A diagnosis of breast cancer and subsequent treatment may increase the risk of depression, especially among younger women with breast cancer. A new study showed that behavioral interventions—specifically mindfulness meditation and survivorship education classes—may reduce depressive symptoms, as well as symptoms such as anxiety, fatigue, and sleep disturbance, in younger breast cancer survivors.¹

About 50% of the women enrolled in the trial were clinically depressed at baseline. By the end of the study and 6 months later, the proportion was reduced by about 20%, according to the study presented at the 2020 San Antonio Breast Cancer Symposium.¹

Younger women account for about 20% of all diagnosed breast cancers. Women aged 50 or younger are known to be at increased risk for negative effects of breast cancer and its treatment, which may include emotional distress, explained lead author Patricia A. Ganz, MD, Associate Director for Population Science Research at the UCLA Jonsson Comprehensive Cancer Center and Distinguished Professor of Medicine at the David Geffen School of Medicine at UCLA.

Patricia A. Ganz, MD

“Younger breast cancer survivors represent a vulnerable population, with well-documented side effects from breast cancer treatments and notable increases in depressive symptoms. These lasting effects of breast cancer treatments can have a negative impact on quality of life in the survivorship period,” she stated.

Study Details

The multicenter, randomized, phase III Pathway to Wellness trial was undertaken to evaluate the efficacy of mindfulness meditation and survivorship education classes in reducing the symptoms of depression in younger breast cancer survivors and compare them with a concurrent waitlist control group. A total of 247 patients were included in the intent-to-treat population; 85 were randomly assigned to the mindfulness awareness practices intervention; 81 were randomly assigned to survivorship education; and 81 were on a waitlist (control group), recruited from Los Angeles, Boston, and Baltimore.

The median age of patients was 45.4 years. The majority of patients were White (82%), married (75%), and employed full time (68%). The median time from diagnosis was 2.6 years. More than half the study population had a mastectomy (56%), chemotherapy (57%), or radiation therapy (65%). Two-thirds were on endocrine therapy during the study period.

Interventions Described

Each intervention comprised a 6-week program conducted for 2 hours each week. The survivor education intervention was   led by oncology nurses. Participants were provided with a series of educational seminars, supplemented by ample time for discussions about life after breast cancer.

The mindfulness awareness practices sessions were taught by experienced mindfulness instructors recruited from each of the three sites, who were trained by the director of the mindfulness center at UCLA.   

Both intervention programs had a standard curriculum, with training materials. Sessions given by the instructors in both groups were recorded for quality assurance throughout the study.

The 6-week program of 2-hour sessions included the following content:

Mindfulness Sessions

• Understanding the definition of mindfulness
• Listening, embodiment, and obstacles
• Working with pain
• Working with difficult emotions and cultivating positive emotions
• Working with thoughts and mindful interactions
• A wrap-up session

Survivorship Education

• Breast cancer 101: Important issues for younger survivors
• Quality of life in breast cancer survivors
• Energy balance, nutrition, and physical activity
• Cancer in the family: Cancer genetics and testing
• Relationships and work-life balance
• Body image, menopause, and sexual health.

Women were screened by phone to determine whether they met entry criteria. The study population included women aged 50 years or younger diagnosed with nonmetastatic stage 0 to 3 breast cancer who completed primary treatment between 6 months and 5 years previously. To be enrolled, participants had to have no history of practicing meditation and had to exhibit a minimum level of depressive symptoms on the Patient Health Questionnaire-8.

“We cast a wide net for participant recruitment, using hospital tumor registry listings of age-eligible participants, direct engagement of clinicians, flyers, and media announce­ments during 3 years of recruitment,” Dr. Ganz told the virtual audience.

The primary outcome of the study was measurement of depression symptoms after the interventions, according to the Center for Epidemiologic Studies Depression (CES-D) scale. Secondary outcomes included anxiety, fatigue, sleep disturbance, and hot flashes. An exploratory analysis will be conducted to examine changes in inflammatory markers. Assessments were conducted before the intervention, after the intervention, and at 3- and 6-month postintervention follow-ups.

Changes in Symptoms

At baseline, all three groups reported mean CES-D scores above 16, which is the cutpoint for significant depressive symptoms, with more than 50% of participants scoring in the clinically depressed range before the intervention. However, after the intervention, depression scores declined significantly for both intervention groups (P < .01 for both), with just 30% of women scoring in the clinically depressed range. These scores were sustained at 3 months in both cohorts and at 6 months in the mindfulness awareness practices cohort. Both intervention groups were compared to the waitlist control group for all of these analyses.

Compared with controls, researchers observed a postintervention decrease in anxiety in both intervention groups (P < .05 for both). However, this effect did not persist through follow-up, Dr. Ganz noted.

The mindfulness meditation intervention led to a significant decrease in fatigue severity, sleep disturbances, and hot flashes, which persisted through the 6-month follow-up (P < .05 for all).

“The Pathway to Wellness participants had high levels of depression, anxiety, fatigue, sleep disturbance, and other symptoms an average of 2.6 years after diagnosis. They were living in well-resourced, urban environments and were still suffering with depression. Further dissemination and evaluation of these interventions are warranted to address the unmet psychosocial needs of young breast cancer survivors. We need to screen for depression and provide some type of intervention,” Dr. Ganz said. 

DISCLOSURE: Dr. Ganz reported no conflicts of interest.

REFERENCE

1. Ganz P, Bower JE, Partridge AH, et al: Targeting depressive symptoms in younger breast cancer survivors. 2020 San Antonio Breast Cancer Symposium. Abstract GS2-10. Presented December 10, 2020.