A cancer diagnosis is a life-changing and highly stressful event for most patients, often resulting in marked declines in quality-of-life (QOL) both during and after treatment. Prevalence estimates suggest that up to 35% of cancer patients report symptoms of depression and/or anxiety.1 Additionally, up to 40% of patients report chronic cancer-related fatigue2, 30–50% report chronic sleep impairment, and 33% of patients continue to experience pain.3 These rates are often higher in patients with metastatic illness, with 42% meeting criteria for a psychiatric disorder, at least 50% reporting fatigue, up to 60% reporting sleep impairment4, and 64% experiencing pain.4,5 There are approximately 3.8 million women living with a history of invasive breast cancer in the U.S., with over 150,000 living with metastatic disease. The average woman with metastatic breast cancer will live 2–3 years, with 25% living 4 + years.5 With ever-increasing advances in targeted therapies, survival with metastatic disease will continue to improve.
In recognition of the need to address these long-lasting symptoms of cancer treatment, the NCCN developed Clinical Practice Guidelines for Survivorship in 2013, most recently updated in 2021. These guidelines focus on several areas that patients often continue to struggle with post-treatment: cardiotoxicity, anxiety, depression, cognitive function, fatigue, pain, sexual function, and sleep disorders.6 While the Survivorship Guidelines provide algorithms for the assessment and treatment of each of these areas, efforts to develop validated measures and interventions are ongoing. Patient preferences indicate a high need for non-pharmacologic, complementary and alternative medicine (CAM) interventions to address these chronic symptoms. Unique to the metastatic population is the experience of chronic symptomatology and treatment course – a ‘living with’ rather than ‘living after’ cancer.
Many interventions have been developed aimed at improving these symptoms in cancer patients, with mindfulness-based interventions (MBIs) showing particular promise. Mindfulness-Based Stress Reduction (MBSR) and Mindfulness-Based Cancer Recovery (MBCR) are two well-validated MBI treatments shown to be effective for the improvement of stress, mood, fatigue, and QOL, that can affect several biomarkers related to cancer.7–10 MBSR was developed by Kabat-Zinn and focuses on one’s present awareness, with a view toward life circumstances that is open, accepting, and non-judgmental.11 This was later adapted by Carlson and Speca with the creation of MBCR to assist patients undergoing cancer treatment in managing symptom burden.12 It has been widely supported as a beneficial intervention in improving patient’s experience of pain, anxiety, depression, sleep concerns, fatigue, and health-related QOL13–15, as well as with patients dealing with metastatic breast cancer.16,17
While evaluations of MBIs have been promising, most MBI psychological interventions are almost exclusively delivered face-to-face, often in a group format. As a result, high attrition rates are often reported as patients experiencing ongoing side effects or living a distance from the hospital may find it difficult to adhere to a time-intensive treatment.17 In addition, MBIs are typically validated on earlier-stage cancer patients, and those that do include patients with metastatic illness often result in very low enrollments and/or high attrition rates. Metastatic patients are highly impacted by chronic symptoms, yet paradoxically, are often the least-studied.
In addition, MBSR may improve physiological outcomes and biomarkers associated with disease outcomes. Breast cancer patients with advanced disease often have high circulating levels of pro-inflammatory cytokines, which are consistently associated with increased levels of stress, pain, depression, and fatigue,18,19 that may be associated with breast cancer progression and poorer prognosis in patients with metastatic breast cancer.20,21 Reductions in pro-inflammatory cytokine levels or expression, including IL-6 and TNFα have occurred following participation in MBIs that are as short as 6 weeks in length.22,23 No studies, however, have broadly examined the potential impact of MBSR training on pro- and anti-inflammatory cytokines that can affect disease prognosis and none have examined the impact of MBSR on biomarkers associated with regulating stress response that may play a role in modulating inflammation among patients with metastatic disease.24–26
The area of telemedicine has grown vastly in the past several years and is allowing patients to gain access to clinical trials, psychological treatment, and ongoing medical care that was previously very difficult to engage in, particularly for late-stage patients. Online interventions are becoming increasingly common and show positive effects on emotional health and coping with the effects of cancer treatment.14,27
The objectives of the study were: 1) to test a novel online MBSR treatment for distressed metastatic breast cancer patients who may otherwise be unable to participate in a traditional in-person intervention due to high symptom burden. It was hypothesized that the online format would be accessible to a majority of patients, easily adopted, and would result in high completion rates; and 2) to determine the impact of the intervention on patient self-reported outcomes and on biomarkers of inflammation and sympathetic activation as markers of the stress response. It was hypothesized that patients assigned to the intervention, compared to wait-listed controls, would show improvements in psychological and physical symptoms associated with QOL, including depression, anxiety, fatigue, sleep impairment, and pain; increases in indices of mindfulness; and improvements in blood pressure measurements and immune biomarkers associated with better QOL, reduced levels of stress, and/or better disease prognosis.