Benefits of a mindfulness and compassion program for cancer patients: experience in a Spanish public hospital setting

Abstract

Background

Mindfulness-based interventions have been shown to improve the quality of life of cancer patients and are widely recommended.

Methods

This was a non-randomized, single-center study designed to assess the feasibility and benefits of a mindfulness and compassion program for individuals living with cancer (MCP-C). The primary objective was to evaluate the feasibility of the program, while the secondary objective was to assess its effectiveness in adult cancer patients and their relatives. Before and after completing the program, participants completed the 12-item General Health Questionnaire (GHQ- 12) and the Hospital Anxiety and Depression Scale (HADS). A qualitative study was also conducted using focus groups and a structured qualitative survey.

Results

A total of eight courses were delivered, six in person in 2019 and two online in 2020.

A total of 153 participants were enrolled, of whom 142 were considered evaluable. Among them, 90 (64.3%) completed the program, including 75 patients (83.3%) and 15 relatives. The intervention was associated with significant reductions (p < 0.01) in mean scores on the GHQ- 12 and the HADS-A and HADS-D subscales. In the qualitative assessment, participants reported multiple benefits, including increased awareness of health-related decision-making, improved relationship with the disease, a sense of companionship, emotional support, and overall enhancements in daily life.

Conclusions

Implementing an 8-week mindfulness and self-compassion program within the routine practice of a public hospital was feasible and led to significant improvements in the psychological well-being of cancer patients and their relatives.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12094-025-03913-1.

Introduction

Cancer is a major global health concern with high incidence and mortality rates. The global cancer burden is projected to reach 28.4 million cases by 2040, representing a 47% increase from 2020 [1]. A cancer diagnosis and its treatment mark a significant turning point in an individual’s life, often leading to profound physical and emotional suffering. These challenges also have a substantial impact on relatives, ultimately diminishing overall quality of life. In this context, interventions aimed at improving mental health, quality of life, and well-being have gained increasing attention [2]. Psycho-oncology services, delivered by trained professionals within multidisciplinary teams, play a crucial role in providing integrated, patient-centered care that addresses psychological needs at all stages of the cancer experience [3].

Mindfulness is oriented toward training awareness of the present moment -intentionally and without judgment- through exercises of personal inquiry, sitting and movement-based meditation practices, and the cultivation of physiological and emotional self-regulation skills [4–9]. Mindfulness-based interventions have been used as effective complementary strategies for cancer patients to improve their quality of life and address psychological issues, including stress, anxiety, and depression [4–8]. Specifically, Mindfulness-Based Stress Reduction (MBSR) and Mindfulness-Based Cognitive Therapy (MBCT) are formally recommended by the American Society of Clinical Oncology (ASCO) for managing anxiety and depression in individuals diagnosed with cancer [9].

Compassion is defined as a sympathetic awareness of others'distress, combined with a desire to alleviate it [11, 13, 16]. Self-compassion refers to a healthy and positive attitude towards oneself, particularly during times of adversity and suffering [17–19]. Individuals with higher levels of self-compassion tend to adopt more adaptive coping behaviors in response to stressful circumstances [43]. Based on this, we hypothesized that the explicit introduction of compassion skills training in a mindfulness program could be feasible and could enhance the well-being of cancer patients and their relatives. We designed a Mindfulness and Compassion Program for individuals living with cancer (MCP-C), integrating theoretical and practical aspects from leading models and authors in the fields of mindfulness and compassion, while adapting this framework to the specific needs of individuals affected by cancer [10–16].

This exploratory study aimed to assess the feasibility (primary objective) and effectiveness of implementing an 8-week Mindfulness and Compassion Program for Cancer (MCP-C) within the medical oncology department of a public hospital in Catalonia, Spain.

Method

Design and participants

Between March 2019 and December 2020, a single-center, exploratory before-and-after study was conducted at the Department of Medical Oncology of Hospital Clínic de Barcelona, a 767-bed acute-care teaching hospital integrated into the public hospital network of Catalonia, Spain. As one of the largest hospitals in Barcelona, it serves a reference population of 540,000 residents. The primary objective of the study was to assess the feasibility of implementing a mindfulness and self-compassion program for cancer patients and their relatives within routine clinical practice, as well as to evaluate the benefits associated with this intervention.

Participants included adult patients diagnosed with solid tumors, as well as their first-degree relatives or caregivers, who were undergoing treatment and/or follow-up at the hospital’s Department of Medical Oncology. Patients with uncontrolled psychiatric disorders and/or cognitive impairments that could prevent them from completing the study questionnaires were excluded. Participants were referred to the mindfulness program by their attending oncologists or nurses, or they were recruited through program advertisements that provided contact information via phone and email. Additionally, informational face-to-face and virtual sessions were held quarterly by mindfulness instructors.

The study protocol was approved by the Clinical Research Ethics Committee of Hospital Clinic de Barcelona (codes HCB/2019/0140 and HCB/2021/0764, approved in February and August 2019, respectively) (Barcelona, Spain). The study was conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from all participants.

Design of the mindfulness program and study procedures

The MCP-C program was based on methodologies proposed by Compassion Focused Therapy [11], Compassionate Mind Training [13, 16], Mindfulness-Based Stress Reduction (MBSR) for cancer patients [10, 12, 15, 46], Polyvagal Theory [20], Mindful Self-Compassion [14], Brief Integrated Mindfulness Practices [21], the Hanson Healing Method [22], and Trauma-Sensitive Mindfulness [23].

This 8-week mindfulness program included one 2.5-h session per week. Between weeks 6 and 7, a 5-h practice day was held to reinforce exercises from previous sessions while introducing new practices. Sessions were conducted either in person (in hospital rooms) or online, depending on the time period (before and during the COVID- 19 pandemic). An overview of the content for the 8-week sessions is presented in Table 1, with more detailed information available in Supplementary Table 1.

Table 1.

Description of the 8-week Mindfulness-Based Program

Week	Session topics	Summary of contents
1	Finding safeness in illness	Discerning neuroceptive signals of danger and safeness, and learning to regulate sympathetic and vagal dorsal activation [20], through focal attention and soothing rhythm breathing [11, 13], to widen the tolerance window [41]
2	Cultivating the shooting system	Describing the three motivational systems (emotion regulation systems) and developing an inner safeness place through imagery and anchor practices [11, 13]
3	Befriending pain	Observing pain without judgment and relating to it from the caring system [11]. Practicing with the compassionate body scan [14], the mindful pause, and the self-compassion break
4	Shooting emotional pain	Checking the three emotion regulation systems [11]. Practicing the soothing/supportive touch “BEING”
5	Opening to self-compassion	Practicing the three components of self-compassion: mindfulness (vs. over-identification), common humanity (vs. isolation), and self-kindness (vs. self-judgment) [14]
6	Connecting with others	Developing the compassionate self (wisdom, strength, and care) [11, 13] and attending a possible backdraft effect [14] Practicing interpersonal compassion through the four steps of non-violent communication (observation, feelings, needs, requests [42]
	5-h practice day	Compassionate body-scan, contemplation of mind, open presence, compassionate self, loving-kindness, mindful walking, interpersonal compassion
7	Cultivating positive emotions	Cultivating positive emotions and relating to the illness(22)
8	Integrating the practice in daily life	Closing the program with a final inquiry on how to integrate the practice in daily life. Loving-kindness practice directed toward the entire group. Participants share gifts, and the teacher offers options for continuity

Instructors guided participants through three main domains: (1) didactic presentations, (2) guided meditations, and 3) inquiry. The practices in the program were brief in duration [21], with some adapted from the aforementioned methodologies. Participants were provided with recorded guided meditations to practice at home before the next session. The audio recordings included: audio 1: safety breathing [5 min], audio 2: safe place [10 min], audio 3: exploring body sensations [15 min], audio 4: emotional care [15 min], audio 5: opening to self-compassion [15 min], audio 6: cultivating self-compassion [15 min], and audio 7: ideal compassionate other [15 min]).

Before the first session and after completing the final session at week 8, participants completed the 12-item General Health Questionnaire (GHQ- 12) and the Hospital Anxiety and Depression Scale (HADS). The GHQ- 12 is a self-administered screening tool designed to assess psychological distress and mental well-being. It consists of 12 statements, with participants indicating their level of agreement on a 4-point scale ranging from 0 (“not at all”) to 3 (“much more than usual”). Total scores range from 0 to 36, with scores greater than 11 suggesting evidence of distress. A validated Spanish version of the GHQ- 12 was used [24].

The HADS is a widely used screening tool for anxiety and depression in psycho-oncology [25, 26]. It consists of 14 items, with 7 assessing anxiety (HADS-A) and 7 assessing depression (HADS-D). Each item is scored on a 4-point scale ranging from 0 to 3. The sum score for each subscale ranges from 0 to 21, with scores of ≥ 8 and ≥ 11 indicating possible and definitive cases of anxiety or depression, respectively. A validated Spanish version of the HADS was used [27].

The qualitative study consisted of two online focus group interviews, each with five participants. A qualitative phenomenological analysis was conducted using a convenience sample of patients who had completed the mindfulness program. Focus group participants were selected based on their availability, interest, and ability to contribute to discussions by providing in-depth descriptions of their experiences, perceptions, and beliefs [28, 29]. The two online focus groups took place in April 2020. Patients were contacted by the researchers, informed about the study, and invited to participate. After obtaining their consent, connection details for the focus groups were provided, and all participants were offered telephone technical support before and during the sessions.

All data collection occurred during the online meetings. Two experienced moderators, trained in conducting focus groups, facilitated the sessions in a non-directive manner, following a semi-structured discussion guide. Each session lasted 60 min and was recorded and transcribed verbatim while ensuring participant anonymity. Transcripts were manually analyzed using MAXQDA software (VERBI GmbH, Germany). Based on key insights from the group discussions, including participant’s opinions and perceptions of the mindfulness program’s usefulness, a qualitative survey consisting of 20 questions was developed. This survey was administered to participants at the end of the final session. Each question was rated on a scale from 0 (minimum) to 10 (maximum). Details of the survey are provided in Table 2.

Table 2.

Questions of the Qualitative Survey

Answer from 0 to 10 the following questions, considering 0 = nothing and 10 = maximum score

1. Did you know about mindfulness before participating in the course? 2. How would you rate the confidence of the mindfulness program that has been offered to you? 3. You would say that mindfulness has helped you to take more consciously decisions related to your health? 4. Has mindfulness improved your relationship with the illness? 5. Have you noticed improvement in pain or physical discomfort with mindfulness? 6. Have you noticed improvement in the feeling of being tired with mindfulness? 7. Has mindfulness helped you sleep better? 8. Do you consider the mindfulness course as a type of emotional support? 9. Do you feel that you are more accompanied in the process of your oncological disease because of the fact to participate in the mindfulness program? 10. If we consider compassion as the intention or desire to alleviate your own (or others) suffering, do you consider that mindfulness has improved this ability or intention? 11. Do you notice that the relationship with the healthcare staff is closer after having participated in the mindfulness course? 12. Do you think that mindfulness has improved your relationship with your family or other people? 13. Do you think that mindfulness has helped you to understand better your vital needs and to attend them? 14. Do you think that mindfulness has helped you to feel more comfortable or feel better at the time of testing, visits or attend the hospital for treatment? 15. Would you say that your day-to-day life has improved with mindfulness? 16. Can you control better your anxiety and/or mood with mindfulness? 17. Do you live more in the present and less in the past or the future? 18. Did the mindfulness course meet the expectations that you had before starting the program? 19. Do you favorably rate offering to participate in the maintenance group for continuing practicing? 20. Would you recommend mindfulness to other cancer patients or their family members?

Recorded Data included gender, age, participant type (patient or family member), attendance modality (face-to-face or online), tumor location, cancer stage, and treatment type (biologic therapy, hormone therapy, radiotherapy, chemotherapy, surgery, or immunotherapy). Events related to the clinical course of the disease (e.g., disease progression, treatment-related toxicity, or death due to cancer or other causes) during the program, as well as other potential stressors, were prospectively recorded.

Statistical methods

Categorical variables were summarized using frequencies and percentages, while quantitative variables were described using the mean and standard deviation (SD). Average pre-post change scores (with 95% confidence intervals) for the GHQ- 12, HADS-A, and HADS-D following the mindfulness-based intervention were estimated using linear mixed models. These models included time (pre- vs. post-course) as a fixed factor, and both participant and mindfulness group as random factors. Additionally, change scores were modeled using linear mixed models that included pre-course scores as a fixed effect and the mindfulness group as a random factor. These models were used to predict average post-course scores based on pre-course scores and to compute the corresponding 95% confidence intervals. Simultaneous confidence intervals and adjusted p-values were calculated using the multivariate t-distribution [44]. Furthermore, these models were separately adjusted for sex, course type (online vs. face-to-face), and participant type (patient vs. family member) to examine whether the pre-post changes differed among the respective subgroups. All analyses included pre- and post-scores of participants who completed the program, assuming that missing data were missing at random. Cohen’s d was used to assess effect sizes, with values of 0.2, 0.5, and 0.8 indicating small, moderate and large effects, respectively. Statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS; IBM Corp.) and the statistical package R, version 4.4.2 (R Foundation for Statistical Computing). Statistical significance was set at 0.05.

Results

Between March 2019 and December 2020, a total of 8 courses were implemented, consisting of 6 face-to-face courses in 2019 and 2 online courses in 2020. A total of 153 participants were recruited. However, in March 2020, with the onset of the COVID- 19 pandemic, the face-to-face format of the program was rapidly adapted to an online format, resulting in the loss of 13 participants. As a result, 140 participants (91.5%) completed the pre-course assessments and were considered evaluable.

In terms of feasibility, which was the primary objective of the study, 90 of the 140 participants (64.3%) completed the program. The remaining 50 participants did not complete the program due to cancer-related symptoms (n = 15), including death (n = 3), lack of interest (n = 10), personal reasons (n = 7), emotional deterioration (n = 1), or unknown causes (n = 14).

Thus, the study population used to assess the emotional effects consisted of 90 participants, including 74 patients (78.4%) and 16 relatives (21.6%). Among the cancer patients, 36 were men and 38 were women, with a mean age of 59.4 years (range 30–85 years). Notably, 15 of the 16 relatives (93.7%) were women. The MCP-C was delivered face-to-face to 66 participants (73.3%) and online to the remaining 24 participants (26.7%). As shown in Table 3, breast cancer was the most common malignancy (27.0%), followed by prostate cancer (18.9%), and renal and lung cancer (10.8% each). Stage IV was diagnosed in 52 patients (57.7%). Additionally, most patients (87.8%) were receiving active cancer treatment during the study, particularly chemotherapy and hormone therapy.

Table 3.

Clinical characteristics of participants before starting the Mindfulness Program

Data	Number (%)
Total participants	90 (100)
Type of participants
Cancer patients	74 (82.2)
Family members/accompanying persons	16 (16.7)
Cancer patients (n = 74)
Men	36 (48.6)
Women	38 (51.3)
Age, years, mean (range)	59.4 (30–85)
Mindfulness program modality
Face-to-face	66 (73.3)
Online	24 (26.7)
Tumor location, n = 74
Breast	20 (27.0)
Prostate	14 (18.9)
Lung	8 (10.8)
Renal	8 (10.8)
Pancreas	7 (9.5)
Colorectal	4 (5.4)
Gastric	3 (4.1)
Gynecologic	3 (4.1)
Esophageal	2 (2.7)
Other	5 (6.7)
Tumor stage, n = 74
I	11 (14.9)
II	5 (6.7)
III	6 (8.1)
IV	52 (70.3)
Cancer treatment, n = 65
Chemotherapy	24 (36.9)
Hormone therapy	22 (33.8)
Biologic therapy	6 (9.2)
Immunotherapy	3 (4.6)
Biologic + hormone therapy	3 (4.6)
Chemotherapy + immunotherapy	2 (3.1)
Radiotherapy	1 (1.5)
Surgery	1 (1.5)
Biologic + surgery	1 (1.5)
Antiangiogenic + immunotherapy	1 (1.5)
Chemotherapy + biologic	1 (1.5)

Mean (SD) scores of the GHQ- 12, HADS-A, and HADS-D questionnaires before beginning the MCP-C were similar between the group of participants who did not complete the 8-week program and the 90 participants who did. Specifically, GHQ- 12 scores were 14.7 (5.87) for non-completers and 14.9 (6.44) for completers; HADS-A scores were 7.92 (4.21) for non-completers and 7.99 (3.94) for completers; and HADS-D scores were 4.92 (4.04) for non-completers and 4.53 (3.41) for completers. Among the 90 participants who completed the 8-week MCP-C, 65.3% had a pre-course GHQ- 12 score ≥ 11, indicating high emotional distress. Additionally, 30% and 7.8% presented clinically significant anxiety and depression, as defined by HADS-A and HADS-D scores > 10, respectively.

The intervention was associated with a statistically significant improvement in emotional distress, anxiety, and depression when the mean scores of the three study questionnaires were compared before and after the intervention (Table 4). For the GHQ- 12 questionnaire, the average change was − 4.52 (95% CI − 6.1 to − 2.94) (p < 0.01). In the HADS-A subscale, the average change was − 1.38 (95% CI − 2.07 to − 0.69) (p < 0.01), and in the HADS-D subscale, the average change was − 1.11 (95% CI − 1.69 to − 0.53) (p < 0.01). Regarding clinical significance, as measured by the standardized mean difference (Cohen’s d), the pre-post course values were − 0.42 for HADS-A and − 0.34 for HADS-D, indicating a small clinical benefit for anxiety and depression, respectively. For the GHQ- 12 questionnaire, Cohen’s d was − 0.72, showing a moderate clinical reduction in emotional distress (Table 4).

Table 4.

Scores of the GHQ- 12, HADS-A, and HADS-D questionnaires before and after completion of the 8-week mindfulness program all participants and in the different subgroups

Variables	All participants (n = 90)	p value	Men (n = 37)	Women (n = 53)	p value	Face-to-face (n = 66)	Online (n = 24)	p value	Patients (n = 74)	Family/other (n = 16)	p value
GHQ- 12, mean (SD)
Before	14.9 (6.44)	< 0.01	11.6 (4.74)	16.5 (6.58)	0.27	14.0 (5.98)	16.5 (7.10)	0.76	15.4 (6.57)	12.8 (5.63)	0.21
After	10.4 (6.09)		9.83 (4.32)	10.6 (6.79)		10.2 (6.03)	10.8 (6.32)		10.1 (5.42)	11.5 (8.31)
HADS-A, mean (SD)
Before	7.99 (3.74)	< 0.01	6.54 (3.24)	9.0 (3.76)	0.57	7.14 (3.24)	10.3 (4.07)	0.4	7.92 (3.85)	8.31 (3.28)	0
After	6.63 (2.85)		5.97 (2.79)	7.09 (2.82)		6.42 (2.87)	7.16 (2.78)		6.24 (2.63)	8.44 (3.20)
HADS-D, mean (SD)
Before	4.53 (3.41)	< 0.01	3.43 (3.05)	5.30 (3.46)	0.71	3.89 (2.97)	6.29 (3.96)	0.06	4.70 (3.46)	3.75 (3.17)	0.09
After	3.45 (3.05)		2.76 (2.58)	3.94 (3.27)		2.79 (2.70)	5.20 (3.25)		3.36 (2.94)	3.88 (3.58)

GHQ- 12 12-item General Health Questionnaire, HADS-A Hospital Anxiety and Depression Scale, subscale anxiety, HADS-D Hospital Anxiety and Depression Scale, subscale depression; SD standard deviation

We acknowledge that the results might have varied had all 153 participants completed the program. To account for this, we performed a carry-forward imputation, assuming that the 63 participants who did not complete the program would have achieved the same results in the second evaluation. Under this assumption, the average pre-post changes were smaller but remained statistically significant: HADS-A: − 0.86 (95% CI: [− 1.31, − 0.41]; p < 0.01); HADS-D: − 0.69 (95% CI: [− 1.07, − 0.31]; p < 0.01); and GHQ- 12: − 2.87 (95% CI: [− 3.94, − 1.81]; p < 0.01).

Furthermore, there were no statistically significant differences in the mean scores of the three questionnaires before and after the implementation of the mindfulness program between men and women, face-to-face and online teaching modalities, or patients and family members/accompanying persons (Table 4). When exploring the relationship between pre-intervention scores and the benefits obtained, higher baseline scores were significantly associated with greater improvements in the HADS-A and GHQ- 12 questionnaires (Table 5). However, as this subanalysis was exploratory, no definitive conclusions can be drawn.

Table 5.

Estimated average changes of HADS-A, HADS-D and GHQ- 12 scores according to cutoff of baseline values

Baseline value	Estimated average change (95% confidence interval)), p value
Cutoff score	HADS-A	HADS-D	GHQ- 12
5	0.420 (– 0.320 to 1.150), p = 0.270	– 1.138 (– 1.970 to – 0.780), p < 0.001	1.470 (– 1.000 to 3.940), p = 0.240
10	– 2.568 (– 3.230 to – 1.189), p < 0.001	– 3.720 (– 4.710 to – 2.720), p < 0.001	– 1.530 (– 3.220 to 0.150), p = 0.070
15	– 5.540 (– 6.680 to – 4.390), p < 0.001	– 5.050 (– 7.700 to – 4.410), p < 0.001	– 4.540 (– 5.870 to – 3.210), p < 0.001
20	Not applicable	Not applicable	– 7.540 (– 9.230 to – 5.850), p < 0.001

HADS-A Hospital Anxiety and Depression Scale, subscale anxiety; HADS-D Hospital Anxiety and Depression Scale, subscale depression; GHQ- 12 12-item General Health Questionnaire

According to the qualitative evaluation, the most relevant aspects identified in the focus groups were the subjective benefits derived from their participation in the course (43%), the format (40%), and the course proposal (17%). In terms of perceived benefits, patients reported that mindfulness positively impacted their mood, helped them feel more supported, and improved their personal relationships. They also mentioned becoming more aware of the present moment, enjoying daily life, worrying less about the future, and reducing fear before visits or control tests. Regarding the format, patients agreed that the virtual format was convenient, and many expressed a desire for follow-up sessions after the 8-week program. Additionally, participants appreciated that mindfulness programs were offered at the hospital by their oncologists. As noted in the methods section, a qualitative survey was designed based on relevant information derived from the group interviews. Responses to the qualitative survey were available from 36 patients and are shown in Table 6. Scores ≥ 7 were obtained for 16 (80%) of the 20 questions, including awareness of health-related decisions (88% of responders rated ≥ 7), better relationship with the disease (80%), improvement in pain (40%), decrease in fatigue (48%), improvement in sleep (60%), feeling supported (92%), emotional support (96%), desire to alleviate one’s own suffering and that of others (84%), improvement in relationships with healthcare staff (60%) and family (68%), better understanding of vital needs (80%), feeling better before medical visits or tests (72%), improvement in daily life (80%), better control of anxiety or mood (68%), living more in the present moment (84%), and a favorable disposition to continue in the maintenance mindfulness group (96%). Notably, 100% of participants rated ≥ 7 on the question regarding whether the fact that the course was offered at the hospital was a determining factor in their decision to join the course.

Table 6.

Results of the qualitative survey

Questions	Scores (from 0: minimum to 10: maximum), % responses										Unknown
	1	2	3	4	5	6	7	8	9	10
1. Did you know about mindfulness before participating in the course?	0	0	0	0	0	0	8	4	20	68	0
2. How would you rate the confidence of the mindfulness program that has been offered to you?	0	0	0	0	0	0	0	8	32	60	0
3.You would say that mindfulness has helped you to take more consciously decisions related to your health?	4	0	0	4	4	0	20	28	12	28	0
4. Has mindfulness improved your relationship with the illness?	4	4	4	0	0	8	20	32	8	20	0
5. Have you noticed improvement in pain or physical discomfort with mindfulness?	12	0	0	0	20	16	20	8	8	4	12
6. Have you noticed improvement in the feeling of being tired with mindfulness?	8	0	0	0	20	12	16	16	8	8	12
7. Has mindfulness helped you sleep better?	4	4	0	0	0	24	16	28	12	4	8
8. Do you consider the mindfulness course as a type of emotional support?	0	0	0	0	0	4	4	28	24	40	0
9. Do you feel that you are more accompanied in the process of your oncological disease because of the fact to participate in the mindfulness program?	4	0	4	0	0	0	8	24	20	40	0
10. If we consider compassion as the intention or desire to alleviate your own (or others) suffering, do you consider that mindfulness has improved this ability or intention?	4	0	0	0	4	4	12	36	8	28	4
11. Do you notice that the relationship with the healthcare staff is closer after having participated in the mindfulness course?	8	4	0	0	16	12	16	24	8	12	0
12. Do you think that mindfulness has improved your relationship with your family or other people?	4	0	8	0	0	16	24	16	16	12	4
13. Do you think that mindfulness has helped you to understand better your vital needs and to attend them?	4	4	0	0	4	8	12	32	16	20	0
14. Do you think that mindfulness has helped you to feel more comfortable or feel better at the time of testing, visits or attend the hospital for treatment?	4	0	4	0	8	8	16	16	16	24	4
15. Would you say that your day-to-day life has improved with mindfulness?	4	0	8	0	0	8	20	32	16	12	0
16. Can you control better your anxiety and/or mood with mindfulness?	4	4	0	0	4	12	16	36	12	8	4
17. Do you live more in the present and less in the past or the future?	4	4	0	0	4	4	16	20	32	16	0
18. Did the mindfulness course meet the expectations that you had before starting the program?	0	0	0	0	0	0	12	8	12	68	0
19. Do you favorably rate offering to participate in the maintenance group for continuing practicing?	4	0	0	0	4	8	4	28	24	28	0
20. Would you recommend mindfulness to other cancer patients or their family members?	0	0	0	0	4	0	4	8	16	68	0

Percentage of responses corresponding to each item

Discussion

In this study, we demonstrate that the implementation of an 8-week Mindfulness and Self-Compassion Program for Cancer (MCP-C) in the medical oncology department of a public Spanish hospital was feasible. Furthermore, the program proved effective, yielding multiple benefits for participants. Notably, MPC-C was beneficial even for patients in advanced cancer stages and during active treatment, a period when managing psychological distress is particularly challenging.

The MCP-C was designed and implemented to help patients, relatives, and caregivers cope with the physical and psychological suffering associated with a cancer diagnosis and treatment. The program was offered to all eligible individuals, with the exception of those with uncontrolled psychiatric conditions. As shown in Table 3, the participant population was diverse, reflecting the “real-life” conditions of a medical oncology department. Regarding feasibility, which was the primary objective of the study, we found that 64.4% of participants successfully completed the program. Importantly, most of the participants were patients with advanced solid tumors who were undergoing active oncological treatment during the program. To understand the factors that might predict non-completion, we compared baseline levels of emotional distress, anxiety, and depression between participants who completed the program and those who did not. We did not find any statistically significant differences between the two groups. The primary reasons for discontinuation were disease -and treatment-related issues. In response, we have now adapted the program to a hybrid format, offering both in-person and online sessions, allowing participants to choose the format that best suits their needs. Mindfulness-based interventions are increasingly being delivered online [30], and improvements in health outcomes associated with online training have been reported [31]. The online format is especially valuable for rural or remote cancer patients who may not have access to in-person groups [32].

Regarding efficacy, the key finding of the study was that participation in the MCP-C led to a significant reduction in emotional distress, anxiety, and depression. The benefits were similar for both men and women, as well as for participants attending the program either in person or virtually. However, it is important to note that 63 of the original 153 participants did not complete the program, which may limit the interpretation of the results. To account for this loss to follow-up, we performed a carry-forward imputation, assuming that these participants would not have shown any improvement and would have obtained the same scores in the second evaluation. As shown in the results section, even under this assumption, the average pre-post changes were smaller but remained statistically significant.

Although our study included cancer patients with various tumor types, most published mindfulness studies demonstrating beneficial effects in cancer patients have primarily focused on women with breast cancer [33–35]. In contrast, our study included 48.6% male participants with different tumor types, supporting our strategy of offering the program to all cancer patients, regardless of diagnosis. While the program was also open to relatives and caregivers, only 16 individuals from this group participated, making it difficult to draw definitive conclusions about the program’s impact on them. There is limited evidence regarding the benefits of mindfulness interventions for cancer caregivers [36–38], but we continue offering these programs at our institution to gather further data on this specific population.

Evaluating the impact of mindfulness interventions is inherently complex, as patients receive diverse influences, and biological markers of improvement are difficult to establish. Therefore, incorporating both qualitative and quantitative methodologies is crucial [39]. To comprehensively assess the program’s effects, we conducted focus groups and administered a qualitative survey. Most participants positively evaluated the mindfulness program, highlighting its beneficial impact on their emotional well-being, daily life, and relationships. Notably, many participants reported discovering mindfulness for the first time through the course. According to focus group discussions and survey responses, participants experienced subjective improvements in pain and sleep quality, better emotional regulation, enhanced personal relationships, reduced anxiety about the future, and decreased fear of medical tests. Many also emphasized the need for periodic reinforcement sessions to sustain the benefits over time. Based on this feedback, we have implemented weekly mindfulness sessions open to all former participants of the program.

An important finding of our study was the positive evaluation of mindfulness interventions being offered within the hospital setting. Given the complexities faced by cancer patients -particularly those in advanced stages- delivering mindfulness within a structured, supportive hospital environment, integrated into a multidisciplinary team of psycho-oncologists, oncologists, nurses, and other healthcare professionals, is essential.

Mindfulness-based interventions (MBIs), specifically Mindfulness-Based Stress Reduction (MBSR) and Mindfulness-Based Cognitive Therapy (MBCT) are formally recommended for managing anxiety and depression in cancer patients [9]. A recent systematic review and meta-analysis, which included 1.677 patients from 36 independent studies (including randomized trials), found that MBIs have a significant medium effect in reducing symptoms of depression and anxiety [45]. Another meta-analysis evaluating the effects of MBSR and MBCT on quality of life, pain, fatigue, anxiety, and depression in cancer patients demonstrated significant benefits across these domains, particularly in younger patients and those in early cancer stages [7]. Overall, our findings align with previously published literature on mindfulness-based interventions, further supporting their integration into comprehensive cancer care.

Although the efficacy of mindfulness interventions in cancer patients has been systematically reviewed and meta-analyzed, the methodological quality of studies is generally considered acceptable. However, several factors should be taken into account, including the heterogeneity of cultural contexts in which studies were conducted, variations in cancer types, lifestyle differences, disease stages, and discrepancies in outcome measures [38]. This heterogeneity in mindfulness-based interventions makes direct comparisons between studies challenging. In our national context, published studies remain scarce. To our knowledge, only one prior study has examined mindfulness-based training in oncology patients in our country. In a non-randomized naturalistic study involving Spanish oncology patients, those who received mindfulness-based cognitive therapy showed greater improvements in distress, depression, quality of life, and meta-awareness of emotions compared to the control group [40]. Our study further supports the efficacy of mindfulness programs in the Spanish cancer population.

Overall, our findings on the effectiveness of MCP-C in enhancing psychological well-being among cancer patients align with data from previous studies, as well as systematic reviews and meta-analyses [5–8]. As part of our ongoing research, we are currently investigating the effectiveness of a 16-week sequential program for cancer patients that integrates Compassionate Mind Training (CMT) with MBSR.

Clinical implications

Integrating mindfulness and compassion programs within a public hospital setting, as part of a multidisciplinary care team that includes psycho-oncologists, can be an effective strategy for enhancing the quality of life of individuals living with cancer, particularly those with advanced disease.

Study limitations

The results of this study should be interpreted within the context of an exploratory study design, where the primary objective was to assess the feasibility of implementing the MCP-C program in a public hospital. In terms of efficacy, the non-randomized nature of the study represents a significant limitation. Without a control group, it remains unclear whether the observed improvements can be directly attributed to MCP-C. To confirm its efficacy, future research should adopt a randomized controlled trial (RCT) design, comparing MCP-C with a control group.

Another limitation is the short-term evaluation of outcomes. While the immediate benefits observed may be particularly relevant in the context of advanced cancer, it would be valuable to investigate the long-term effects of the program on participants'psychological well-being and quality of life. To address this, we are currently conducting a multicenter trial in which participant`s quality of life and psychological well-being will be assessed three months after completing the program.

Conclusions

This study demonstrates that implementing an 8-week MCP-C program in routine clinical practice at an acute-care public hospital is feasible for a non-selected group of cancer patients and their relatives. The program led to significant improvements in mental well-being, including reductions in anxiety and depression. Additionally, participants reported other benefits, such as symptom relief, emotional support, a better understanding of their illness and essential needs, and increased awareness of the present moment.

Supplementary Information

Below is the link to the electronic supplementary material.

Funding

The study was supported by resources obtained from the EBOCA-Vida benefic event (Catalonia Hotel, EBOCA restaurants, and Outlok wine), as well as by grants from IPSEN, and Pfizer. The sponsors had no role in the study’s design, development, or evaluation.

Data availability

The datasets generated and analyzed during the study are available from the corresponding author upon request.

Declarations

Conflicts of interest

Begoña Mellado has received research grants, funding, and honoraria for speaking engagements and travel accommodations from Astellas, Bayer, BMS, Ipsen, Janssen, Pfizer, Roche, and Sanofi. Laia Fernández has participated in the Speakers Bureau for IPSEN, received travel support from MSD, and has other affiliations with Merck. Tamara Sauri has received honoraria as a speaker from Bristol Myers Squibb (BMS), MSD, AstraZeneca, Astellas, and Jazz Pharmaceuticals. She has also served as a member of the Advisory Board for Amgen SA and Beigene Esp. SLU.