Comparison of Two Types of Meditation on Patients' Psychosocial Responses During Radiation Therapy for Head and Neck Cancer

Abstract

Objectives:

Radiation treatment for head and neck cancer introduces adaptive demands and subjects patients to significant and unique psychosocial challenges. There is growing evidence that meditation is useful in lessening anxiety and depression in cancer patients. This study compared the effects of two types of meditation training on the psychological responses of patients with head and neck cancer during radiation therapy.

Design:

Randomized clinical trial.

Setting:

Smilow Cancer Hospital at Yale New Haven.

Patients:

A total of 29 patients with head and neck cancers were recruited and 28 patients were followed during their radiation therapy over 12 weeks.

Interventions:

Depending on their group assignment, patients were taught one of two standardized meditations: meditation with a coach or self-meditation with a CD.

Outcome measures:

Patient psychosocial responses were defined as anxiety, depression, and emotional distress and were measured by the Hospital and Anxiety Depression Scale (HADS) and the Emotional Distress Thermometer. Measures were self-reported and collected by the nurse manager at baseline and 6 and 12 weeks during the patient's scheduled weekly visit.

Results:

Conclusions:

This study demonstrated two equally effective meditation techniques that can be implemented with patients experiencing high stress during radiation treatments in any health care setting to decrease patient anxiety, depression, and emotional distress. The data established self-meditation with a CD as a more cost-effective alternative to meditation with a coach, which requires intensive training and time commitment for patients.

Introduction

Head and neck cancers make up the sixth most common cancer worldwide, and approximately 41,000 individuals are diagnosed with these annually in the United States.¹ These individuals experience high morbidity from their disease and its treatment. They often undergo disfiguring surgery, chemotherapy, and radiation therapy. In addition, treatment requires long-term attention and lifestyle changes: Individuals with head and neck cancer may need feeding tubes for nutrition, tracheostomies for breathing, multiple hospitalizations, and emergency department visits.

Radiation therapy is used globally as a standard treatment for many forms of cancer; however, utilization rates vary widely, from 25% to 75%. It is used as primary treatment alone or in combination with other cancer treatment, such as surgery or chemotherapy. Delaney and colleagues reported that at least 52% of all patients diagnosed with cancer could benefit from external-bean radiotherapy, including over 75% of patients with head and neck.² The purpose of radiation therapy is to damage cancer cells by altering their genetic material and ability to replicate, thereby eradicating the cancer. Radiation doses are now delivered with greater precision to spare destruction of normal tissues, but it is impossible to eliminate all of its harmful effects. For sites such as the oral cavity, salivary glands, and sinuses, surgery is often used as a first-line treatment, followed by radiation therapy to optimize tumor eradication. If the tumor is inoperable, combination radiation and chemotherapy may be used.³

Standard radiation therapy for head and neck cancer includes intensive therapy 5 days a week for a minimum of 6 weeks. During treatment, patients are escorted to the treatment machine and given assistance to lie flat on a hard treatment table. To ensure minimal movement, many patients are required to wear a form-fitting mesh mask that attaches to the table with openings for the eyes and nose. Depending on the area that is being treated, it may be necessary to apply special straps that push the patient's shoulders down to limit movement. Some patients may be given a bite block to insert in their mouth to limit swallowing during each treatment. Patients are alone in a closed treatment room to minimize exposure to personnel.

Many patients undergoing radiation treatment for head and neck cancer exhibit symptoms of psychosocial distress even before beginning treatment, and this number increases significantly during radiation treatment.⁴ A study by Neilson and colleagues has shown that anxiety and depression levels remain high more than a year after completion of cancer treatment.⁵

It is well acknowledged that patients with multiple chronic illnesses increasingly use different types of complementary and alternative modalities (CAM), including dietary supplements, mind–body therapies, chiropractic or osteopathic manipulation, massage, movement therapies, special diets, acupuncture, and naturopathy.⁶ Within the field, mind–body therapies are among the top most commonly used. In Ospina and colleagues' systematic review of clinical trials assessing meditation practices in health care, they identified five broad categories of meditation, including mantra meditation, mindfulness meditation, yoga, t'ai chi, and qigong. The three most common conditions studied were hypertension, cardiovascular disease, and substance abuse.⁷ Khoury and colleagues' comprehensive meta-analysis found that mindfulness-based therapy showed large and clinically significant effects in reducing anxiety and depression.⁸ Although meditation is popular relative to other CAM practices, mind–body therapies are used by only a small segment of cancer survivors and predominantly by women with breast cancer.^9,10 Wolsko and colleagues' assessment of mind–body therapy use among respondents to a random national survey (n = 2055) found that mind–body therapies appear to be underused by individuals with conditions known to have the most efficacious response to mind–body interventions.¹¹

Over the decades, research has been conducted on a variety of forms of meditation and relaxation. Much of this research attempts to differentiate between the physiological and psychological benefits that can be expected by using one technique as opposed to another in different therapeutic settings. Some of these data present compelling evidence that relaxation and meditation have distinct physiological and psychological effects; therefore, they will produce a different experience for the participant. A substantial body of literature has grown in support of meditation use in areas defined as important to patients with cancer, such as anxiety, depression, sense of control, and finding meaning and purpose in life.^12,13 Millegan and colleagues demonstrated significant reduction in distress among patients undergoing chemotherapy.¹⁴ Similarly, Johns and his team demonstrated a significant reduction in persistent fatigue in cancer survivors randomly assigned to a mindfulness intervention compared to usual care.¹⁵ Similar improvements in anxiety, depression, fatigue, and quality of life have occurred in women with breast cancer undergoing radiation therapy who participate in mindfulness meditation.¹⁶

Other studies support the efficacy of meditation as an intervention for men experiencing cancer. Klafke and colleagues showed that Australian men adhered to using meditation as a coping strategy during cancer treatment.¹⁷ Victorson and colleagues demonstrated that mindfulness meditation was feasible, acceptable, and psychologically beneficial to men diagnosed with prostate cancer who were on active surveillance.¹⁸ Meditation is generally considered a safe practice with low to negligible potential for adverse events.

As a team of multidisciplinary providers, the authors recognized that patients with head and neck cancers seemed to be highly stressed during treatment. The daily Monday-through-Friday treatment these patients received provided an opportunity to teach them about meditation, follow them over time, and test two different methods of how to meditate. Although meditation services were available for patients, they were underused, especially men. The authors' goal was to increase patients' interest and use of meditation; therefore, this study was designed to see how the largest number of patients could be reached, with the greatest effect. The purpose of the current study was to compare the effects of two forms of meditation on the psychological responses of patients with head and neck cancer during radiation therapy.

Materials and Methods

The study was designed as a randomized clinical trial to compare the effects of two standardized methods of meditation on patients' psychosocial responses over time. The study was exempted by the Human Investigation Committee at Yale University.

Setting

Smilow Cancer Hospital at Yale New Haven is part of a National Cancer Institute–designated comprehensive cancer center in the northeastern United States. In collaboration with nationally ranked schools of medicine, nursing, and public health and as an academic-based hospital, the Yale Cancer Center has strived to deliver high-quality cancer care throughout the state and the northeast region since 1974. Patients with head and neck cancer were recruited from the Radiation Therapy Department located on the lower level of Smilow Cancer Hospital. Patients are given a comprehensive list of available resources and contact information at their initial meeting. Meditation provided through the Complementary Services Department is available to all patients undergoing radiation therapy upon request.

Recruitment and randomization

The nurse manager identified new patients scheduled for radiation therapy from the Radiation Therapy Department who met the following criteria: (1) definitive primary diagnosis of head and neck cancer, (2) physician's order for radiation treatment, (3) age 21 years or older, and (4) residence within the state of Connecticut. All consecutive new patients with head and neck cancer were informed about the study. If interested, patients were invited to participate and completed an investigator-developed demographic and clinical information sheet including comorbidities. Once baseline information was collected by using a sealed envelope technique, the nurse manager randomly assigned patients to one of two standardized meditation groups: meditation with a coach or self-meditation with a CD. Patients in both groups were taught individually the meditation techniques by the same trained meditation coach from the Complementary Services Department at the hospital. As a certified meditation coach, the coach has over 10 years' experience in training patients with cancer in meditation techniques.

Meditation interventions

This project used two standard methods of meditation: meditation with a coach and self-meditation with a CD. The certified coach instructed both groups on their respective method of meditation.

Group A: meditation with coach

Setting

Patients participated in meditation with a coach in the Radiation Therapy Department. Patients in this group were guided through a 20-minute standardized meditation session once a week following one of their radiation treatments. The session was provided on the same day of the week at the same time with the same coach.

Intent

The goal of meditation with a coach is to create a sense of relaxation, peace, and calm. The meditation session is intended to empower patients to manage any perceived anxiety and depression experienced around the treatment period. Mindful meditation is meant to help the participant focus in the current moment. It attempts to address the sense of unease created when one's mind dwells on past events and emotions or on thoughts and concerns of what might happen in the future.

Description

A series of structured steps were taught and reviewed weekly at the coached visit during radiation treatment over 6 weeks. Each session began with engagement in conversation with the meditation coach to achieve a level of comfort before beginning meditation. The participants were instructed that there is no absolute correct way to practice the meditation. Instead, they were invited to follow as best they can. Specific instructions for mindful meditation included focused, mindful breathing and scanning of the body.

Because these techniques can be effective in many contexts throughout treatment, the participants were encouraged near the end of each meditation to use these learned/practiced techniques throughout the day; before and after radiation treatment; when feeling tightness, tension, or anxiety; and at bedtime.

Group B: self-meditation with CD

Setting

The guided meditation CD was provided to patients by the same meditation coach after completion of the initial baseline questionnaires during week 1 in the Radiation Therapy Department.

Intent

The goal of the guided meditation CD is to create a sense of relaxation, peace, and calm. The self-meditation guided by the CD recording is meant to empower patients to manage any perceived anxiety and depression that is experienced around the treatment period.

Description

The CD guides the participant through a standardized 20-minute meditation, which can be used at any time before or after radiation during the week. The participants were instructed that there is no absolute correct way to practice meditation but were told simply to follow the CD the best they can. The CD describes a series of structured steps, including breathing, body awareness, and the use of ones' senses. A gentle reminder encourages the participant that these practices can be recalled at any time. When participants met with the nurse each week, they were asked to complete the form to evaluate their adherence to using the CD. This data collection contact may have helped to remind the participant to use the CD. The data collection procedures were consistent for both groups.

Measures

Patient psychosocial responses were defined as anxiety, depression, and emotional distress and were measured by the Hospital and Anxiety Depression Scale (HADS) and the Emotional Distress Thermometer. At the patients' weekly radiation nurse visits, adherence to meditation and satisfaction with meditation were self-reported.

Patients completed the measures at baseline and 6 and 12 weeks. Patients were asked weekly to report their emotional distress and adherence to meditation throughout their radiation treatments and to evaluate their satisfaction with meditation (see Table 1 for schedule).

Table 1.

Data Collection Schedule

Variable	Baseline	Week 2	Week 3	Week 4	Week 5	Week 6	Week 12
Demographic	x
Emotional distress	x	x	x	x	x	x	x
Anxiety and depression	x					x	x
Treatment interruption/completion						x	x
Adherence to meditation		x	x	x	x	x	x
Satisfaction with meditation		x	x	x	x	x	x

Emotional distress

This was measured by the Emotional Distress Thermometer, a quick method to evaluate whether patients have distress on a scale of 0 to 10. A mark of 4 or above denotes that patients have problems signifying a need for referral to a social worker. The tool is used similarly to other rating scales that measure pain. The patient is asked, “How would you rate your distress today on a scale of 0 to 10?” Along with the scale to quantify the level of distress, the patient is asked to complete a six-item problem list to identify the types of issues that are causing the patient's distress: illness-related, family, emotional, practical, financial, or spiritual.¹⁹ Initial psychometric testing confirmed that the scale is a valid and reliable measure of emotional distress.²⁰

Anxiety and depression

These were measured by HADS, a 14-item instrument designed to detect the presence and severity of anxiety (7 items) and depression (7 items). Scores of 0–7 in each subscale are considered normal; 8–10, borderline; and 11 or greater, clinical “caseness.” HADS gives clinically meaningful results as a psychological screening tool in clinical group comparisons and in studies with several aspects of disease and quality of life. It is sensitive to change both during the course of disease and in response to medical and psychological interventions.^21,22 HADS has been used widely to detect psychological distress in patients with cancer.^23,24

Statistics

Statistical analyses were conducted by using SAS software, version 9.1 (SAS Institute, Inc., Cary, NC). Descriptive statistics were computed for demographic and clinical variables. Means and standard deviations were calculated for patients' self-reported HADS and Emotional Distress Thermometer scores. Changes in the anxiety and depression scores were evaluated by using repeated-measures analysis of variance (group by time) for longitudinal data.

Results

Of the 29 patients recruited into the 12-week randomized controlled trial, 1 patient decided to receive his treatment at another center; therefore, he did not participate. A total of 28 patients with head and neck cancers were enrolled. The average age of participants was 59 years and the sample was predominantly male (79.3% male and 20.7% female). Half of the sample reported that they had prior experience meditating. Table 2 describes the demographic and clinical characteristics. Thirteen patients were randomly assigned to the meditation with a coach group and 15 patients were assigned to self-meditation with a CD.

Table 2.

Demographic and Clinical Characteristics (n = 29)

Characteristic	Value
Mean age ± SD (yr)	59.1 ± 10.6
Age
<65 yr	20 (69.0)
≥65 yr	9 (31.0)
Sex
Male	23 (79.3)
Female	6 (20.7)
Race/ethnicity
White	23 (79.3)
African American	2 (6.8)
Asian American	1 (3.4)
Latino/Hispanic	3 (10.4)
Marital status
Single	4 (13.8)
Married	21 (72.4)
Divorced/separated	4 (13.8)
Education
High school or less	5 (17.2)
College or more	24 (82.8)
Employment
Full-/part-time working	13 (44.8)
Not working	16 (55.2)
Living condition^a
Alone	3 (10.7)
With others	25 (89.3)
Religious affiliation
None	2 (6.9)
Protestant	5 (17.2)
Catholic	18 (62.1)
Jewish	1 (3.4)
Other	3 (10.4)
Self-rated spirituality
Not at all spiritual	1 (3.4)
A little spiritual	4 (13.8)
Somewhat spiritual	14 (48.3)
Very spiritual	9 (31.1)
Don't know	1 (3.4)
Comorbidities
≤2	19 (65.5)
≥3	10 (34.5)
Self-rated health^b
Excellent	8 (28.6)
Very good	14 (50.0)
Good	4 (14.3)
Fair or poor	2 (7.1)
Assignment condition
CD meditation	15 (51.7)
Coached meditation	14 (48.3)
Ever meditation
No	14 (48.3)
Yes	15 (51.7)
Current meditation
No	25 (86.2)
Yes	4 (13.8)

One missing.

One missing; higher score indicates lower level of self-rated health.

SD, standard deviation.

No significant mean differences were found between the two meditation groups on all three outcomes: anxiety, depression, and emotional distress. Patients in both the meditation with a coach and self-meditation with a CD groups reported less distress from baseline and at all three time points, as evidenced by the HADS anxiety scale (from 6.2 to 3.3 and from 6.2 to 2.3, respectively). Anxiety and emotional distress mean scores in both groups remained stable or declined over time (Table 3). There were no differences between groups for patients with prior meditation experience or on use of other CAM.

Table 3.

Outcomes by Group by Time

Outcome	Condition	Baseline (n = 28)	Week 6 (n = 21)	Week 12 (n = 10)	P-Value ^a	p-Value ^b
HADS-anxiety	CD meditation	6.2 ± 2.7	4.8 ± 2.9	2.3 ± 2.1	0.191	0.631
	Coached meditation	6.2 ± 3.6	3.4 ± 3.6	3.3 ± 2.9	0.846
HADS-depression	CD meditation	2.4 ± 2.1	4.7 ± 3.7	1.7 ± 1.2	0.330	0.272
	Coached meditation	3.8 ± 2.7	3.7 ± 3.1	5.3 ± 4.7	0.548
EDT	CD meditation	2.9 ± 2.0	2.6 ± 2.0	1.8 ± 1.5	0.478	0.850
	Coached meditation	3.5 ± 2.9	2.0 ± 2.1	2.0 ± 2.4	0.645

Values are expressed as mean ± standard deviation. Repeated-measures analysis of variance was conducted on patients who completed data at all three time points.

Within group.

Between groups.

EDT, Emotional Distress Thermometer; HADS, Hospital Anxiety and Depression Scale.

Eighteen participants (64%) reported practicing their meditation regularly during the 6 weeks of their radiation treatments. A higher percentage of participants in the CD group responded than the coach group. Once their 6-week treatments ended, their participation over the remaining 6 weeks declined to 8 participants (29%). Of those who meditated, 20 participants (70%) were very satisfied with its use, and all reported they would recommend it to other patients (Table 4). Notably, patients from each meditation group showed no difference in completion of their treatment (Table 5).

Table 4.

Meditation Adherence by Group (n = 28)

Group	Weekly meditation: yes/no/missing	Frequency (on average)	Whether would recommend to other patients: yes/no/missing
Weeks 1–2 (n = 25)
Coach (n = 11)	7/3/1	2.1	7/0/4
CD (n = 14)	11/3/0	2.2	9/0/5
Overall (n = 25)	18/6/1	2.2	16/0/9
Weeks 3–5 (n = 22)
Coach (n = 9)	8/1/0	2.8	8/1/0
CD (n = 13)	10/2/1	2.2	11/0/2
Overall (n = 22)	18/3/1	2.4	19/1/2
Weeks 6–12 (n = 13)
Coach (n = 6)	4/2/0	1.2	4/0/2
CD (n = 7)	4/3/0	0.9	7/0/0
Overall (n = 13)	8/5/0	1.0	11/0/2

Based on adherence data collected. Missing 3, 6, and 15 responses at the three time points, respectively.

Table 5.

Radiation Treatment Completion by Group (n = 28)

Group	No. of radiation treatments completed (mean ± SD)	Range
Coach (n = 13)	31.45 ± 3.50	24–35
CD (n = 15)	30.93 ± 2.37	28–35
Overall (n = 28)	31.15 ± 2.85	24–35

Treatment stopped among three patients (coach = 2, CD = 1) and restarted within 1 week; number of completed radiation treatments the same as scheduled.

Discussion

Unlike other cancer treatments, radiation for head and neck cancer requires treatment 5 days a week over 6 weeks, providing unique opportunities for providers to teach and enforce the use of meditation and its benefits. Patients in this study voluntarily used meditation during their treatment, reported the benefits of the meditation practice, and stated they would recommend the use of meditation to other patients undergoing radiation treatment. Self-reported scores on the Emotional Distress Thermometer and HADS remained the same or decreased over time, supporting the effectiveness of the use of meditation.

The number one reason patients were unable to attend all meditation sessions in the meditation with a coach group was their inability to stay for the scheduled 20-minute meditation session following radiation treatment. Conversely, the use of the CD allowed participants to meditate at times most convenient for them. User flexibility has broader implications for patients undergoing other high-stress radiation treatments and medical procedures.

Patients in both groups reported the same or lower anxiety or distress levels over time. Meditation was effective in reducing their psychosocial responses. These results are encouraging for a patient population that has consistently reported increasing levels of psychosocial distress over the course of radiation therapy.^25,26

In comparing the two standardized meditation treatments, this study supports the use of self-meditation with a CD as an equally appropriate meditation technique to meditation with a coach, which requires intensive training and time commitment for patients. The cost benefits of self-meditation versus meditation with a coach must be considered. Meditation with a coach necessitates a trained meditation coach on staff to provide the service and regularly meet with patients on a weekly basis. Self-meditation only requires an initial meeting to distribute the meditation CD and teach participants how to use it.

The establishment of self-meditation as an equally effective meditation technique as meditation with a coach has potential significance beyond those explored in this study. Our results contribute to the current literature of meditation in men by establishing two methods that may be used to enhance well-being throughout radiation therapy. This study also revealed that meditation with a CD is an effective intervention for male patients with the flexibility of practicing at their convenience.

Several limitations need to be acknowledged. The sample of 28 participants was small, and significant group differences may have been found with a larger sample. Although information was collected on whether participants adhered to the meditation, these data were limited to self-report and no effort was taken to monitor the fidelity of either intervention. It would have been informative to know what aspects of the intervention were helpful to these participants and under what circumstances and when they practiced the meditation. Also, not all patients randomly assigned to one of the two groups completed the adherence questions, so it is not known whether participants who did not respond practiced the meditation or not. These data were collected as part of the weekly nurse visit; more thorough data may have been collected if a separate research assistant had been used rather than asking a clinic nurse to collect additional data not related to her usual clinical responsibilities.

Conclusions

In this small, randomized clinical trial, patients with head and neck cancers reported they meditated as instructed during their radiation treatments. This low-budget study provides information that can be applied to reduce anxiety and depression in patients with head and neck cancers. In addition, results demonstrated that self-meditation with a CD is a practical and successful method of meditation that decreases anxiety and depression symptoms in patients undergoing radiation therapy for head and neck cancers. Results show great promise for meditation as an intervention strategy for patients, especially men, who are at risk for increased levels of distress and anxiety during their cancer experience.

Footnotes

Acknowledgments

This study was partially funded by a grant from the Closer to Free Fund, Yale Cancer Center (G. Boxleitner, project director).

Author Disclosure Statement

No competing financial interests exist.

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