Madeline Foster, MSPH
Clinical Psychology Ph.D. Student
School of Psychology
Fielding Graduate University
In 2024 alone, more than two million Americans will be diagnosed with cancer, marking the beginning of what is often a long and challenging treatment journey (Siegel et al., 2024). For the almost 20 million Americans currently living with cancer, much of their treatment centers around physically managing their disease and associated medical symptoms (Gallicchio et al., 2022). However, cancer not only impacts the physical body; it is estimated that almost half of those who are diagnosed with cancer experience significant psychological distress (Foley et al., 2010; Park et al., 2020). Moreover, for specific cancer subpopulations, such as those less than a year post-diagnosis and those with head and neck cancers, the rates of psychological distress are even higher (Momenimovahed et al., 2021; Zabora et al., 2001). One specific psychological intervention with a strong evidence base in oncology settings is mindfulness (Park et al., 2020). This paper will explore how mindfulness can help patients with cancer increase their ability to cope with the physical and psychological side effects of their medical treatment, how mindfulness can be utilized to improve access to psychological treatment for those with cancer, and the limitations of the existing psychotherapy research on the use of mindfulness in this specific population.
The Importance of Promoting Psychological Well-Being in Oncology Patients
Promoting psychological well-being and reducing the psychological distress of those with cancer is important for several reasons. Cancer treatment commonly requires patients to face many challenges, including surgery, invasive treatments, financial obstacles, functional impairments, and social shifts (Foley et al., 2010). These issues and the uncertainty surrounding them can negatively affect coping and quality of life (Momenimovahed et al., 2021; Lichtenthal et al., 2020). As a result of the psychological toll of cancer, literature has consistently shown that individuals with cancer have a heightened risk of psychological diagnoses, such as depression and anxiety (Momenimovahed et al., 2021).
Furthermore, providing psychotherapy interventions, such as mindfulness, can help patients with cancer be more compliant with their treatment (Baydoun et al., 2021). By increasing a patient’s psychological well-being and reducing their distress, literature has shown there are typically fewer interruptions of anticancer treatments (Yee et al., 2017). Specifically, improved psychological functioning can enhance patients’ ability to communicate effectively with their healthcare providers, promote treatment-related behavioral change, and help develop a stronger commitment to their treatment plan (Baydoun et al., 2021).
The long-term outcomes of cancer are also important to consider, with psychological factors related to cancer often persisting long after medical treatment has been completed (Tian et al., 2022). By promoting psychological well-being during treatment, patients with cancer have been shown to have a reduced risk of poor psychological outcomes, such as post-traumatic stress disorder (PTSD; Dinapoli et al., 2021). Moreover, patients with cancer who receive psychological interventions during their cancer treatment develop a sense of meaning that can buffer against psychological distress, depression, and hopelessness (Lichtenthal et al., 2020). The psychological skills, such as mindfulness taught to patients during their cancer treatment, can also be utilized long-term, further enhancing their ability to maintain medical and psychological treatment outcomes (Lichtenthal et al., 2020).
The Use of Mindfulness in Oncology Populations
Extensive psychotherapy research has examined the effectiveness of various techniques, skills, and theoretical approaches to reducing distress and promoting psychological well-being in oncology patients (Lee & Singh, 2021; Momenimovahed et al., 2021; Park et al., 2020). One such therapeutic method is mindfulness (Hill & Norcross, 2023). Considered part of the third wave of cognitive-behavioral therapy (CBT), mindfulness-based interventions are used to cultivate a sense of awareness of the present moment, particularly a non-judgmental awareness of thoughts, emotions, physical sensations, and the surrounding environment (Zhang et al., 2021). Mindfulness can be used in several forms, including meditation, deep breathing, progressive muscle relaxation, and body scans (Zhang et al., 2021). Research has demonstrated the efficacy of mindfulness in treating common mental health conditions, such as depression, anxiety, stress, insomnia, eating disorders, addiction, and PTSD (Zhang et al., 2021).
Psychotherapy research on oncology populations has explored the specific mechanisms of change that make mindfulness effective immediately after diagnosis and throughout treatment. A 2022 study conducted by Tian and colleagues looked at 300 patients receiving treatment for lung cancer who participated in a mindfulness intervention, exploring the mechanisms by which mindfulness reduced psychological distress. The study found that mindfulness directly impacted two specific factors: illness perception and perceived stress (Tian et al., 2022). Similarly, another study on lung cancer patients found that mindfulness reduced psychological distress by reducing perceived stigma (Tian et al., 2021).
Mindfulness for Managing Emotions and Cognitions Related to a Cancer Diagnosis and Treatment
Receiving a cancer diagnosis and engaging in cancer treatment are high-risk time periods for psychological distress (Dinapoli et al., 2021). Several psychotherapy studies have examined the role of mindfulness interventions delivered to patients with cancer either shortly after diagnosis or while they are receiving treatment (Joshi et al., 2021; Liu et al., 2022; Park et al., 2020). One 2020 randomized controlled trial (RCT) randomly assigned 74 patients with breast cancer to an eight-week mindfulness intervention or a wait-list control group (Park et al., 2020). Those in the mindfulness intervention group reported significantly lower psychological distress, as measured by the Hospital Anxiety and Depression Scale (HADS), compared to the control group. They also experienced significant decreases in psychological distress from baseline to the end of the eight-week treatment period. Another study, which also focused on breast cancer patients, also utilized the HADS to measure the effectiveness of a mindfulness-based treatment compared to conventional care in reducing anxiety and depression (Liu et al., 2022). The results showed that the intervention group experienced more significant remission of anxiety and depressive symptoms than the control group, further demonstrating the role of mindfulness interventions in reducing psychological distress in cancer patients.
Mindfulness interventions have also been shown to elicit psychological improvements in a relatively short period of time compared to other psychotherapy interventions. For example, a 2021 study of women with breast cancer found that one week of mindfulness-based therapy significantly decreased psychological distress and increased spiritual well-being as measured by the Distress Thermometer (DT) and Functional Assessment of Chronic Illness Therapy-SWB Scale 12 (FACIT-SP12; Joshi et al., 2021). Similarly, a recent 2024 single-blinded RCT recruited 120 cancer patients and randomized participants into two groups: a group of 60 who participated in a 10-day mindfulness-based stress reduction program and a group of 60 who served as the control group (Yildirim et al., 2022). The intervention group reported significantly higher psychological well-being after ten days as measured by the State Trait Anxiety Inventory-State (STAI-S), Psychological Well-being Scale (PWBS), and Beck Depression Inventory (BDI). Notably, this study is one of the few that included patients with any type of cancer diagnosis, as a majority of studies focus on a specific cancer diagnosis.
Psychotherapy research has also examined the use of mindfulness with patients who are at different points in their cancer journey, from early-stage through to advanced. For example, a 2013 RCT with 172 participants with early-stage breast cancer examined the use of mindfulness-based stress reduction intervention compared to a nutrition education intervention and usual care (Henderson et al., 2013). Those in the intervention group received weekly 2.5 to 3.5 hour group sessions and an additional 7.5-hour intensive mindfulness retreat delivered by masters’ or doctoral-level psychotherapists. The results showed that those in the intervention group demonstrated reductions in anxiety, hostility, paranoid ideation, and depression and had improved stress management and emotional control. These findings are consistent with other studies on mindfulness in early-stage breast cancer patients (Liu et al., 2022). Qualitative and quantitative literature on advanced cancer patients has also mirrored these findings (Zimmermann et al., 2018). A 2020 mixed methods analysis of adults with advanced cancer reported that, following a mindfulness-based intervention, patients’ perspectives shifted from a sense of vulnerability to self-encouragement and optimism (Zimmermann et al., 2020).
Mindfulness for Coping with Physical Symptoms
Cancer can be symptomatic or asymptomatic (Koo et al., 2020). For those whose cancer causes physical symptoms, such as pain, skin changes, weight changes, bleeding, and swelling, mindfulness can be a useful psychological tool to increase coping and maintain quality of life (Koo et al., 2020). One of the most common physical symptoms of cancer is fatigue, with increased fatigue then being linked to greater psychological distress for patients with cancer (Johns et al., 2015; Zimmaro et al., 2019). Psychotherapy research has examined the role of mindfulness in reducing fatigue and subsequently reducing psychological distress in oncology populations. A 2015 RCT enrolled 35 cancer patients with clinically significant cancer-related fatigue and randomized participants into two groups: a seven-week mindfulness-based stress reduction intervention or a waitlist control group (Johns et al., 2015). At follow-up, depression scores were significantly lower for those in the intervention group, demonstrating the role of mindfulness in managing cancer-related physical symptoms like fatigue.
Pain is another common cancer symptom closely linked to psychological distress (Koo et al., 2020). As a result, psychotherapy research on mindfulness interventions for patients with cancer has specifically examined how the method can reduce pain-related psychological distress. One study conducted by Shergill and colleagues (2022) took a sample of 98 women with neuropathic pain associated with breast cancer and randomized them into two equal groups. One group received eight weekly 2.5 hour sessions of group-based mindfulness along with a full-day mindfulness retreat. The other group served as the waitlist control group and received a pain medicine consultation. After completing the mindfulness treatment, the intervention group reported reduced pain-related disability. However, there were no significant differences in terms of psychological distress between groups. Shergill and colleagues’ study is one of the few RCTs on mindfulness in the oncology population published that shows no significant differences between the intervention and control groups. The study’s authors highlight the need for more transparency through the publication of non-significant findings in this area of psychotherapy research.
Mindfulness for Cancer Survivors
The completion of cancer treatment for many patients does not mark the end of psychological or physical symptoms related to cancer. Survivorship brings a unique set of challenges, including psychological stressors like guilt and fear of cancer recurrence and physical stressors like chronic pain, which often require psychological interventions to reduce distress and promote well-being (Bower et al., 2021; Lengacher et al., 2021; Nissen et al., 2019). A 2021 RCT by Bower and colleagues randomly assigned 247 breast cancer survivors under the age of 50 with elevated depressive symptoms into three groups: a six-week mindfulness intervention, survivorship education, or waitlist control. Those in the mindfulness intervention group and those in the survivorship education group had significantly lower depressive symptoms as measured by the Center for Epidemiologic Studies-Depression Scale (CESDS) than those in the waitlist control group. Notably, at the six-month follow-up, changes in depressive symptoms only persisted in patients who received the mindfulness intervention. This finding highlights the ability of mindfulness to facilitate long-term psychological change, a strength highlighted in mindfulness literature in general (Bergomi et al., 2013).
Similarly, an RCT by Lengacher and colleagues used a sample of 322 breast cancer survivors who had been diagnosed with stage 0-III breast cancer and had undergone a lumpectomy, mastectomy, radiation, or chemotherapy more than two years ago. The participants were equally assigned to either a six-week mindfulness-based intervention or the waitlist control group. Results showed that those in the mindfulness intervention group significantly reduced overall fear of cancer recurrence and lowered perceived stress. At the 12-week follow-up, the mindfulness-based intervention was also associated with significantly larger reductions in fatigue and state anxiety. These results reiterate findings from other psychotherapy research suggesting mindfulness-based interventions have lasting effects on psychological distress and psychological well-being after the intervention has ended (Bower et al., 2021).
Internet-Based Mindfulness Interventions for Oncology Patients
Given the prevalence of cancer and high rates of cancer-related psychological distress, there has been an increase in psychotherapy research examining the effectiveness of internet-based mindfulness interventions led by psychotherapists for cancer patients (Cillessen et al., 2020; Nissen et al., 2019). Internet-based interventions are especially important for patients with cancer, given the symptom burden that can compromise participation in traditional in-person psychological interventions (Cillessen et al., 2020). Studies with cancer patients specifically have shown the adherence benefits of cognitive-behavioral psychotherapy interventions like mindfulness when delivered electronically (Cillessen et al., 2020).
Psychotherapy research has shown that therapist-delivered internet-based mindfulness interventions can improve psychological functioning in patients with cancer. A 2019 RCT by Nissen and colleagues recruited 1282 cancer patients and screened them for anxiety and depression. Those who screened positive for depression or anxiety based on a brief two-item measure were randomized into the mindfulness-based intervention group or wait-list control group. The groups were not weighted equally, with 70% of participants randomized into the mindfulness-based intervention group. Anxiety and depression were both significantly improved in the intervention group immediately after treatment, with psychological results maintained at the six-month follow-up mark for anxiety.
While these results are favorable for the use of mindfulness, Nissen and colleagues’ study (2019) was limited by its brief, unstandardized measurement tool to measure anxiety and depression. Follow-up research is needed using psychometrically sound measures. Moreover, another notable limitation of the literature on internet-based mindfulness interventions is the lack of studies that allow the comparison of psychological outcomes between internet and in-person interventions. Therefore, it remains unclear if internet-based interventions are equally effective as in-person interventions, an important gap in the literature on this topic.
Limitations of Research on Mindfulness in Oncology Settings
While a majority of the literature supports the use of mindfulness to promote the psychological well-being of patients with cancer, there are some notable limitations to the available research that should be noted. First, much of the psychotherapy research available focuses on patients with highly prevalent cancers, including breast, prostate, and lung cancer (Eyles et al., 2015; Tian et al., 2022). Given that literature has shown that head and neck cancers have the highest rate of psychological distress, the dearth of literature on the use of mindfulness in these cancer populations is an area that requires future research. More diverse cancer diagnosis representation would also allow for a greater understanding of how the efficacy and effectiveness of mindfulness may vary between patients with different diagnoses.
Additionally, the outcomes of most psychotherapy studies are measured through self-report tools like the HADS, STAI-S, PWBS, and BDI (Liu et al., 2022; Park et al., 2020; Yildirim et al., 2022). Several factors can influence self-reported data, including response bias, a lack of objectivity, mood and context influences, and over-reporting of extreme experiences (Bergomi et al., 2013). Self-report measures can also limit the ability to capture the complexities of a participant’s psychological state and may, therefore, not accurately reflect the nuances of their current experiences (Bergomi et al., 2013). Limited qualitative psychotherapy studies have been published on the use of mindfulness in oncology populations; however, there is a need for more mixed methods and qualitative analysis to complement the self-reported quantitative data available on the topic.
Another notable limitation of the psychotherapy research on the effectiveness of mindfulness in patients with cancer is the fact that many studies exclude those with cognitive impairment, those who have a preexisting serious mental illness, or those who are already taking psychotropic medication (Liu et al., 2022; Park et al., 2020; Wang et al., 2022; Yildirim et al., 2022). This common exclusion criterion limits the generalizability of findings, as it omits a large portion of cancer patients who have cognitive or psychiatric impairments (Lee & Singh, 2021). Moreover, cancer itself and the physical reality of living with cancer further limit the generalizability of the research findings. Several studies highlighted how disease progression led to participants dropping out of treatment (Eyles et al., 2014; Yildirim et al., 2022). Given the unpredictable nature of psychotherapy, researchers face the challenge of attrition, which can lead to incomplete data and selection bias, further impacting the generalizability of findings.
Conclusion
Ultimately, the available psychotherapy research on the use of mindfulness with oncology patients highlights its effectiveness in reducing psychological distress and promoting psychological well-being. The literature demonstrates how mindfulness can help cancer patients manage some of the most common psychological and physical challenges, including anxiety, depression, fatigue, and pain (Eyles et al., 2015; Liu et al., 2022; Shergill et al., 2022). Several notable strengths of mindfulness are evident in the literature, such as its effectiveness for patients at different stages of treatment, its benefits for cancer survivors, and its adaptability to internet-based interventions (Baydoun et al., 2021; Cillessen et al., 2020; Henderson et al., 2013). While there are some limitations to the available research on mindfulness, including the reliance on self-reported data, the limited range of cancer diagnoses represented in study samples, and the exclusion of patients with psychiatric and cognitive impairments, the majority of the literature supports its effectiveness in the oncology population. These limitations highlight the need for more diverse research on this psychotherapy method to better understand the impact mindfulness can have on the psychological functioning of cancer patients.
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