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Mindfulness meditation

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 INTEGRATIVE ONCOLOGY

Mindfulness Meditation
for its effects on health and well-being.
Susan Bauer-Wu, PhD, RN, FAAN Mindfulness involves intentionally bringing aware-
Associate Professor ness to present-moment experience with an attitude of
Neil Hodgson Woodruff School of Nursing openness and curiosity. Shapiro and Carlson define it
Emory University as “the awareness that arises through intentionally at-
Atlanta, Georgia tending in an open, caring, and nonjudgmental way.”[4]
Mindfulness is essentially seeing and experiencing
Guest Editors things as they are, using all senses while also being
Debra Barton, PhD, RN, AOCN, FAAN aware of thoughts, emotional tones, and reactions as
Susan Bauer-Wu, PhD, RN, FAAN they arise without judging them as good, bad, right, or
wrong. It also includes catching oneself on “automatic
pilot” and when one reflexively reacts, and noticing

M
E
indfulness meditation and other mind- how those reactions manifest in the body. Mindfulness
fulness-based practices are gaining or this quality of being mindful is cultivated by mental
popularity due to a burgeoning evidence training or practices such as mindfulness meditation.
base supporting its benefits for a broad There are two general styles of mindfulness medi-
range of conditions and populations, including cancer tation practice: focused attention and open monitor-
patients[1] and healthcare professionals.[2,3] While ing.[5] Focused attention involves deliberately focusing
this mind-body approach is rooted in Eastern religion attention on a neutral point of awareness, like the
and philosophy, namely Buddhism, which dates back sensations and rhythm of breathing; whenever the
well over 2,000 years, its integration into modern mind starts to wander (which it inevitably will), one
healthcare settings and society is rela- simply acknowledges that the mind has
tively recent. The seminal launch of drifted off and then gently returns to
the mindfulness movement in the West a neutral focus (ie, the breath) and its
was the establishment of the Stress Re- associated sensory experience. Focus-
duction Clinic and Mindfulness Based ing attention in this way helps to settle
Stress Reduction (MBSR) program at the mind and reduce distractions. The
the University of Massachusetts Medi- second style of mindfulness meditation
cal Center by Jon Kabat-Zinn, PhD, in is open monitoring, also referred to
1979. Today tens of thousands of people as choiceless awareness. This practice
have been trained in MBSR and related is a more advanced practice that pro-
mindfulness-based clinical interven- ceeds after stability of mind is attained
tions throughout the world, in every continent except through focused attention.[5] With open monitoring,
Antarctica. Research in mindfulness meditation, not one receptively notices whatever comes into one’s field
limited to MBSR, is also mounting. A recent search of awareness, which ultimately facilitates acuity of
of the term ‘mindfulness meditation’ on PubMed.gov experience and recognition of mental and emotional
yielded more than 450 peer-reviewed journal articles. habits (eg, automatic reactions, self-narratives).
These studies elucidate mechanisms of how mindfulness
meditation may work in the body and provide support HOW DOES IT WORK?
Mindfulness meditation is a type of mental training.
Financial Disclosure: The author has no significant financial inter-
est or other relationship with the manufacturers of any products At the most fundamental level, it works because of neu-
or providers of any service mentioned in this article. roplasticity, which literally means that neurons (brain

36 ONCOLOGY Nurse Edition • VOLUME 24 • NUMBER 10

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 INTEGRATIVE ONCOLOGY

cells) are malleable. In essence the brain has the ability physiology, and how to integrate mindfulness practices
to change its structure and function depending on what into everyday life.
neural circuitry is used. Mindfulness training has been In addition to MBSR, one can learn and practice
shown to strengthen regions of the brain associated mindfulness meditation in classes or “sitting groups” led
with attention and executive function,[6–9] interocep- by experienced teachers in the community, at hospitals
tion (ability to perceive internal body sensations),[10] or universities, or at Buddhist meditation centers. In
and mental flexibility.[11] Mindfulness training has some clinical settings, mindfulness practices are taught
also been shown to attenuate activity in the amygdala on an individual level and are designed to meet par-
(limbic area of brain associated with fear).[9] Of note, ticular patient needs.[18] There are also innumerable
inattentiveness (or mindlessness) in everyday activities books and guided meditation audio recordings avail-
is associated with stress reactivity and chronic stimula- able, although working with a teacher and having the
tion of this brain region. support of other meditation practitioners is helpful.
From a psychological perspective,
mindfulness meditation promotes affective
ONCE ONE LEARNS THE BASIC SKILLS
balance and emotion regulation.[13] By min-
imizing extreme emotional lows and highs needed for mindfulness meditation, it can
and lessening threat and stress perception,
mindfulness training can impact a cascade be practiced anywhere
of neuroendocrine and immune processes,
including down-regulation of the sympathetic nervous MBSR and other introductory classes are simply
system and the hypothalamic-pituitary-adrenal axis. an entry into mindfulness meditation. Sustained
As a result, decreased cardiovascular reactivity, lower and maximum benefits occur with ongoing practice.
levels of stress hormones and inflammatory markers, Research clearly demonstrates a direct relationship
and improved immune function have been associated between the amount of formal meditation practice
with mindfulness meditation training.[14,15] and the magnitude of positive effects, as demonstrated
by changes in brain structure[8] and function[9] and
HOW ARE MINDFULNESS-BASED outcomes associated with sense of well-being.[19] The
PRACTICES CURRENTLY USED? goal is to have mindfulness infuse one’s way of being
The most common mindfulness training program in and relating to the world in everyday life, which
in conventional clinical settings is MBSR or other is developed and sustained through regular, ongoing
similar programs modified for specific conditions, such meditation practice.
as Mindfulness Based Cognitive Therapy to prevent Mindfulness practices are accessible to anyone
depression relapse.[16] The typical MBSR program regardless of physical condition and are inexpensive
is delivered weekly in a group format over 8 weeks, to do. MBSR, meditation retreats, and introductory
covering approximately 20 hours of classroom training classes range in cost from free of charge (offered at
(didactic and experiential learning) and a 6-hour retreat some hospitals and centers) to hundreds of dollars.
(usually between weeks 6 and 7), as well as home medi- Once one learns the basic skills, mindfulness medi-
tation practice (recommended formal practice of 45 tation can be practiced anywhere. Some people use
minutes daily, 6 days per week).[17] The core practices meditation cushions and mats, though these are not
of the MBSR program include body scan (systematic essential. While mindfulness meditation is generally
awareness of different body sensations, generally done practiced in a seated position, it can be done lying
lying down), mindful movement (gentle Hatha yoga), down, which may be preferred by some cancer pa-
and sitting meditation (which incorporates aspects of tients. It is important to be in a comfortable and stable
focused attention and open monitoring, described ear- position with minimal distractions and where one will
lier in this article). Didactic content includes perception not likely fall asleep. Also, informal practices, like
(and the impact of thoughts on the way one feels), stress mindful eating or walking, are options for deepening

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 INTEGRATIVE ONCOLOGY

skills and integrating mindfulness into one’s life. Several studies have been done exclusively with
Here is a practical example of a cancer patient breast cancer survivors.[23–27] One single-arm
using mindfulness: a man in his 50s with a history pre–post design study demonstrated less stress, hope-
of colorectal cancer who handles the experience of lessness, and anxious preoccupation about cancer, and
a new twinge differently before vs after mindfulness- greater internal locus control after MBSR training.[23]
meditation training. Before learning mindfulness, the In a similar study, Matousek and Dobkin identified
man automatically reacted and went into a tailspin significant reductions in self-reported stress, medi-
by creating a mental story about the pain; he inter- cal symptoms, and depression, and improvements in
preted it to mean that his cancer had recurred, and sense of coherence post intervention.[24] Lengacher
the rest of his life unpleasantly flashed in his mind. and colleagues, in a randomized controlled trial com-
His body tensed up and contracted around the pain, paring a 6-week MBSR program to usual care, found
statistically significant differences
with lower depression, anxiety, and
SYSTEMATIC REVIEWS provide reasonably fear of recurrence, and higher energy
and physical functioning in those who
strong evidence supporting mindfulness participated in the mindfulness train-
ing.[25] Witek-Janusek et al found
meditation for cancer patients/survivors
improvements in biological measures
(specifically cortisol, natural killer
which seemed to make his pain worse. cell cytotoxicity, gamma interferon, IL-4, IL-6, and
After learning mindfulness, he intentionally brought IL-10) as well as in quality of life and optimistic coping
awareness to what he was experiencing. He noticed in early-stage breast cancer patients who self-selected
that his mind was racing and catastrophizing, that his participation in MBSR, compared with those who
heart was pounding, and his breathing was shallow. did not.[26]
He re-centered himself by taking a deep breath and Carlson, Speca, and colleagues have conducted a
then gently focused on the sensations of breathing, number of studies evaluating MBSR for cancer pa-
one breath at a time. He felt more in control, relaxed, tients.[28–34] In their first study, patients with mixed
and grounded. He then recognized how irrational his cancer diagnoses who participated in mindfulness
thoughts were. He gradually brought his attention to training had lower mood disturbance and symptoms
the area of the pain; he noticed that the sensations, of stress at post-intervention[28] and 6 months
dull throbbing, were not constant. He was surprised later.[29] Subsequent work by the same group with
and relieved; in that moment the sensation was not as early-stage breast and prostate cancer patients revealed
uncomfortable or scary as he had thought. improvements in quality of life, symptoms of stress,
and sleep quality, as well as trends toward improve-
WHAT IS THE EVIDENCE RELATED TO ments in neuroendocrine and immune measures post-
MINDFULNESS MEDITATION FOR intervention,[30,31] with sustained effects at 1-year
CANCER PATIENTS? follow-up.[32]
Systematic reviews[20–22] and a recent meta-analy- Other studies have explored innovative approaches
sis[1] provide reasonably strong evidence supporting of delivering mindfulness interventions to cancer
the use of mindfulness meditation and related practices patients. In a randomized controlled trial, Monti and
for cancer patients/survivors. The meta-analysis of 10 colleagues found that Mindfulness Based Art Therapy
studies found large effects for mental health outcomes lowered psychological distress and improved quality
like anxiety, depression, stress, and distress (d = 0.48 of life for women with cancer.[35] Loizzo et al found
overall, 0.35 randomized trials and 0.50 observational similar findings along with trends in improvements in
studies) and small effects for physical health variables biological stress measures (morning salivary cortisol
such as immune function, blood pressure, and tumor and resting heart rate), but no change in IL-6, natural
markers (d = 0.18, no difference between randomized killer cells, or cortisol diurnal rhythm, in early-stage
or observational studies).[1] breast and gynecologic cancer survivors who partici-

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 INTEGRATIVE ONCOLOGY

modifies subsystems of attention. Cogn Affect Behav Neurosci

pated in a 20-week meditation-based self-care inter- 7(2):109–119, 2007.
vention.[36] A dietary intervention (high vegetable 7. Jha A, Stanley EA, Kiyonaga A, et al: Examining the protec-
protein and nutrients, low animal fat) combined with tive effects of mindfulness training on working memory capacity
MBSR was found to slow prostate specific antigen and affective experience. Emotion 10(1):54–64, 2010.
8. Lazar SW, Kerr CE, Wasserman RH, et al: Meditation experi-
(PSA) growth in men with prostate cancer.[37] Specifi-
ence is associated with increased cortical thickness. Neuroreport
cally, the PSA doubling time for the men in the MBSR 16(17):1893–1897, 2005.
plus nutrition group was nearly threefold longer after 9. Brefczynski-Lewis JA, Lutz A, Schaefer HS, et al: Neural
the intervention compared to controls; PSA doubling correlates of attentional expertise in long-term meditation
practitioners. Proc Natl Acad Sci U S A 104(27):11483–11488,
time is an indicator of risk of recurrence and disease
2007.
progression. Other studies have explored and demon- 10. Farb NAS, Segal ZV, Mayberg H, et al: Attending to the
strated feasibility and promising findings of individual present: Mindfulness meditation reveals distinct neural modes of
mindfulness training for cancer patients undergoing self-reference. Soc Cogn Affect Neurosci 2(4):313–322, 2007.
11. Slagter HA, Lutz A, Greischar LL, et al: Mental training
hematopoietic stem cell transplant.[18,38]
affects distribution of limited brain resources. PLoS Biol 5(6):
e138, 2007.
WHAT ARE THE POTENTIAL RISKS? 12. Way BM, Creswell D, Eisenberger NI, et al: Dispositional
Mindfulness meditation is very safe and has few mindfulness and depressive symptomatology: Correlations with
associated risks. Sometimes people may experience a limbine and self-referential neural activitiy at rest. Emotion
10(1):12–24, 2010.
transient increase in anxiety when learning it, as they 13. Williams JMG: Mindfulness and psychological process.
let go of usual busyness and distractions and become Emotion 10(1):1–7, 2010.
aware of unsettling thoughts and feelings. Advanced 14. Davidson RJ, Kabat-Zinn J, Schumacher J, et al: Altera-
meditation practitioners who engage in long and tions in brain and immune function produced by mindfulness
meditation. Psychosom Med 65(4):564–570, 2003.
intensive meditation (hours per day and months at a 15. Fang CY, Reibel DK, Longacre ML, et al: Enhanced
time) have added risks and need to work closely with psychosocial wellbeing following participation in a mindful-
an experienced teacher during such intense training ness-based stress reduction program is associated with increased
periods. natural killer cell activitiy. J Altern Comp Med 16(5):531–538,
2009.
16. Teasdale JD, Segal ZV, Williams JM, et al: Prevention of
WHAT IS THE BOTTOM-LINE MESSAGE? relapse/recurrence in major depression by mindfulness-based
Mindfulness meditation and mindfulness-based cognitive therapy. J Consult Clin Psychol 68(4):615–623, 2000.
clinical interventions are low-cost and low-risk mind- 17. Kabat-Zinn J: Full Catastrophe Living: Using the Wisdom
of Your Body and Mind to Face Stress, Pain and Illness. New
body practices that have been shown to positively affect York, Delacourt, 1990.
quality of life and biological outcomes in many different 18. Bauer-Wu S, Sullivan A, Rosenbaum E, et al: Facing the
populations, including cancer patients and healthcare challenges of hematopoietic stem cell transplantation with
professionals. mindfulness meditation: A pilot study. Integr Cancer Ther
7(2):62–69, 2008.
19. Carmody J, Baer RA: Relationships between mindfulness
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