Mind the Gap: Oncologist perceptions and knowledge of meditation as a complementary therapy

doi:10.21203/rs.3.rs-4693774/v1

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Mind the Gap: Oncologist perceptions and knowledge of meditation as a complementary therapy

https://doi.org/10.21203/rs.3.rs-4693774/v1

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Purpose

To understand the recommendation practices of mind-body complementary therapies by Canadian oncologists. In particular, to examine oncologist perceptions and knowledge of meditation, awareness for 2018 ASCO guidelines that recommend meditation to breast cancer patients for reducing anxiety/stress, and associated changes in oncologists’ recommendation of mind-body therapies to their patients.

Methods

Medical oncologists were invited to complete an online survey about prescribing meditation for improving quality of life. The survey assessed demographic and professional practice characteristics. Current complementary therapy recommendations, knowledge of meditation, and general awareness for the ASCO guidelines were assessed. Data was analyzed using a series of descriptive statistics.

Results

A large portion of oncologists (83%) reported recommending at least one form of complementary therapy; with 40% recommending meditation. Most oncologists were knowledgeable about the benefits of meditation, and had a general awareness of resources (i.e., digital meditation tools, 80%). Less than one third of oncologists were aware of the ASCO guidelines, however 56% of those unaware of the guidelines indicated that they plan on recommending these therapies in the future.

Conclusion

The results from this study are promising, as becoming aware of the guidelines had a positive impact on the willingness of oncologists to recommend complementary therapies to their patients. Future research should replicate the study in a larger sample of oncologists, and further explore potential reasons why some oncologists may be hesitant to recommend complementary therapies, such as meditation.

complementary therapy

meditation

oncologist survey

integrative therapy

cancer

The use of complementary and alternative medicine (CAM) has been increasing among cancer patients to alleviate the side effects of treatment, manage disease symptoms, and improve overall well-being. Estimates across North America and Europe suggest that between 40–85% of cancer patients use some form of CAM throughout their cancer journey [1–5]. CAM therapies can vary greatly in their usage and form, encompassing both alternative forms of medicine aimed at substituting conventional treatments, and complementary therapies which supplement traditional medicine. Spiritual and mind-body therapies such as meditation and relaxation techniques are complementary therapies that have been growing in their popularity partly due to their perceived safety and emphasis on holistic wellness. [1, 6–8] Cancer patients have been turning to mind-body therapies for emotional well-being and to improve stress-related symptoms such as anxiety, depression, fatigue, pain, and insomnia [9, 10].

Meditation has become one of the most utilized forms of mind-body therapies, with some online surveys reporting that over one third of cancer patients use it as a complementary therapy [9]. Briefly, meditation can be described as any mind-body practice that requires the focus of one’s attention in a particular way in order to achieve mental clarity. There are countless different methods of meditation including mindfulness, guided meditation, mantras, and many others. In each of these forms, there may be a different point or focus of concentration (e.g., breathwork, body scans, sounds) [11]. Several evidence-based mindfulness programs that encompass meditation (i.e., stress reduction, cognitive training) have been developed or adapted specifically for cancer patients (i.e., mindfulness-based cancer recovery) [12–14].

Amidst the variety of meditation-based programs available to cancer patients, studies have also consistently demonstrated that meditation in most forms can improve mental health symptoms (i.e., anxiety, depression, fear of recurrence), physical health (i.e., pain, fatigue, sleep), and improve the overall quality of life of cancer patients [15, 16]. These positive effects of meditation on those with cancer have been demonstrated in face-to-face mindfulness based programs [17, 18], online group/individual sessions [13, 19], and self-guided commercial digital meditation applications such as Calm and Headspace [20, 21]. Moreover, the benefits of meditation have also been documented across different treatment and survivorship phases of cancer, and across different stages and types of cancer (e.g., breast, colorectal, gastrointestinal) [22–24].

As a result of the overwhelming amount of literature available on the benefits of meditation, clinical practice guidelines and various cancer societies have begun to endorse the recommendation of meditation for alleviating anxiety, treating mood disturbances and for improving overall quality of life. In 2018, the American Society for Clinical Oncology (ASCO) endorsed guidelines proposed by the Society for Integrative Oncology (SIO), which included prescribing meditation for the management of the aforementioned symptoms/adverse effects for breast cancer patients [25]. More recently in 2023, ASCO updated their guidelines to reflect that mindfulness-based interventions should be offered to all people with cancer during active treatment and post-treatment to reduce symptoms of anxiety and depression [26]. In addition, most cancer societies and centres around the world provide information and resources for meditation on their respective websites (e.g., American Cancer Society, Canadian Cancer Society, Cancer Council NSW, Cancer Research UK).

Despite these guidelines and evidence demonstrating the benefits of meditation for those with cancer, little is known about whether oncologists are aware of these guidelines or recommend meditation to their patients. To our knowledge, only a few studies have examined general patient-physician conversations around CAM. Findings to date suggest that very few patients (15–27%) report discussing CAM therapies with their oncologist or primary physician, despite patients reporting that they would like more information on CAM to be provided by specialists during treatment periods (49%), via brochures (29%), or on clinic websites (16%) [27–29]. It is also important to note that studies to date have been largely conducted in Germany and northern Europe, and prior to the ASCO guidelines released in 2018. Therefore, the aim of this study was to better understand Canadian oncologists practices around recommending complementary therapy to their patients subsequent to ASCO guidelines and to understand if the guidelines had any impact on oncologist practices. In particular, we sought to understand oncologists current knowledge of meditation, awareness for existing ASCO guidelines, and resulting changes to their recommendation of meditation and other mind-body therapies to their patients. As this study was exploratory in nature, no a priori hypotheses were made.

Study Population and Recruitment

Medical oncologists were invited to complete an online survey about their knowledge and perspectives of meditation for improving the quality of life in cancer patients. As this cross-sectional survey was part of a larger study examining patient and oncologist perceptions of meditation which was been previously published (blinded for review); a brief summary of study population and recruitment are described below. To capture a broad geographical range of oncologists, members of the Canadian Association of Medical Oncologists (CAMO) were contacted via an email blast in August 2023. CAMO has over 350 members, including residents, fellows, oncologists, and associates. However, due to low recruitment rates, an additional 303 oncologists were individually emailed by the study team, using publicly available information, in September 2023. The inclusion criteria of participants were as follows: (a) adults aged 18 and above, (b) having completed their fellowship, and (c) practicing medical oncology in Canada. To encourage recruitment efforts, up to two reminder emails were sent out to potential participants. Those who were interested in completing the survey were directed to an electronic consent form via a link contained in the invitation email. Participants who completed the electronic consent were automatically directed to the survey on their browser. Upon completion of the survey, oncologists interested in receiving more information about meditation were provided with a downloadable resource (see Supplement A). All participants who completed the survey were compensated with a $5 electronic gift card. This study was performed in line with the principles of the Declaration of Helsinki. The study received ethics approval from Veritas Independent Review Board.

Content of Survey

The survey assessed demographic characteristics such as participant age, sex, and main location of professional practice (i.e., province). Professional practice characteristics collected included: work setting (i.e., academic health sciences centre, community hospital, community clinic, university, etc.), number of years of practice, and area of oncology specialty (i.e., medical oncology, pediatric, surgical, etc.). To determine current practices around recommending alterative and complementary therapies for alleviating stress and anxiety among cancer patients, participants were asked to identify any therapies they currently recommend from the following list: breathing techniques, acupressure/acupuncture, massage, stretches, information/pamphlet, meditation, none, or other (please specify). In addition, participants who did not select meditation as an option were specifically asked if they had ever recommended meditation to their patients (yes/no). Further questions explored the forms of meditation that have been recommended, how the recommendation was made, and resources that were provided to patients.

To assess oncologist knowledge of meditation, a series of 10 items that were developed by Russell et al. were utilized (i.e., General Perceptions of Meditation (GPM)) [30]. Oncologists were asked to rate their agreement with 10 statements—seven facts and three misconceptions—using the response options 1 for “Agree”, 0 for “Don’t know” or -1 for “Disagree. All GPM items are presented in Fig. 1.

The last component of the survey was to understand oncologists’ general awareness for the 2018 ASCO- endorsed SIO guidelines that currently recommend meditation to breast cancer patients; whether this awareness changed their recommendations of integrative therapies, and for those previously unaware, if current awareness would influence their recommendation of integrative therapies moving forward.

Statistical Analysis

The primary analysis plan was to predict the characteristics (e.g., age, sex) and alternate therapy recommendation practices of oncologists who prescribe meditation to their patients, using a multivariate Logistic Regression with two-sided p < 0.05 as a critical value as per the previously published protocol (blinded for review). However, due to difficulties in recruitment and the resulting small sample size of N = 36, the minimum required sample size (N = 150) to conduct a logistic regression was not achieved. Therefore, a series of descriptive statistics were used to examine oncologists’ awareness for ASCO 2018 guidelines, general knowledge and perceptions of meditation, and current recommendation practices. All analyses were conducted using Python 3.11 (Python Software Foundation; https://www.python.org/).

Over 300 medical oncologists were contacted to participate in the survey. In total, 43 oncologists consented to participate, of which 36 completed the online survey and were included in the analysis. Overall, 44.4% of the sample was male, the mean age was 48.0 years (SD = 10.9 years) and participants practiced across eight provinces in Canada; the four most common being Ontario (58.3%), Manitoba (11.1%), British Columbia (8.3%), and Alberta (8.3%). Additionally, the average number of years oncologists had been practicing was 14.9 years (SD = 10.9), and most practiced in an academic health science centre (66.7%) or a community hospital (25.0%).

In regards to current practices around recommending complementary therapies to their patients, the majority of oncologists (83.3%) reported recommending at least one form of complementary therapy, with the most common therapies being massage (46.7%), meditation (40.0%), acupressure/acupuncture (30.0%), stretches (30.0%), and breathing techniques (16.7%). In addition, five participants reported having recommended meditation to their patients in the past, bringing the total proportion of oncologists who had ever recommended meditation in their practice to 47.2%. Overall, most oncologists (80.6%) were interested in learning more about meditation resources. Among medical oncologists who recommend meditation to their patients either presently or in the past, the most common type was mindful meditation (70.6%) and guided meditation (29.4%). Despite 80.6% of the sample having a general awareness for different digital meditation tools such as Calm (69.4%) and Headspace (52.8%), only 27.8% of surveyed oncologists had recommended a digital meditation tool to their patients.

The general perceptions and knowledge of meditation among oncologists is summarized in Fig. 1. Overall, the majority of medical oncologists surveyed believed that meditation is the act of calming the mind (97.2%), can help patients cope with stress (94.4%), can be practised in different ways (91.7%), and is part of a healthy lifestyle (83.3%). Moreover, most oncologists surveyed correctly identified misconceptions about meditation, and often disagreed that meditation is only for religious people (97.2%); is the same as relaxation (86.1%); is about emptying your mind (52.8%). The mean GPM score among oncologists was 7.4 (SD = 2.1).

Note

Items 6,7, and 9 denote common misconceptions about meditation.

Overall, less than one third of medical oncologists sampled were aware of the 2018 ASCO guidelines which recommend meditation for anxiety/stress reduction among breast cancer patients. Of those who were presently aware of the guidelines, 36.4% began recommending complementary therapies to their patients subsequent to the release of the guidelines (i.e., meditation, stress management, yoga and music therapy); whereas more than half of those unaware of the guidelines (56%) indicated that they planned on recommending these complementary therapies in the future.

Overall, the majority of oncologists (83.3%) surveyed in this study currently recommend some form of complementary therapy to their patients to help relieve symptoms of anxiety and stress, with massage and meditation being the most common forms recommended. In contrast to previous literature which has reported that only 25% of physicians/oncologists have conversations about CAM with their patients [28], our findings suggest that perceptions and knowledge of complementary therapies may be improving among oncologists/physicians. This may be in part due to the attention complementary therapies have been recently receiving from large organizations like ASCO and SIO, who promote its use among cancer patients for emotional health and general well-being [25, 26]. Alternatively, general perceptions towards CAM may be more positive among oncologists in North America, as most of the research reporting on patient-physician conversations about CAM and sources of patient information (e.g., 45% receive information from family/friends) to date have been conducted in Europe [27–29].

Regarding meditation specifically, we found that surveyed oncologists were generally well-informed and had a reasonable understanding of the overall health benefits of its practice. Nonetheless, some uncertainty was observed regarding specific aspects of meditation, namely having to practice it regularly to feel a benefit, and meditation being about increasing one’s awareness and not emptying the mind. Overall, these findings suggest that oncologists may be aware of the existing evidence that meditation is beneficial for general health [6, 16], but not necessarily understand the specific processes and mechanisms underlying its practice.

Interestingly, we found that only a third of the medical oncologists surveyed currently recommend meditation to their patients; however, the overwhelming majority, 80.6%, were interested in learning more about meditation and potential resources they could provide to patients. Coupled with the finding that most surveyed oncologists are aware of popular digital meditation resources, yet very few recommend them to patients (less than a third), it may be that oncologists are unsure of what to recommend in the face of too many options (i.e., type of meditation, delivery format, etc.). As a first step, it is recommended that cancer clinics consider building toolkits for oncologists and other healthcare staff with top-rated evidence-based local/online programs. Alternatively, pamphlets can be created for patient distribution during regular appointments, with discussions around CAM use and resources being encouraged. We must also consider that while oncologists are aware of meditation programs, other healthcare providers within a patient’s circle of care (i.e., nurses, social workers, psychotherapists) may be more involved in recommending complementary therapies to patients than physicians. Indeed, future research should examine the knowledge and recommending practices of nurses, social workers and associated mental health care workers that may be involved in managing patients’ emotional well-being alongside their cancer treatments; particularly in larger cancer clinics where care teams may be comprised of several different roles.

Lastly, we found that the majority of oncologists sampled were not aware of the 2018 ASCO guidelines which recommend meditation for anxiety/stress among breast cancer patients. While this finding itself is not surprising, as oncologists have several professional obligations that compete for their time, observing the effects of becoming aware of the guidelines was of note. In particular, we found that on one third of oncologists began recommending complementary therapies to their patients upon becoming aware of the guidelines, and that among those unaware, more than half planned on recommending it to their patients. While there is an openness among our sample to recommend meditation to patients, oncologists may simply be unsure of what specific resources to recommend to patients. Nonetheless, our findings suggest that simply making more oncologists aware of ASCO guidelines [25, 26] around integrative medicine may significantly impact their practices. Therefore, cancer and medical associations should place a greater emphasis on knowledge exchange activities to promote greater awareness for clinical practice guidelines among physicians and oncologists.

While our findings can help researchers and healthcare providers understand the current practices among oncologists for prescribing CAM, and more specifically meditation, the results should be interpreted within the following limitations. Firstly, the study was comprised of a small sample size. Therefore, the results are not generalizable to all Canadian or North American oncologists. Future research should replicate this study and consider alternative forms of recruitment (e.g., annual meetings of professional societies). In addition, this study was limited to medical oncologists, who are often the main physician for cancer patients; however, other oncology specialists or general practitioners who have direct contact with patients should also be included in future research. Lastly, our research was conducted in the midst of the release of the 2023 ASCO guidelines which endorse mindfulness-based intervention (including meditation) for cancer patients experiencing anxiety and or depression symptoms. Awareness of these guidelines may have improved oncologists’ awareness for CAM and meditation in general. Future research should explore oncologists’ awareness of the 2023 guidelines, and any associated practice changes in their recommendations of mindfulness-based interventions.

In this study, we observed that oncologists generally have positive perceptions of certain complementary therapies, including meditation. The vast majority of oncologists surveyed recommended at least one form of complementary therapy to their patients, and most were interested in learning more about meditation in general. Nonetheless, most oncologists sampled were not aware of the 2018 ASCO guidelines promoting the use of meditation among breast cancer patients to reduce symptoms of anxiety and stress. Overall, our results are promising, in that becoming aware of guidelines seemed to have a positive impact on oncologists’ willingness to recommend complementary therapies. This emphasizes the importance of disseminating information to oncologists about the benefits of meditation for their patients, and the ASCO guidelines. Future research should replicate the survey among a larger sample, and further explore reasons for why some oncologists may hesitate to recommend complementary therapies such as meditation.

Author Contribution

All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by AG, CS and KJ. The first draft of the manuscript was written by AG and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Acknowledgement

We would like to thank Avni Shah (North Bay Regional Health Centre) for organizing and conducting the recruitment and data collection of this study; and Kevin Wu (Carleton University) for programming the survey website.

Data Availability

Data is available from the corresponding author upon reasonable request.

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No competing interests reported.

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You are reading this latest preprint version

Mind the Gap: Oncologist perceptions and knowledge of meditation as a complementary therapy

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Abstract

Purpose

Methods

Results

Conclusion

Figures

Introduction

Methods

Study Population and Recruitment

Content of Survey

Statistical Analysis

Results

Discussion

Conclusion

Declarations

Author Contribution

Acknowledgement

Data Availability

References

Additional Declarations

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Version 1