Cognitive-behavioral and mindfulness-based interventions for distress in patients with advanced cancer: A meta-analysis.

OBJECTIVE: Various psychosocial interventions have been developed to reduce distress and improve quality of life (QoL) in patients with advanced cancer, many of which are traditional cognitive-behavioral interventions (CBIs) or mindfulness-based interventions (MBIs). The aims of this meta-analysis were to determine and compare the overall effects of traditional CBIs and MBIs on distress and QoL in this population and to explore potential moderators of intervention efficacy. METHODS: A systematic search was conducted in CINAHL, Embase, PsycINFO, PubMed, and Web of Science. Randomized controlled trials (RCTs) comparing CBIs or MBIs to controls on distress and QoL outcomes were eligible for inclusion. Random effects meta-analyses using standardized baseline to post-intervention mean differences were calculated using Hedges's g. Meta-regressions were used to compare intervention effects and examine potential moderators. RESULTS: Across 37 RCTs (21 CBIs, 14 MBIs, 2 combination therapies), there was a small decrease in distress (Hedges's g = 0.21) and a minimal improvement in QoL (Hedges's g = 0.15). Traditional CBIs and MBIs did not differ in effect sizes. Heterogeneity was significant across distress effect sizes but not across QoL effects. Interventions delivered to individuals (vs. dyads/group) had larger effects on QoL. No moderators of intervention effects on distress were found. CONCLUSIONS: Findings suggest traditional CBIs and MBIs produce small reductions in distress compared to controls in patients with advanced cancer, although effects on QoL appear minimal. Given limitations in the number of studies and their quality, rigorous trials are needed to directly compare the impact of traditional CBIs and MBIs in this population.

Preliminary validation of the Cognitive Affective Mindfulness Scale-Revised in cancer populations.

OBJECTIVE: A brief, valid, and comprehensive measure of mindfulness is needed for cancer populations. This study examined the factor structure, internal consistency, construct validity, and measurement invariance of the 10-item Cognitive Affective Mindfulness Scale-Revised (CAMS-R) in patients with cancer. METHODS: Patients with breast, gastrointestinal, lung, or prostate cancer (N = 404, 50% stage IV cancer, 51% women) were recruited from academic and public clinics in Indianapolis, IN. Patients completed the CAMS-R and other psychological measures at one time point. Confirmatory factor analysis (CFA) was used to examine the dimensionality of the CAMS-R. Internal consistency and construct validity were also assessed. Measurement invariance was examined for gender, cancer type, and cancer stage. RESULTS: CFA showed that the original CAMS-R structure with four first-order factors (attention, present focus, awareness, and acceptance) and one second-order factor (mindfulness) had a reasonable fit (RMSEA = 0.09, CFI = 0.95, SRMR = 0.04). Internal consistency was excellent (α = 0.90). The CAMS-R total score showed significant positive associations with several subscales of a widely used mindfulness questionnaire and self-compassion (rs = 0.61-0.66) and significant negative associations with anxiety, depressive symptoms, rumination, psychological inflexibility, and avoidant coping (rs = -0.35-0.58). Measurement invariance testing indicated that the CAMS-R was invariant across populations of varying genders, cancer types, and stages. CONCLUSIONS: Findings provide preliminary support for using the CAMS-R in cancer populations. Future research should assess the responsiveness of the CAMS-R to intervention.

Relations of perceived injustice to psycho-spiritual outcomes in advanced lung and prostate cancer: Examining the role of acceptance and meaning making.

OBJECTIVE: Many advanced cancer patients struggle with anxiety, depressive symptoms, and anger toward God and illness-related stressors. Patients may perceive their illness as an injustice (i.e., appraise their illness as unfair, severe, and irreparable or blame others for their illness), which may be a risk factor for poor psychological and spiritual outcomes. This study examined relations between cancer-related perceived injustice and psycho-spiritual outcomes as well as potential mediators of these relationships. METHODS: Advanced lung (n = 102) and prostate (n = 99) cancer patients completed a one-time survey. Using path analyses, we examined a parallel mediation model including the direct effects of perceived injustice on psycho-spiritual outcomes (i.e., anxiety, depressive symptoms, anger about cancer, anger towards God) and the indirect effects of perceived injustice on psycho-spiritual outcomes through two parallel mediators: meaning making and acceptance of cancer. We then explored whether these relations differed by cancer type. RESULTS: Path analyses indicated that perceived injustice was directly and indirectly-through acceptance of cancer but not meaning making-associated with psycho-spiritual outcomes. Results did not differ between lung and prostate cancer patients. CONCLUSIONS: Advanced cancer patients with greater perceived injustice are at higher risk for poor psycho-spiritual outcomes. Acceptance of cancer, but not meaning making, explained relationships between cancer-related perceived injustice and psycho-spiritual outcomes. Findings support testing acceptance-based interventions to address perceived injustice in advanced cancer patients.

Symptom experiences in advanced cancer: Relationships to acceptance and commitment therapy constructs.

OBJECTIVE: This study examined relations between acceptance and commitment therapy (ACT) constructs and symptom-based subgroups of advanced cancer patients. METHODS: Patients with advanced breast, gastrointestinal, lung, and prostate cancer (N = 201) completed questionnaires assessing five common symptoms and ACT variables (i.e., psychological inflexibility, cognitive fusion, values obstruction and progress, peaceful acceptance, mindfulness, and activity engagement) on one occasion. RESULTS: Latent profile analysis showed three patient classes: (1) normal levels of all symptoms (32%); (2) normal levels of all symptoms except for mild sleep problems and moderate fatigue (19%); and (3) normal pain, mild levels of sleep problems, anxiety, and depressive symptoms, and moderate fatigue (48%). Controlling for demographic covariates, lower psychological inflexibility, cognitive fusion, and values obstruction were associated with a higher likelihood of being in classes 1 or 2 than class 3. In addition, greater values progress, peaceful acceptance, mindfulness, and activity engagement were associated with a higher likelihood of being in class 1 than class 3. Of these four factors, only greater mindfulness and activity engagement were associated with a higher likelihood of being in class 2 than class 3. CONCLUSIONS: Advanced cancer patients show heterogeneous symptom profiles, and even mild to moderate symptom levels are related to greater withdrawal from personally meaningful activities and less acceptance of cancer and internal experiences (e.g., symptoms, thoughts, feelings). Findings are consistent with the ACT model and support further testing of ACT to address symptom interference with functioning in advanced cancer patients.

Symptom Treatment Preferences of Cancer Survivors: Does Fatigue Level Make a Difference?

BACKGROUND: Cancer-related fatigue (CRF) is among the most prevalent symptoms in cancer survivors and often co-occurs with other symptoms. However, little is known about survivors' preferences for treating CRF and associated symptoms. OBJECTIVE: The aim of this study was to examine cancer survivors' interest in learning skills to manage CRF and associated symptoms and their interest in various nonpharmacologic interventions and modalities. These outcomes were compared between survivors with high and normal fatigue. METHODS: Breast, gastrointestinal, lung, and prostate cancer survivors (N = 338) completed a 1-time survey, including a Patient-Reported Outcomes Measurement Information System fatigue measure and a checklist assessing interest in learning skills to manage CRF and associated symptoms as well as interest in nonpharmacologic interventions and modalities. RESULTS: Many cancer survivors reported interest in learning skills to manage CRF (range, 35%-78%) and associated symptoms (range, 13%-48%). Compared with survivors with normal fatigue (n = 180), highly fatigued survivors (n = 158; Patient-Reported Outcomes Measurement Information System fatigue T score ≥ 55) were more likely to report interest in learning skills to manage various symptoms, self-compassion training, and programs offered individually and in person. Interest in other interventions and modalities did not vary by fatigue level. CONCLUSIONS: Many cancer survivors, especially those with high fatigue, report interest in learning symptom management skills. Given survivors' high level of interest in complementary and integrative health interventions, future research should continue to assess their impact on symptoms and functioning. IMPLICATIONS FOR PRACTICE: Nurses can offer a menu of evidence-based options for symptom management, given survivors' diverse preferences. Nurses can also provide psychoeducation regarding their preferred treatments.

Effects of mindfulness-based interventions on fatigue in cancer survivors: A systematic review and meta-analysis of randomized controlled trials.

This systematic review and meta-analysis was designed to determine the efficacy of mindfulness-based interventions (MBIs) in improving fatigue-related outcomes in adult cancer survivors. Randomized controlled trials (RCTs) were identified from PubMed, MEDLINE, PsycINFO, CINAHL, Web of Science, and EMBASE databases and reference lists of included studies. Separate random-effects meta-analyses were conducted for fatigue and vitality/vigor. Twenty-three studies reporting on 21 RCTs (N = 2239) met inclusion criteria. MBIs significantly reduced fatigue compared to controls at post-intervention (g = 0.60, 95 % CI [0.36, 0.83]) and first follow-up (g = 0.42, 95 % CI [0.20, 0.64]). Likewise, MBIs significantly improved vitality/vigor at post-intervention (g = 0.39, 95 % CI [0.25, 0.52]) and first follow-up (g = 0.35, 95 % CI [0.03, 0.67]). The evidence grade was low due to risk of bias, substantial heterogeneity, and publication bias among studies. MBIs show promise in improving fatigue and vitality/vigor in cancer survivors. More rigorous trials are needed to address current gaps in the evidence base.

Relations of Mindfulness and Illness Acceptance With Psychosocial Functioning in Patients With Metastatic Breast Cancer and Caregivers.

OBJECTIVES: To examine relationships in mindfulness and illness acceptance and psychosocial functioning in patients with metastatic breast cancer and their family caregivers. SAMPLE & SETTING: 33 dyads from an academic cancer center in the United States. METHODS & VARIABLES: Participants completed questionnaires on mindfulness, illness acceptance, relationship quality, anxiety, and depressive symptoms. Dyadic, cross-sectional data were analyzed using actor-partner interdependence models. RESULTS: Greater nonjudging, acting with awareness, and illness acceptance among caregivers were associated with patients' and caregivers' perceptions of better relationship quality. Higher levels of these processes were associated with reduced anxiety and depressive symptoms in patients and caregivers. IMPLICATIONS FOR NURSING: Aspects of mindfulness and illness acceptance in dyads confer benefits that are primarily intrapersonal in nature. Nurses may consider introducing mindfulness and acceptance-based interventions to patients and caregivers with adjustment difficulties.

Examining the effect of peer helping in a coping skills intervention: a randomized controlled trial for advanced gastrointestinal cancer patients and their family caregivers.

PURPOSE: At the end of life, spiritual well-being is a central aspect of quality of life for many patients and their family caregivers. A prevalent spiritual value in advanced cancer patients is the need to actively give. To address this need, the current randomized trial examined whether adding a peer helping component to a coping skills intervention leads to improved meaning in life and peace for advanced gastrointestinal cancer patients and their caregivers. Feasibility and acceptability outcomes were also assessed. METHODS: Advanced gastrointestinal cancer patients and caregivers (n = 50 dyads) were randomly assigned to a 5-session, telephone-based coping skills intervention or a peer helping + coping skills intervention. One or both dyad members had moderate-severe distress. Peer helping involved contributing to handouts on coping skills for other families coping with cancer. Patients and caregivers completed measures of meaning in life/peace, fatigue, psychological symptoms, coping self-efficacy, and emotional support. Patient pain and caregiver burden were also assessed. RESULTS: Small effects in favor of the coping skills group were found regarding meaning in life/peace at 1 and 5 weeks post-intervention. Other outcomes did not vary as a function of group assignment, with both groups showing small decreases in patient and caregiver fatigue and caregiver distress and burden. High recruitment and retention rates supported feasibility, and high participant satisfaction ratings supported acceptability. CONCLUSIONS: Although a telephone-based intervention is feasible and acceptable for this population, peer helping in the context of a coping skills intervention does not enhance spiritual well-being relative to coping skills alone.