Final Research Paper: Investigate if social-economic status and environment factors influence tobacco use and dependence amongst adults and teens in New Hampshire This paper should be a summary of you
Running head: BENEFITS OF MINDFULNESS BASED STRESS REDUCTION 0 Benefits of Mindfulness Based Stress Reduction in Breast Cancer Patients Literature Review Benefits of Mindfulness Based Stress Reduction in Breast Cancer Patients Introduction When developing a comprehensive treatment plan for breast cancer patients it is necessary to factor in not only the specific medical treatment approach for the cancerous tumor(s) such as surgery, radiation and/or chemotherapy, but also a viable complimentary treatment to address the patients physical and psychological needs. Patient care does not end when surgery, radiation and/or chemotherapy are complete. An effective complementary treatment tool to pick up where these medical interventions left off is essential for the continued recovery and well-being of breast cancer patients. Problem/Significance This report aims to present data collected in five randomized control trials (RCT) that explores the use of Mindfulness Based Stress Reduction (MBSR) to address physical and psychological factors (stress, anxiety, fear of recurrence, pain, fatigue and overall quality of life) that impact long term recovery in this patient population. As the landscape of healthcare changes with Medicare reimbursement levels being dictated by patient satisfaction, where the mindset is geared towards lean practices, the forces of consumer driven services must be in the forefront of the minds of those delivering healthcare. The October 2015 American Journal of Nursing cites the 2010 Samueli Institute – Health Forum Study which surveyed 714 medium to large size urban hospitals on the types of complimentary or alternative medicine (CAM) offered at their institution and why. The overwhelming reason for offering CAM services at the institutions surveyed was patient demand at 85% (Halm & Katseres, 2015). Therefore, it behooves cancer treatment centers to find low costs means to meet these vital patient care thresholds. And, based on the current research reviewed for this report, MBSR fits the bill. Literature Review Mindfulness Based Stress Reduction (MBSR) in the reviewed RCT’s combines mind-body exercises including visualization, meditation, mental and breathing exercises and/or yoga and is based on mindful awareness in the Buddhist tradition and follows the program model developed by Jon Kabat- Zinn (Branstrom, Kvillemo, Brandberg, & Moskowitz, 2010). The stated goals in each study were virtually the same, explore the use of MBSR to address specific physical and psychological needs of cancer patients and each study employed randomization in determining an intervention group and a control group. As well, each of the studies also utilized reliable and valid measurement tools and statistical analysis software to survey the study participants and compiled the subsequent data. The execution of the MBSR treatment (who provided the treatment, the setting where treatment was provided and for how long), the duration of follow-up questionnaires and the depth to which specific physical and psychological components were surveyed varied widely however. Many confounding factors were identified within each of these studies and could clearly be the catalyst for future studies to further refine RCT’s for this research. Intervention Administration, Data Collection and Analysis To better illustrate the positive results gleaned from these RCT’s we need to look closer at the delivery mechanism of the MBSR intervention and the analysis of the participant survey responses. Lengacher et al. (2009) chose to have their 6-week MBSR program, based on the original program developed by Jon Kabat-Zinn at the Stress Reduction and Relaxation Clinic at Massachusetts Medical Centere, administered by a psychologist certified in MBSR in 2-hour weekly sessions with observers monitoring the sessions for consistency but also included tools for home practice and a diary to track homework activities. Similarly, Branstrom et al. (2010) conducted their study in Sweden and utilized an 8-week MBSR program also based on the program of Kabat-Zinn, with 2-hour weekly sessions with training and tools to perform homework activities, but the sessions were not administered by certified MBSR psychologists, rather they had previous personal experience using MBSR and did receive 8-days of advanced training. Malboeuf-Hurtubise et al. (2013) also propose an 8 week Kabat-Zinn based program in their study protocol with 90 minute weekly sessions lead by two trained therapists (psychologist and psychiatrist), alternating roles (leader vs. co-leader) and homework activities and meditation journaling. As well, Henderson et al. (2013) cite Kabat-Zinn in their trial and employ an 8-week MBSR program but they also provide 3 additional sessions focuses on special needs associated with BrCA and don’t indicate homework activities/journaling were completed. One study in Alberta, Canada proposes the use of online MBSR sessions for their 8-week program to better reach patients in rural communities and Zernicke et al. (2013) indicate that limited resources or geographical location should not lead to an underserved population. A broad spectrum of valid and reliable measurement tools were used across the studies and each queried numerous physical and psychological factors impacting participants but when the questionnaires were administered varied. For Lengacher et al. (2009) seven questionnaires were used (Concerns about Recurrence Scale (CARS) closed response, State-Trait Anxiety Inventory (STAI) forced choice, Center for Epidemiological Studies Depression Scale (CES-D) forced choice, Life Orientation Test – Revised (LOT-R) Likert, Perceived Stress Scale (PSS) closed response, Medical Outcomes Studies Short-form General Health Survey (MOS) closed response, Medical Outcomes Social Support Survey (MOS) closed response) and each instrument was completed three times, once at a baseline orientation session, with in two weeks and at the end of the six week intervention. Branstrom et al. (2010) chose to administer their questionnaires three times however, once at the point of randomization, at 3 months after randomization and at 6 months after randomization and used only five instruments (Five-Facet Mindfulness Questionnaire (FFMQ) closed response, Perceived Stress Scale (PSS) closed response, Hospital Anxiety and Depression Scale (HADS) closed response, Positive States of Mind (PSOM) closed response, Impact of Event Scale- Revised (IES-R) closed response). Because of the focus of the participant population in Malboeuf-Hurtubise et al. (2013) specific instruments for adolescents age 11-18 (Beck Youth Inventories Depression and Anxiety Scale (BYI-DAS) Likert, Positive and Negative Affect Schedule –Child (PANAS-C) Likert, Pediatric Cancer Quality of Life Inventory (PCQLI) Likert, Pittsburgh Sleep Quality Index (PSQI) open-ended and closed response) were distributed at enrollment/consent, at the end of the 8th session and at 6 months. In the online only proposed trail from Zernicke et al. (2013) no fewer than six proven valid and reliable instruments were used (Distress Thermometer (DT) closed response, Profile of Mood States (POMS) closed response, Calgary Symptoms of Stress Inventory (C-SOSI) closed response, Post-Traumatic Growth Inventory (PTGI) closed response, Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being (FACIT-Sp) closed response, Five Facet Mindfulness Questionnaire (FFMQ) closed response) and each tool was completed two times; baseline at enrollment/consent and at the end of the online 8 week MBSR program. To better understand the long term impact of MBSR Henderson et al. (2013) also used six measurement tools (Functional Assessment of Cancer Therapy (FACT-B) closed response, Dealing With Illness Questionnaire closed response, Beck Anxiety and Depression Inventory, Rosenberg Self-Esteem Scale, resilience to stress and adversity (Sense of Coherence Scale), subjective social support (Revised UCLA Loneliness Scale),adjustment to cancer (Mini-Mental Adjustment to Cancer Scale), emotional control (Courtauld Emotional Control Scale), general psychological distress (Symptom Checklist 90–Revised)) but each tool was completed four times; at recruitment into the study/baseline and at 4 months, 12 months, and 24 months from the beginning of the intervention. In addition to the widely supported measurement instruments noted above, the authors also employed statistical analysis tools to distill the raw data collected. Because each study identified a confounding factor in their analysis a statistical model that incorporated a covariant was essential and ANCOVA was used in 80% of the studies reviewed. In over half of the studies, the number of MBSR hours practiced (within the 8 week program and in ongoing self-practice) became an important component to further compare within participant results. Data Summary What makes these studies interesting and of significant use in the treatment of breast cancer patients is the positive change in mean scores realized in the vast majority of the physical and psychological elements studied. Lengacher et al. (2009) provides comparative data at the end of the 6-week session from baseline on mean levels of depression (6.3 vs 9.6), anxiety (28.3 vs 33.0), fear of recurrence (9.3 vs 11.6), higher energy (53.5 vs 49.2), physical functioning (50.1 vs 47.0), and physical role functioning (49.1 vs 42.8). Similarly, Branstrom et al. (2010) also realized participant improvement when comparing mean scores at 3-month follow up versus baseline and against the control group with perceived stress (16.91 vs 22.56, a decrease of 5.66 versus 1.86 in the control group), depression (4.67 vs 6.41, a decrease of 1.74 versus 0.69 in the control group), anxiety (8.26 vs 10.53, a decrease of 2.27 versus 1.15 in the control group), and posttraumatic stress symptoms (impact of event scale –IES) of intrusion (11.27 vs 13.28, a decrease of 2.01 versus 1.56 in the control group), avoidance (6.97 vs 10.55, a decrease of 3.12 versus 0.21 in the control group) and hyperarousal (6.28 vs 9.50, a decrease of 3.22 versus 1.49 in the control group). In the study of breast cancer patients undergoing radiotherapy treatment (Henderson et al., 2013), improvements were noted in the following comparisons between MBSR groups and usual care (UC) groups at 4 months; active behavioral coping (63.1 vs 58.8), active cognitive coping (64.8 vs 58.6), social/family well-being (22.2 vs 19.8), emotional well-being (18.0 vs 16.9), spirituality (8.9 vs 7.6), meaningfulness (47.3 vs 43.8), helplessness (10.1 vs 11.7 lower value represents improved), cognitive avoidance (8.2 vs 9.4 lower value represents improved), anxiety (0.14 vs 0.28 lower value represents improved), hostility (0.12 vs 0.32 lower value represents improved), depression (0.31 vs 0.58 lower value represents improved), paraniod ideation (0.12 vs 0.26 lower value represents improved), anxious preoccupation (14.1 vs 15.9 lower value represents improved) and overall emotional control (41.7 vs 46.3 lower value represents improved). The stand out feature in the Henderson et al. study is the follow-up at 12 and 24 months after MBSR treatment which still yielded positive results in the categories provided. For example, both active behavioral and cognitive coping remained positive between the MBSR and UC group at the 12 month marker (62.9 vs 56.6 and 62.6 vs 58.2) respectively. And in taking the questionnaire out to a 24 month marker two areas provided in the study maintained positive results. Meaningfulness retained positive results in the MBSR group versus the UC group at the 24 month marker (48.4 vs 44.6) and anxious preoccupation was lower in the MBSR group than the UC group (14.5 vs 16.4) at the 24 month marker as well. Because the outcomes of these three studies are favorable in the continued integration of MBSR treatment in breast cancer patients, and given that the RCT’s modeled in both studies by Malboeuf-Hurtubise et al. (2013) and Zernicke et al. (2013) are similar in method, construction and proposed execution, the expectation is that positive participant experiences with exist in their work as well. Theoretical Framework The work of nursing theorist Margaret A. Newman has significant applicability to the question of mindfulness based stress reduction treatments (MBSR) in breast cancer patients and its positive impact on their physical and psychological well- being. Newman established a theory of ‘health as expanding consciousness’ (HEC) from personal experience and because of that personal experience eventually theorized that ‘illness reflected the life patterns of the person and that what was needed was the recognition of that pattern and acceptance of it for what it meant to that person.’ (Alligood, 2014). Newman believes that ‘Humans are open to the whole energy system of the universe and constantly interacting with the energy. With this process of interaction humans are evolving their individual pattern of whole.’(Nursing Theories, 2013). In addition, Newman states that “The theory of health as expanding consciousness (HEC) was stimulated by concern for those for whom health as the absence of disease or disability is not possible. Nurses often relate to such people: people facing the uncertainty, debilitation, loss and eventual death associated with chronic illness. The theory has progressed to include the health of all persons regardless of the presence or absence of disease. The theory asserts that every person in every situation, no matter how disordered and hopeless it may seem, is part of the universal process of expanding consciousness – a process of becoming more of oneself, of finding greater meaning in life, and of reaching new dimensions of connectedness with other people and the world” (Nursing Theories, 2013). In the practice of mindfulness based stress reduction (MBSR) techniques such as meditation, yoga and mind-body exercises the basis for each is a connectedness with your own breathing ‘pattern’ as a mechanism to delve deeper into your consciousness and connect with the wide expanse of positive energy in our universe. I believe that Newman’s theories about how the patterns of a persons’ life directly relates to disease, “the manifestation of disease depends on the pattern of individual so the pathology of the diseases exists before the symptoms appear so removal of disease symptoms does not change the individual structure.’’ (Nursing Theories, 2013) can be applied further into disease management by incorporating a pattern of mindfulness to expand a patient’s consciousness. As Alligood notes (2013), “the theory has been used extensively in exploring and understanding the experience of health within illness, supporting a basic premise of the theory, that disruptive situations provide a catalytic effect and facilitate movement to higher levels of consciousness.” Health within illness is a powerful description of what is believed breast cancer patients are in need of regardless of the stage of their disease and why this research question and the use of MBSR is so impactful. Conclusion Though the method used to administer the MBSR intervention was not consistent among the studies reviewed, there is no doubt that these varied forms have merit based on the improvements noted in the vast majority of the physical and psychological factors queried. Often it is necessary to test varied approaches to an issue to see which approach meets the needs of most and therefore I see why each study applied varied methods for administration. What is remarkable, given that variance in administration that is noted from study to study is that there are valid, discernable benefits in the vast majority of the physical and psychological categories monitored (anxiety, depression, fear of recurrence, physical functioning, social and spiritual well-being) and in the aggregate there were improvements noted in overall well-being. Given that data, these results are a resounding cry for continued application and research into this mechanism of patient support (and its wide variety of administration modes) to ensure it finds its way into the clinical treatment model for not only breast cancer patients but those suffering from other cancers which would benefit greatly from improved physical, emotional and spiritual well-being. References Alligood M R 2014 Nursing Theorists and Their WorkAlligood, M. R. (2014). Nursing Theorists and Their Work (8 ed.). 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