Assessing a multidisciplinary survivorship program in a group of predominantly Hispanic women with breast cancer
Background The prevalence of long-term mental and physical illness is significant among many breast cancer survivors. We have previously reported that Hispanic survivors of breast cancer have a diminished mental and physical health-related quality of life (QoL), though in general, there is a paucity of data for this population and other minorities. Implementing a cancer survivorship program as an integral component of care during and after treatment could improve long-term QoL in survivors of breast cancer and empower them in the transition from treatment to survivorship.
Objective To determine the value of implementing a multidisciplinary survivorship program that includes psychological counselling and interventions based on mindfulness and counselling.
Methods Survivors of stages I-III breast cancer were recruited within 5 years of their diagnosis at an institution in El Paso, Texas, where the majority of patients are of Hispanic ethnicity, to participate for a year in a multidisciplinary program that provided psychological counselling in conjunction with oncology care, dietary advice, and an 8-week course based on mindfulness-based stress reduction. Self-administered questionnaires - the Patient Health Questionnaire-9 for depression, the General Anxiety Disorder-7, and the Short-Form Health Survey-36 (version 2) for QoL - were completed at baseline and every 3 months for 12 months.
Results 94 patients, of whom >90% were Hispanic, were included in this 12-month analysis. 60 patients (63.8%) completed all follow-ups at 12 months. Significant improvement from baseline was observed for patient health and anxiety measures for all ethnic groups combined.
Limitations Small, single-center study; no control arm using other possible interventional methods
Conclusion All breast cancer survivors who participated in this 12-month multidisciplinary interventional survivorship program reported less anxiety and depression, compared with baseline measurements and showed a trend toward improved Mental Component Summary of QoL. We believe these findings are representative of outcome in Hispanic women since >90% of participants were Hispanic.
Funding Cancer Prevention and Research Institute of Texas (CPRIT)-RP120528
Accepted for publication January 4, 2017
Correspondence Safa Farrag, MD; safa.farrag@ssmhealthx.com
Disclosures The authors report no disclosures/conflicts of interest.
Citation JCSO 2017;15(4):e208-e216
©2017 Frontline Medical Communications
doi https://doi.org/10.12788/jcso.0322
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Discussion
In this study, we showed that a group of predominately Hispanic breast cancer survivors benefited from participating in a multidisciplinary cancer survivorship program that emphasized in-depth psychological care and MBSR. They also benefited from an education effort that included providing survivors with personalized summaries of their treatment and oncology survivorship care, addressing potential long-term side effects of treatment, referral for genetic counselling and screening for other cancers as appropriate, as well dietary advice. We found significant improvement compared with baseline in both mental and physical determinants of the patient-reported outcomes, including anxiety (GAD-7), depression (PHQ-9), and HR-QoL (PCS) and (MCS). Survivors demonstrated significant improvement on the MCS and PHQ-9 if they attended 5 or more sessions of the 8-week MBSR course, and attending 8 sessions was associated with significant improvement in GAD-7 and PCS. This might suggest that survivors who are more motivated do benefit the most from such program.
To our knowledge, this study is the first to address the benefit of the MBSR intervention in Hispanic breast cancer survivors. In a randomized controlled trial that included breast cancer survivors with stages 0-III breast cancer who completed surgery, adjunctive radiation, and/or chemotherapy, MBSR was shown to reduce the symptoms of depression and anxiety and increase energy and physical functioning compared with participants who received “usual care”.3 Furthermore, Bower and colleagues have reported improvements in sleep, fatigue, and pro-inflammatory signaling in younger survivors of breast cancer.17 A similar standardized MBSR program was tested on Danish women who had been treated for stage I-III breast cancer18 and the results showed reduced levels of anxiety and depression at the 12-month follow-up. A similar study by Hoffman and colleagues19 reported improved mood, breast- and endocrine-related quality of life, and well-being with MBSR compared with standard care in women with stage 0-III breast cancer.
Several theories have been suggested to explain how MBSR reduces symptoms of depression, anxiety, and fear of recurrence in breast cancer survivors, one of which is that it provides supportive interaction between group members to practice meditation and apply mindfulness in daily situations.3 In addition, evidence is beginning to emerge that stress-reducing interventions such as MBSR may improve telomere length (TL) and telomerase activity (TA), the markers for cellular aging, psychological stress, and disease risk.20-24 Lengacher and colleagues conducted a randomized controlled study to investigate the effects of MBSR on TL and TA in women with breast cancer, and suggested that MBSR increases telomere length and telomerase activity.25 The 142 patients with stages 0-III breast cancer had completed adjuvant treatment with radiation and/or chemotherapy at least 2 weeks before enrollment and within 2 years of completion of treatment with lumpectomy and/or mastectomy. They were randomly assigned to either a 6-week MBSR for breast cancer program or usual care.25 Assessments of TA and TL were obtained along with psychological measurements at baseline, 6 weeks, and 12 weeks after the patients had completed the MBSR program. The mean age of the participants was 55.3 years; 72% were non-Hispanic white; 78% had stage I or II cancer; and 36% received both chemotherapy and radiation. In analyses adjusted for baseline TA and psychological status, TA increased steadily by about 17% over 12 weeks in the MBSR group, compared with about 3% (P < .01) in the control group. No difference was observed for TL (P = .92). The authors concluded that the data provide preliminary evidence that MBSR increases TA in peripheral blood mononuclear cells from breast cancer patients and have implications for understanding how MBSR may extend cell longevity at the cellular level.
In another study among healthy volunteers who were randomly assigned to a 3-month meditation retreat or a control group, the 30 participants in the meditation group had higher TA compared with controls.20 In a nonrandomized study among prostate cancer patients, TA increased and psychological stress decreased following a stress-reducing, lifestyle-modification program.21 The results of another intervention study among overweight women showed improvement in distress, eating behavior, and metabolic health in women participating in a MBSR program, all of which correlated with increases in TA.22 Most recently, researchers explored the impact on TA of a Kirtan Kriya yogic meditation intervention compared with exposure to relaxing music in 39 dementia family caregivers. The yogic-meditation intervention group had a 43% increase in TA after the 8-week intervention period compared with 3.7% the music group (P < .05).23 Finally, among 22 patients with cervical cancer who were randomized to a psychosocial telephone counseling intervention,24 investigators found a significant association between increased TL and changes in psychological distress.20 Findings from other studies have assessed interventions to improve outcome of breast cancer survivors, such as the Taking CHARGE self-management intervention that is designed to facilitate the transition to survivorship after breast cancer treatment.8 Another intervention using home-based physical activity was shown in a randomized controlled trial to improve self-reported physical activity, body-mass index, and health-related QoL.9 Findings from another study suggested that a combined exercise and psychological counselling program might improve QoL more than a single entity intervention.26 As noted previously, these studies did not focus on minority breast cancer survivors’ population, and it is not clear if they are generalizable to Hispanics.
In addition to the MBSR component, our program has also included one-on-one psychological assessment for long-term treatment complications and provided participants with appropriate care and follow-up plans, adding the benefits of self-awareness and self-attention for the survivors, which can effectively reduce the fear of recurrence.3 Furthermore, we included dietary consults based on general cancer survivor guidelines recommending a high fruit and vegetable diet that is low in fat and sugar.27 Healthier dietary lifestyle has been reported to improve breast cancer prognosis, metabolic disease, and cardiovascular outcomes among Hispanic breast cancer survivors.28
Our study has some limitations, including a relatively small sample size. It did not include an exercise program, which would have been helpful in addressing the issue of overweight and obesity we encountered in the most of the Hispanic breast cancer survivors (baseline average BMI, 31.32 kg/m2; obesity range, >30 kg/m2). Because of the small sample size and nonrandomized design of the study, it is hard to evaluate the confounding effect of time on intervention effect. However, a subgroup analysis by MBSR number of sessions showed that the survivors who completed the full course of MBSR sessions (8 sessions) achieved superior benefit, compared with those who did not complete the full course, which indicates that the intervention did weigh in regardless of time. Despite these limitations, the participants in this interventional program showed improved outcomes, including less anxiety and depression and improved MCS score of the SF-36. A larger and longer follow-up prospective, randomized study is needed to validate the findings of this study. Implementing cancer survivorship as an integral component of cancer care during and after treatment is essential to improve the quality of life of cancer survivors and empower them in their transition from cancer treatment to survivorship.
