Mindfulness-Based Cognitive Therapy Intervention for Young Adults with Cancer: A Pilot Mixed-Method Study

Abstract

Purpose:

Group mindfulness-based interventions are emerging as a promising, nonstigmatizing, and cost-effective strategy that may improve the well-being of individuals living with cancer. This study is a pilot pre–post mixed-method study to examine the feasibility, acceptability, and effects of an 8-week Mindfulness-based Cognitive Therapy group for Young Adults with Cancer (YA-MBCT).

Methods:

We approached young adults with cancer, who enrolled in YA-MBCT groups, offered at a large cancer hospital in Toronto, Ontario, Canada. Feasibility and acceptability were assessed through attendance rate and a postintervention satisfaction scale. Psychosocial outcomes were evaluated with a pre–post questionnaire package, with validated self-report measures, assessing depression, anxiety, perceived stress, quality of life, mindfulness, and self-compassion. Qualitative interviews were completed among a subset of participants to gain additional feedback.

Results:

Participants were 70 young adults with cancer, recruited from five YA-MBCT groups. Sixty participants (85%) attended a minimum of six of eight sessions, and overall satisfaction rates were high. All psychosocial outcomes demonstrated statistically significant changes (p < 0.01), with medium to large effect sizes (Cohen's d > 0.5). Qualitative interviews (n = 14) demonstrated overall positive views about the intervention, and provided insight into unique age-specific benefits, including reducing fear of cancer recurrence, improving body image, and creating a sense of belonging.

Conclusion:

The YA-MBCT is feasible and acceptable among young adults with cancer, with the potential to improve psychosocial outcomes. Our preliminary results should be replicated with larger studies with an active control group.

Introduction

Adolescents and young adults (AYAs) with cancer show an elevated risk of unmet needs and emotional distress,^1–7 and psychosocial interventions designed to enhance coping with cancer and improve quality of life in this population are urgently needed.^7,8

Group mindfulness-based interventions (MBIs) are emerging as a promising, nonstigmatizing, and cost-effective strategy that may improve the well-being of individuals living with cancer.^9–11 Kabat-Zinn¹² defined mindfulness as a capacity, which can be taught through MBIs, to nonjudgmentally observe present-moment experiences, including emotions, cognitions, and body sensations. The two most common MBIs are the Mindfulness-based Stress Reduction program (developed by Kabat-Zinn¹²), and the Mindfulness-based Cognitive Therapy (MBCT) program, which incorporates elements of cognitive therapy, designed to help participants recognize and disengage from rumination and other unproductive thought processes.¹³ Both programs are manualized 8-week group interventions, with demonstrated effectiveness for a range of patient populations and clinical problems.¹⁴ In individuals with cancer, MBIs have been associated with improvement in depression, anxiety, fatigue, sleep, quality of life, and fear of cancer recurrence.^9–11

In cancer populations, MBI studies typically involve individuals >50 years of age.¹⁰ We identified only four studies that examined the impact of MBIs in AYA cancer patients, all had small sample sizes (ranging from 7 to 25 participants per study), with three focusing on adolescents^15–17 and one conducted with young adults (YAs) <29 years.¹⁸ Thus, YAs between 18 and 40 years are poorly represented in MBI research.

Our hospital began offering MBCT groups to adult cancer patients in 2014. Initially, the groups were offered as general groups for all ages, but there was low relative attendance (<10%) of those <40 years. Our anecdotal observation mirrored prior studies documenting YAs dissatisfaction with cancer psychosocial support programs due to lack of age-appropriate attention.^19–21 Therefore, in 2016, we began to offer MBCT specific to YA (YA-MBCT), as part of a comprehensive effort to better serve this population, which includes ∼1300 YAs seen annually at our hospital.²²

The current pilot mixed-method study aims to examine the feasibility, acceptability, and potential benefits of the YA-MBCT. We hypothesized that (1) the YA-MBCT would be feasible, as measured by attendance of at least six of eight sessions by at least 80% of participants; (2) the YA-MBCT would be acceptable, as measured by a postgroup satisfaction measure with scores of at least 4 on a 5-point scale, and by feedback from qualitative interviews; and (3) the YA-MBCT would reduce symptoms of depression, anxiety, and perceived stress, and improve quality of life, mindfulness, and self-compassion; and that additional age-specific benefits would be elucidated in qualitative interviews.

Methods

The YA-MBCT intervention

The YA-MBCT program is a group intervention of eight weekly sessions, 2.5 hours in length, and a 5.5-hour silent day of practice between weeks 6 and 7. The intervention is based on the original MBCT curriculum of Segal et al.¹³ Each session includes experiential practices, such as meditation and yoga, psychoeducation, and group debriefs. Each group includes between 10 and up to 20 participants. Groups were delivered at the Princess Margaret Cancer Centre in Toronto, Ontario, Canada, by two co-facilitators, both with expertise in psychosocial oncology and mindfulness training. The YA-MBCT groups were advertised mostly through the Princess Margaret AYA clinic, which sees ∼100 YAs annually.²³ Participation in the YA-MBCT groups was limited to those <40 years. Exceptions were made for cancer patients <45 years who were interested in enrolling in a YA-MBCT due to perceived similarities in life stage (e.g., marital, career, or parenting status).

Procedure and recruitment

The study was approved by the institution research ethics board. Study participants were recruited from a pool of YAs who were attending the YA-MBCT groups. We included five groups of YA-MBCT in this study to have at least 59 participants, as per Viechtbauer et al.'s²⁴ guideline for the calculation of sample size in pilot studies. All YA-MBCT attendees were asked to arrive early before the first session to complete a preintervention questionnaire package and to stay longer after the last session to complete a postintervention package, and were asked to indicate on the paper questionnaire package if they agreed for the use of their questionnaire data for research. Those who indicated “yes” were contacted by a research assistant (RA) to obtain written informed consent for the use of their questionnaire data for research, collection of additional information from their medical charts, and for the possibility of contacting them for postintervention qualitative interviews. The RA also contacted participants in the case of incomplete data within a 2-week time frame.

A subsample of study participants was contacted for qualitative interviews based on their demographics and responses on the questionnaires, to ensure varied representation of gender, age, marital status, and degree of satisfaction/improvement after the YA-MBCT. Interviews were audio-taped and transcribed verbatim. Interviews continued until theme saturation was achieved.²⁵

Measures

The pre–post questionnaire package was comprised of self-report measures that have been previously validated in cancer patients and demonstrated sensitivity to change in psychosocial interventions studies with this population. The measures included (1) the Patient Health Questionnaire-9,²⁶ a 9-item measure used to assess depression; (2) the Generalized Anxiety Disorder-7,²⁷ a 7-item measure of symptoms of anxiety; (3) the Perceived Stress Scale,²⁸ a 10-item measure of the extent to which individuals appraise situations as stressful; (4) the Edmonton Symptom Assessment System,²⁹ a 10-item measure of symptom intensity and quality of life in cancer patients; (5) the Philadelphia Mindfulness Scale,³⁰ a 20-item measure of mindfulness; and (6) the Self-Compassion Scale-Short Form,³¹ a 12-item tool designed to assess self-compassion. In addition, a 5-item satisfaction measure created for this study was included in the postintervention questionnaire package.

A subsample of participants took part in qualitative interviews postintervention. The interview guide included open-ended questions organized by the following topics: motivations and hesitations about participating in the YA-MBCT, general views about the YA-MBCT, perceived impact of the program in general, and of specific components, and suggestions for improvement. Interviews lasted between 30 and 60 minutes and were conducted by two trained interviewers, in-person or over the phone.

The RA collected demographic and medical information from medical charts. Group attendance and dropout rates were recorded.

Analysis

Mean (standard deviation), frequency, and percentage were used for data description. t-Tests and chi-square analyses were conducted to compare between completers and noncompleters of the postintervention questionnaire package. Paired t-tests were conducted to compare the pre- and postintervention outcome measures and the effect size of pre–post changes was calculated with Cohen's d (small effect = 0.20, medium effect = 0.50, large effect = 0.80).³²

Qualitative analyses of semistructured interviews were conducted using a conventional content analysis method.²⁵ This is an iterative process whereby an initial set of themes are coded and a preliminary thematic scheme is developed. Then, the themes are applied to a new subset of data, and revised to adjust for new information, until no new themes emerge.

Results

Participants

Five YA-MBCT groups were completed from April 2016 to June 2017 with a total of 77 participants. Of those, 70 consented for the use of their questionnaire data for research. The demographic and medical information of these 70 study participants is detailed in Table 1. The mean age of study participants was 34 years. Seven study participants (10%) were aged 40–45 years (they attended a YA-MBCT group based on similarities in life stage).

Table 1.

Characteristics of Participants (N = 70)

Characteristics	Description
Gender (female)	60 (85.7%)
Age (M [SD]; range)	34 (6.3); 19–45
Marital status
Married/common-law	27 (39%)
Single/divorced	43 (61%)
Cancer type
Breast	27 (38%)
Lymphoma	9 (13%)
Gynecology	8 (11%)
Leukemia	7 (10%)
Brain	7 (10%)
Other	12 (18%)
Cancer stage
0–III	58 (82%)
IV	12 (18%)
Treatment status
On active treatment (chemotherapy/radiation/both)	27 (37%)
Completed treatment	43 (63%)
Months since diagnosis (M [SD]; range)	30 (37.4); 1–192

SD, standard deviation.

Of the 70 study participants, 33 (47%) returned both their pre- and postintervention questionnaire packages. No statistically significant differences in demographic variables or preintervention measures were detected between completers (n = 33) and noncompleters (n = 37). Noncompletion of either the pre- or postintervention questionnaire packages occurred when participants were not able to arrive early or stay longer to complete the questionnaires, and then were not able to be reached by the RA to have the packages completed within a 2-week time frame.

A subsample of 14 participants also completed qualitative interviews about their experience with the YA-MBCT. The demographic and medical characteristics of these 14 participants are detailed in Table 2. Interviews were conducted at a mean of 1 month after the group ended (range: 13 days to 3 months). The interviews capture the perspectives of participants who attended at least four sessions, with the median (five participants) completing six of the eight sessions of the intervention, and three completing all eight sessions.

Table 2.

Characteristics of Qualitative Participants (N = 14)

Characteristics	Description
Gender (female)	12 (85.7%)
Age (M [SD]; range)	32 (7.98); 19–45
Marital status
Married/common-law	6 (42%)
Single/divorced	8 (58%)
Cancer type
Breast	6 (42.9%)
Lymphoma	2 (14.3%)
Lung	1 (7.1%)
Leukemia	3 (21.4%)
Brain	2 (14.3%)
Cancer stage
0–III	12 (86.7%)
IV	2 (14.3%)
Treatment status
On active treatment (chemotherapy/radiation/both)	6 (43%)
Completed treatment	8 (57%)
Months since diagnosis (M [SD]; range)	51 (48.14); 2–171

Feasibility and acceptability

Sixty study participants (85%) attended at least six of the eight sessions of YA-MBCT, and of those, 15 (21%) attended all eight sessions. Only six (8%) participants completed less than two sessions. Overall satisfaction rates were high: 82% agreed or strongly agreed that the group met/exceeded their expectations, and 94% agreed or strongly agreed that the group was beneficial. Detailed evaluation results can be found in Table 3.

Table 3.

Feasibility and Acceptability

	Description
Feasibility
Attendance of at least six sessions	60 (85%)
Dropped out (completed less than two sessions)	6 (8%)
Acceptability (scale of 1–5), (M [SD]; range)
The group met/exceeded my expectations	4.68 (0.76); 3–5
The group was beneficial for me	4.47 (0.7); 2–5
I will recommend the group to others	4.47 (0.7); 3–5
The content was understandable and clear	4.48 (0.66); 2–5
The group facilitators were effective	4.35 (0.77); 3–5

In qualitative interviews, participants expressed very positive views about the YA-MBCT and no harm or adverse events were reported. Most importantly, the qualitative analysis revealed that the YA-only format contributed to the feasibility and acceptability of the program. In fact, our analysis suggests that homogeneity in age/life stage may be more important to YAs when considering support resources than homogeneity in cancer type or stage. As one participant remarked: “what made me more eager to join the group was knowing that it was just focused on that younger community within the cancer group.” Another commented: “I liked that it was for the young adults. I'd never been in a class just like that geared just for that age. So, I thought that that would be really great, because maybe we can relate to each other on a different level.”

Participants commented that the YA-only format made them feel more “comfortable,” “safe and understood” and less “vulnerable” while attending the group. They commented that they often feel, in the cancer world, as they are “in between…not children who don't have the emotional complexity to voice what they may be going through, and not older people who have a different experience” and that a YA-only group addressed this “in between” gap for them. This is illustrated in an interview with a participant who completed the YA-MBCT group, after trying and dropping out of a general MBCT group (before a YA-only option was available):

“I'm glad they decided to make a young adult [group]… I went into the original program first. You've got to understand that when a young adult has cancer and goes into a group with 50-plus-year-old women…you feel worse, because you're like, ‘I could understand these people getting cancer, but why the F am I here?’ Like, ‘why did this happen to me?’ and it makes you feel worse. And even though they're trying to get you to deal with stuff, it's a negative result, because just being in those places is like, ‘this isn't supposed to happen’ and that's all you focus on…But, then when you see a group of your peers…There's a sense of camaraderie. There's a sense of ‘you are not isolated anymore,’ and that means a ton for these kinds of programs.”

It is important to note that our analysis suggested that similarities in life stage are more important than age per se. In fact, even within the YA-specific groups, some participants felt different than the other group members, as one described: “I guess I qualify as a young adult, but at this point in my life, I'm not really. A lot of people [in the group] live with their parents still and talked about that. I have a husband, I have a kid, I have a mortgage, I work, so there was certain things about where I'm at in my life that wasn't relatable.”

Psychosocial outcomes

Paired t-tests were conducted to examine change from baseline to postintervention in psychosocial outcomes. All outcomes, depression, anxiety, perceived stress, quality of life, mindfulness, and self-compassion, demonstrated statistically significant improvements at the p < 0.01 (Table 4). Effect sizes for changes were medium to large, with the largest occurring for depression (Cohen's d = 0.809).

Table 4.

Pre–Post Results (n = 33)

Outcome	Pre (M [SD])	Post (M [SD])	t-Test	p	Cohen's d
PHQ-9	8.96 (5.67)	6.12 (4.49)	4.581	<0.0001	0.809
GAD-7	8.9 (6.04)	5.46 (4.3)	4.307	<0.0001	0.761
PSS	20.21 (7.63)	14.96 (7.48)	4.002	<0.0001	0.697
ESAS	27 (15.94)	19.93 (14.25)	4.105	<0.0001	0.726
PHLMS	62.68 (10.12)	68.96 (9.79)	−2.973	<0.0001	0.710
SCS-SF	32.65 (9.14)	35.89 (10.5)	−3.060	0.005	0.568

ESAS, Edmonton Symptom Assessment System; GAD-7, Generalized Anxiety Disorder-7; PHLMS, The Philadelphia Mindfulness Scale; PHQ-9, Patient Health Questionnaire-9; PSS, Perceived Stress Scale; SCS-SF, Self-Compassion Scale-Short Form.

The qualitative analysis provided insights with regard to additional psychosocial benefits, and demonstrated how they are uniquely shaped by the YA context, as detailed under the four themes as follows.

Theme 1: accepting difficult emotions

Participants described in interviews how being a YA with cancer created pressure “to try to go back to your old life” once cancer treatment is completed, and not giving themselves “permission” to feel negative emotions. One common benefit described by interviewees was learning to accept emotions, rather than judge or reject them, and thus avoid getting entangled in them. Here is how one participant described this process, and how it manifests for a YA:

“A lot of what I struggled with was ‘I'm young and I'm better off than a lot of other people and my cancer was a, not a simple case, but not a tragic case. It was early; it was treatable; I was fine.’ I kind of felt bad for feeling bad and I didn't understand why and I resented myself for that. I kind of felt like a privileged brat who didn't appreciate the silver lining of it all. What I learned from the program, very shortly after I started it, was ‘that was okay.’ It was okay to feel [bad] and it doesn't necessarily mean that you'll feel that way forever, so here's what you can do about it now.”

Theme 2: tools for coping with fear of cancer recurrence

The YA-MBCT helped participants deal with fears of cancer recurrence by “learning that I have a choice” in terms of what to focus on in each moment. As one participant described: “There's nothing guaranteed in the future, and there might not be a future, but the mindfulness course helped me switch my main focus of the future towards today.” The ability to choose what to focus on was especially useful when attending medical appointments, as one participant noted: “I had to go for some tests recently and I didn't feel as stressed out about it. I actually brought the meditation with me to the scan.”

Theme 3: restoring body image

Participants empathized that the YA-MBCT also helped them with body image challenges. As one noted: “I have this very new-found appreciation for my body.” Another elaborated:

“I lost touch with my youth and my body as a young body that's capable of things…mindfulness helped me see myself as beautiful again and that is something that the treatment took away from me”

Theme 4: community and a sense of belonging

Participants described that in most support programs, “you can't help but notice that you're the youngest person in the room…You stick out” and how this brought a sense of isolation and often made them “feel worse.” Being in a YA-only program not only increased participants' motivation to attend, thus contributing to the feasibility and acceptability of the program, but also created a psychosocial benefit in itself, by helping “eliminate that acute awareness of being somehow different from everybody around you” and by creating a sense of camaraderie and belonging, as one remarked:

“When you're sitting there with another young person… It was just like, ‘I get it’ and especially when we talked about menopause. I feel like talking to an older woman about menopause, well, she's already been through that and cancer didn't really affect her fertility or affect her chances of having children later…the long-term implications just don't resonate the same way with an older crowd. It's good to be among younger people.”

Discussion

This pilot study is the first to examine the MBCT program when applied to YAs with cancer. It demonstrated that the YA-MBCT is feasible and acceptable, and should be considered as an important intervention for this population. When offered MBI, YAs experience significant improvement in depression, anxiety, and quality of life, and also describe benefits with regard to fear of cancer recurrence, body image, and a sense of belonging.

Adherence to the YA-MBCT was very high, with 60 (85%) participants attending at least six of the eight sessions, and reporting high satisfaction. Indeed, MBIs are perceived as less stigmatizing and thus may be more attractive than traditional support group among YAs.^15,19

Feedback from qualitative interviews revealed that the YA-only format contributed to the acceptability of the program, and made the program more attractive for participants. This is in line with the literature on support needs of YAs with cancer, which consistently demonstrates an unmet need for YA-specific services.^20,21,33 Of note, the qualitative feedback indicated that participants valued similarities in life stage more than age per se. This suggests the need to consider a developmental perspective when offering services to YAs, which recognizes the heterogeneity of psychosocial developmental stages in this population.³⁴ Thus, although chronological age is a good proxy for life stage, our study demonstrates that inclusion criteria for YA-specific interventions can be broadened to accommodate for similarities in variables such as parenting or marital status.

The YA-MBCT yielded statistically significant improvements in multiple outcomes, including symptoms of depression and anxiety, perceived stress, quality of life, mindfulness, and self-compassion. Effect sizes were medium to large for all outcomes, with reduction of depressive symptoms having the largest effect size. These findings are comparable with previous studies of MBIs in cancer patients.^9–11 Our qualitative interviews provided further insights into additional psychosocial benefits, including better coping with fear of cancer recurrence and body image. These potential benefits are particularly relevant to YAs, as the literature consistently shows that YAs are more vulnerable to these disturbances.^1,35–37 Importantly, our participants indicated that the YA-only format had been psychologically beneficial in itself, as it addressed the isolation YAs feel both outside and within the cancer world.^19,38

In summary, our pilot study demonstrates that the YA-MBCT is a feasible and acceptable intervention among YAs with cancer, with the potential to improve mood, anxiety, and quality of life. Although MBI studies in cancer tend to be cancer-type-specific,^10,11 our study suggests that homogeneity in age/life stage may be more important to YAs than homogeneity in cancer type or stage. This study has several limitations, including a low rate of completion of both pre- and postintervention surveys, which prohibited us from assessing the potential impact of demographic and medical factors, such as cancer type and stage. Our preliminary results should be replicated with larger samples, from more than one cancer hospital, with a randomized-control design. The use of an active control group that is also YA-specific is especially warranted given that our participants spoke of benefitting from being among their peers. Future studies should also assess sustainability of effect, and any long-term impact of the program. Lastly, it is important to note that the majority (86%) of our participants were women. This is similar to previous studies that examined the impact of MBIs in AYAs with cancer^15–18 and to the MBI literature in general.³⁹ Thus, future studies should further tailor MBIs to young men with cancer.

Footnotes

Acknowledgments

The authors thank the study participants for the time and effort they have given to this project and for sharing their experiences with us.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

This project was supported in part by The Princess Margaret Cancer Foundation Michael Kamin Hart Research Award in AYA Oncology and by the Ontario Ministry of Health and Long-Term Care (MOHLTC). The views expressed do not necessarily reflect those of the MOHLTC.

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