mindfulness-Based Stress Reduction seems to be a promising alternative for treatment of this disease's symptoms.

Keywords:
Meditation; Breast neoplasms; Stress, psychological; Psychosocial intervention; Quality of life

All criteria	Yes/No	Score
Eligibility criteria were specified	Yes/No	1/0
Subjects were randomly allocated into groups (in a crossover study, subjects were randomly allocated in the order in which treatments were received)	Yes/No	1/0
Allocation was concealed	Yes/No	1/0
The groups were similar at baseline regarding the most important prognostic indicators	Yes/No	1/0
There was blinding of all subjects	Yes/No	1/0
There was blinding of all therapists who administered the therapy	Yes/No	1/0
There was blinding of all assessors who measured at least one key outcome	Yes/No	1/0
Measures of at least one key outcome were obtained from more than 85% of the subjects initially allocated to groups	Yes/No	1/0
All subjects for whom outcome measures were available received the treatment or control condition as allocated or, if this was not the case, data for at least one key outcome was analyzed by “intention to treat”	Yes/No	1/0
The results of between-group statistical comparisons are reported for at least one key outcome	Yes/No	1/0
The study provides both point measures and measures of variability for at least one key outcome	Yes/No	1/0
	Total	Total /11

Studies	Studies local	Questionnaire
Henderson et al.,⁽⁴⁶46. Henderson VP, Massion AO, Clemow L, Hurley TG, Druker S, Hébert JR. A randomized controlled trial of mindfulness-based stress reduction for women with early-stage breast cancer receiving radiotherapy. Integr Cancer Ther. 2013;12(5):404-13.⁾	4 practice sites of Massachusetts, United States	SCL-90-R, DWI
Reich et al.,⁽⁴⁷47. Reich RR, Lengacher CA, Kip KE, Shivers SC, Schell MJ, Shelton MM, et al. Baseline immune biomarkers as predictors of MBSR(BC) treatment success in off-treatment breast cancer patients. Biol Res Nurs. 2014;16(4):429-37.⁾	University of South Florida in Tampa, Florida, United States	MDASI
Rahmani et al.,⁽⁴⁸48. Rahmani S, Talepasand S, Ghanbary-Motlagh A. Comparison of effectiveness of the metacognition treatment and the mindfulness-based stress reduction treatment on global and specific life quality of women with breast cancer. Iran J Cancer Prev. 2014;7(4):184-96.⁾	Division of Oncology and Radiotherapy of Imam Hossein hospital in Tehran, Iran	EORTC QLQ-C30
Lengacher et al.,⁽⁴⁹49. Lengacher CA, Shelton MM, Reich RR, Barta MK, Johnson-Mallard V, Moscoso M, S.et al. Mindfulness based stress reduction (MBSR(BC)) in breast cancer: evaluating fear of recurrence (FOR) as a mediator of psychological and physical symptoms in a randomized control trial (RCT). J Behav Med. 2014;37(2):185-95.⁾	H. Lee Moffitt Cancer Center and Research Institute, in Tampa, Florida, United States	STAI; CAMSR
Eyles et al.,⁽⁵⁰50. Eyles C, Leydon GM, Hoffman CJ, Copson ER, Prescott P, Chorozoglou M, et al. Mindfulness for the self-Management of fatigue, anxiety, and depression in women with metastatic breast cancer: a mixed methods feasibility study. Integr Cancer Ther. 2015;14(1):42-56.⁾	3 local oncology, United Kingdom	BFI; HADS
Rahmani et al.,⁽⁵¹51. Rahmani S, Talepasand S. The effect of group mindfulness - based stress reduction program and conscious yoga on the fatigue severity and global and specific life quality in women with breast cancer. Med J Islam Repub Iran. 2015;29:175.⁾	Division of Oncology and Radiotherapy of Imam Hossein hospital in Tehran, Iran	FSS; EORTC QLQ-C30
Sarenmalm et al.,⁽⁵²52. Sarenmalm EK, Martensson LB, Andersson BA, Karlsson P, Bergh I. Mindfulness and its efficacy for psychological and biological responses in women with breast cancer. Cancer Med. 2017;6(5):1108-22.⁾	Research and Development Centre, Sweden	HADS

Author	PEDro scale criteria	Subjects	Intervention	Findings
Henderson et al.,⁽⁴⁶46. Henderson VP, Massion AO, Clemow L, Hurley TG, Druker S, Hébert JR. A randomized controlled trial of mindfulness-based stress reduction for women with early-stage breast cancer receiving radiotherapy. Integr Cancer Ther. 2013;12(5):404-13.⁾	7/11	163 women with stage I or II of breast cancer (20 to 65 years old)	G1 = UC (n=58) G2 = MBSR (breast cancer) (n=53) G3 = NEP (n=52) Follow-up: 4 months	Anxiety - SCL-90-R mean (SD) p value Follow-up: 4 months MBSR versus UC = 0.14 (0.05) versus 0.28 (0.05); p≤0.05 Depression - SCL-90-R mean (SD) p value Follow-up: 4 months MBSR versus NEP = 0.31 (0.08) versus 0.58 (0.08); p≤0.05
Reich et al.,⁽⁴⁷47. Reich RR, Lengacher CA, Kip KE, Shivers SC, Schell MJ, Shelton MM, et al. Baseline immune biomarkers as predictors of MBSR(BC) treatment success in off-treatment breast cancer patients. Biol Res Nurs. 2014;16(4):429-37.⁾	6/11	41 women with stage 0, I, II, or III of breast cancer (mean, SD) 58.2 (9.5) years old)	G1 = UC (n=24) + standard clinic visits G2 = MBSR^* * MBSR: Kabat-Zinn's original 8-week program, weekly 2-hours sessions.(39) The program includes three components: (a) educational materials and exercises related to meditation practices and the mind-body connection, (b) practice time and a CD on which verbal support for four meditative practices was recorded (sitting meditation, walking meditation, body scan, and gentle hatha yoga), and (c) opportunity for group discussion, including time to answer questions related to barriers with formal and informal practice. Participants were asked to spend 15 to 45 minutes daily outside of the group sessions for formal and informal practice and to record their daily practice in a diary. Formal mindfulness practice includes sitting meditation, walking meditation, body scan, and yoga practice. Informal mindfulness meditation practices, or mindfulness in everyday life, incorporate an awareness of pleasant and unpleasant events, and encourage awareness of routine activities; (breast cancer) 6-week program (n=17)	Fatigue - MADSI mean (SD) p value Baseline to 6 weeks UC = 9.1 (7.1) to 7.3 (6.0) ns MBSR = 8.8 (6.9) to 4.6 (5.3); p≤0.05 Cognitive/psychological - MADSI mean (SD) p value Baseline to 6 weeks UC = 9.1 (8.7) to 7.8 (8.5) ns MBSR = 7.1(10.1) to 4.3 (5.1) ns
Rahmani et al.,⁽⁴⁸48. Rahmani S, Talepasand S, Ghanbary-Motlagh A. Comparison of effectiveness of the metacognition treatment and the mindfulness-based stress reduction treatment on global and specific life quality of women with breast cancer. Iran J Cancer Prev. 2014;7(4):184-96.⁾	7/11	36 women with stages I, II, III of BC (38 to 49 years old)	G1= CG (n=12) G2= GTM (n=12) G1= MBSR (breast cancer) (n=12) Follow-up: 2 months	Fatigue - EORTC QLQ-C30 mean (SD) p value Baseline to 8 weeks to follow-up CG = 76.85 (5.72) to 71.29 (12.93)^† † GTM: 8-week program. Introducing the model/identifying rumination periods (metacognition enhancement)/practicing techniques of increasing attention/completing. Attention training technique form/homework; practicing detached mindfulness/showing the postponing of rumination in an experimental way for modifying uncontrollable beliefs/practicing attention training technique; checking homework, examining the rumination, positive thoughts and activity level/examining and extensive application of detached mindfulness/continuing to the challenge with positive thoughts about rumination/examining activity levels and increasing time of contemplation to reaction (sinking in thought), identifying and preventing harmful coping behavior (e.g. sleep or drinking alcohol)/practicing attention training technique/homework). to 72.22 (11.11); p≤0.00 GTM = 75.00 (8.37) to 64.81 (7.97)^† † GTM: 8-week program. Introducing the model/identifying rumination periods (metacognition enhancement)/practicing techniques of increasing attention/completing. Attention training technique form/homework; practicing detached mindfulness/showing the postponing of rumination in an experimental way for modifying uncontrollable beliefs/practicing attention training technique; checking homework, examining the rumination, positive thoughts and activity level/examining and extensive application of detached mindfulness/continuing to the challenge with positive thoughts about rumination/examining activity levels and increasing time of contemplation to reaction (sinking in thought), identifying and preventing harmful coping behavior (e.g. sleep or drinking alcohol)/practicing attention training technique/homework). to 76.85 (10.00); p≤0.00 MBSR = 77.77 (4.73) to 37.96 (8.81)^† † GTM: 8-week program. Introducing the model/identifying rumination periods (metacognition enhancement)/practicing techniques of increasing attention/completing. Attention training technique form/homework; practicing detached mindfulness/showing the postponing of rumination in an experimental way for modifying uncontrollable beliefs/practicing attention training technique; checking homework, examining the rumination, positive thoughts and activity level/examining and extensive application of detached mindfulness/continuing to the challenge with positive thoughts about rumination/examining activity levels and increasing time of contemplation to reaction (sinking in thought), identifying and preventing harmful coping behavior (e.g. sleep or drinking alcohol)/practicing attention training technique/homework). to 47.22 (11.72)^‡ ‡ The nutrition education intervention, led by registered dieticians, was a group intervention focused on dietary change through education and group meal preparation. Practices followed the principles of social cognitive theory and patient-centered counseling. The nutrition education intervention was equivalent to the MBSR in terms of contact time and homework assignments but did not contain any meditation or yoga. G1: group 1; UC: usual care (Control Group); G2: group 2; MBSR: Mindfulness-Based Stress Reduction; G3: group 3; NEP: nutrition education intervention; SCL-90-R: Symptom Checklist-90-Revised; SD: standard deviation; MADSI: MD Anderson Symptom Inventory; ns: no significant; CG: Control Group; GTM: metacognition group therapy; EORTC QLQ-C30: European Organization for Research and Treatment of Cancer Quality Life Questionnaire; CD: compact disc; BFI: Brief Fatigue Inventory; HADS: Hospital Anxiety and Depression Scale; FSS: Fatigue Severity Scale. ; p≤0.00, baseline to 8 weeks^† † GTM: 8-week program. Introducing the model/identifying rumination periods (metacognition enhancement)/practicing techniques of increasing attention/completing. Attention training technique form/homework; practicing detached mindfulness/showing the postponing of rumination in an experimental way for modifying uncontrollable beliefs/practicing attention training technique; checking homework, examining the rumination, positive thoughts and activity level/examining and extensive application of detached mindfulness/continuing to the challenge with positive thoughts about rumination/examining activity levels and increasing time of contemplation to reaction (sinking in thought), identifying and preventing harmful coping behavior (e.g. sleep or drinking alcohol)/practicing attention training technique/homework). /8 weeks to follow-up^‡ ‡ The nutrition education intervention, led by registered dieticians, was a group intervention focused on dietary change through education and group meal preparation. Practices followed the principles of social cognitive theory and patient-centered counseling. The nutrition education intervention was equivalent to the MBSR in terms of contact time and homework assignments but did not contain any meditation or yoga. G1: group 1; UC: usual care (Control Group); G2: group 2; MBSR: Mindfulness-Based Stress Reduction; G3: group 3; NEP: nutrition education intervention; SCL-90-R: Symptom Checklist-90-Revised; SD: standard deviation; MADSI: MD Anderson Symptom Inventory; ns: no significant; CG: Control Group; GTM: metacognition group therapy; EORTC QLQ-C30: European Organization for Research and Treatment of Cancer Quality Life Questionnaire; CD: compact disc; BFI: Brief Fatigue Inventory; HADS: Hospital Anxiety and Depression Scale; FSS: Fatigue Severity Scale. Cognitive/psychological - EORTC QLQ-C30 mean (SD) Baseline to 8 weeks to follow-up CG = 59.72 (8.58) to 59.72 (11.14) to 58.33 (15.07) GTM = 45.83 (10.36) to 61.11 (10.86) to 58.33 (8.71) MBSR = 62.50 (10.35) to 75.00 (11.23) to 72.22 (12.97)
Lengacher et al.,⁽⁴⁹49. Lengacher CA, Shelton MM, Reich RR, Barta MK, Johnson-Mallard V, Moscoso M, S.et al. Mindfulness based stress reduction (MBSR(BC)) in breast cancer: evaluating fear of recurrence (FOR) as a mediator of psychological and physical symptoms in a randomized control trial (RCT). J Behav Med. 2014;37(2):185-95.⁾	7/11	82 women with stages 0, I, II, III of breast cancer (mean 57 years old)	G1 = UC (n=42) waitlisted Control Group were offered the MBSR (breast cancer) G2 = MBSR (breast cancer) 6-week program (n=40) Follow-up: 2 week	Depression - mean (SD) Baseline to 6 weeks UC =14.2 (8.5) to 4.0 (1.7) MBSR = 13.3 (12.0) to 7.2 (4.6) Anxiety - mean (SD) Baseline to 6 weeks UC = 40.4 (11.9) to 6.4 (12.1)^† † GTM: 8-week program. Introducing the model/identifying rumination periods (metacognition enhancement)/practicing techniques of increasing attention/completing. Attention training technique form/homework; practicing detached mindfulness/showing the postponing of rumination in an experimental way for modifying uncontrollable beliefs/practicing attention training technique; checking homework, examining the rumination, positive thoughts and activity level/examining and extensive application of detached mindfulness/continuing to the challenge with positive thoughts about rumination/examining activity levels and increasing time of contemplation to reaction (sinking in thought), identifying and preventing harmful coping behavior (e.g. sleep or drinking alcohol)/practicing attention training technique/homework). MBSR = 35.3 (12.0) to 7.8 (9.8)^† † GTM: 8-week program. Introducing the model/identifying rumination periods (metacognition enhancement)/practicing techniques of increasing attention/completing. Attention training technique form/homework; practicing detached mindfulness/showing the postponing of rumination in an experimental way for modifying uncontrollable beliefs/practicing attention training technique; checking homework, examining the rumination, positive thoughts and activity level/examining and extensive application of detached mindfulness/continuing to the challenge with positive thoughts about rumination/examining activity levels and increasing time of contemplation to reaction (sinking in thought), identifying and preventing harmful coping behavior (e.g. sleep or drinking alcohol)/practicing attention training technique/homework).
Eyles et al.,⁽⁵⁰50. Eyles C, Leydon GM, Hoffman CJ, Copson ER, Prescott P, Chorozoglou M, et al. Mindfulness for the self-Management of fatigue, anxiety, and depression in women with metastatic breast cancer: a mixed methods feasibility study. Integr Cancer Ther. 2015;14(1):42-56.⁾	6/11	19 women with metastatic breast cancer (37 to 65 years old)	G1 = MBSR = adapted (the class sessions were reduced to 2 hours in length (instead of 2 hours and 30 minutes) except the first and last, which lasted 2 hours and 30 minutes. The day of mindfulness in week 6 was 4 hours and 30 minutes (instead of 6-7 hours), and the mindfulness home practice using CDs of the above-mentioned mindfulness practices was 30 min/day, instead of 45 minutes/day) Follow-up: 24 week	Fatigue - BFI mean (SD) p value Baseline to 8 weeks = 4.19 (2.32) to 3.86 (2.45) ns 8 weeks to follow-up = 3.86 (2.45) to 3.28 (1.86) ns Baseline to follow-up = 4.19 (2.32) to 3.86 (2.45) ns Depression - HADS mean (SD) p value Baseline to 8 weeks = 5.74 (3.28) to 5.12 (4.46) ns 8 weeks to follow-up = 5.12 (4.46) to 3.79 (3.14) p≤0.04 Baseline to follow-up = 5.74 (3.28) to 3.79 (3.14) p≤0.04 Anxiety - HADS mean (SD) p value Baseline to 8 weeks = 9.42 (3.49) to 6.66 (3.63) 8 weeks to follow-up = 6.66 (3.63) to 5.79 (3.22) Baseline to follow-up = 9.42 (3.49) to 5.79 (3.22) p≤0.00
Rahmani et al.,⁽⁵¹51. Rahmani S, Talepasand S. The effect of group mindfulness - based stress reduction program and conscious yoga on the fatigue severity and global and specific life quality in women with breast cancer. Med J Islam Repub Iran. 2015;29:175.⁾	7/11	24 women with stages I, II, III of BC (30 to 55 years old)	G1= CG (n=12) G2 = MBSR (breast cancer) + yoga (n=12) Follow-up: 2 months	Severe fatigue - FSS mean (SD) p value Baseline to 8 weeks to follow-up CG = 5.69 (1.58) to 5.60 (1.45) to 5.52 (3.07) ns MBSR = 5.85 (1.97) to 4.81 (2.60)^* * MBSR: Kabat-Zinn's original 8-week program, weekly 2-hours sessions.(39) The program includes three components: (a) educational materials and exercises related to meditation practices and the mind-body connection, (b) practice time and a CD on which verbal support for four meditative practices was recorded (sitting meditation, walking meditation, body scan, and gentle hatha yoga), and (c) opportunity for group discussion, including time to answer questions related to barriers with formal and informal practice. Participants were asked to spend 15 to 45 minutes daily outside of the group sessions for formal and informal practice and to record their daily practice in a diary. Formal mindfulness practice includes sitting meditation, walking meditation, body scan, and yoga practice. Informal mindfulness meditation practices, or mindfulness in everyday life, incorporate an awareness of pleasant and unpleasant events, and encourage awareness of routine activities; to 4.95 (2.61)^† † GTM: 8-week program. Introducing the model/identifying rumination periods (metacognition enhancement)/practicing techniques of increasing attention/completing. Attention training technique form/homework; practicing detached mindfulness/showing the postponing of rumination in an experimental way for modifying uncontrollable beliefs/practicing attention training technique; checking homework, examining the rumination, positive thoughts and activity level/examining and extensive application of detached mindfulness/continuing to the challenge with positive thoughts about rumination/examining activity levels and increasing time of contemplation to reaction (sinking in thought), identifying and preventing harmful coping behavior (e.g. sleep or drinking alcohol)/practicing attention training technique/homework). ; p≤0.00, baseline to 8 weeks^* * MBSR: Kabat-Zinn's original 8-week program, weekly 2-hours sessions.(39) The program includes three components: (a) educational materials and exercises related to meditation practices and the mind-body connection, (b) practice time and a CD on which verbal support for four meditative practices was recorded (sitting meditation, walking meditation, body scan, and gentle hatha yoga), and (c) opportunity for group discussion, including time to answer questions related to barriers with formal and informal practice. Participants were asked to spend 15 to 45 minutes daily outside of the group sessions for formal and informal practice and to record their daily practice in a diary. Formal mindfulness practice includes sitting meditation, walking meditation, body scan, and yoga practice. Informal mindfulness meditation practices, or mindfulness in everyday life, incorporate an awareness of pleasant and unpleasant events, and encourage awareness of routine activities; /8 weeks to Follow-up^† † GTM: 8-week program. Introducing the model/identifying rumination periods (metacognition enhancement)/practicing techniques of increasing attention/completing. Attention training technique form/homework; practicing detached mindfulness/showing the postponing of rumination in an experimental way for modifying uncontrollable beliefs/practicing attention training technique; checking homework, examining the rumination, positive thoughts and activity level/examining and extensive application of detached mindfulness/continuing to the challenge with positive thoughts about rumination/examining activity levels and increasing time of contemplation to reaction (sinking in thought), identifying and preventing harmful coping behavior (e.g. sleep or drinking alcohol)/practicing attention training technique/homework). Fatigue - EORTC QLQ-C30 mean (SD) p value Baseline to 8 weeks to follow-up CG = 76.85 (5.72) to 71.29 (12.93) to 72.22 (11.11) ns MBSR = 77.77 (4.73) to 37.96 (8.81)^* * MBSR: Kabat-Zinn's original 8-week program, weekly 2-hours sessions.(39) The program includes three components: (a) educational materials and exercises related to meditation practices and the mind-body connection, (b) practice time and a CD on which verbal support for four meditative practices was recorded (sitting meditation, walking meditation, body scan, and gentle hatha yoga), and (c) opportunity for group discussion, including time to answer questions related to barriers with formal and informal practice. Participants were asked to spend 15 to 45 minutes daily outside of the group sessions for formal and informal practice and to record their daily practice in a diary. Formal mindfulness practice includes sitting meditation, walking meditation, body scan, and yoga practice. Informal mindfulness meditation practices, or mindfulness in everyday life, incorporate an awareness of pleasant and unpleasant events, and encourage awareness of routine activities; to 47.22 (11.72)^† † GTM: 8-week program. Introducing the model/identifying rumination periods (metacognition enhancement)/practicing techniques of increasing attention/completing. Attention training technique form/homework; practicing detached mindfulness/showing the postponing of rumination in an experimental way for modifying uncontrollable beliefs/practicing attention training technique; checking homework, examining the rumination, positive thoughts and activity level/examining and extensive application of detached mindfulness/continuing to the challenge with positive thoughts about rumination/examining activity levels and increasing time of contemplation to reaction (sinking in thought), identifying and preventing harmful coping behavior (e.g. sleep or drinking alcohol)/practicing attention training technique/homework). ; p≤0.00, baseline to 8 weeks^* * MBSR: Kabat-Zinn's original 8-week program, weekly 2-hours sessions.(39) The program includes three components: (a) educational materials and exercises related to meditation practices and the mind-body connection, (b) practice time and a CD on which verbal support for four meditative practices was recorded (sitting meditation, walking meditation, body scan, and gentle hatha yoga), and (c) opportunity for group discussion, including time to answer questions related to barriers with formal and informal practice. Participants were asked to spend 15 to 45 minutes daily outside of the group sessions for formal and informal practice and to record their daily practice in a diary. Formal mindfulness practice includes sitting meditation, walking meditation, body scan, and yoga practice. Informal mindfulness meditation practices, or mindfulness in everyday life, incorporate an awareness of pleasant and unpleasant events, and encourage awareness of routine activities; /8 weeks to follow-up^† † GTM: 8-week program. Introducing the model/identifying rumination periods (metacognition enhancement)/practicing techniques of increasing attention/completing. Attention training technique form/homework; practicing detached mindfulness/showing the postponing of rumination in an experimental way for modifying uncontrollable beliefs/practicing attention training technique; checking homework, examining the rumination, positive thoughts and activity level/examining and extensive application of detached mindfulness/continuing to the challenge with positive thoughts about rumination/examining activity levels and increasing time of contemplation to reaction (sinking in thought), identifying and preventing harmful coping behavior (e.g. sleep or drinking alcohol)/practicing attention training technique/homework). Cognitive/psychological - EORTC QLQ-C30 mean (SD) Baseline to 8 weeks to follow-up CG = 59.72 (8.58) to 59.72 (11.14) to 61.11 (16.41) ns MBSR = 62.50 (10.35) to 75.00 (11.23) to 72.22 (12.97)
Sarenmalm et al.,⁽⁵²52. Sarenmalm EK, Martensson LB, Andersson BA, Karlsson P, Bergh I. Mindfulness and its efficacy for psychological and biological responses in women with breast cancer. Cancer Med. 2017;6(5):1108-22.⁾	7/11	166 women diagnosed with cancer at (34 to 80 years old)	G1 = active control (8 weeks self-instructing MBSR program), n=52 G2=MBSR (8 weeks self-instructing MBSR program + instructor and weekly group sessions), n=62 G3=non MBSR n=52	Anxiety - HADS mean (SD) p value MBSR = 6.5 (4.3) to 6.0 (3.9) ns Non MBSR = 4.8 (3.6) to 5.5 (4.1) ns Active control = 5.6 (3.9) to 5.1 (3.9) ns Depression - HADS mean (SD) p value MBSR = 4.3 (3.7) to 3.3 (3.3) p≤0.00 Non MBSR = 3.5 (3.5) to 3.8 (3.8) ns Active control = 3.4 (3.4) to 3.8 (3.8) ns

^*
MBSR: Kabat-Zinn's original 8-week program, weekly 2-hours sessions.⁽39⁾ The program includes three components: (a) educational materials and exercises related to meditation practices and the mind-body connection, (b) practice time and a CD on which verbal support for four meditative practices was recorded (sitting meditation, walking meditation, body scan, and gentle hatha yoga), and (c) opportunity for group discussion, including time to answer questions related to barriers with formal and informal practice. Participants were asked to spend 15 to 45 minutes daily outside of the group sessions for formal and informal practice and to record their daily practice in a diary. Formal mindfulness practice includes sitting meditation, walking meditation, body scan, and yoga practice. Informal mindfulness meditation practices, or mindfulness in everyday life, incorporate an awareness of pleasant and unpleasant events, and encourage awareness of routine activities;
^†
GTM: 8-week program. Introducing the model/identifying rumination periods (metacognition enhancement)/practicing techniques of increasing attention/completing. Attention training technique form/homework; practicing detached mindfulness/showing the postponing of rumination in an experimental way for modifying uncontrollable beliefs/practicing attention training technique; checking homework, examining the rumination, positive thoughts and activity level/examining and extensive application of detached mindfulness/continuing to the challenge with positive thoughts about rumination/examining activity levels and increasing time of contemplation to reaction (sinking in thought), identifying and preventing harmful coping behavior (e.g. sleep or drinking alcohol)/practicing attention training technique/homework).
^‡
The nutrition education intervention, led by registered dieticians, was a group intervention focused on dietary change through education and group meal preparation. Practices followed the principles of social cognitive theory and patient-centered counseling. The nutrition education intervention was equivalent to the MBSR in terms of contact time and homework assignments but did not contain any meditation or yoga. G1: group 1; UC: usual care (Control Group); G2: group 2; MBSR: Mindfulness-Based Stress Reduction; G3: group 3; NEP: nutrition education intervention; SCL-90-R: Symptom Checklist-90-Revised; SD: standard deviation; MADSI: MD Anderson Symptom Inventory; ns: no significant; CG: Control Group; GTM: metacognition group therapy; EORTC QLQ-C30: European Organization for Research and Treatment of Cancer Quality Life Questionnaire; CD: compact disc; BFI: Brief Fatigue Inventory; HADS: Hospital Anxiety and Depression Scale; FSS: Fatigue Severity Scale.

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[1] Corresponding author: Flavia Del Castanhel, Rua Delfino Conti S/N, Trindade Zip code: 88040-370 - Florianópolis, SC, Brazil Phone: (55 48) 3721-9000 E-mail: flaviadelcastanhel@gmail.com