1. Mindfulness Based Stress Reduction (MBSR) in breast cancer: research and practice
Caroline Hoffman, PhD Clinical Director & Research Co-ordinator The Haven Breast Cancer Support Centres London - Hereford - Leeds

2. The Haven (Breast Cancer Support Centres)
Free programmes of emotional support and complementary therapies for breast cancer
Also an outreach programme called The Haven at Home (2.5h DVD and 1h CD)
The Haven in London

3. Mindfulness at The Haven
MBSR has been taught to 500 people at the Haven.
Mindful movement and meditation practice classes (drop-in) are also available twice a month 3

4. What is mindfulness?
Mindfulness means paying attention (being aware) in a particular way: on purpose, in the present moment, and non-judgmentally.
Dr Jon Kabat-Zinn
Founder
Mindfulness-Based Stress Reduction Programme

5. What is mindfulness?
“Mindfulness is about being fully awake in our lives. It is about perceiving the exquisite vividness of each moment. We feel more alive. We also gain immediate access to our own powerful inner resources for insight, transformation, and healing.”
Jon Kabat-Zinn

7. Mindfulness training is worldwide
Up to 3,000 health professionals among 18,000 participants in the MBSR programme at the Center for Mindfulness, University of Massachusetts, USA
lists mindfulness courses available by area in Great Britain (GB)
Mindfulness at Monash University, Melbourne, Australia
Professional teacher training centres:
University of Massachusetts USA (MBSR)
University of Oxford, G.B. (MBCT)
University of Bangor, G.B. (MBSR and MBCT)

8. Aim of MBSR study
The aim of this randomised controlled trial was to determine if and how much MBSR affects mood, disease-related quality of life, including endocrine symptoms, and wellbeing in women with stages 0 to III breast cancer.

9. Numbers of study participants
229 women who had attended the Haven
Computer randomised into blocks of four
114 in intervention group
115 in wait-list control group
Sample size calculated for 80% power from Profile of Mood States (Speca et al 2000)

10. Age and socioeconomic status
Mean age 49 years (Intervention Group) 50 years (Control Group) Socio-economic status AB: (Higher and intermediate manager/ administrator/ professional) Intervention Group 84 (73.7) Control Group 90 (78.3) C1: (Supervisory clerical junior managerial/ administrator/ professional) Intervention Group 20 (17.5) Control Group 16 (13.9)

11. Measurement tools Profile of Mood States (POMS) (65 item)
Primary outcome measure
Quality of Life measures:
FACT-B (Breast) (37 item)
FACT-ES (Endocrine Symptoms) (19 item)
WHO-5 Wellbeing questionnaire (5 item)

12. MBSR Programme taught 8-week MBSR programme
Week 1 and 8: 2 and a quarter hours (Uni. Mass 3 hrs)
Week 2 to 6: 2 hours per week (Uni.Mass 2.5 hrs)
6-hour day of mindfulness in week 6 on a Saturday:
10am to 4pm (both groups together for this)
Number of groups
Pilot group
7 cycles of 8 week programmes (13 groups) in
Regular clinical supervision for clinician-researcher

13. Contents of MBSR programme
Ways of seeing – how we perceive our world
Awareness of thoughts, emotions and body sensations
Mindful body scan, mindful stretches, mindful sitting practice
Understanding stress
Awareness of habitual thought patterns and emotional reactions
Mindfulness in everyday life

14. MBSR spaces at The Haven in London
Group Room
Reception area

15. Home Practice
Home Practice Manual included photos of stretching exercises, meditation sitting positions, information on stress, some stories, exercises, tips
4 x 45 minute CDs: Mindful Body Scan, Mindful Lying Stretches, Mindful Sitting Meditation, Mindful Standing Stretches
Home practice sheets
Record of formal home mindfulness practice

16. Profile of mood states (POMS) (primary outcome)
Total Mood Disturbance
Subscales Anxiety
Depression
Anger
Vigour
Fatigue
Confusion

17. POMS T1 = weeks -2 to 0, T2 = weeks 8 to 10, T3 = weeks 12 to 14
Outcome measure mean (SD)
Intervention (N=103)
Control
(N=111)
Mean
Difference +
p value
CI (95%) for difference
T1 Total Mood Disturbance
43.65 (34.73)
49.23 (39.37) N=110
-5.58
T2 Total Mood Disturbance
30.02 (31.60)
47.81 (39.81)
-17.79***
-27.44, -8.14
T3 Total Mood Disturbance
29.83 (34.19)
45.43 (35.51)
-15.60***
-25.01, -6.20
T1 Tension-Anxiety
13.16 (7.21)
13.42 (7.24)
-0.26
T2 Tension-Anxiety
10.32 (7.0)
13.36 (7.20)
-3.04**
-4.95, -1.18
T3 Tension-Anxiety
10.33 (7.02)
12.73 (6.59)
-2.40**
-4.24, -5.66
T1 Depression-Dejection
12.79 (10.76)
15.70 (12.79)
-2.91
T2 Depression-Dejection
10.0 (9.95)
14.96 (13.23)
-4.96**
-8.11, -1.83
T3 Depression-Dejection
10.34 (10.32)
14.10 (11.60)
-3.76**
-6.72, -0.80
T1 Anger-Hostility
10.75 (8.08)
11.60 (8.62)
-0.85
T2 Anger-Hostility
8.78 (7.57)
11.11 (8.88)
-2.33*
-4.57, -0.10
T3 Anger-Hostility
7.87 (6.72)
11.04 (8.95)
-3.17**
-5.29, -1.04
T1 = weeks -2 to 0, T2 = weeks 8 to 10, T3 = weeks 12 to 14
*p<0.05, **p<0.01, *** p<0.001

18. POMS T1 = weeks -2 to 0, T2 = weeks 8 to 10, T3 = weeks 12 to 14
Outcome measure mean (SD)
Intervention (N=103)
Control
(N=111)
Mean difference
and p value
CI (95%) for difference
T1 Vigour-Activity
(6.53)
(6.19)
0.25
T2 Vigour-Activity
(6.0)
(6.61)
-2.34**
-4.05, -0.64
T3 Vigour-Activity
(6.63)
(6.22)
-2.76**
-4.50, -1.03
T1 Fatigue-Inertia
11.17 (6.64)
11.75 (7.20)
-0.58
T2 Fatigue-Inertia
8.71 (6.10)
11.62 (7.16)
-2.91**
-4.71, -1.11
T3 Fatigue-Inertia
9.27 (6.90)
11.39 (6.73)
-2.12*
-3.95, -0.28
T1 Confusion-Bewilderment
10.11 (5.58)
10.65 (5.57) N=110
-0.54
T2 Confusion-Bewilderment
8.13 (4.71)
10.32 (5.28)
-2.19**
-3.54, -0.87
T3 Confusion-Bewilderment
8.24 (5.32)
9.64 (4.79)
-1.4*
-2.76, -0.40
T1 = weeks -2 to 0, T2 = weeks 8 to 10, T3 = weeks 12 to 14
*p<0.05, **p<0.01, *** p<0.001

19. FACT - quality of life measure
FACT-B (breast) and FACT ES (endocrine symptoms)
Subscales:
Physical wellbeing
Social and family wellbeing
Emotional wellbeing
Functional wellbeing
Breast-specific subscale (B)
Endocrine-specific subscale (ES) 19

20. FACT-B results
FACT scores mean (SD)
Intervention Group (N=102)
Control Group
(N=111)
Mean difference and p value
CI (95%) for difference
T1 FACT- ES
(18.84)
(23.20)
-0.06
T2 FACT- ES
(19.25)
(23.48) N=108
7.69**
1.83, 13.55
T3 FACT- ES
(19.54)
(21.17) N=110
7.88**
2.33, 13.44
T1 FACT-ES TOI
92.51 (14.54)
92.20 (16.98)
0.31
T2 FACT-ES TOI
98.47 (14.37)
92.58 (17.67) N=110
5.89**
1.52, 10.28
T3 FACT-ES TOI
98.67 (14.63)
92.75 (16.75) N=107
5.92**
1.65, 10.19
T1 FACT-B
96.57 (17.22)
96.68 (12.05)
-0.11
T2 FACT-B
(17.01) N=101
96.87 (21.05) , N=107
6.69*
1.33, 12.05
T3 FACT-B
(17.85) N=101
96.36 (19.39) , N=107
7.42**
2.32, 12.52
T1 FACT-B TOI
62.04 (12.01)
61.92 (14.03)
0.12
T2 FACT-B TOI
67.02 (11.96) N=101
62.10 (14.38)
N=109
4.92**
1.31, 8.54
T3 FACT-B TOI
67.11 (12.30) N=101
61.67 (13.67)
5.44**
1.89, 8.98
T1 = weeks -2 to 0, T2 = weeks 8 to 10, T3 = weeks 12 to 14
*p<0.05, **p<0.01, *** p<0.001

21. FACT subscales
FACT scores mean (SD)
Intervention Group (N=102)
Control Group
(N=111)
Mean difference + p value
CI (95%) for difference
T1 PWB (physical)
21.88 (4.29)
21.89 (4.35)
-0.01
T2 PWB
22.86 (4.22)
21.84 (4.54)
1.02
-0.16, 2.21
T3 PWB
22.96 (4.34)
21.67 (4.87)
1.29*
0.05, 2.54
T1 SWB (social)
17.59 (5.91)
18.78 (6.01)
-1.19
T2 SWB
18.36 (5.65)
18.26 (5.88) N=109
0.1
-1.46, 1.67
T3 SWB
18.08 (5.81)
18.30 (5.75) N=109
-0.22
-1.78, 1.35
T1 EWB (emotional)
16.91 (3.84)
15.97 (4.58)
0.94.
T2 EWB
18.13 (3.82)
16.53 (4.42) N=110
1.6**
0.48, 2.73
T3 EWB
18.58 (3.75)
16.28 (4.40) N=110
2.3***
1.19, 3.41
T1 FWB (functional)
17.83 (5.03)
17.65 (5.82)
-0.18
T2 FWB
19.46 (5.27)
17.41 (6.06) N=110
2.05**
0.50, 3.59
T3 FWB
19.45 (5.32)
17.53 (5.37) N=110
1.92**
0.47, 3.37
T1 = weeks -2 to 0, T2 = weeks 8 to 10, T3 = weeks 12 to 14
*p<0.05, **p<0.01, *** p<0.001

22. Minimally important differences scores (MIDs) for FACT
Scales
MIDs score
Reference: Clinically significant range for MIDs
T2 FACT-B 7*
7-8
T3 FACT-B 8*
T2 FACT-B TOI 5*
5-6
T3 FACT-B TOI
T2 Breast subscale
2-3
T3 Breast subscale
* denotes significant values
T1= weeks -2 to 0, T2= weeks 8 to 10, T3 = weeks 12 to 14

23. WHO 5-item wellbeing questionnaire
For each of the five statements below, please put a circle round one number, which is closest to
how you have been feeling over the last week. Notice that the higher numbers mean better well-being.
Over the last week
All the time
Most of the time
More than half of the time
Less than half of the time
Some of the time
At no time
I feel cheerful and in good spirits 5 4 3 2 1
I feel calm and relaxed
I feel active and vigorous
I wake up feeling fresh and rested
My daily life is filled with things that interest me

24. Scores for WHO-5 wellbeing questionnaire
WHO 5-item wellbeing
questionnaire mean (SD) % score
Intervention
(N=102)
Control
(N=110)
Mean difference and p value
CI (95%) for difference
T1 WHO-5
13.04 (4.48) 52.2%
12.53 (4.68) 50.1%
0.09
T2 WHO-5
14.91 (4.23) 59.6%
12.59 (4.92) 50.4%
2.32***
1.06, 3.56
T3 WHO-5
15.08 (4.61) 60.3%
12.64 (4.30) 50.6%
2.44***
1.23, 3.64
T1 = weeks -2 to 0, T2 = weeks 8 to 10, T3 = weeks 12 to 14
*p<0.05, **p<0.01, *** p<0.001

25. Clinical significance for WHO-5
WHO-5 mean (SD) %
score
Intervention (N=102)
Control (N=110)
Level of clinical significance in % (changes of ≥10% are significant)
T1 WHO-5
52.2%
50.1%
1.1%
T2 WHO-5
59.6%
50.4%
9.2%
T3 WHO-5
60.3%
50.6%
9.7%
T1 = weeks -2 to 0, T2 = weeks 8 to 10, T3 = weeks 12 to 14

26. Measurements of illness stress and life stress
How difficult or stressful is your illness for you at the moment?
Apart from your illness, have you had any recent events in your life which has affected you strongly or been particularly stressful?

27. Perceptions of difficulty or stress caused by breast cancer (independent sample t-tests)
Intervention Group
Means (SD)
Control Group
Mean difference
and p value
CI 95% for difference T1
4.20 (2.03)
(N=105)
4.11 (2.24)
(N=110)
0.09
-0.48, 0.67 T2
3.28 (2.20)
(N=92)
3.98 (2.24)
(N=104)
-0.7**
-1.32, -0.07 T3
2.63 (1.94)
(N=86)
3.64 (2.24)
(N=94)
-1.01***
-1.63, -0.40
*p<0.05, **p<0.01, *** p<0.001
T1 = weeks -2 to 0, T2 = weeks 8 to 10, T3 = weeks 12 to 14
Perceptions of difficulty or stress from other live events did not give significant results.

28. Themes from qualitative data (intervention group only)
Main themes
(N = 92) (%)
More mindful
92 (100%)
Being calmer, centred, at peace, connected and more confident
30 (32.6%)
The value and challenges of mindfulness practice
28 (30.4%)
Being more aware
27 (29.3%)
Coping with stress, anxiety and panic
Accepting things as they are, being less judgemental of myself and others
18 (19.6%)
Improved communication and personal relationships
16 (17.4%)
Making time and creating space for myself
15 (16.3%)

29. ‘Great to be supported through a difficult time and this (MBSR) has truly been a gift that I will always have and I think not only support me, but my family and friends because I will be in a better place’

30. How mindfulness helped with pain, stress and anxiety
‘I at first wondered if the programme was for me. After the first session, I was in tears, but Caroline convinced me to continue with the body scan and I did. It has helped me greatly with my pain (peripheral neuropathy for 18 months). Other practices have helped me with daily stress and remaining calm’
More aware now of anxious thoughts and their effects on the body. Aware of when I am reacting to thoughts in a stressed and anxious manner.

31. Köszönöm