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Original article
INTRODUCTION
Across different stages of the cancer trajectory many
cancer patients and carers experience cancer-related
FISH ET AL.
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
FISH ET AL.
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).
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
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).
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.
417
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.
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
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
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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