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. 2023 Sep 15;102(37):e34917. doi: 10.1097/MD.0000000000034917

Using mindfulness-based stress reduction to relieve loneliness, anxiety, and depression in cancer patients: A systematic review and meta-analysis

Junye Yu a,*, Mingyue Han a, Fengru Miao a, Dan Hua a
PMCID: PMC10508374  PMID: 37713902

Abstract

Background:

Mindfulness-based stress reduction (MBSR) has been suggested as an effective mind-body approach for relieving stress in patients with chronic diseases. As of yet, there is no conclusive research on MBSR’s role in reducing affective disorders among cancer patients. A systematic review and meta-analysis was conducted to determine whether MBSR has an impact on loneliness, anxiety, and depression in cancer patients.

Methods:

Systematic searches were conducted in PubMed, Embase, and the Cochrane Library from the start of these databases to January 2nd, 2022 to identify relevant randomized controlled trials. Two authors independently conducted the literature search, collected the data, and performed the statistical analysis. In order to account for potential between-study heterogeneity, a random-effect model was used in the meta-analysis.

Results:

The meta-analysis included 16 studies with 2072 cancer patients. Among the 16 studies, 13 included patients with breast cancer, and the follow-up duration ranged from 6 to 53 weeks. Compared to controls receiving standard cancer care, interventions of MBSR with sessions for 6 to 8 weeks significantly improved loneliness (standard mean difference [SMD]: −0.35, 95% confidence interval [CI]: −0.59 to −0.12, P = .003, I2 = 46%), anxiety (SMD: −0.51, 95% CI: −0.73 to −0.30, P < .001, I2 = 77%), and depression (SMD: −0.61, 95% CI: −1.02 to −0.20, P = .004, I2 = 94%) in patients with cancer.

Conclusion:

According to recent research, MBSR may be beneficial to patients diagnosed with cancer who are feeling lonely, anxious, or depressed.

Keywords: affective disorder, cancer, loneliness, meta-analysis, mindfulness-based stress reduction

1. Introduction

In the global population, cancer is one of the leading causes of morbidity and mortality.[1,2] Patients with cancer today survive longer than they did decades ago due to the development of multiple cancer treatment modalities.[3] Accordingly, the amount of patients living with cancer is increasing globally.[4] In addition to cancer’s adverse somatic influence, people who have been diagnosed with cancer are known to experience significant stress and are more likely to suffer from affective disorders, such as loneliness, anxiety, and depression.[5–7] A previous survey showed that approximately half of cancer patients stated that the adverse emotional influence of cancer was more challenging to deal with than their physical discomfort.[8] Findings from this survey indicate that psychological distress can significantly impair the quality of life of a cancer patient, and efforts should be continuously made to develop evidence-based psychotherapy for these patients.[9] The psychological distress of patients with cancer may be related to the unsuccessful treatment response. Accordingly, the importance of developing new strategies to successfully address patients with depression who had no or partial response to existing drug treatment and had a higher risk of negative clinical results has been demonstrated.[10]

The theory of positive psychology holds that the purpose of psychological intervention is not to reduce psychological symptoms, but to maximize the utilization of an individual’s inherent positive potential. The purposes of such strategy also involve improving their positive emotions, cognition, or behavior, helping individuals hear their inner voice, eliminating obstacles that hinder the path, and complying with internal self-actualization. The methods of positive psychological intervention mainly include mindfulness therapy, meaning therapy, hope therapy, happiness therapy, humor therapy, etc. Mindfulness based stress reduction (MBSR) is currently the most researched and widely used mindfulness therapy to alleviate stress and depression.[11] Practically, MBSR aims to reduce stress by improving mindfulness skills through regular meditation exercises.[12,13] Psychotherapy methods, such as MBSR, have previously shown efficacy in improving affective disorders in the general population.[14,15] According to a previous meta-analysis, mindfulness-based interventions can improve symptoms of anxiety and depression in cancer patients.[16] However, this meta-analysis was published 7 years ago,[16] and, as a result, multiple recently published clinical trials were not included.[17–23] In addition, various mindfulness-based interventions were used in this study alongside MBSR, which may confound the results.[16] Therefore, the purpose of this systematic review and meta-analysis was to comprehensively evaluate the effects of MBSR on loneliness, anxiety, and depression among cancer patients. Based on previous research, we hypothesized that MBSR can improve loneliness, anxiety, and depression in cancer patients.

2. Methods

When designing and implementing the study, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement[24,25] and Cochrane Handbook guidelines[26] were followed.

2.1. Search strategy

An integrated search of Medline (PubMed), Embase (Ovid), and CENTER (Cochrane Library) databases was conducted for relevant studies using the combined terms including: (1) “mindful” OR “mindfulness”; (2) “cancer” OR “carcinoma” OR “malignancy” OR “malignant” OR “tumor” OR “neoplasm”; and (3) “random” OR “randomized” OR “RCT” OR “randomized” OR “randomly” OR “placebo.” Only studies including human subjects and published in English were considered. Studies relevant to the current topic were also searched in references of related reviews and original articles. On January 2nd, 2022, the final database search was conducted.

As this study did not involve the examination or treatment of patients or review of patient records, it was exempt from review and approval by our research ethics committee.

2.2. Selection of studies

Studies meeting the following criteria were included in the meta-analysis: (1) a full-length article published in English; (2) a randomized controlled trial (RCT) with parallel groups; (3) included adult patients who were diagnosed with cancer that were allocated to an intervention of MBSR or a control group of usual/standard cancer care; and (4) as evaluated by the validated scoring systems, at least one outcome was reported, including loneliness, anxiety, and depression. Studies conducted in non-cancer patients, not using MBSR, or not reporting any outcomes of interest were excluded. The study with the largest sample size was included for the meta-analysis if there was overlap in patient population.

2.3. Collection of study information and assessment of study quality

In this study, 2 independent authors searched databases, extracted data, and evaluated the quality of the data. Disagreements were resolved through discussion with the corresponding author. Data regarding study characteristics (name of first author and year of publication), study design (open-label or blind), patient data (number of patients, and types and stages of cancers), sessions of MBSR, details of controls, follow-up durations, and outcomes and related scoring systems for evaluating the outcomes was collected. In order to evaluate quality, we used the Cochrane Risk of Bias Tool[26] as listed below: (1) random sequence generation; (2) allocation concealment; (3) blinding of participants and personnel; (4) blinding of outcome assessors; (5) incomplete results; (6) selection of outcome reporting; and (7) other biases.

2.4. Statistical analysis

Since different scales were used when evaluating loneliness, anxiety, and depression in patients with cancer, the influence of MBSR on these outcomes as compared to controls were presented as standard mean difference (SMD) and corresponding 95% confidence intervals (CIs). For detection of heterogeneity, we used Cochrane Q test.[27] We also calculated the I2 statistic, and an I2 > 50% signified significant heterogeneity.[28] A random effect model was used in the pooled analyses to account for potential heterogeneity and provide a more general conclusion.[26] The meta-analysis’ results were assessed by sensitivity analysis, which excluded one study at a time, to evaluate their influence.[26] A visual inspection of funnel plots and the Egger regression asymmetry test were used to evaluate publication bias.[29] Statistical significance was defined as P < .05. In order to conduct the statistical analyses, RevMan (version 5.1; Cochrane, Oxford) and Stata (version 12.0; Stata Corporation, College Station, TX) were used.

3. Results

3.1. Results of the study selection

A diagram showing how the databases were searched and the studies were identified is shown in Figure 1. After excluding duplicates from the database search, 922 articles were retrieved, totaling 1392 articles. When the titles and abstracts were examined, 820 articles were excluded, mainly because they were not suitable for the meta-analysis. After full-text review of 102 articles, 86 articles were further excluded for the reasons shown in Figure 1. Ultimately, 16 RCTs[17–23,30–38] were included for the subsequent analysis in the meta-analysis.

Figure 1.

Figure 1.

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Flowchart of the literature search.

3.2. Study information and quality

Table 1 shows the characteristics of the studies that were included. The meta-analysis included 16 RCTs involving 2072 cancer patients. These studies were performed between the years 2009 and 2020, and located in the United States,[20,23,30,32,36–38] Sweden,[17,31] Canada,[18] the United Kingdom,[33] Denmark,[34] Iran,[22,35] and China.[19,21] Ten studies included patients with breast cancer only,[17–20,22,30,32–35,38] one included patients with thyroid cancer only,[21] and the remaining studies included patients with various types of cancers.[23,31,36,37] Patients with stage I–II, I–III, and I–IV cancers were included in 1,[32] 8,[18–20,33–35,37,38] and 4[21,23,30,36] studies, respectively. The remaining 3 studies[17,22,31] did not report the stages of cancer of the included patients. Patients who were allocated to the intervention groups received MBSR sessions for 6 to 8 weeks, while the patients allocated to the control groups primarily received usual/standard cancer care. The follow-up durations varied between 6 and 53 weeks, and various scales were used to evaluate the changes in the degrees of affective disorders after treatments, including loneliness, anxiety, and depression. As noted in Table 2, each RCT included in the review was assessed with the Cochrane Risk of Bias Tool. Eight of the included studies reported the details of sequence generation,[17,20–23,33,34,37] and 5 studies described allocation concealment details.[17,20,21,33,37] The blindness in performance was applied in 4 studies,[19–21,37] while the blindness in outcome detection was used in 5 studies.[19,20,30,33,37]

Table 1.

Characteristics of the included RCTs.

Study Design Country Cancer type Cancer stage No. of patients MBSR sessions Controls Follow-up duration (weeks) Outcomes
Lengacher (2009) R USA Breast cancer I–IV 82 6 weeks Usual care 6 weeks Social isolation (QOL), anxiety (STAI), and depression (CESD)
Bränström (2010) R Sweden Various NR 60 8 weeks Wait list control 12 weeks Anxiety and depression (HADS)
Henderson (2012) R USA Breast cancer I–II 111 8 weeks Usual supportive care 16 weeks Loneliness (UCLA loneliness scale), anxiety (CEC), and depression (SCL-90R)
Hoffman (2012) R UK Breast cancer I–III 229 8 weeks Standard care 12 weeks Anxiety and depression (POMS)
Wurtzen (2013) R Denmark Breast cancer I–III 336 8 weeks Usual care 53 weeks Anxiety and depression (SCL-90R)
Rahmani (2014) R Iran Breast cancer I–III 24 8 weeks Usual care 8 weeks Social isolation (QOL)
Johns (2015) R USA Breast cancer, esophageal cancer, and hematologic malignancies I–IV 35 7 weeks Wait list control 24 weeks Anxiety (GAD-7) and depression (PHQ-8)
Lengacher (2016) R USA Breast cancer I–III 322 6 weeks Usual care 12 weeks Anxiety (STAI) and depression (CESD)
Johns (2016) R USA Breast cancer and colorectal cancer I–III 71 8 weeks Psychoeducation/support 24 weeks Anxiety (GAD-7) and depression (PHQ-8)
Sarenmalm (2017) R Sweden Breast cancer NR 114 8 weeks Usual care 8 weeks Anxiety and depression (HADS)
Schellekens (2017) R Canada Breast cancer I–III 139 8 weeks Supportive expressive group therapy 8 weeks Social isolation (QOL)
Zhang (2017) R China Breast cancer I–III 60 8 weeks Usual care 12 weeks Anxiety (STAI)
Janusek (2019) R USA Breast cancer I–III 192 8 weeks Cancer recovery and health education 24 weeks Depression (CESD)
Liu (2019) R China Thyroid cancer I–IV 120 8 weeks Usual care 12 weeks Social isolation (QOL) and anxiety and depression (Zung self-rated anxiety and depression scale)
Mirmahmoodi (2020) R Iran Breast cancer NR 51 8 weeks Usual care 8 weeks Anxiety (BAI) and depression (BDI)
Victorson (2020) R USA Various I–IV 126 8 weeks Wait list control 16 weeks Social isolation, anxiety and depression (PROMIS-CAT)
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BAI = Beck anxiety inventory, BDI = Beck-II depression inventory, CEC = Courtauld Emotional Control Scale, CESD = Center for Epidemiological Studies Depression Scale, GAD-7 = 7-item Patient Health Questionnaire Generalized Anxiety Disorder Scale, HADS = Hospital Anxiety and Depression Scale, NR = not reported, PHQ-8 = the Patient Health Questionnaire 8-item depression scale, POMS = profile of mood states, PROMIS-CAT = patient reported, QOL = quality of life, R = randomized, RCT = randomized controlled trials, SCL-90R = symptom checklist-90-revised, STAI = state-trait anxiety inventory outcomes measurement information system computer adaptive tests.

Table 2.

Details of study quality evaluation via the Cochrane Risk of Bias Tool.

Random sequence generation Allocation concealment Blinding in performance Blinding in outcome detection Incomplete outcome data Reporting bias Other bias
Lengacher (2009) Unknown Unknown High Low Low Low Low
Bränström (2010) Unknown Unknown High High Low Low Low
Henderson (2012) Unknown Unknown Unknown Unknown Low Low Low
Hoffman (2012) Low Low High Low Low Low Low
Wurtzen (2013) Low Unknown Unknown Unknown Low Low Low
Rahmani (2014) Unknown Unknown Unknown Unknown Low Low Low
Johns (2015) Unknown Unknown High High Low Low Low
Lengacher (2016) Unknown Unknown High High Low Low Low
Johns (2016) Low Low Low Low Low Low Low
Sarenmalm (2017) Low Low High High Low Low Low
Schellekens (2017) Unknown Unknown Unknown Unknown Low Low Low
Zhang (2017) Unknown Unknown Low Low Low Low Low
Janusek (2019) Low Low Low Low Low Low Low
Liu (2019) Low Low Low High Low Low Low
Mir Mahmoodi (2020) Low Unknown Unknown Unknown Low Low Low
Victorson (2020) Low Unknown Unknown Unknown Low Low Low
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3.3. Effects of MBSR on loneliness in patients with cancer

Six studies[18,21,23,30,32,35] reported the changes in the degree of loneliness after treatment. Pooled results showed that MBSR significantly improved loneliness (SMD: −0.35, 95% CI: −0.59 to −0.12, P = .003, I2 = 46%; Fig. 2A) when compared with controls. The results did not change significantly when sensitivity analyses excluded one study at a time (SMD: −0.28 to −0.42, P all < 0.05).

Figure 2.

Figure 2.

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Forest plots for the meta-analysis of MBSR on loneliness, anxiety, and depression in patients with cancer; (A) forest plots for the meta-analysis of MBSR on loneliness; (B) forest plots for the meta-analysis of MBSR on anxiety; and (C) forest plots for the meta-analysis of MBSR on depression.

3.4. Effects of MBSR on anxiety and depression in patients with cancer

Pooled results with 13 studies showed that MBSR significantly improved anxiety (SMD: −0.51, 95% CI: −0.73 to −0.30, P < .001, I2 = 77%; Fig. 2B), and depression (SMD: −0.61, 95% CI: −1.02 to −0.20, P = .004, I2 = 94%; Fig. 2C) in patients with cancer. The results did not change significantly when sensitivity analyses excluded one study at a time (for anxiety, SMD: −0.45 to −0.55, P all < 0.05; for depression, SMD: −0.45 to −0.68, P all < 0.05).

3.5. Publication bias

There was a low risk of publication bias among the meta-analyses of MBSR on loneliness, anxiety, and depression, as shown by symmetrical funnel plots (Fig. 3A–C). Similarly, Egger regression tests showed a low risk of publication bias for the meta-analyses of the outcomes of loneliness, anxiety, and depression, respectively (P = .322, .217, and .134, respectively).

Figure 3.

Figure 3.

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Funnel plots for the publication biases underlying the meta-analyses; (A) funnel plots for the meta-analysis of MBSR on loneliness in cancer patients; (B) funnel plots for the meta-analysis of MBSR on anxiety in cancer patients; and (C) funnel plots for the meta-analysis of MBSR on depression in cancer patients.

4. Discussion

This meta-analysis of 16 RCTs found that compared to controls of usual/standard care of cancer, MBSR was associated with significantly relieved loneliness, anxiety, and depression in patients with cancer. Sensitivity analyses excluding one study at a time also produced consistent results. This indicates that MBSR may be an effective treatment for cancer patients suffering from loneliness, anxiety, and depression.

Loneliness is a subjective feeling where an individual experiences isolation from other individuals or the community. Cancer survivors with loneliness may live in a negative state without social groups.[39] In this meta-analysis, a total of 6 studies evaluated how MBSR can impact the feeling of loneliness in patients with cancer. The results showed that the feeling of loneliness was significantly improved in patients with cancer after the implementation of MBSR. Four of the 6 studies dealt with breast cancer patients, one dealt with thyroid cancer patients, and one dealt with mixed cancer patients. From the perspective of intervention time, the intervention of an 8-week MBSR session was primarily adopted. In general, all studies followed the main content design of MBSR courses, such as body scanning, mindfulness meditation, mindfulness walking, mindfulness yoga, and other training programs. The follow-up durations of the studies ranged from 6 weeks to 16 weeks after the intervention, indicating that MBSR is an effective method to improve the loneliness of cancer patients in the short term. However, its long-term effect still needs further study.

Patients with cancer are likely to suffer from continuous depression and anxiety, which may cause serious challenges to the treatment and daily living of the patients.[40] The core element of MBSR intervention is meditation, which has a positive regulating effect on individual moods. The role of MBSR in improving anxiety and depression of cancer patients has also been confirmed in this study. The results of this study show that compared with standard cancer care, MBSR can significantly reduce the anxiety and depression levels of cancer patients. Fear of cancer progression and/or recurrence can be a major source of anxiety and depression in patients with cancer. Previous meta-analyses have confirmed that a mind-body intervention, primarily with MBSR, was effective in reducing the fear of cancer recurrence.[41,42] This may be a key mechanism underlying the possible beneficial influences of MBSR on anxiety and depression in patients with cancer. In this meta-analysis, although the population set in the inclusion criteria of this study was patients with any types of cancers, patients with breast cancer were predominantly included. Accordingly, the influence of MBSR on patients with other cancers should also be investigated in future high-quality and large-scale RCTs. In terms of intervention time, the MBSR intervention was mainly based on 8-week training. The standard MBSR training is an 8-week session, which includes the process of encouraging patients to internalize the exercise process. This may be because the process of positive impact from exposure to MBSR internalization requires a certain period.[43] In addition, multiple scales were used in the included studies for evaluating anxiety and depression of the cancer patients. Although these evaluation tools are different, they are all widely used and show good reliability and validity in previous studies. In the meta-analysis, SMD is used to combine and standardize the data and to minimize the influence of potential heterogeneity.[26] On the other hand, the fact that multiple anxiety and depression evaluation tools were used in previous studies reflects that there is a lack of specific tools for anxiety and depression assessment of patients with cancer. Optimal tools for evaluating these affective disorders in patients with cancer should be developed and validated in future studies.

5. Clinical implications

MBSR, as an auxiliary treatment, can actively influence the brain’s stress management through mindfulness meditation. It can also help individuals regulate their psychological state, manage their emotions, awaken their inner focus, and supplement the shortcomings of routine care to help alleviate negative emotions such as loneliness, anxiety, and depression in cancer patients. At the same time, MBSR is suitable for clinical psychological intervention due to its strong accessibility, low requirements for individual age and education level, wide usage environment, simple implementation, and no additional costs. The follow-up research can verify the influence of MBSR on loneliness, anxiety and depression in a wider range of tumor population, and further explore the long-term effect of MBSR, so as to better manage the psychological distress of tumor patients, alleviate their negative emotions, improve their quality of life, and provide new directions and ideas for the psychological care of tumor patients.

6. Study limitations

Our study is not without its limitations. First of all, the included RCTs had modest quality. It is therefore essential to validate the results of the meta-analysis in high-quality studies before relying on them. Second, as mentioned previously, patients with breast cancer were predominantly included. The influence of MBSR on affective moods in patients with other cancer types should be further evaluated. Third, the evaluation tools used for inclusion in the study were diverse, but due to the limitation of the number of included literatures, subgroup analysis according to the different tools was not possible. Therefore, the difference of evaluating scales for the negative affective disorders may affect the results of the meta-analysis, but the impact of this difference can be reduced by using the SMD analysis method. Furthermore, future studies should determine the standard MBSR protocol and the best tools to measure loneliness, anxiety, and depression among cancer patients. Lastly, only studies published in English were considered for the meta-analysis, which may lead to publication bias. However, our evaluation of publication bias showed low risk. Moreover, including gray literature (such as conference abstracts or unpublished data) may confound the results of the meta-analysis as these materials may not be peer-reviewed.

7. Conclusions

In conclusions, according to the meta-analysis, MBSR may benefit cancer patients by reducing loneliness, anxiety, and depression. These results should be validated in high-quality RCTs. Furthermore, standardizing MBSR protocols and developing effective evaluation tools will be helpful in reducing loneliness, anxiety, and depression in cancer patients.

Author contributions

Conceptualization: Junye Yu.

Data curation: Mingyue Han.

Formal analysis: Mingyue Han, Fengru Miao, Dan Hua.

Visualization: Fengru Miao.

Writing – original draft: Junye Yu, Mingyue Han.

Writing – review & editing: Junye Yu, Dan Hua.

Abbreviations:

CI
confidence interval
MBSR
mindfulness-based stress reduction
RCT
randomized controlled trials
SMD
standard mean difference

The authors have no conflicts of interest to disclose.

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

How to cite this article: Yu J, Han M, Miao F, Hua D. Using mindfulness-based stress reduction to relieve loneliness, anxiety, and depression in cancer patients: A systematic review and meta-analysis. Medicine 2023;102:37(e34917).

Contributor Information

Mingyue Han, Email: lilyueer@163.com.

Fengru Miao, Email: pekinglihanyu@126.com.

Dan Hua, Email: xingtailyj@126.com.

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