Journal of Behavioral Medicine

, Volume 35, Issue 1, pp 86–94 | Cite as

Mindfulness based stress reduction in post-treatment breast cancer patients: an examination of symptoms and symptom clusters

  • Cecile A. Lengacher
  • Richard R. Reich
  • Janice Post-White
  • Manolete Moscoso
  • Melissa M. Shelton
  • Michelle Barta
  • Nancy Le
  • Pinky Budhrani


To investigate prevalence and severity of symptoms and symptom clustering in breast cancer survivors who attended MBSR(BC). Women were randomly assigned into MBSR(BC) or Usual Care (UC). Eligible women were ≥ 21 years, had been diagnosed with breast cancer and completed treatment within 18 months of enrollment. Symptoms and interference with daily living were measured pre- and post-MBSR(BC) using the M.D. Anderson Symptom Inventory. Symptoms were reported as highly prevalent but severity was low. Fatigue was the most frequently reported and severe symptom among groups. Symptoms clustered into 3 groups and improved in both groups. At baseline, both MBSR(BC) and the control groups showed similar mean symptom severity and interference; however, after the 6-week post-intervention, the MBSR(BC) group showed statistically-significant reduction for fatigue and disturbed sleep (P < 0.01) and improved symptom interference items, compared to the control group. For the between-group comparisons, 11 of 13 symptoms and 5 of 6 interference items had lower means in the MBSR(BC) condition than the control condition. These results suggest that MBSR(BC) modestly decreases fatigue and sleep disturbances, but has a greater effect on the degree to which symptoms interfere with many facets of life. Although these results are preliminary, MBSR intervention post-treatment may effectively reduce fatigue and related interference in QOL of breast cancer survivors.


MBSR Breast cancer Symptom clusters 



The National Cancer Institute R-21 grant, R21-Ca109168-01A2.


  1. Ashbury, F. D., Findlay, H., Reynolds, B., & McKerracher, K. (1998). A Canadian survey of cancer patients’ experiences: are their needs being met? Journal of Pain and Symptom Management, 16, 298–306. doi: S088539249800102X PubMedCrossRefGoogle Scholar
  2. Baker, F., Denniston, M., Smith, T., & West, M. M. (2005). Adult cancer survivors: how are they faring? Cancer, 104, 2565–2576. doi: 10.1002/cncr.21488 PubMedCrossRefGoogle Scholar
  3. Barsevick, A. M. (2007). The elusive concept of the symptom cluster. Oncology Nursing Forum, 34, 971–980. doi: MP3H25H0117T0547 PubMedCrossRefGoogle Scholar
  4. Bender, C. M., Ergyn, F. S., Rosenzweig, M. Q., Cohen, S. M., & Sereika, S. M. (2005). Symptom clusters in breast cancer across 3 phases of the disease. Cancer Nursing, 28, 219–225. doi: 00002820-200505000-00011 PubMedCrossRefGoogle Scholar
  5. Bower, J. E., Ganz, P. A., Desmond, K. A., Rowland, J. H., Meyerowitz, B. E., & Belin, T. R. (2000). Fatigue in breast cancer survivors: occurrence, correlates, and impact on quality of life. Journal of Clinical Oncology, 18, 743–753.PubMedGoogle Scholar
  6. Byar, K. L., Berger, A. M., Bakken, S. L., & Cetak, M. A. (2006). Impact of adjuvant breast cancer chemotherapy on fatigue, other symptoms, and quality of life. Oncology Nursing Forum, 33, E18–E26. doi: 10.1188/06.ONF.E18-E26 PubMedCrossRefGoogle Scholar
  7. Carlson, L. E., & Garland, S. N. (2005). Impact of mindfulness-based stress reduction (MBSR) on sleep, mood, stress and fatigue symptoms in cancer outpatients. Int J Behav Med, 12, 278–285. doi: 10.1207/s15327558ijbm1204_9 PubMedCrossRefGoogle Scholar
  8. Carlson, L. E., Ursuliak, Z., Goodey, E., Angen, M., & Speca, M. (2001). The effects of a mindfulness meditation-based stress reduction program on mood and symptoms of stress in cancer outpatients: 6-month follow-up. Supportive Care in Cancer, 9, 112–123.PubMedCrossRefGoogle Scholar
  9. Carpenter, J. S., Elam, J. L., Ridner, S. H., Carney, P. H., Cherry, G. J., & Cucullu, H. L. (2004). Sleep, fatigue, and depressive symptoms in breast cancer survivors and matched healthy women experiencing hot flashes. Oncology Nursing Forum, 31, 591–5598. doi: 10.1188/04.ONF.591-598 PubMedCrossRefGoogle Scholar
  10. Chen, M. L., & Lin, C. C. (2007). Cancer symptom clusters: a validation study. Journal of Pain and Symptom Management, 34, 590–599. doi: 10.1016/j.jpainsymman.2007.01.008 PubMedCrossRefGoogle Scholar
  11. Chen, M. L., & Tseng, H. H. (2005). Identification and verification of symptom clusters in cancer patients. J Support Oncol, 3, 28–29.PubMedGoogle Scholar
  12. Chen, M. L., & Tseng, H. C. (2006). Symptom clusters in cancer patients. Supportive Care in Cancer, 14, 825–830. doi: 10.1007/s00520-006-0019-8 PubMedCrossRefGoogle Scholar
  13. Cimprich, B., Janz, N. K., Northouse, L., Wren, P. A., Given, B., & Given, C. W. (2005). Taking CHARGE: A self-management program for women following breast cancer treatment. Psychooncology, 14, 704–717. doi: 10.1002/pon.891 PubMedCrossRefGoogle Scholar
  14. Cleeland, C. S., Bennett, G. J., Dantzer, R., Dougherty, P. M., Dunn, A. J., & Meyers, C. A. (2003). Are the symptoms of cancer and cancer treatment due to a shared biologic mechanism? A cytokine-immunologic model of cancer symptoms. Cancer, 97, 2919–2925. doi: 10.1002/cncr.11382 PubMedCrossRefGoogle Scholar
  15. Cleeland, C. S., Mendoza, T. R., Wang, X. S., Chou, C., Harle, M. T., & Morrissey, M. (2000). Assessing symptom distress in cancer patients: the M.D. Anderson Symptom Inventory. Cancer, 89, 1634–1646. doi: 10.1002/1097-0142(20001001)89:7<1634:AID-CNCR29>3.0.CO;2-V PubMedCrossRefGoogle Scholar
  16. Dodd, M. J., Miaskowski, C., & Paul, S. M. (2001). Symptom clusters and their effect on the functional status of patients with cancer. Oncology Nursing Forum, 28, 465–470.PubMedGoogle Scholar
  17. Esper, P., & Heidrich, D. (2005). Symptom clusters in advanced illness. Seminars in Oncology Nursing, 21, 20–28.PubMedCrossRefGoogle Scholar
  18. Francoeur, R. B. (2005). The relationship of cancer symptom clusters to depressive affect in the initial phase of palliative radiation. Journal of Pain and Symptom Management, 29, 130–155. doi: 10.1016/j.jpainsymman.2004.04.014 PubMedCrossRefGoogle Scholar
  19. Fu, O. S., Crew, K. D., Jacobson, J. S., Greenlee, H., Yu, G., & Campbell, J. (2009). Ethnicity and persistent symptom burden in breast cancer survivors. J Cancer Surviv, 3, 241–250. doi: 10.1007/s11764-009-0100-7 PubMedCrossRefGoogle Scholar
  20. Ganz, P. A., Desmond, K. A., Leedham, B., Rowland, J. H., Meyerowitz, B. E., & Belin, T. R. (2002). Quality of life in long-term, disease-free survivors of breast cancer: a follow-up study. Journal of the National Cancer Institute, 94, 39–49.PubMedCrossRefGoogle Scholar
  21. Ganz, P. A., Guadagnoli, E., Landrum, M. B., Lash, T. L., Rakowski, W., & Silliman, R. A. (2003). Breast cancer in older women: quality of life and psychosocial adjustment in the 15 months after diagnosis. Journal of Clinical Oncology, 21, 4027–4033. doi: 10.1200/JCO.2003.08.097 PubMedCrossRefGoogle Scholar
  22. Gaston-Johansson, F., Fall-Dickson, J. M., Bakos, A. B., & Kennedy, M. J. (1999). Fatigue, pain, and depression in pre-autotransplant breast cancer patients. Cancer Pract, 7, 240–247.PubMedCrossRefGoogle Scholar
  23. Gelinas, C., & Fillion, L. (2004). Factors related to persistent fatigue following completion of breast cancer treatment. Oncology Nursing Forum, 31, 269–278. doi: 10.1188/04.ONF.269-278 PubMedCrossRefGoogle Scholar
  24. Hann, D. M., Denniston, M. M., & Baker, F. (2000). Measurement of fatigue in cancer patients: further validation of the Fatigue Symptom Inventory. Quality of Life Research, 9, 847–854.PubMedCrossRefGoogle Scholar
  25. Ivanova, M. O., Ionova, T. I., Kalyadina, S. A., Uspenskaya, O. S., Kishtovich, A. V., & Guo, H. (2005). Cancer-related symptom assessment in Russia: validation and utility of the Russian M.D. Anderson Symptom Inventory. Journal of Pain and Symptom Management, 30, 443–453. doi: 10.1016/j.jpainsymman.2005.04.015 PubMedCrossRefGoogle Scholar
  26. Kabat-Zinn, J., Lipworth, L., & Burney, R. (1985). The clinical use of mindfulness meditation for the self-regulation of chronic pain. Journal of Behavioral Medicine, 8, 163–190.PubMedCrossRefGoogle Scholar
  27. Kabat-Zinn, J., Massion, A. O., Kristeller, J., Peterson, L. G., Fletcher, K. E., & Pbert, L. (1992). Effectiveness of a meditation-based stress reduction program in the treatment of anxiety disorders. American Journal of Psychiatry, 149, 936–943.PubMedGoogle Scholar
  28. Kenefick, A. L. (2006). Patterns of symptom distress in older women after surgical treatment for breast cancer. Oncology Nursing Forum, 33, 327–335. doi: 10.1188/06.ONF.327-335 PubMedCrossRefGoogle Scholar
  29. Kim, H. J., Barsevick, A. M., & Tulman, L. (2009). Predictors of the intensity of symptoms in a cluster in patients with breast cancer. J Nurs Scholarsh, 41, 158–165. doi: 10.1111/j.1547-5069.2009.01267.x PubMedCrossRefGoogle Scholar
  30. Kim, H. J., Barsevick, A. M., Tulman, L., & McDermott, P. A. (2008). Treatment-related symptom clusters in breast cancer: a secondary analysis. Journal of Pain and Symptom Management, 36, 468–479. doi: 10.1016/j.jpainsymman.2007.11.011 PubMedCrossRefGoogle Scholar
  31. Kornblith, A. B., Herndon, J. E., 2nd, Weiss, R. B., Zhang, C., Zuckerman, E. L., & Rosenberg, S. (2003). Long-term adjustment of survivors of early-stage breast carcinoma, 20 years after adjuvant chemotherapy. Cancer, 98, 679–689. doi: 10.1002/cncr.11531 PubMedCrossRefGoogle Scholar
  32. Kwon, Y. C., Yun, Y. H., Lee, K. H., Son, K. Y., Park, S. M., & Chang, Y. J. (2006). Symptoms in the lives of terminal cancer patients: which is the most important? Oncology, 71, 69–76. doi: 10.1159/000100450 PubMedCrossRefGoogle Scholar
  33. Lee, K., Cho, M., Miaskowski, C., & Dodd, M. (2004a). Impaired sleep and rhythms in persons with cancer. Sleep Med Rev, 8, 199–212. doi: 10.1016/j.smrv.2003.10.001 PubMedCrossRefGoogle Scholar
  34. Lee, B. N., Dantzer, R., Langley, K. E., Bennett, G. J., Dougherty, P. M., & Dunn, A. J. (2004b). A cytokine-based neuroimmunologic mechanism of cancer-related symptoms. Neuroimmunomodulation, 11, 279–292. doi: 10.1159/000079408 PubMedCrossRefGoogle Scholar
  35. Lengacher, C. A., Johnson-Mallard, V., Barta, M., Fitzgerald, S., Moscoso, M. S., Post-White, J. (2010). Feasibility of a Mindfulness-Based Stress Reduction Program for Early-Stage Breast Cancer Survivors. J Holist Nurs. doi:  10.1177/0898010110385938
  36. Lengacher, C. A., Johnson-Mallard, V., Post-White, J., Moscoso, M. S., Jacobsen, P. B., & Klein, T. W. (2009). Randomized controlled trial of mindfulness-based stress reduction (MBSR) for survivors of breast cancer. Psychooncology, 18, 1261–1272. doi: 10.1002/pon.1529 PubMedCrossRefGoogle Scholar
  37. Liu, L., Fiorentino, L., Natarajan, L., Parker, B. A., Mills, P. J., & Sadler, G. R. (2009). Pre-treatment symptom cluster in breast cancer patients is associated with worse sleep, fatigue and depression during chemotherapy. Psychooncology, 18, 187–194. doi: 10.1002/pon.1412 PubMedCrossRefGoogle Scholar
  38. Miaskowski, C., Dodd, M., & Lee, K. (2004). Symptom clusters: the new frontier in symptom management research. J Natl Cancer Inst Monogr, 17-21. doi:  10.1093/jncimonographs/lgh023
  39. Minor, H. G., Carlson, L. E., Mackenzie, M. J., Zernicke, K., & Jones, L. (2006). Evaluation of a Mindfulness-Based Stress Reduction (MBSR) program for caregivers of children with chronic conditions. Social Work in Health Care, 43, 91–109.PubMedCrossRefGoogle Scholar
  40. Mishel, M. H., Germino, B. B., Gil, K. M., Belyea, M., Laney, I. C., & Stewart, J. (2005). Benefits from an uncertainty management intervention for African-American and Caucasian older long-term breast cancer survivors. Psychooncology, 14, 962–978. doi: 10.1002/pon.909 PubMedCrossRefGoogle Scholar
  41. Okuyama, T., Wang, X. S., Akechi, T., Mendoza, T. R., Hosaka, T., & Cleeland, C. S. (2003). Japanese version of the MD Anderson Symptom Inventory: a validation study. Journal of Pain and Symptom Management, 26, 1093–1104. doi: S0885392403004196 PubMedCrossRefGoogle Scholar
  42. Rosenzweig, S., Reibel, D. K., Greeson, J. M., Brainard, G. C., & Hojat, M. (2003). Mindfulness-based stress reduction lowers psychological distress in medical students. Teach Learn Med, 15, 88–92.PubMedCrossRefGoogle Scholar
  43. Savard, J., Simard, S., Ivers, H., & Morin, C. M. (2005). Randomized study on the efficacy of cognitive-behavioral therapy for insomnia secondary to breast cancer, part I: Sleep and psychological effects. Journal of Clinical Oncology, 23, 6083–6096. doi: 10.1200/JCO.2005.09.548 PubMedCrossRefGoogle Scholar
  44. Scheier, M. F., Helgeson, V. S., Schulz, R., Colvin, S., Berga, S., & Bridges, M. W. (2005). Interventions to enhance physical and psychological functioning among younger women who are ending nonhormonal adjuvant treatment for early-stage breast cancer. Journal of Clinical Oncology, 23, 4298–4311. doi: 10.1200/JCO.2005.05.362 PubMedCrossRefGoogle Scholar
  45. Servaes, P., Verhagen, C., & Bleijenberg, G. (2002). Fatigue in cancer patients during and after treatment: prevalence, correlates and interventions. European Journal of Cancer, 38, 27–43. doi: S095980490100332X PubMedCrossRefGoogle Scholar
  46. Shapiro, S. L., Bootzin, R. R., Figueredo, A. J., Lopez, A. M., & Schwartz, G. E. (2003). The efficacy of mindfulness-based stress reduction in the treatment of sleep disturbance in women with breast cancer: an exploratory study. Journal of Psychosomatic Research, 54, 85–91. doi: S0022399902005469 PubMedCrossRefGoogle Scholar
  47. Shimozuma, K., Ganz, P. A., Petersen, L., & Hirji, K. (1999). Quality of life in the first year after breast cancer surgery: rehabilitation needs and patterns of recovery. Breast Cancer Research and Treatment, 56, 45–57.PubMedCrossRefGoogle Scholar
  48. Speca, M., Carlson, L. E., Goodey, E., & Angen, M. (2000). A randomized, wait-list controlled clinical trial: the effect of a mindfulness meditation-based stress reduction program on mood and symptoms of stress in cancer outpatients. Psychosomatic Medicine, 62, 613–622.PubMedGoogle Scholar
  49. Stanton, A. L., Ganz, P. A., Kwan, L., Meyerowitz, B. E., Bower, J. E., & Krupnick, J. L. (2005). Outcomes from the Moving Beyond Cancer psychoeducational, randomized, controlled trial with breast cancer patients. Journal of Clinical Oncology, 23, 6009–6018. doi: 10.1200/JCO.2005.09.101 PubMedCrossRefGoogle Scholar
  50. Thornton, L. M., Andersen, B. L., & Blakely, W. P. (2010). The pain, depression, and fatigue symptom cluster in advanced breast cancer: covariation with the hypothalamic-pituitary-adrenal axis and the sympathetic nervous system. Health Psychology, 29, 333–337. doi: 10.1037/a0018836 PubMedCrossRefGoogle Scholar
  51. Tsai, J. S., Wu, C. H., Chiu, T. Y., & Chen, C. Y. (2010). Significance of symptom clustering in palliative care of advanced cancer patients. Journal of Pain and Symptom Management, 39, 655-662. doi:  10.1016/j.jpainsymman.2009.09.005 PubMedCrossRefGoogle Scholar
  52. Tseng, T. H., Cleeland, C. S., Wang, X. S., & Lin, C. C. (2008). Assessing cancer symptoms in adolescents with cancer using the Taiwanese version of the M. D. Anderson Symptom Inventory. Cancer Nurs, 31, E9–E16. doi: 10.1097/01.NCC.0000305728.50098.51 Google Scholar
  53. Wang, X. S., Fairclough, D. L., Liao, Z., Komaki, R., Chang, J. Y., & Mobley, G. M. (2006a). Longitudinal study of the relationship between chemoradiation therapy for non-small-cell lung cancer and patient symptoms. Journal of Clinical Oncology, 24, 4485–4491. doi: 10.1200/JCO.2006.07.1126 PubMedCrossRefGoogle Scholar
  54. Wang, X. S., Laudico, A. V., Guo, H., Mendoza, T. R., Matsuda, M. L., & Yosuico, V. D. (2006b). Filipino version of the M. D. Anderson Symptom Inventory: validation and multisymptom measurement in cancer patients. J Pain Symptom Manage, 31, 542–552. doi: 10.1016/j.jpainsymman.2005.11.011 Google Scholar
  55. Wang, X. S., Wang, Y., Guo, H., Mendoza, T. R., Hao, X. S., & Cleeland, C. S. (2004). Chinese version of the M. D. Anderson Symptom Inventory: validation and application of symptom measurement in cancer patients. Cancer, 101, 1890–1901. doi: 10.1002/cncr.20448 Google Scholar
  56. Yamagishi, A., Morita, T., Miyashita, M., & Kimura, F. (2009). Symptom prevalence and longitudinal follow-up in cancer outpatients receiving chemotherapy. Journal of Pain and Symptom Management, 37, 823–830. doi: 10.1016/j.jpainsymman.2008.04.015 PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  • Cecile A. Lengacher
    • 1
  • Richard R. Reich
    • 2
    • 3
  • Janice Post-White
    • 4
  • Manolete Moscoso
    • 1
  • Melissa M. Shelton
    • 1
  • Michelle Barta
    • 1
  • Nancy Le
    • 1
  • Pinky Budhrani
    • 1
  1. 1.College of NursingUniversity of South FloridaTampaUSA
  2. 2.H. Lee Moffitt Cancer Center and Research InstituteTampaUSA
  3. 3.College of Arts and SciencesUniversity of South Florida Sarasota-ManateeSarasotaUSA
  4. 4.School of NursingUniversity of MinnesotaMinneapolisUSA

Personalised recommendations