Close
Home
Collections
Login
USC Login
Register
0
Selected
Invert selection
Deselect all
Deselect all
Click here to refresh results
Click here to refresh results
USC
/
Digital Library
/
University of Southern California Dissertations and Theses
/
Mindfulness among patients with advanced colorectal cancer
(USC Thesis Other)
Mindfulness among patients with advanced colorectal cancer
PDF
Download
Share
Open document
Flip pages
Contact Us
Contact Us
Copy asset link
Request this asset
Transcript (if available)
Content
MINDFULNESS IN ADVANCED CANCER 1
Mindfulness among Patients with Advanced Colorectal Cancer
Megan Taylor-Ford
University of Southern California
Degree being conferred: Doctor of Philosophy (Psychology)
Conferral date: December 2014
MINDFULNESS IN ADVANCED CANCER 2
Table of Contents
Abstract 3
Introduction 5
Methods 14
Results 27
Discussion 37
Limitations & Strengths 48
Clinical Implications 52
References 55
Tables 73
Figures 83
Appendices 89
MINDFULNESS IN ADVANCED CANCER 3
Abstract
Objective: Advanced cancer is a life-limiting condition, but improvements in medical
care are contributing to longer survival among some patients, including many with advanced
colorectal cancer. Unfortunately, the advanced colorectal cancer experience is often marked by
physical and emotional challenges that may be compounded by patients’ cancer-related intrusive
thoughts and maladaptive coping patterns. The present study sought to investigate mindfulness
as one factor that may demonstrate beneficial relations with physical and emotional outcomes
both directly and indirectly through cancer-related intrusive thoughts and coping strategies.
Additionally, possible sex differences in these relations were investigated. Methods:
Questionnaire data were collected from 102 adults on active treatment for advanced colorectal
cancer. Partial least squares modeling was used to test the hypothesized relations for the full
sample as well as in men and women separately. Results: Patients reported moderate levels of
emotional distress and physical symptoms, while mindfulness levels were higher than levels
reported in other samples, possibly as a result of the patients’ advanced cancer status.
Mindfulness was associated with positive outcomes in emotional and, to a lesser extent, physical
domains, and intrusive thoughts explained some of the relations between these variables such
that more mindfulness was associated with reduced intrusive thoughts which were associated
with reduced physical symptoms in men and reduced emotional distress in men and women.
Coping strategies did not account for a significant proportion of the relations between
mindfulness and emotional distress or physical symptoms in either sex. In general, mindfulness
demonstrated more robust relations among women. Conclusion: Mindful patients with
advanced colorectal cancer may be at a reduced risk for emotional distress and physical
symptoms with cancer-related intrusive thoughts partially accounting for these relations. These
MINDFULNESS IN ADVANCED CANCER 4
findings lend preliminary support for the use of mindfulness-enhancing interventions to improve
the physical and emotional well-being of patients with advanced colorectal cancer.
MINDFULNESS IN ADVANCED CANCER 5
Introduction
Advanced cancer, or cancer that has spread from the original tumor site to distant parts of
the body, is more serious, and less treatable than early-stage cancer (American Cancer Society,
2011). While disease-free survival has been achieved for some patients with advanced cancer,
this outcome is rare. The aggressive and hard-to-treat nature of advanced cancer contributes to
the disease’s poor prognosis. The average five-year survival rate in advanced cancer across
cancer sites is only 20%, compared to 70% in non-advanced cancer (American Cancer Society,
2013). Fortunately, improvements in treatments are emerging for some diagnoses and
researchers are hopeful that continued treatment gains will result in more patients living longer
with advanced disease (e.g., Morgan & Parker, 2011).
Colorectal cancer is one diagnosis in which treatment advances are resulting in longer
survival for patients with advanced disease (Chu, 2012). Colorectal cancer is the third most
commonly diagnosed cancer in the United States, resulting in an estimated 137,000 new cases in
2014 (American Cancer Society, 2013). Approximately 20% of new colorectal cancer patients
are diagnosed with advanced disease (American Cancer Society, 2014) and approximately 50%
of patients with early-stage colorectal cancer will eventually develop advanced cancer (Kindler
& Shulman, 2001). Despite these discouraging statistics, the five-year survival rate of advanced
colorectal cancer has increased from 8% in 2000 to 13% in 2013 (American Cancer Society,
2000, 2013).
Although length of survival is increasing for many patients, advanced colorectal cancer
remains a challenging diagnosis. Physically, advanced cancer patients may be compromised by
the disease and associated treatments, especially those aimed at slowing tumor growth (as
opposed to palliating symptoms). These treatments are often physically demanding and result in
MINDFULNESS IN ADVANCED CANCER 6
enduring side effects. Pain is one of the most prevalent physical symptoms in advanced cancer
(van den Beuken-van Everdingen et al., 2007), with over 75% of patients experiencing it at some
point in their cancer trajectory (American Pain Society, 2008; National Comprehensive Cancer
Network, 2010). The quality of cancer-related pain is described as more intense than non-cancer
pain (Groenwald, Frogge, Goodman, & Yarbro, 1993), and for the patient with advanced cancer,
this pain can be all-consuming (Luoma & Hakamies-Blomqvist, 2004) and debilitating (Coyle,
2004). Often co-occurring with pain, fatigue, described as a worse-than-normal pervasive and
persistent feeling of exhaustion marked by weakness and a lack of energy that interferes
considerably with daily functioning (Mock et al., 2000), is a physical challenge faced by a
majority of patients with advanced cancer (Aranda et al., 2005; Donnelly & Walsh, 1995; Osse,
Vernooij-Dassen, Schadé, & Grol, 2005). Patients may also experience many other challenging
cancer symptoms and treatment side effects such as nausea and vomiting, dyspnea, anorexia
(American Cancer Society, 2011), and in colorectal cancer more specifically, constipation and
diarrhea (American Cancer Society, 2014).
In addition to physical concerns, patients with advanced cancer are susceptible to
emotional distress. Common psychological experiences among patients with advanced cancer,
including those with advanced colorectal cancer, include fear of suffering, uncertainty,
existential concerns, and hopelessness (Taylor-Ford, 2014) -- all of which may contribute to
patients’ distress. The prevalence of emotional distress among patients with advanced cancer
varies widely depending on the sample, diagnostic criteria, and method of assessment used. For
example, among patients with advanced cancer, major depression assessed by diagnostic
interview was diagnosed in 5-26% of patients, with a reported mean of 15% (Hotopf, Chidgey,
Addington-Hall, & Ly, 2002), while other studies have reported lower (3%; Warmenhoven, van
MINDFULNESS IN ADVANCED CANCER 7
Rijswijk, van Weel, Prins, & Vissers, 2012) and higher (58%; Meyer, Sinnott, & Seed, 2003)
levels of depression. Anxiety is also thought to be relatively common (Stark et al., 2002)
although less widely studied. Moreover, approximately 30% of patients experience milder or
sub-clinical presentations of symptoms of depression or anxiety (Härter et al., 2001; Kissane et
al., 2004; Mitchell et al., 2011).
The extent to which patients experience physical symptoms and emotional distress
depends on a number of factors. For instance, advanced cancer patients who are younger, less
educated, or female tend to report worse emotional and physical well-being (Lam et al., 2013;
Simon, Thompson, Flashman, & Wardle, 2009; Step, Kypriotakis, & Rose, 2013). Among
commonly studied personality characteristics, neuroticism, or the tendency to experience
negative emotions, has also been associated with worse physical and emotional outcomes among
people affected by cancer (Barrineau, Zarit, King, Costanzo, & Almeida, 2014).
In addition to these individual-difference variables, patients’ cognitive-behavioral
responses to their cancer experience may compound the burden of the physical and emotional
sequelae of advanced colorectal cancer. Cognitively, patients may experience involuntary
cancer-related intrusive thoughts. Intrusive thoughts are automatic, repetitive thoughts that are
perceived as uncontrollable. They are often present during and following a particularly stressful
life event (Horowitz, 1975) such as cancer (Cordova, Andrykowski, Kenady, & McGrath, 1995).
The content of advanced cancer-related intrusive thoughts may vary considerably, ranging from
worries about the future (e.g., “This pain is going to ruin my weekend.” “Who will take care of
my kids when I die?”) to ruminations on the past (e.g., “I should have scheduled my colonoscopy
sooner.” “What did I do to deserve cancer?”). While intrusive thoughts such as these may help
facilitate the processing of the traumatic cancer experience over time (Horowitz, 1986), they are
MINDFULNESS IN ADVANCED CANCER 8
often perceived as unpleasant and distressing due in part to their unsolicited and unexpected
nature. Furthermore, considering the biopsychosocial model of health (Engel, 1977) in which
biological and psychological factors (including cognitions) are theorized to interact to inform
patients’ physical functioning, cognitive intrusions related to the colorectal cancer experience
may contribute negatively to patients’ cancer-related physical symptoms. In fact, among early-
stage breast and prostate cancer patients, intrusive thoughts have been linked directly to poorer
physical health and emotional well-being (Baider & Kaplan De-Nour, 1988; Cordova et al.,
1995; Lepore, 2001; Lewis et al., 2001).
Intrusive thoughts likely relate indirectly to these emotional and physical outcomes via
cancer-related coping strategies, as well. Coping strategies are deliberate cognitive and
behavioral responses that are used by individuals to manage stressful experiences (Luecken &
Compas, 2002; Taylor & Stanton, 2007). The literature on coping often distinguishes between
categories of coping strategies based on their emphases. One classification distinguishes
between active coping strategies that are focused on doing something about the stressor and
related distress and avoidant coping strategies that emphasize disengaging from the source of
distress (e.g., Billings & Moos, 1981; Luecken & Compas, 2002). Active coping involves
strategies such as planning to do something about the stressor or thinking about the stressor
differently. Studies conducted with healthy and cancer samples have demonstrated associations
between active coping strategies and improved physical and emotional outcomes (Stanton et al.,
2000; Taylor & Stanton, 2007). In contrast, avoidant coping involves strategies such as denial; it
has been implicated in worse emotional (e.g., Stanton & Snider, 1993) and physical (e.g.,
Kershaw, Northouse, Kritpracha, Schafenacker, & Mood, 2004) outcomes among patients with
cancer.
MINDFULNESS IN ADVANCED CANCER 9
Patients’ cancer-related intrusive thoughts may negatively impact the pattern of coping
strategies that they use. Cognitive-processing models of post-trauma reactions (e.g., Creamer,
Burgess, & Pattison, 1992) theorize that avoidant coping strategies are used in response to
intrusive thoughts as a way to escape the discomfort and distress that the thoughts cause.
Furthermore, the distressing nature of intrusive thoughts is unlikely to inspire active engagement
with the source of the stress, and thus may interfere with individuals’ use of active coping
strategies. As such, intrusive thoughts have been shown to relate to a maladaptive pattern of
coping: they have been shown to relate positively to avoidant coping strategies and negatively to
active coping strategies among patients with cancer (Culver, Arena, Antoni, & Carver, 2002;
Roesch et al., 2005).
In sum, cancer-related intrusive thoughts and related coping strategies may contribute to
the diminished emotional and physical quality of life that many patients with advanced colorectal
cancer may experience. Considering the low rates of survival and improbable likelihood of cure
in advanced cancer, it follows that patients’ physical and emotional well-being is of the utmost
importance. For that reason, the present study sought to investigate mindfulness, an individual
characteristic that is hypothesized to relate to fewer cancer-related intrusive thoughts and less
maladaptive coping which may, in turn, bolster patients’ emotional and physical health in the
face of advanced colorectal cancer.
Mindfulness is the receptive awareness of and attention to internal (e.g., thoughts,
emotions) and external (e.g., behaviors, physical surroundings) phenomena in the present
moment (Brown & Ryan, 2003). Through non-judgmental awareness and attention in moment-
to-moment experiences, thoughts, emotions, and sensations are simply observed rather than
evaluated as being accurate, meaningful, or permanent (Hayes, Strosahl, & Wilson, 1999;
MINDFULNESS IN ADVANCED CANCER 10
Linehan, 1993). In this way, the quality of being mindful is believed to foster an objectivity in
relation to internal and external experiences (Hayes et al., 1999; Kabat-Zinn, 1994; Shapiro,
Carlson, Astin, & Freedman, 2006). This psychological distancing coupled with the present-
moment focus of mindfulness is theorized to benefit patients with advanced cancer (Carlson &
Halifax, 2011). More specifically, in the context of advanced cancer-related intrusive thoughts,
mindfulness would be expected to lead to fewer intrusive thoughts as they would be perceived as
“just thoughts” rather than distressing, unwanted, and uncontrollable cognitions. Furthermore,
mindfulness’ exclusive focus on the present is the perfect antidote to the emphasis of intrusive
thoughts on the past and future. Recent, unpublished research conducted with patients with
cancer noted a negative bivariate correlation between ruminations, or non-specific intrusive
thoughts focused on the past, and mindfulness (Labelle, 2013), lending preliminary support to
this hypothesized relation between mindfulness and cancer-related intrusive thoughts.
In addition to and as a result of reduced intrusive thoughts, mindfulness may benefit
patients with advanced cancer by facilitating more adaptive coping in the form of more active
and less avoidant coping. Theory suggests that given mindful individuals’ objective stance
towards their cognitions, they may be less likely to fall into automatic and often maladaptive
reactive patterns such as avoidance (Hayes & Feldman, 2004; Teasdale et al., 2002).
Additionally, when mindful individuals objectively attend to information in the present moment,
they are accessing data that can then be used to inform more choiceful, adaptive responding
(Brown & Ryan, 2003) such as the use of active coping strategies. While these hypothesized
relations between mindfulness and coping strategies have not been tested in the context of
cancer, a small study conducted with healthy college students did report that mindfulness was
MINDFULNESS IN ADVANCED CANCER 11
associated with the use of fewer avoidant and more active coping strategies (Weinstein, Brown,
& Ryan, 2009).
In addition to mindfulness’ relations with cancer-related intrusive thoughts and coping
strategies, mindfulness may also benefit patients with advanced cancer by acting directly on their
physical symptoms and emotional distress. Again, the present moment awareness and non-
judgmental attention that is mindfulness is theorized to foster a psychological distance from the
physical and emotional aspects of the cancer experience, thereby rendering these potential
sources of distress benign. In previous research, dispositional mindfulness has been shown to
relate to reduced physical symptoms, medical visits, depression, and anxiety in healthy adults
(Baer, Smith, Hopkins, Krietemeyer, & Toney, 2006; Brown & Ryan, 2003), less physical
disability in chronic pain sufferers (McCracken, Gauntlett-Gilbert, & Vowles, 2007), and less
fatigue and insomnia in early-stage cancer patients (Brown & Ryan, 2003; Garland, Campbell,
Samuels, & Carlson, 2013). Additionally, longitudinal studies have reported negative
correlations between changes in mindful awareness over time and changes in depression,
anxiety, physical symptoms, and other measures of distress in early-stage cancer patients (Baer
et al., 2008; Carmody & Baer, 2008; Dobkin & Zhao, 2011; Garland, Tamagawa, Todd, Speca,
& Carlson, 2013; Matousek, Dobkin, & Pruessner, 2010).
Expanding on these correlational data, experimental research suggests that mindfulness
does, in fact, influence emotional and physical outcomes. For example, compared to control
groups, groups exposed to a mindfulness induction (e.g., focusing on one’s breathing in the
moment) evidenced less negative reactivity and emotional volatility to affectively-valenced
images (Arch & Craske, 2006) and faster recovery from an induced sad mood (Broderick, 2005).
In another experiment, three groups of study participants were subjected to a cold pressor task.
MINDFULNESS IN ADVANCED CANCER 12
During the task, one group was instructed to suppress the pain, another group was instructed to
avoid the pain, and the final group was instructed to engage in a mindful-like practice,
monitoring details of the pain such as its location and intensity in real-time. In concordance with
the idea that mindfulness is directly associated with physical outcomes, the study found that
compared to the other conditions, the mindfulness-induced group demonstrated the quickest
recovery from the cold pressor task (Cioffi & Holloway, 1993).
In sum, findings from experimental and correlational studies indicate a direct relation
between mindfulness and physical and emotional outcomes in localized cancer and community
samples. While informative, the question of the generalizability of these findings to more
seriously-impaired, life-limited populations such as advanced cancer patients remains open. In
fact, although there has been a considerable amount of mindfulness research conducted with
cancer samples, substantially less research has been done with patients with advanced cancer. In
one review of mindfulness studies, fewer than 20% of the patients in the reviewed studies were
diagnosed with advanced cancer (Ledesma & Kumano, 2009), and almost no studies
investigating mindfulness used advanced cancer samples exclusively. It is unknown if the results
from mindfulness research conducted with non-advanced and mixed-diagnosis samples will
remain consistent for patients with advanced cancer. It is conceivable that the central tenant of
mindfulness – focused observation of present-moment experiences – may not be advantageous
for patients with advanced cancer who are dealing with a progressive disease and are often
tasked with preparing for a foreshortened future. Thus, it is important to investigate mindfulness
specifically in the context of advanced cancer.
Furthermore, while theory and a small collection of research points towards mindfulness
being beneficial to intrusive thoughts and coping strategies, mindfulness’ relation with cancer-
MINDFULNESS IN ADVANCED CANCER 13
related processes more specifically has not been addressed in the literature. By looking at the
relation of mindfulness to cancer-related intrusive thoughts and cancer-related coping strategies,
more targeted clinical considerations may be gained.
Using a sample of patients with advanced colorectal cancer, the present study
investigated mindfulness and its associations with demographic and medical variables, as well as
tested for the hypothesized negative relations between mindfulness and physical symptoms and
emotional distress. Additionally, the mediational role of cancer-specific processes in the
association between the dispositional quality of being mindful and physical and emotional
outcomes was examined. Specifically, cancer-related intrusive thoughts, and active and avoidant
coping strategies were tested as mediators in the relations between mindfulness and physical
symptoms and emotional distress, with intrusive thoughts also relating directly to coping
strategies (see Figure 1). Individual-difference variables (e.g., age, sex) and personality
tendencies (i.e., neuroticism) found to relate to emotional distress and physical symptoms in
previous research were controlled for in order to isolate more effectively the relation that
mindfulness might have with these outcomes. Finally, although sex differences on levels of
mindfulness have not been found in previous research (e.g., Brown & Ryan, 2003; Carlson &
Brown, 2005), no studies have addressed the possibility that mindfulness may demonstrate
different patterns of relations in men and women with cancer. There is a growing emphasis on
considering sex in health-related research (Wessels et al., 2010; Wizemann & Pardue, 2001) and
the provision of health services (Peppercorn et al., 2011), and research has consistently
demonstrated sex differences in many aspects of health and illness (e.g., distress and adjustment
[Keller & Henrich, 1999], coping [Volkers, 1999], health care preferences [Wessels et al.,
2010]). As such, exploratory analyses were planned to examine whether the hypothesized
MINDFULNESS IN ADVANCED CANCER 14
relations differed between men and women in the present sample of advanced colorectal cancer
patients.
Methods
The current study was conducted as a cross-sectional, questionnaire-based study at
University of Southern California (USC) Norris Comprehensive Cancer Center. The study was
reviewed and approved by the Clinical Investigations Committee and the Institutional Review
Board of USC.
Participants
Eligibility requirements stated that participants must be (1) 18 years of age or older, (2)
receiving active treatment for a diagnosis of advanced colorectal cancer, (3) without evidence of
another active malignancy other than treated squamous/basal cell carcinoma of the skin, (4)
physically and mentally able to complete questionnaires as determined by their medical
oncologist, and (5) able to read and write English.
One hundred and two patients with advanced colorectal cancer participated in the study.
Tables 1 and 2 provide information on patients’ demographic and medical characteristics.
Patients ranged in age from 29 to 83 years (M=55.07, SD=11.24) and were predominantly non-
Hispanic white (69%) and married or partnered (83%). The sample was nearly evenly split
between men (n=49) and women (n=53). Half of the sample was college educated and 37% had
a yearly salary in excess of $110,000.
In regards to their cancer, 66% of patients were diagnosed with colon cancer while the
other 34% were diagnosed with rectal cancer. Half of the patients were diagnosed with advanced
disease within 17 months of participating in the present study, but some patients received a
diagnosis as long ago as 14 years. Despite the wide range of time since patients had received
MINDFULNESS IN ADVANCED CANCER 15
their advanced colorectal cancer diagnosis, they were all on active treatment at the time of the
study. With the exception of six patients, every patient was receiving chemotherapy, and all but
one patient had received chemotherapy at some point during their cancer experience.
Additionally, 25% of patients had received radiation therapy for their cancer and 81% had
cancer-related surgery in the past. Physician ratings of patients’ performance status – a single
score given by a medical professional to quantify how much cancer affects the patient’s daily
living abilities (ranging from 0 [“fully active, able to carry out all pre-disease performance
without restriction”] to 5 [“Dead”]; Oken et al., 1982) – indicated that on average patients’
physical health was good (M= 0.71, SD=0.55; only 4 individuals had a scores greater than 1).
Procedures
During a medical appointment, patients were approached for study enrollment by their
treating oncologist or nurse at the Cancer Center. Patients were asked if they would like to
participate in a study investigating quality of life of patients living with colorectal cancer and
were then informed that participation was entirely voluntary and would not impact their medical
care. Interested patients were consented by study investigators in a private location at the Cancer
Center where the study was explained in more detail and patients were given the opportunity to
ask questions. Following the explanation of the study, patients were asked to summarize the
study back to the investigator. This was done to ensure understanding and as an informal check
for cognitive functioning in lieu of an official cognitive screening. Immediately following
consent procedures, investigators collected information regarding the patient’s contact
information, age, sex, marital status, education level, and ethnicity by way of brief interview.
After consenting, participants received a questionnaire packet containing study measures.
The packet took approximately 50 minutes to complete. Patients were given the choice to
MINDFULNESS IN ADVANCED CANCER 16
complete the questionnaire in a private location at the Cancer Center or at home. Participants
who completed the questionnaire packet while at the Cancer Center (40%) returned it in person
to study investigators. Participants who completed the questionnaire packet at home (60%)
returned the packet by mail using a provided, postage-paid envelope. Participants were asked to
return the packet within 14 days of receipt. Once returned to study investigators, questionnaires
were reviewed for complete data. Any participants with missing data were contacted by
telephone up to two times to obtain the missing information. If an entire page or multiple pages
had been omitted from the returned questionnaire, the page was returned by mail to the
participant for completion. Finally, for a small subset of patients, brief interviews were
conducted by investigators following the completion of the questionnaire packet with the
purpose of obtaining qualitative information regarding how the patients interpreted a sample of
questionnaire items. Results from these interviews are presented in Appendix 1.
For participants who did not return their questionnaire packets within the two week time
period, investigators attempted to contact them either in person (during subsequent appointments
at the Cancer Center) or by phone, placing up to three reminder phone calls with approximately
five days between calls. A patient was considered to “soft decline,” and was not contacted
further if after three phone attempts the questionnaire packet was not returned. If the patient
expressed the desire to cease participation at any point during the study, study procedures were
stopped.
In order to obtain accurate and complete medical information for each participant,
patients’ medical information was collected from their oncology nurse via a single-page
questionnaire (see Appendix 2). At the time the patient received the questionnaire packet, the
MINDFULNESS IN ADVANCED CANCER 17
patient’s nurse was given the medical information form to complete and return directly to study
investigators.
One hundred and thirty-six patients with advanced colorectal cancer were recruited
between October 2011 and July 2013. Nine patients (7%) who were approached for the study
refused citing the length of the questionnaire (n=1), lack of time (n=1), limitations due to starting
treatment (n=1), or no reason was given (n=6).
The remaining 127 patients were consented for the present study. Of these patients, 22
were “soft declines,” and three withdrew from the study after consenting because the questions
made them uncomfortable (n=2) or they did not have time (n=1). Thus, 102 patients returned
their questionnaires, reflecting 75% of eligible patients and 80% of consented patients. A
recruitment flow chart is provide in Figure 2.
Independent t-tests and chi-square tests of independence did not demonstrate differences
between eligible participants who returned their questionnaires (n=102) and eligible participants
who did not return their questionnaires (i.e., patients who soft declined or withdrew; n=25) on
age (t(125)=0.31; p=0.78), sex [ χ
2
(1, n=127)=0.13, p=0.72], marital status [ χ
2
(1, n=127)=2.83,
p=0.09], college education [ χ
2
(1, n=127)=0.01, p=0.97], Caucasian ethnicity [ χ
2
(1,
n=127)=0.93, p=0.34], or current use of chemotherapy [ χ
2
(1, n=127)=1.48, p=0.22).
Differences on other medical variables were not observed. No data were collected from patients
who declined participation (n=9) thus precluding comparisons with this patient group.
Measures
Measures used in the proposed study are described below and included in Appendix 2.
The time frame for responses on all of the measures was “the past month” (e.g., “indicate which
coping strategies you used during the past month”) except for the neuroticism measure which
MINDFULNESS IN ADVANCED CANCER 18
had no time frame. In order to inform the measurement of latent variables in subsequent
analyses, exploratory factor analyses (EFA) were conducted to examine the factor structure of
several key study variables including mindfulness, depressive symptoms, anxiety symptoms,
emotional dysfunction, intrusive thoughts, and coping. Because physical symptoms were not
conceptualized as a single scale but instead as a checklist of individual, potentially unrelated
physical symptoms, an EFA was not conducted for this variable. Results from these factor
analyses are included in Appendix 3.
Demographic and medical information. Participants reported their age, sex, ethnicity,
highest completed level of education, and partner status. Medical information collected from the
patients’ nurses included the primary diagnosis (colon or rectum cancer), date first diagnosed
with advanced disease
1
, current treatment (chemotherapy: yes/no; radiation: yes/no; other:
yes/no), past treatment (chemotherapy: yes/no; radiation: yes/no; surgery: yes/no; other: yes/no),
and performance status.
Mindfulness. The Mindful Attention Awareness Scale (MAAS) was used to measure the
frequency of mindful states in daily life (Brown & Ryan, 2003). The MAAS contains 15-items
that are scored from 1 (”Almost never”) to 6 (”Almost always”). Items are reverse-scored and
averaged so that total scores can range from 1-6 with higher scores indicating greater
mindfulness.
The MAAS is considered to have a single-factor structure and has demonstrated good
reliability in non-cancer ( α=0.82; Brown & Ryan, 2003) and cancer samples ( α=0.87; Carlson &
Brown, 2005). In the present study, alpha was 0.87. However, inspection of the item-total
correlations and the squared multiple correlations revealed that item 5 (“I tend not to notice
1
Dates were converted to “Number of days between diagnosis and the return of the questionnaire.”
MINDFULNESS IN ADVANCED CANCER 19
feelings of physical tension or discomfort until they really grab my attention”) was poorly related
to the other items. Its item-total and squared multiple correlations were very low (0.11 and 0.08,
respectively), and Cronbach’s alpha increased to 0.88 when the item was deleted. Among the
other items, all item-total correlation were above 0.42 and all squared multiple correlations were
above 0.34. Furthermore, when an EFA was performed on all 15 items, the commonality of item
5 was very low at 0.09 (with the next lowest communality value being 0.34 for item 6). In the
original manuscript introducing the MAAS (Brown & Ryan, 2003), item 5 demonstrated
similarly poor reliability, likely as a result of its negative wording which is in contrast to the
positive wording of all other items. Thus, item 5 was removed from subsequent analyses.
Emotional distress. Emotional distress was hypothesized to be a latent variable predicted
by three reflective indicator variables measuring depressive symptoms, anxiety symptoms, and
emotional dysfunction. Descriptions of the scales used to assess these variables follow.
Depressive symptoms. Depressive symptoms were assessed with the Center for
Epidemiological Studies Depression Scale (CES-D; Radloff, 1977). The scale contains 20 items
representing clinical manifestations of depression that are rated on a scale from 0 (“Rarely or
none of the time”) to 3 (“Most or all of the time”). A total score is comprised by summing
across item totals (four items are reverse scored; possible range: 0-60), with higher scores
indicating more severe depressive symptomatology and scores at or above 16 indicating risk for
clinical depression. Among cancer and healthy populations, scale reliability has been
demonstrated to be good (α > 0.85; Hann, Winter, & Jacobsen, 1999; Radloff, 1977). In the
present study, reliability was also good (α = 0.88).
Anxiety symptoms. Anxiety symptoms were assessed with the Hospital Anxiety and
Depression Scale - Anxiety subscale (HADS-A; Zigmond & Snaith, 1983). The HADS-A
MINDFULNESS IN ADVANCED CANCER 20
contains 7 items that assess anxiety symptoms on a 4-point scale from 0 to 3. All but two items
are reverse-scored, and then all items are summed so that total scores can range from 0 to 21
with higher scores indicating more anxiety. The scale has demonstrated good internal reliability
in various medical populations as well as concurrent validity with other established measures of
state and trait anxiety (Bjelland, Dahl, Haug, & Neckelmann, 2002). In the present study,
internal reliability was good ( α=0.76).
Emotional dysfunction. Emotional dysfunction was measured with the European
Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC
QLQ-C30; Aaronson et al., 1993). The EORTC QLQ-C30 is a questionnaire designed to assess
the quality of life of people with cancer. The emotional dysfunction scale consists of four items
on which patients report whether they have felt tense, irritable, depressed, or have experienced
worry in the past month. Items responses range from 1 (“Not at all”) to 4 (“Very much”), and
items are averaged to create a total score. This scale has demonstrated good reliability and
validity in a colorectal cancer population (Neuman et al., 2007; Whistance et al., 2009). In the
present study, internal consistency was good ( α=0.79).
Physical symptoms. Items measuring the prevalence of common cancer-related physical
symptoms were used as formative indicators to create a latent variable for physical symptoms.
Items from the EORTC QLQ-C30 were used including a three-item subscale assessing fatigue, a
two-item subscale assessing pain, a two-item subscale assessing nausea and vomiting, and four
individual items assessing dyspnea, lack of appetite, constipation, and diarrhea. All item scores
range from 1 (“Not at all”) to 4 (“Very much”), and subscale scores were calculated as averages
across items. The scale has been used successfully with advanced cancer samples (Coates,
MINDFULNESS IN ADVANCED CANCER 21
Porzsolt, & Osoba, 1997) and has demonstrated good psychometric properties in colorectal
cancer samples (Neuman et al., 2007; Whistance et al., 2009), including this one ( α=0.75).
Cancer-related intrusive thoughts. The intrusive thoughts subscale from the Impact of
Event Scale - Revised (IES-R; Weiss & Marmar, 1997) was used to asses cancer-related
intrusive thoughts. In the present study, patients responded to 8 items concerning their
experiences with intrusive thoughts related to their colorectal cancer. Patients rated the degree to
which bother associated with the thoughts had affected them during the past month on a 5-point
scale from 0 (“Not at all”) to 4 (“Extremely”). Item scores are averaged to create a total score
with higher responses reflecting more intrusive thoughts. This measure has been shown to
reliably and validly assess cancer-specific intrusive thoughts in patients with advanced cancer
(Badr, Carmack, Kashy, Cristofanilli, & Revenson, 2010) and colorectal cancer (Norum, 1997).
Internal reliability for the intrusive thoughts subscale has shown to be good (0.87 to 0.92; Weiss
& Marmar, 1997); in the present study it was 0.87.
Coping strategies. The Brief Coping Orientation to Problems Experienced Scale (Brief
COPE; Carver, 1997) is a 28-item scale comprised of 14 two-item subscales. Patients respond to
items that assess how they coped with their colorectal cancer experience during the past month.
Items are rated on a four-point scale ranging from 1 (“I haven’t been doing this at all”) to 4
(“I’ve been doing this a lot”), and scores are averaged to create total subscale scores that range
from 1 to 4. For the purposes of the present study, twelve items were used from the Brief COPE
reflecting two overarching coping strategies: active and avoidant coping.
Active and avoidant coping strategies were hypothesized to be latent variables with two-
item subscales from the Brief COPE as their formative indicators. Indicators for the active
coping latent variable were the planning (e.g., “I’ve been trying to come up with a strategy about
MINDFULNESS IN ADVANCED CANCER 22
what to do”), positive reframing (e.g., “I’ve been trying to see it in a different light, to make it
seem more positive”), self-distraction (e.g., “I’ve been turning to work or other activities to take
my mind off things”), and active coping (e.g., “I’ve been taking action to try to make the
situation better”) subscales from the Brief COPE. Indicators for the avoidant coping latent
variable were the behavioral disengagement (e.g., “I’ve been giving up trying to deal with it”)
and denial (e.g., “I’ve been saying to myself, ‘this isn’t real’”) subscales from the Brief COPE.
In the present study, Cronbach’s alphas for active and avoidant coping were 0.78 and 0.69,
respectively.
Neuroticism. The Short-Scale Eysenck Personality Questionnaire-Revised Neuroticism
subscale (EPQR-N; Eysenck, Eysenck, & Barrett, 1985) was used to assess for a tendency to
experience negative emotions. More specifically, neuroticism was included as a variable in the
present study to help to distinguish between the overall tendency to experience distress and
actually experiencing distress in the particular context of advanced colorectal cancer. The
measure asks patients whether or not they experience various characteristics of neuroticism (e.g.,
mood-fluctuations, nervousness). Twelve items are rated 1 (“yes”) or 0 (“no”). A total score is a
sum of item totals with higher scores reflecting more neuroticism. Internal reliability in the
present study was good ( α=0.79).
Statistical Analyses
Data analysis included preliminary analyses to describe and prepare the data for
hypothesis testing and partial least squares (PLS) analyses used to test specific hypotheses.
Statistical significance levels were set a priori at p < 0.05.
Preliminary analyses. In the event that data were missing, averages calculated from all
existing data on the variable in question were used to replace the missing datapoint. This is
MINDFULNESS IN ADVANCED CANCER 23
considered the most widely used and reliable method of handling missing data in PLS analyses
(Kock, 2013). Following established guidelines (Hair, Black, Babin, & Anderson, 2009), this
was only considered in variables with less than 10 percent of values missing. Across the
variables of interest in the present study, no variable exceeded 6% missing data. Descriptive
statistics including means, medians, standard deviations, frequencies, and minimum and
maximum values were determined for demographic, medical, and key study variables.
Correlations among variables were also computed.
Partial least squares analyses. To test the full model as well as specific hypotheses,
structural equation modeling employing a PLS approach was used. PLS is a statistical analytic
technique that allows for the simultaneous modeling of direct and indirect relations among
multiple predictor and outcome variables (Haenlein & Kaplan, 2004). Specifically, PLS
analyses can be divided into two parts. First, multiple indicator (manifest) variables build
constructs that are represented as latent variables in a measurement model. Second, theoretical
relations among the latent variables are estimated and tested with multiple regression in a
structural model (Chin & Newsted, 1999; Vinzi, Trinchera, & Amato, 2010). PLS is particularly
well-suited for the present study as it is recommended for research in which the assumption of
normal or known distributions may not be met (Fornell & Bookstein, 1982) and large sample
sizes are not tenable (Vinzi et al., 2010). Analyses were conducted in the WarpPLS statistical
software program (Kock, 2013).
Measurement model. All variables in a PLS model are latent variables. Physical
symptoms and both coping strategies were measured as formative latent variables. Distress was
measured as a reflective latent variable. Their respective indicators are noted in the
Measurement section of this paper. PLS estimates the latent variable based on the shared
MINDFULNESS IN ADVANCED CANCER 24
variance of the indicator variables while minimizing individual variable residuals and
measurement error (Hair et al., 2009). Through an iterative process, weights are calculated
through least squares regressions in which the latent variable score is the predictor and the
indicators are the criteria. These weights are then used to determine the latent variable score
which is calculated as an exact linear combination of the indicators (Fornell & Bookstein, 1982;
Kock, 2013). Mindfulness, intrusive thoughts, neuroticism and other covariates were single-
indicator “latent” (i.e., manifest) variables whose respective composite scores were used as the
indicator with a loading of one.
Validity and reliability of the measurement model were informed by several parameters.
Among reflective latent variables, convergent validity is indicated by individual loadings greater
than 0.50 with significance at the 0.05 level (Hair et al., 2009). Loadings greater than 0.50
indicate that an indicator shares at least 25% (0.50
2
) variance with other indicators that form the
theoretical construct; this is also known as its communality (or the squared loading). A related
parameter, the average variance extracted (AVE), is an average of all communalities associated
with a latent variable. It is used to assess a variable’s construct validity, and AVEs above 0.5 are
acceptable (Kock, 2013). Reliability of reflective latent variables is determined with the
composite reliability coefficient – a reliability measure for latent variables similar to
Chronbach’s alpha, but one that takes indicator loadings into consideration in its calculation
(Kock, 2013); coefficients above 0.70 are acceptable (Fornell & Larcker, 1981).
Among formative latent variables, validity is confirmed when weights linking indicators
to their respective latent variables have p values less than 0.05 and variance inflation factors
(VIFs) below 2.50, indicating an absence of redundancy among the indicators (Kock, 2013).
MINDFULNESS IN ADVANCED CANCER 25
Finally, among both reflective and formative latent variables the square root of the AVEs
and the full collinearity VIF parameters were assessed. Square roots of the AVEs associated
with each latent variable should be higher than any of the correlations involving that latent. In
this way they help determine discriminant validity of a latent variable (Fornell & Larcker, 1981).
The full collinearity VIF evaluates collinearity in the complete model, across all latent variables;
scores below 3.30 are considered satisfactory (Hair et al., 2009).
Structural model. Once the measurement model was estimated and its validity and
reliability confirmed, case values for all latent variables were used in regression testing to
determine the parameters of the structural, linear relations. Path coefficients were standardized,
and significance of these relations was determined by examining their t-statistics, standard errors,
and resulting p-values provided by jackknife resampling. Jackknifing uses a resampling
algorithm that creates a number of resamples equal to the original sample size, with each
resample having one fewer entry than the sample before. Jackknifing is recommended for use
with small samples (e.g., Chiquoine & Hjalmarsson, 2009). Effect sizes were also estimated. In
PLS, effect sizes are similar to Cohen’s (1988) f-square coefficients, and reflect the absolute
value of the individual contribution of a predictor variable on the R
2
value of an outcome
variable (Kock, 2013).
In order to present the most parsimonious model, paths with effect sizes smaller than 0.02
were systematically removed (Kock, 2013). Parameters were then re-estimated with the
“trimmed” model and significant paths were interpreted. To examine the extent to which the
data fit the trimmed model, the trimmed model was compared to the full model (with all possible
paths between latent variables) which represented the upper limit of model fit.
MINDFULNESS IN ADVANCED CANCER 26
Analyses for study hypotheses. Prior to hypothesis and model testing, possible covariates
of the relations between mindfulness and the outcome variables were determined using PLS
modeling. Nine variables were tested as possible covariates: age, sex, ethnicity (white/not white),
partner status (partnered/not partnered), education, cancer site, having had surgery or radiation as
a current treatment, and time since diagnosis. In a single model, paths were drawn connecting
potential covariates to both outcome latent variables (physical symptoms and emotional distress).
Variables that were significantly related to and accounted for more than 2% of the variance in the
outcome variables were included in subsequent modeling as a covariates (Kock, 2013).
To test whether mindfulness was associated with less emotional distress and fewer
physical symptoms, the statistical significance of the respective paths in the trimmed model were
examined. Significant negative coefficients on the direct paths between mindfulness and the
outcome variables would support this hypothesis.
To test if intrusive thoughts or coping strategies mediated the relations between
mindfulness and physical symptoms and mindfulness and emotional distress, the statistical
significance of the indirect paths from mindfulness to physical symptoms and emotional distress
via these hypothesized mediators were tested. This was done by examining whether the
coefficients for the indirect paths in the proposed model were significantly different from zero.
The significance of the coefficients for paths signifying a direct associations between
intrusive thoughts and active and avoidant coping were also tested to determine if intrusive
thoughts were directly related to coping strategies. A significant negative coefficient between
intrusive thoughts and active coping and a significant positive coefficient between intrusive
thoughts and avoidant coping would provide support for these hypotheses.
MINDFULNESS IN ADVANCED CANCER 27
Exploratory analyses. Analyses were conducted separately in models for men and women
to investigate possible sex differences in the hypothesized relations.
Results
Descriptive Results
Information pertaining to key study variables including means, standard deviations,
medians, and ranges is provided in Table 3. Results from correlation analyses of indicator
variables including Pearson correlations for continuous variables and point biserial correlations
for dichotomous variables are presented in Table 4. Study variables are described below along
with significant correlations with patient characteristics in the present study. Additionally, when
possible, z-test and t-test statistics are reported comparing the present study’s means with means
from other published reports.
Mindfulness. In general, patients reported frequent mindful states (M=4.92 SD=0.70)
with 50% of patients reporting experiencing mindful states “very frequently” on average. The
frequency of mindfulness in the present study exceeded levels of mindfulness reported in other
cancer samples including a sample of 122 mixed-diagnosis, mixed-stage (11% with advanced
stage) outpatients (Carlson & Brown, 2005; M=4.08, SD=0.74; z=8.71) and 41 early-stage breast
and prostate cancer patients (Brown & Ryan, 2003; M=4.27; SD=0.64; z=5.34).
Responses on the items with the highest loadings on the mindfulness factor (considered
the most pure measure of the factor), provided descriptive understanding of the experience of
mindful states in the study’s sample. For example, 70% of patients “almost never” “[did] jobs or
tasks automatically, without being aware of what [they were] doing,” 46% of patients “almost
never” “[did] things without paying attention,” and 44% “almost never” “rush[ed] through
activities without being really attentive to them.” These high frequencies stood in contrast with
MINDFULNESS IN ADVANCED CANCER 28
the small proportion of patients who “somewhat frequently” or “very frequently” did any one of
these behaviors (12%, 10%, and 8%, respectively). Taken together, this pattern of responding
points towards a sample of patients who frequently experienced mindful states in their daily
lives. Of the demographic and medical variables investigated, only education was correlated
with mindfulness such that more mindful individuals had fewer years of education (r=-0.21).
Patients who endorsed more neuroticism also endorsed less mindfulness (r=-0.44).
Depressive symptoms. Forty-three percent of patients scored at or above the cut-off
score of 16 (Radloff, 1977), indicating that these patients were experiencing symptoms similar to
individuals at risk for depressive disorders. The average level of depressive symptoms in the
present study (M=16.37, SD=9.50) was higher than levels in mixed-stage colorectal cancer
patients (M=10.55, SD=7.92; z=5.16; Tuinstra et al., 2004) and mixed-diagnosis, advanced-stage
cancer sample (M=13.80, SD=8.90; z=2.36; Bakitas et al., 2009). Depressive symptoms were
also negatively correlated with education (r=-0.22).
Anxiety symptoms. Compared to depression, fewer patients in the present study
expressed clinical levels of anxiety. In their sample of patients in nonpsychiatric hospital clinics,
Zigmond & Snaith (1983) recommended that scores of 8 or more on the HADS-A indicate
possible pathology. In a more recent review of the literature, optimal balance between sensitivity
and specificity of HADS-A as a screening instrument was achieved most frequently at a cut-off
of 9 in cancer samples (Bjelland et al., 2002). Using these cut-offs, 16% and 12% of patients,
respectively, endorsed clinically elevated symptoms of anxiety; a majority of patients were
experiencing few or no symptoms of anxiety.
Emotional dysfunction. On average, patients endorsed “a little” bit of emotional
dysfunction in the form of worries and feelings of tension, irritability, and depression.
MINDFULNESS IN ADVANCED CANCER 29
Approximately 30% of patients did not “feel tense” and an additional 30% of patients did not
“feel depressed” at all in the past month. This sample’s mean level of emotional dysfunction
was similar to the level reported in the cancer patient normative sample for the scale (N=91;
z=0.61; Hjermstad, Fayers, Bjordal, & Kaasa, 1998). Emotional dysfunction was correlated
positively with having had surgery (r=0.21).
In addition to the bivariate correlations mentioned above, all three of the emotional
distress indicators (depressive symptoms, anxiety symptoms, and emotional dysfunction) were
negatively correlated with being male and positively correlated with neuroticism. The three
indictors of emotional distress were also significantly correlated with each other (all rs ≥ 0.69;
see Table 4).
Physical symptoms. Consistent with the literature on advanced cancer-related physical
symptoms (e.g., Johnsen, Petersen, Pedersen, & Groenvold, 2009), fatigue was the most
frequently endorsed symptom in the present study (M=2.66, SD=0.77). The level of fatigue in
the present study was also comparable to fatigue reported in the scale’s normative sample of 91
cancer patients (z=0.31; Hjermstad et al., 1998). Additionally, approximately half of patients
reported experiencing severe pain (scores ≥ 3 on the EORTC QLQ-C30 pain subscale; Johnsen
et al., 2009; M=2.06, SD=0.93). Patients experienced loss of appetite, constipation, and diarrhea
“a little”, on average (M
appetite
=2.13, SD
appetite
=0.97; M
constipation
=2.13, SD
constipation
=0.98;
M
diarrhea
=2.10, SD
diarrhea
=0.96). The least frequently endorsed physical symptoms were dyspnea
(M=1.75, SD=0.84) and nausea and vomiting (M=1.69, SD=0.72). Approximately 30% of
patients reported that they had not experienced nausea and vomiting during the past month. It
was noted that the nausea and vomiting subscale was not correlated with treatment type
(r
chemotherapy
=-0.03, r
radiation
= -0.10, r
other treatment
=0.07). However, there were other significant
MINDFULNESS IN ADVANCED CANCER 30
relations between physical symptoms and demographic variables. These included positive
relations between dyspnea and being male (r=0.23) and lacking appetite and neuroticism
(r=0.20), and a negative relation between pain and education (r=-0.23). The composite physical
symptoms variable was also positively correlated with performance status (r=0.27).
Intrusive thoughts. In general, patients did not report many intrusive thoughts. The
average item response indicated that patients experienced intrusive thoughts “a little bit”
(M=1.08, SD=0.74), which is comparable to levels reported in mixed-stage ovarian cancer
patients (56% with recurrence, 13% with Stage IV cancer; Arden-Close, Gidron, Bayne, &
Moss-Morris, 2013; z=1.32). In the present study, 13% of patients reported experiencing
intrusive thoughts at or above a “moderate” level (scores ≥ 2) on average. The most frequently
endorsed item was, “any reminder brought back feelings about [my cancer]” (M=1.66; SD=1.14).
A quarter of patients endorsed this item at the “quite a bit” or “extremely” levels, compared to
17% who said they did not experience this at all. Similarly, approximately 10% of patients
reported the frequency of “thought about my cancer when I didn’t mean to” and “other things
kept making me think about my cancer” at the “quite a bit or extremely” level, compared with
approximately 30% of patients who did not report these intrusive thought experiences at all. In
the present sample, men were less likely to report intrusive thoughts (r=-0.27), and individuals
high in neuroticism were more likely to report intrusive thoughts (r=0.56).
Coping. On average, patients reported using more active coping strategies (M=2.71,
SD=0.64) than avoidant coping strategies (M=1.31, SD=0.48). The most common avoidant
strategy was “saying this isn’t real” (M=1.38, SD=0.74); 25% of patients reported doing this to
some extent (scores ≥ 2). The most common active strategy was “taking action to make it better”
(M=3.10; SD=0.98); 85% reported doing this to some extent (scores ≥ 2). The least common
MINDFULNESS IN ADVANCED CANCER 31
active strategy was “coming up with a strategy of what to do” (M=2.40, SD=1.04), which was
still more common than the most frequently endorsed avoidant strategy. Active and avoidant
coping demonstrated a negative bivariate relation with each other (r=-0.21) and opposite
relations with age (r
active
=-0.28; r
avoidant
=0.20). Avoidant coping was also correlated positively
with neuroticism (r=0.36)
Neuroticism. Approximately one fifth of the present sample did not endorse any neurotic
tendencies and only 18% scored higher than the midway point of the scale. Levels of neuroticism
in the present sample were comparable to those reported in the normative community sample (z
= -0.64, Eysenck et al., 1985). Women endorsed experiencing more neuroticism than men.
Partial Least Squares Analyses
Measurement model. Figure 3 depicts the measurement model with latent variables and
their respective indicators (manifest variables). Emotional distress, the only reflective latent
variable in the model, demonstrated excellent convergent validity. The individual loadings of
depressive symptoms, anxiety symptoms, and emotional dysfunction on the emotional distress
latent were 0.89, 0.90, and 0.90, respectively, and the AVE was acceptable at 0.80, suggesting
that the indicators shared approximately 80% variance with each other. All loadings were
significant at the 0.001 level. Furthermore, the composite reliability coefficient for emotional
distress latent variable was 0.92, signifying excellent internal consistency. In sum, depressive
symptoms, anxiety symptoms, and emotional dysfunction were reliable and consistent in their
defining of emotional distress.
The formative latent variables, active coping, avoidant coping, and physical symptoms
demonstrated acceptable discriminant validity. Indicator weights and VIFs are listed in Table 5.
MINDFULNESS IN ADVANCED CANCER 32
All formative latent variable indicators were significant at the 0.01 level, and their VIFs were
below the 2.50 cut-off pointing to the lack of multicollinearity among indicators.
In the full model, multicollinearity was not a problem either as indicated by full
collinearity VIFs below the cut-off of 3.30 for all latent variables (Hair et al., 2009). The highest
full collinearity VIF value was for emotional distress at 3.19. Finally, Table 6 provides
correlations among latent variables along with square roots of their AVEs on the diagonal.
Values on the diagonal are all higher than any of the values to the left in the same row or below
in the same column, reflecting good discriminant validity in the measurement model. In
summary, the measurement model of the present study demonstrated reasonable reliability and
adequate validity to proceed with structural model testing.
Structural model. The hypothesized model was designed to test the direct relations
between mindfulness and the outcome variables, physical symptoms and emotional distress, as
well as the indirect relations between mindfulness and the outcome variables via intrusive
thoughts and coping strategies. Of the 15 hypothesized paths (see Figure 1), five did not meet
the threshold of explaining at least 2 % of the variance in a predicted variable. These included
the paths linking mindfulness to avoidant coping, intrusive thoughts to active coping, active
coping to both physical symptoms and emotional distress, and neuroticism to physical
symptoms. These paths were “trimmed” from the model. The variance explained in emotional
distress was 64% and the variance explained in physical symptoms was 8%. The variance
explained in the full model was not significantly greater than the variance explained in the
trimmed model (Table 7). Thus, the trimmed model is considered more parsimonious and
interpretations of relations were based on this model. The trimmed model with path weights and
MINDFULNESS IN ADVANCED CANCER 33
amount of variance accounted for by each path is included in Figure 4. Appendix 4 includes the
full, un-trimmed model with weights and variances explained.
Results from the structural model are presented in three sections. First, covariates are
reported. Second, direct relations between mindfulness and the outcome variables are reported.
Third, all indirect relations are reported. Direct, indirect, and total effects (in addition to their
respective effect sizes) between mindfulness and the outcome variables of emotional distress and
physical symptoms are provided in Table 8.
Covariates. PLS modeling was used to determine covariates of emotional distress and
physical symptoms. Analyses revealed that education ( =-0.14, p=0.03) was significantly
associated with less emotional distress and thus was retained in subsequent modeling as a
covariate of emotional distress. No other significant covariates of emotional distress or physical
symptoms were found.
Neuroticism was a planned control variable; however, it did not explain enough variance
in physical symptoms to be retained as a covariate in the model for physical symptoms. In
contrast, neuroticism was significantly associated with more emotional distress ( =0.55, p<0.01)
and was retained as a covariate in the trimmed model.
Direct relations. As hypothesized, greater mindfulness was associated with less
emotional distress ( =-0.17, p=0.02). Mindfulness was not associated with physical symptoms
in the full model ( =-0.15, p=0.12); however, inspection of the correlation table (Table 6)
revealed a significant bivariate relation between the two variables in the predicted direction (r=-
0.21, p=0.03).
More mindfulness was also associated with fewer intrusive thoughts ( =-0.49, p<0.01),
as hypothesized. Intrusive thoughts demonstrated predicted relations with emotional distress and
MINDFULNESS IN ADVANCED CANCER 34
avoidant coping in the positive direction ( = 0.48, p<0.01 and =0.31, p<0.01, respectively) and
no significant relation with physical symptoms ( =0.07, p=0.27).
In regards to coping, mindfulness demonstrated a significant relation with active coping
in the model; however, it was in the negative direction, opposite to what was hypothesized ( =-
0.21, p<0.01). Avoidant coping showed a positive relation with emotional distress ( =0.16,
p<0.01), but no relation with physical symptoms ( =0.16, p=0.11).
Indirect relations. Intrusive thoughts did not mediate the relation between mindfulness
and physical symptoms (indirect effect: -0.04, p=0.27), as the relation between intrusive thoughts
and physical symptoms was null. In contrast, mindfulness was indirectly associated with
emotional distress through its association with intrusive thoughts (indirect effect: -0.23, p<0.01)
such that more mindfulness was associated with fewer intrusive thoughts which were associated
with less emotional distress. Intrusive thoughts accounted for an insignificant amount of the
variance (<2%) between mindfulness and avoidant coping (indirect path: -0.15, p<0.01).
Active and avoidant coping strategies were also hypothesized to mediate the relation
between mindfulness and the outcome variables. In the trimmed model, there were no possible
paths involving coping as a mediator from mindfulness to emotional distress or physical
symptoms. Thus, coping strategies did not mediate the relations between mindfulness and
emotional distress or physical symptoms.
Although not a central aim of the present study, coping was also investigated as a
mediator between intrusive thoughts and the outcome variables. The indirect path between
intrusive thoughts and physical symptoms via avoidant coping was not significant (indirect
effect: 0.05, p=0.14). However, there was a significant indirect association between intrusive
thoughts and emotional distress through avoidant coping (indirect effect: 0.05, p=0.02, ES=0.04)
MINDFULNESS IN ADVANCED CANCER 35
such that greater intrusive thoughts were associated with more avoidant coping which was
associated with more emotional distress.
There were two possible three-segment paths linking mindfulness with the outcome
variables in the trimmed model. The indirect relation between mindfulness and physical
symptoms through intrusive thoughts and avoidant coping was not significant (indirect relation: -
0.02, p=0.15). When emotional distress was the outcome variable, this same indirect path
showed a significant effect (indirect effect: -0.02, p=0.02); however, its effect was too small to
be consequential (ES=0.01).
Exploratory analyses. Exploratory analyses were planned to test the hypothesized
relations in women and men separately. Means and standard deviations of key study variables
among men and women as well as t-tests comparing key study variables between sexes are
included in Appendix 5; women endorsed significantly more depressive and anxiety symptoms,
emotional dysfunction, and intrusive thoughts than men. Of the demographic and medical
variables collected in the study, men and women only differed on age (M
men
=58.00,
SD
men
=10.30; M
women
=52.36, SD
women
=11.49; t[100]=2.60). The measurement model for each sex
was examined to ensure adequate reliability and validity. Covariates were estimated for each
outcome variable and models were trimmed separately for women and men as well. The
trimmed models for women and men with path weights and the amount of variance accounted
for by each path are included in Figures 5 and 6, respectively. Direct, indirect, and total effects
in addition to their respective effect sizes are provided in Table 8. Correlations between latent
variables are provided separately for women and men in Tables 9 and 10, respectively.
In general, findings from the female subset of the data closely resembled findings from
the full dataset, albeit, effects were slightly stronger. There were two differences compared to
MINDFULNESS IN ADVANCED CANCER 36
the trimmed model with the full sample: mindfulness demonstrated a direct relation with
physical symptoms in the negative direction ( =-0.24, p<0.01), and active coping was negatively
associated with emotional distress ( =-0.23, p<0.01), as hypothesized. Intrusive thoughts
remained a significant mediator of the relation between mindfulness and emotional distress
(indirect effect: -0.22, p<0.01, ES=0.06), and there were no other significant indirect effects in
the model.
The model from the male subset of the data had fewer significant paths. Of 13
hypothesized paths (not including paths related to covariates or neuroticism), only six paths
remained in the trimmed model, in contrast to 10 for women. To begin, mindfulness did not
directly predict a significant amount of variance in either emotional distress or physical
symptoms for these paths to be retained in the model. For the same reason, the paths between
mindfulness and both coping strategies, both coping strategies and emotional distress and
avoidant coping and physical symptoms were trimmed.
In this trimmed model, mindfulness demonstrated only one direct relation, and it was
with intrusive thoughts ( =-0.38, p<0.01). Intrusive thoughts demonstrated a positive relation
with avoidant coping ( =0.32, p=0.04) and emotional distress ( =0.63, p<0.01). As in women,
the relation between mindfulness and emotional distress was mediated by intrusive thoughts
(indirect effect: -0.24, p<0.01). Departing from findings from the female subset of the data,
however, intrusive thoughts were strongly and positively related to physical symptoms in males
( =0.38, p<0.01). The indirect path between mindfulness and physical symptoms via intrusive
thoughts was significant (indirect effect: -0.14, p=0.01), but the effect size was small (ES=0.02).
Active coping was also related to physical symptoms in the negative direction ( =-0.24, p=0.04).
MINDFULNESS IN ADVANCED CANCER 37
Post hoc analyses. Although a relation between the two outcome variables was not
included in the hypothesized model, a path was added to the trimmed model from physical
symptoms to emotional distress. Additionally, the path between physical symptoms and
mindfulness was switched so that the arrow was going towards mindfulness, allowing for
mindfulness to be tested as a mediator of the relation between physical symptoms and emotional
distress. The path between physical symptoms and emotional distress was significant ( =0.20,
p<0.01) in the full sample; however, mindfulness did not significantly mediate the relation
(indirect effect: 0.03, p=0.10). The direction of the relations were also flipped around, and
physical symptoms were tested as a mediator of the relation between mindfulness and emotional
distress; however, this was a non-significant mediation as well (indirect effect, -0.03, p=0.13).
Thus, while physical symptoms and emotional distress are related, mindfulness does not explain
part of this relationship. Finally, mindfulness was also examined as a moderator of the relation
between physical symptoms and emotional distress, and this, too, was not significant ( =0.004,
p=0.47). These analyses were repeated in the male and female subsets of the data as well, and
findings were found to be consistent with those reported from the full sample.
Discussion
Given the reduced likelihood of cure or long-term survivorship in advanced cancer,
physical and emotional well-being are paramount clinical outcomes for patients with this disease.
Unfortunately, these are two domains that may be particularly challenging for patients with
advanced colorectal cancer given the incurable and progressive nature of the disease.
Furthermore, processes related to the cancer experience including cancer-related intrusive
thoughts and cancer-related maladaptive coping patterns may be detrimental to these outcomes
as well. The goal of the present study was to examine mindfulness as one factor that may
MINDFULNESS IN ADVANCED CANCER 38
demonstrate beneficial relations to physical symptoms and emotional distress both directly and
indirectly through cancer-related processes in this vulnerable patient population.
Reflecting the emotionally difficult nature of the advanced colorectal cancer experience,
approximately one third of patients endorsed depressive symptoms as occurring at least some of
the time, and four out of every ten patients endorsed clinically significant levels of depressive
symptoms, with rates higher among women (5.3 patients out of 10) than men (3.5 patients out of
10). Furthermore, overall mean levels of depressive symptoms in the present study were higher
than reported levels in other advanced cancer samples (Bakitas et al., 2009; Hotopf et al., 2002;
Mitchell et al., 2011). This may be due, in part, to the fact that the present study used a self-
report measure of depressive symptoms -- a method with lower specificity and generally higher
prevalence rates than methods used in some of the other studies conducted with patients with
advanced cancer (e.g., structured clinical interview; Hotopf et al., 2002; Mitchell et al., 2011).
Additionally, in another comparable study conducted with an advanced cancer sample (Bakitas
et al., 2009), the same self-report measure of depressive symptoms as used in the present study
was used, however eligibility criteria stated that participants had to identify a support person
willing to participate in the study along with them. Given the buffering effect of social support
in emotional distress (e.g., Cohen & Wills, 1985), this factor likely contributed to recruitment of
a biased sample with relatively lower levels of depressive symptoms.
In the present study, even after the removal of five somatic items on the CES-D (Radloff,
1977; items that may elevate scores due to the physically challenging nature of advanced
cancer), approximately 40% of patients continued to meet criteria for being at risk for clinical
depression with similar sex breakdowns as reported in the full scale. These findings are
noteworthy as depression has been shown to be an independent predictor of, among other things,
MINDFULNESS IN ADVANCED CANCER 39
poor survival in advanced cancer (Lloyd-Williams, Shiels, Taylor, & Dennis, 2009) and desire
for hastened death in the terminally ill (Breitbart et al., 2000; van der Lee et al., 2005).
Other indicators of emotional distress including anxiety symptoms and emotional
dysfunction were reported at more moderate levels compared to depressive symptoms. Overall,
while emotional distress was substantial for some patients in the present study, it was not
ubiquitous. The role of previous psychopathology in current levels of distress could not be
determined in the present study given that the onset and course of patients’ psychological
symptoms were not assessed. The fact that emotional distress was correlated with cancer-related
physical symptoms and the amount of time since the last CT scan (to determine tumor response
to treatment; r=0.44) suggests that distress had at least some relation to the current cancer
experience.
Another indication of the challenging nature of the advanced colorectal cancer experience
was noted in the physical symptoms reported by patients. The physical symptoms reported in the
present study mirrored symptom profiles reported by other patients with incurable cancer
(Teunissen et al., 2007) and demonstrated the common constellation of pain and fatigue often
observed in cancer samples (National Institutes of Health State-of-the-Science Panel, 2003).
Together pain, fatigue and other common side effects and symptoms endorsed in the present
study have been implicated in worse quality of life in cancer (e.g., Akin, Can, Aydiner, Ozdilli,
& Durna, 2010; Kurtz, Kurtz, Stommel, Given, & Given, 2001; van den Beuken-van Everdingen
et al., 2009).
Several of the physical symptoms assessed, including two of the more commonly
endorsed physical symptoms (i.e., fatigue and pain), were those in which patients’ psychological
states may play a role (e.g., Gatchel, Peng, Peters, Fuchs, & Turk, 2007). In fact, physical
MINDFULNESS IN ADVANCED CANCER 40
symptoms were highly related to emotional distress (rs=0.39 and 0.51 in women and men,
respectively). As such, one concern was that the measure of physical symptoms used in the
present study was simply capturing patients’ psychological states and thus possibly inflating the
relation between physical symptoms and other more “psychological” variables such as intrusive
thoughts. To address this concern, analyses were re-run with a modified physical symptom
variable in which loss of appetite, pain, and fatigue were removed, leaving dyspnea, nausea and
vomiting, constipation, and diarrhea to comprise the physical symptom latent variable. In these
modified analyses, however, the pattern of results remained the same as analyses conducted with
the original physical symptoms variable suggesting that the “psychological” physical symptoms
were not altering the results.
Given the emotionally and physically challenging nature of advanced cancer, this study
set out to investigate if mindfulness demonstrated beneficial relations with these outcomes.
Levels of mindfulness in the present study were high and were significantly higher than other
reported levels of mindfulness in the literature both among early-stage cancer and non-cancer
samples (Brown & Ryan, 2003; Carlson & Brown, 2005). To understand these differences, the
studies’ samples and methodologies were compared. No noteworthy differences were found
save for the participants’ cancer stage. It may be that the advanced cancer experience itself
encourages a mindful cognitive stance. Many persons with terminal and progressive disease
endorse high bodily vigilance, monitoring their body for signs of the cancer (Jones,
Hadjistavropoulos, & Gullickson, 2013). Furthermore, it has been shown that the prevailing
orientation in time perspective among patients with advanced cancer is the present compared to
patients without evidence of cancer whose orientation is towards the future (van Laarhoven et al.,
MINDFULNESS IN ADVANCED CANCER 41
2011). Thus, simply being closer to the end of life with a life-limiting disease may alter one’s
attention to and awareness of present moment occurrences.
Mindfulness in the context of the present study’s advanced cancer sample did not
demonstrate any significant relations with medical variables. This is consistent with its
conceptualization as a generally stable quality (Brown & Ryan, 2003). In regards to patient
variables, one concern was that mindfulness was simply capturing patients’ ability to work (e.g.,
“I am aware of my job or task (item 10 on the MAAS), goals (item 9), and/or what others are
saying (item 11), because it is part of my job to do these things”) or participation in mindfulness-
enhancing activities (e.g., meditation, yoga). Sixty percent of patients were not currently
working or were on leave, with the remaining patients being split between working part-time and
full-time. Eighty percent of patients prayed or meditated at least “a little bit” (40% did it “a lot”)
and approximately 30% practiced yoga on a regular basis. Bivariate relations between
mindfulness and employment status and mindfulness and the frequency of participating in
prayer/meditation or yoga, however, were not significant.
In fact, the only significant correlates with mindfulness were neuroticism and education,
both in the negative direction. While the finding with neuroticism was in the expected direction
and corroborated findings from other studies (Baer, Smith, & Allen, 2004; Baer et al., 2006;
Brown & Ryan, 2003), the relation with education was counter to two other published reports
that found positive (Baer et al., 2008) and null (McCracken et al., 2007) relations between the
variables in non-cancer samples.
Discussions with physicians affiliated with the present study provided some qualitative
insight into the negative relation between mindfulness and education. Physicians reported that
patients they believed to have fewer years of education did not seem to grasp the consequences
MINDFULNESS IN ADVANCED CANCER 42
of the physician’s message (i.e., that they [the patients] are most likely going to die within five
years, if not sooner) and instead focused on present or more proximal issues (e.g., the presence of
symptoms, the next round of treatment). In comparison, physicians noted that patients whom
they perceived to be more highly educated tended to have a greater understanding of the
foreshortened future associated with their diagnosis and, as a result, were more focused on
(avoiding, delaying, changing) that future. These observations point towards mindfulness, at
least in the present study, as relating to a more myopic perspective on the part of the patient,
possibly as a result of reduced understanding of the cancer prognosis. However, it is noted that
this hypothesis has not been empirically tested and should be interpreted with caution.
In the present study, the hypothesis that education was a proxy for patients’ accurate
understanding of their prognosis could not be tested directly as patients’ understanding of their
cancer diagnosis and prognosis was not formally assessed. The item that got closest to assessing
accuracy of illness perceptions asked patients to rate “How long do you think your illness will
continue?” on a scale from 1 (“a short amount of time”) to 10 (“forever”). The item was drawn
from the Brief Illness Perceptions Questionnaire (Broadbent, Petriea, Maina, & Weinmanb,
2006) that was collected as part of a related project involving the present study’s sample.
Unfortunately, the anchors of the continuum were such that a patient who expected to live a short
amount of time but also have their cancer for the rest of their life (i.e., “forever”) did not have a
clear response choice. No relations between this item and mindfulness or education were found.
In addition to contradicting findings from previous research, the negative relation
between education and mindfulness is also perplexing given that these two variables were both
negatively related to emotional distress. One possible explanation for this paradox is that
educational level moderated the relation between mindfulness and emotional distress. This
MINDFULNESS IN ADVANCED CANCER 43
moderation would be such that for patients who were highly educated (and, presumably,
understood their terminal diagnosis) being mindful of their present situation would be associated
with more emotional distress compared to patients with less education (who, presumably, had a
less accurate understanding of their prognosis). However, moderation analyses did not confirm
this hypothesis. It may be that education is a double-edged sword: it is beneficial in that it is
associated with reduced emotional distress, but it is detrimental in that it is associated with
reduced mindfulness. Future research is needed to elucidate the relation between mindfulness
and education, and to determine if mindfulness is in fact capturing patients’ understanding of
their cancer diagnosis.
Although mindfulness levels were high, findings from PLS modeling confirmed the
hypothesis that the quality of being mindful is associated with less emotional distress in
advanced cancer patients. In women, being attentive to and aware of current circumstances
explained nearly a fifth of the variance in emotional distress, even after controlling for patients’
general tendency to endorse distress (i.e., neuroticism), as well as their intrusive thoughts and
coping strategies. In the male subset of the sample, a direct relation between mindfulness and
emotional distress was not observed given that the relation was fully mediated by cancer-related
intrusive thoughts. In fact, in both sexes, as hypothesized, intrusive thoughts were significant
mediators such that more mindfulness was associated with fewer cancer-related intrusive
thoughts which were associated with less emotional distress.
It was noted, however, that the mediator, cancer-related intrusive thoughts, was highly
correlated with the outcome variable emotional distress (r=0.72 in the full sample), calling into
question of the distinctness of these variables. To address this concern, the emotional distress
latent variable was deconstructed into its three manifest variables (depressive symptoms, anxiety
MINDFULNESS IN ADVANCED CANCER 44
symptoms, and emotional dysfunction) and replaced with the one manifest variable that
demonstrated the smallest bivariate relation with mindfulness: depressive symptoms (measured
with the CES-D; r=0.58, in the full sample). Analyses were run with both the full form of the
CES-D as well as the reduced form of the CES-D with the somatic items removed (given their
confounding with symptoms associated with advanced colorectal cancer and its treatments; e.g.,
loss of appetite). Findings from both of these modified models mirrored the findings from the
original model in men and women. In sum, mindfulness demonstrated a consistent indirect and
negative relation with emotional distress via cancer-related intrusive thoughts regardless of the
measure of emotional distress used. In women, the direct and indirect effects were moderate in
size (ESs=0.18 and 0.15, respectively) and in men the indirect effect was small (ES=0.07).
Mindfulness was also related negatively to physical symptoms in the present study,
although to a lesser extent than emotional distress. Among women with advanced colorectal
cancer, mindfulness demonstrated a small direct relation to physical symptoms (ES=0.06).
Among men, mindfulness only demonstrated an indirect relation to physical symptoms through
intrusive thoughts – a mediation similar in pattern to that observed with emotional distress;
however, this effect bordered on statistical irrelevance (ES=0.02). These smaller relations
between mindfulness and physical symptoms in comparison to the stronger relations with
emotional distress may reflect the fact that as a psychological variable mindfulness shares more
variance with psychological outcomes such as emotional distress compared to physical
symptoms.
Taken together, findings from the present study point towards mindfulness being a
beneficial quality for patients with advanced cancer. Despite the fact that patients with advanced
cancer are often tasked with preparing for future treatment and end-of-life needs (e.g., making
MINDFULNESS IN ADVANCED CANCER 45
choices about healthcare, deciding when to start a new treatment or enter hospice, putting
advanced directives in place, preparing wills; National Institutes of Health, 2012) or experience
physically and emotionally distressing symptoms, focused awareness of and attention to the
present moment still demonstrated an advantageous relation to patients’ well-being. This is the
first study to demonstrate such a relation in advanced cancer, mirroring research on mindfulness
in healthy and early-stage cancer samples (e.g., Brown & Ryan, 2003).
Furthermore, this is the first study to investigate the mediational role of cancer-related
intrusive thoughts in the relations between mindfulness and emotional and physical outcomes.
While cancer-related intrusive thoughts were not a reliable mediator between mindfulness and
physical symptoms (likely as a result of the limited amount of shared variance between
mindfulness and physical symptoms to be explained), cancer-related intrusive thoughts did
mediate the relation between mindfulness and emotional distress. This finding suggests that the
quality of being mindful does not only relate to a reduction in the general tendency to worry or
ruminate (as previous, unpublished research had suggested; Labelle, 2013) but that mindfulness
may help patients specifically in the context of their cancer-related intrusive thoughts. Although
mindful patients may still harbor cancer-related cognitions such as thoughts about why they got
cancer or what will happen when they die, findings from the present study suggest that a
mindful stance may reduce the frequency of these thoughts that are perceived as upsetting and in
doing so may facilitate improved emotional well-being.
Although the direction and general trend of the present study’s findings were the same
across sexes, the magnitude of the relations between mindfulness and the endogenous variables
in the model were smaller in men than in women. To this point, among men mindfulness only
demonstrated a statistically significant relation with intrusive thoughts. In contrast, among
MINDFULNESS IN ADVANCED CANCER 46
women mindfulness demonstrated at least some relation (although not always statistically
significant) with all variables in the model including both coping strategies, intrusive thoughts,
emotional distress, and physical symptoms. One interpretation of this pattern of results is that
the quality of being mindful was less beneficial for men than for women.
Explanations for why mindfulness would demonstrate smaller beneficial relations with
emotional and physical variables among men are not discussed in the theoretical or empirical
literature on mindfulness. Often studies will report that no differences between levels of
mindfulness exist between sexes (as was found in the present study), but stop there (e.g., Brown
& Ryan, 2003; Carlson & Brown, 2005). One possibility for the reduced effects in men is that
there was less variance in study variables among men than women. However, this was only the
case for emotional distress, not mindfulness, physical symptoms, intrusive thoughts or either
coping strategy.
Another consideration is that men as a group interpreted items on the MAAS differently
than women. To this point, it was noted that while mindfulness demonstrated a negative
bivariate relation with avoidant coping among women (as would be expected given mindfulness’
emphasis on present-moment awareness and attention), these variables were not related among
men. Additionally, it was considered that men may have endorsed items on the MAAS
differently than women -- a trend that has been demonstrated on physical symptom self-reports
measures as well (Williams & Wiebe, 2000). However, at the item level, men and women only
differed significantly on mean levels of item 13 of the MAAS (“I find myself preoccupied with
the future or past”; t[100]=-2.94) with men reporting less preoccupation than women.
Even though men reported the same amount of mindfulness on average as women in the
present study, perhaps the amount of mindful awareness and attention required to reach those
MINDFULNESS IN ADVANCED CANCER 47
levels was less in men than women – a scenario that may account for the attenuated relations
between mindfulness and the other study variables among men. One possibility was given that
men were older, age-related deterioration in the cognitive domain of attention may have
contributed to men’s objectively lower levels of mindful attention but not their self-report of
mindful states. It appears, however, that this was not the case: when age was controlled for in
male and female models, the differences between the models did not disappear. It will be
imperative for additional research to replicate and subsequently flush out these sex differences.
If mindfulness is in fact less beneficial for men, this will be an important consideration for future
clinical work.
In regards to cancer-related coping strategies, counter to hypotheses, they did not mediate
the relations between mindfulness and emotional distress or physical symptoms. While the
general direction of relations between mindfulness and avoidant coping was in the negative
direction as expected, these relations were not significant in men or women. In regards to active
coping, the direction of the relations was unexpectedly negative in both men and women and was
significantly so in women. This pattern of results make sense in hindsight given that
mindfulness is generally about doing nothing whereas coping is about doing something.
Furthermore, active coping strategies are often couched in a future timeframe (e.g., planning
what to do), which stand in contrast to the present moment emphasis of being mindful.
Despite their non-significant role as mediators, coping strategies did relate directly to
other study variables. Among women, avoidant coping was associated with more emotional
distress and active coping was associated with less emotional distress, and among men, active
coping was associated with fewer physical symptoms. Again, the stronger relations among
women between coping and emotional distress may be due in part to the greater variance of
MINDFULNESS IN ADVANCED CANCER 48
emotional distress in women compared to men. Additionally, it may be that physical domains
are more salient for men, thus resulting in the stronger relations between active coping and
physical symptoms among men compared to women.
There was only partial support of the hypothesized relations between coping strategies
and intrusive thoughts. The active coping latent variable did not demonstrate a statistically
significant relation with intrusive thoughts. However, more congruent with the widely-supported
cognitive processing theory (e.g., Creamer et al., 1992) in which interrelations between intrusive
thoughts and avoidant behaviors comprise the process through which individuals adjust to
traumatic experiences, intrusive thoughts were significantly related to more avoidant coping
strategies in both sexes.
In conclusion, findings from the present study suggest that mindfulness is one factor that
may be associated with positive outcomes in emotional and, to a lesser extent, physical domains
among patients with advanced colorectal cancer. Furthermore, a reduction in intrusive thoughts
explained some of the relation between these variables such that more mindfulness was
associated with reduced intrusive thoughts which were associated with reduced physical
symptoms in men and reduced emotional distress in men and women. Coping strategies were
not significant mediators of the relation between mindfulness and emotional distress or physical
symptoms in either sex.
Limitations & Strengths
The present study was limited by its cross-sectional design. This methodological
limitation precludes establishing the direction of effects and poses distinct challenges for
interpreting meditational effects. However, the significant mediations in the present study
provide important evidence to the point that among some patients with advanced colorectal
MINDFULNESS IN ADVANCED CANCER 49
cancer mindfulness, intrusive thoughts, emotional distress, and physical symptoms co-occur.
Thus, changes in one variable likely relate to changes in the others. Whether mindfulness is
considered the beginning of that chain reaction or an intermediary or end variable is a question
that can and should be investigated with a longitudinal study.
An additional limitation of the study is the use of self-report data. In general, self-report
measures lack objectivity and are susceptible to socially desirable responding. Also, they rely on
the assumption that participants have accurate declarative knowledge of their internal and
external states. These factors may be particularly troublesome in the measurement of
mindfulness (Bergomi, Tschacher, & Kupper, 2013; Brown, Ryan, & Creswell, 2007; Grossman,
2008, 2011; van Dam, Earleywine, & Danoff-Burg, 2009). While most participants are likely
familiar with affective states such as depression and its symptoms, they may not be familiar with
mindfulness. To address this weakness, the present study used a measure of mindfulness that
does not require previous knowledge of or exposure to mindfulness theory or techniques (Brown
& Ryan, 2003). On the contrary, the MAAS assesses the opposite of mindfulness, namely
inattention and mindlessness (e.g., lack of attention, fixation on the past and future), and then is
reverse scored. The measure’s authors reason that mindless states are more widespread and
familiar to people and therefore may be easier to recognize and report accurately (Brown &
Ryan, 2003). Unfortunately, this solution introduces the additional limitations of restricted
variance and response bias such that individuals may be unlikely or unwilling to endorse
mindlessness as well as the added challenge of parsing negatively worded statements.
Furthermore, while the MAAS has consistently demonstrated excellent convergent,
divergent, and predictive validity (e.g., Brown & Ryan, 2003; Carlson & Brown, 2005;
Michalak, Heidenreich, Meibert, & Schulte, 2008), there is some question as to whether people’s
MINDFULNESS IN ADVANCED CANCER 50
understanding of mindfulness differs across populations (Grossman, 2011). For example, the
meaning of mindfulness and items on the MAAS may change depending on if someone is trained
in mindfulness. Unfortunately, there are no established external referents by which to assess the
accuracy of self-reported mindful attributes. In the present study, traditionally mindful activities
such as yoga and meditation were not significantly correlated with patients’ scores on the MAAS
(rs<0.10) suggesting that this may not have been an issue. Despite these criticisms, the MAAS is
one of the most widely used and tested mindfulness scales and use of it in this study enabled
comparisons with other studies and samples.
Finally, several qualities of the sample pose limitations to this study. First, the sample
evidenced heterogeneity on some medical (e.g., treatments, time since diagnosis) and
demographic (e.g., age) variables. While many of these variables were tested as covariates and
statistically controlled for as necessary, there may be other unmeasured constructs (e.g., site of
metastases) that could confound the results. Second, the use of an exclusively advanced
colorectal cancer sample being treated at a Los Angeles-based comprehensive cancer center
potentially limits the generalizability of these findings to other malignancies, stages of disease,
and cancer treatment settings such as tertiary care clinics. However, by working with patients
being treated at a single clinic, the potential for heterogeneity in treatment factors may have been
reduced, and thus, contributed to increased internal validity. Third, patients had to be deemed
eligible by their physician in order to participate in the present study. Five patients did not meet
eligibility criteria because their doctors determined that they were too physically weak or
emotionally distressed. Thus, findings from the present study may not capture the experiences of
patients at the lowest extremes of emotional and physical well-being. Although this is a common
problem in research conducted with patients with terminal disease (Steinhauser et al., 2006), it
MINDFULNESS IN ADVANCED CANCER 51
potentially limits generalizability to those patients experiencing the most cancer related-distress.
However, rates of physical symptoms and emotional distress, especially depression, were not
exceptionally low in the present study, suggesting that this possible recruitment bias did not lead
to the exclusion of all patients with psychological and physical distress.
Despite these limitations, the present study has many qualities that strengthen its merit.
First, over the course of nearly two years data were collected from 102 patients, reflecting not
only a sizable majority of eligible patients approached for the study (75%) but also a relatively
large sample for research conducted with an advanced cancer sample.
Second, the use of a colorectal cancer sample specifically enabled the present study to
investigate sex differences in the proposed relations. Sex differences in psycho-oncology are
widely speculated to exist but rarely studied. Generally in the psycho-oncology literature,
research is conducted in tumor silos – breast cancer samples are overwhelmingly used to reflect
what the female cancer experience is like and prostate cancer samples are used, to a lesser extent,
to reflect the male cancer experience; rarely are the sexes studied concurrently except in couples
research. Thus, sex differences in malignancies that affect both sexes are less well understood.
The present study was able to contribute to this small but important literature. Furthermore,
findings pertaining to mindfulness’ different relations with other study variables between men
and women can be used to inform the provision of more individualized care – a growing trend
within the current health system (Peppercorn et al., 2011).
Third, this study used PLS modeling which enabled the investigation of both direct and
indirect relations simultaneously, providing a more comprehensive view on the relations between
mindfulness, mediators, and outcome variables. Furthermore, PLS modeling is more forgiving
MINDFULNESS IN ADVANCED CANCER 52
than regression analyses in regards to meeting the assumption of normality (Fornell & Bookstein,
1982) and the size of the sample used (Vinzi et al., 2010).
Finally, the present study contributes to an understanding of the role of mindfulness in
the emotional and physical experiences of patients with chronic and life-limiting health
conditions. Given the reduced likelihood of cure or long-term survivorship among patients with
advanced colorectal cancer, it follows that their physical and emotional well-being are of the
utmost importance. Findings from this study suggest that mindfulness is one factor that may
potentially influence these outcomes, particularly through a reduction in cancer-related intrusive
thoughts.
Clinical Implications
Improved or maintained quality of life is the best clinical outcome that most patients with
advanced cancer can achieve in the face of an advancing, incurable disease. As such, the present
study was conceptualized as a preliminary step to developing a mindfulness intervention to
address this goal. While mindfulness is conceptualized as an inherent human capacity, it is also
believed to be a response tendency that can be altered by life circumstances and intervention
(Brown & Ryan, 2003; Kabat-Zinn, 2003). Furthermore, mindfulness-based interventions have
been proposed as an especially promising treatment avenue for addressing distress in patients
with advanced cancer (Carlson & Halifax, 2011). Meta-analyses suggest that mindfulness-based
interventions not only increase mindfulness, but also reduce symptoms of depression and anxiety
among patients with early-stage cancer (Piet, Würtzen, & Zachariae, 2012). Although no studies
have examined these interventions among people with advanced cancer, mindfulness-based
interventions may be particularly well suited for patients with advanced cancer as the primary
mechanism of change – focused attention and awareness – may be learned and practiced at home
MINDFULNESS IN ADVANCED CANCER 53
and with very little investment on the part of patients, many of whom are already physically and
emotionally taxed.
Before adapting mindfulness interventions for patients with advanced cancer or asking
them to invest their limited time and resources in participating in trials however, it was important
to demonstrate the beneficial relations between mindfulness and emotional and physical
outcomes. Findings from the present study suggest that, in fact, mindfulness is beneficial for this
patient population and may be best suited to targeting patients’ – especially female patients’ --
emotional distress, with consideration of their cancer-related intrusive thoughts, specifically.
Some mindfulness interventions already exist. Among cancer samples, mindfulness
training has been delivered through structured group interventions such as the widely-used
mindfulness-based stress reduction (Kabat-Zinn, 1990) and mindfulness based cancer recovery
programs (Carlson & Speca, 2010). In brief (approximately 8 week) group interventions,
patients receive didactic instruction in mindfulness, practice mindfulness meditation skills (e.g.,
relaxation, meditation, yoga), and engage in group discussions related to stress, coping, and the
practice of mindfulness. Group sessions are supplemented with the daily practice of mindfulness
techniques at home. Of course, for use with advanced cancer patients, several of the logistical
elements of these existing interventions may need to be modified including the setting (e.g.,
clinic, hospital bedside, home, or over the phone), format (e.g., individual, couple, family, or
group therapy), and involvedness (e.g., duration of intervention protocol, length of each session,
physical and/or emotional requirements; Taylor-Ford, 2014). To this point, trials are currently
underway to investigate mindfulness-based interventions administered over the phone
(Chambers et al., 2013) and via the internet (Zernicke et al., 2013) to patients with advanced
cancer.
MINDFULNESS IN ADVANCED CANCER 54
In conclusion, the present study is the first to consider the role of mindfulness in the
physical and emotional experiences of patients with advanced cancer, specifically. Evidence was
provided showing that mindfulness demonstrates a beneficial relation with these outcomes as
well as cancer-related intrusive thoughts. These findings, coupled with the robust literature on
mindfulness-based interventions, point towards mindfulness-based interventions being a
promising treatment avenue through which strides can be made to improve advanced cancer
patients’ well-being in the remaining life that they have left.
MINDFULNESS IN ADVANCED CANCER 55
References
Aaronson, N. K., Ahmedzai, S., Bergman, B., Bullinger, M., Cull, A., Duez, N. J., … de Haes, J.
C. (1993). The European Organization for Research and Treatment of Cancer QLQ-C30:
A quality-of-life instrument for use in international clinical trials in oncology. Journal of
the National Cancer Institute, 85(5), 365–376.
Akin, S., Can, G., Aydiner, A., Ozdilli, K., & Durna, Z. (2010). Quality of life, symptom
experience and distress of lung cancer patients undergoing chemotherapy. European
Journal of Oncology Nursing, 14(5), 400–409.
doi:http://dx.doi.org.libproxy.usc.edu/10.1016/j.ejon.2010.01.003
American Cancer Society. (2000). Cancer Facts and Figures - 2000. Atlanta, GA: American
Cancer Society.
American Cancer Society. (2011). Advanced Cancer. Atlanta, GA: American Cancer Society.
American Cancer Society. (2013). Cancer Facts and Figures - 2013. Atlanta, GA: American
Cancer Society.
American Cancer Society. (2014). Colorectal Cancer Facts & Figures - 2014-2016. Atlanta,
GA: American Cancer Society.
American Pain Society. (2008). Principles of Analgesic Use in the Treatment of Acute Pain and
Cancer Pain. (6th ed.). Glenview, IL: American Pain Society.
Aranda, S., Schofield, P., Weih, L., Yates, P., Milne, D., Faulkner, R., & Voudouris, N. (2005).
Mapping the quality of life and unmet needs of urban women with metastatic breast
cancer. European Journal of Cancer Care, 14(3), 211–222.
Arch, J. J., & Craske, M. G. (2006). Mechanisms of mindfulness: Emotion regulation following a
focused breathing induction. Behaviour Research and Therapy, 44(12), 1849–1858.
MINDFULNESS IN ADVANCED CANCER 56
Arden-Close, E., Gidron, Y., Bayne, L., & Moss-Morris, R. (2013). Written emotional disclosure
for women with ovarian cancer and their partners: Randomised controlled trial. Psycho-
Oncology, 22(10), 2262–2269. doi:10.1002/pon.3280
Badr, H., Carmack, C. L., Kashy, D. A., Cristofanilli, M., & Revenson, T. A. (2010). Dyadic
coping in metastatic breast cancer. Health Psychology, 29(2), 169–180.
doi:10.1037/a0018165
Baer, R. A., Smith, G. T., & Allen, K. B. (2004). Assessment of mindfulness by self-report: The
Kentucky Inventory of Mindfulness Skills. Assessment, 11(3), 191–206.
Baer, R. A., Smith, G. T., Hopkins, J., Krietemeyer, J., & Toney, L. (2006). Using self-report
assessment methods to explore facets of mindfulness. Assessment, 13(1), 27–45.
Baer, R. A., Smith, G. T., Lykins, E., Button, D., Krietemeyer, J., Sauer, S., … Williams, J. M.
G. (2008). Construct validity of the Five Facet Mindfulness Questionnaire in meditating
and nonmeditating samples. Assessment, 15(3), 329–342.
doi:10.1177/1073191107313003
Baider, L. A., & Kaplan De-Nour, A. (1988). Breast cancer—A family affair. In Stress and
Breast Cancer (pp. 155–170). Oxford, England: John Wiley & Sons.
Bakitas, M., Lyons, K. D., Hegel, M. T., Balan, S., Brokaw, F. C., Seville, J., … Byock, I. R.
(2009). Effects of a palliative care intervention on clinical outcomes in patients with
advanced cancer. JAMA: The Journal of the American Medical Association, 302(7), 741–
749.
Barrineau, M. J., Zarit, S. H., King, H. A., Costanzo, E. S., & Almeida, D. M. (2014). Daily
well-being of cancer survivors: The role of somatic amplification. Psycho-Oncology.
doi:10.1002/pon.3509
MINDFULNESS IN ADVANCED CANCER 57
Bergomi, C., Tschacher, W., & Kupper, Z. (2013). The assessment of mindfulness with self-
report measures: Existing scales and open issues. Mindfulness, 4(3), 191–202.
Billings, A. G., & Moos, R. H. (1981). The role of coping responses and social resources in
attenuating the stress of life events. Journal of Behavioral Medicine, 4(2), 139–157.
Bjelland, I., Dahl, A. A., Haug, T. T., & Neckelmann, D. (2002). The validity of the Hospital
Anxiety and Depression Scale: An updated literature review. Journal of Psychosomatic
Research, 52(2), 69–77.
Black, D. S., Sussman, Steve, Johnson, C Anderson, & Milam, JL. (2011). Psychometric
assessment of the Mindful Attention Awareness Scale (MAAS) among Chinese
adolescents. Assessment, 19(1), 42–52. doi:10.1177/1073191111415365
Breitbart, W., Rosenfeld, B., Pessin, H., Kaim, M., Funesti-Esch, J., Galietta, M., … Brescia, R.
(2000). Depression, hopelessness, and desire for hastened death in terminally ill patients
with cancer. JAMA: The Journal of the American Medical Association, 284(22), 2907.
Broadbent, E., Petriea, K.J., Maina, J. & Weinmanb, J. (2006). The brief illness perception
questionnaire. Journal of Psychosomatic Research, 60, 631-637.
Broderick, P. C. (2005). Mindfulness and coping with dysphoric mood: Contrasts with
rumination and distraction. Cognitive Therapy and Research, 29(5), 501–510.
Brown, K. W., & Ryan, R. M. (2003). The benefits of being present: Mindfulness and its role in
psychological well-being. Journal of Personality and Social Psychology, 84(4), 822.
Brown, K. W., Ryan, R. M., & Creswell, J. D. (2007). Mindfulness: Theoretical foundations and
evidence for its salutary effects. Psychological Inquiry, 18(4), 211–237.
Carlson, L. E., & Brown, K. W. (2005). Validation of the Mindful Attention Awareness Scale in
a cancer population. Journal of Psychosomatic Research, 58(1), 29–33.
MINDFULNESS IN ADVANCED CANCER 58
Carlson, L. E., & Halifax, J. (2011). Mindfulness for cancer and terminal illness. In L. M.
McCracken (Ed.), Mindfulness and Acceptance in Behavioral Medicine: Current Theory
and Practice (pp. 159–186). Oakland, CA: New Harbinger.
Carlson, L. E., & Speca, M. P. (2010). Mindfulness-Based Cancer Recovery: A Step-By-Step
MBSR Approach to Help You Cope with Treatment & Reclaim Your Life. Oakland, CA:
New Harbinger Publications.
Carmody, J., & Baer, R. A. (2008). Relationships between mindfulness practice and levels of
mindfulness, medical and psychological symptoms and well-being in a mindfulness-
based stress reduction program. Journal of Behavioral Medicine, 31(1), 23–33.
doi:10.1007/s10865-007-9130-7
Carver, C. S. (1997). You want to measure coping but your protocol’s too long: Consider the
Brief COPE. International Journal of Behavioral Medicine, 4(1), 92–100.
Cattell, R. B. (1966). The scree test for the number of factors. Multivariate Behavioral Research,
1(2), 245–276.
Chambers, S. K., Smith, D. P., Berry, M., Lepore, S. J., Foley, E., Clutton, S., … Gardiner, R. A.
(2013). A randomised controlled trial of a mindfulness intervention for men with
advanced prostate cancer. BMC Cancer, 13(1), 89.
Chin, W. W., & Newsted, P. R. (1999). Structural equation modeling analysis with small
samples using partial least squares. Statistical Strategies for Small Sample Research,
1(1), 307–341.
Chiquoine, B., & Hjalmarsson, E. (2009). Jackknifing stock return predictions. Journal of
Empirical Finance, 16(5), 793–803.
MINDFULNESS IN ADVANCED CANCER 59
Chu, E. (2012). An update on the current and emerging targeted agents in metastatic colorectal
cancer. Clinical Colorectal Cancer, 11(1), 1–13.
Cioffi, D., & Holloway, J. (1993). Delayed costs of suppressed pain. Journal of Personality and
Social Psychology, 64(2), 274.
Coates, A., Porzsolt, F., & Osoba, D. (1997). Quality of life in oncology practice: Prognostic
value of EORTC QLQ-C30 scores in patients with advanced malignancy. European
Journal of Cancer, 33(7), 1025–1030.
Cohen, J. (1988). Statistical power analysis for the behavioral sciences. Hillsdale, NJ: Lawrence
Erlbaum.
Cohen, S., & Wills, T. A. (1985). Stress, social support, and the buffering hypothesis.
Psychological Bulletin, 98(2), 310–357.
doi:http://dx.doi.org.libproxy.usc.edu/10.1037/0033-2909.98.2.310
Cordova, M. J., Andrykowski, M. A., Kenady, D. E., & McGrath, P. C. (1995). Frequency and
correlates of posttraumatic-stress-disorder-like symptoms after treatment for breast
cancer. Journal of Consulting and Clinical Psychology, 63(6), 981–986.
Costello, A. B., & Osborne, J. W. (2005). Best practices in exploratory factor analysis: Four
recommendations for getting the most from your analysis. Pract Assess Res Eval, 10, 1–
7.
Coyle, N. (2004). In their own words: Seven advanced cancer patients describe their experience
with pain and the use of opioid drugs. Journal of Pain and Symptom Management, 27(4),
300–309. doi:10.1016/j.jpainsymman.2003.08.008
Creamer, M., Burgess, P., & Pattison, P. (1992). Reaction to trauma: A cognitive processing
model. Journal of Abnormal Psychology, 101(3), 452.
MINDFULNESS IN ADVANCED CANCER 60
Culver, J. L., Arena, P. L., Antoni, M. H., & Carver, C. S. (2002). Coping and distress among
women under treatment for early stage breast cancer: Comparing African Americans,
Hispanics and non-Hispanic whites. Psycho-Oncology, 11(6), 495–504.
Dobkin, P. L., & Zhao, Q. (2011). Increased mindfulness – The active component of the
mindfulness-based stress reduction program? Complementary Therapies in Clinical
Practice, 17(1), 22–27. doi:10.1016/j.ctcp.2010.03.002
Donnelly, S., & Walsh, D. (1995). The symptoms of advanced cancer. Seminars in Oncology,
22(2 Suppl 3), 67–72.
Engel, G. L. (1977). The need for a new medical model: A challenge for biomedicine. Science,
196(4286), 129–136.
Eysenck, S. B., Eysenck, H. J., & Barrett, P. (1985). A revised version of the psychoticism scale.
Personality and Individual Differences, 6(1), 21–29.
Fornell, C., & Bookstein, F. L. (1982). Two structural equation models: LISREL and PLS
applied to consumer exit-voice theory. Journal of Marketing Research, 440–452.
Fornell, C., & Larcker, D. F. (1981). Evaluating structural equation models with unobservable
variables and measurement error. Journal of Marketing Research, 39–50.
Garland, S. N., Campbell, T., Samuels, C., & Carlson, L. E. (2013). Dispositional mindfulness,
insomnia, sleep quality and dysfunctional sleep beliefs in post-treatment cancer patients.
Personality and Individual Differences, 55(3), 306–311.
Garland, S. N., Tamagawa, R., Todd, S. C., Speca, M., & Carlson, L. E. (2013). Increased
mindfulness is related to improved stress and mood following participation in a
mindfulness-based stress reduction program in individuals with cancer. Integrative
Cancer Therapies, 12(1), 31–40.
MINDFULNESS IN ADVANCED CANCER 61
Gatchel, R. J., Peng, Y. B., Peters, M. L., Fuchs, P. N., & Turk, D. C. (2007). The
biopsychosocial approach to chronic pain: Scientific advances and future directions.
Psychological Bulletin, 133(4), 581.
Groenwald, S. L., Frogge, M. H., Goodman, M., & Yarbro, C. H. (1993). Cancer Nursing:
Principles and Practice. Sudbury, MA: Jones and Bartlett.
Grossman, P. (2008). On measuring mindfulness in psychosomatic and psychological research.
Journal of Psychosomatic Research, 64(4), 405–408.
doi:10.1016/j.jpsychores.2008.02.001
Grossman, P. (2011). Defining mindfulness by how poorly I think I pay attention during
everyday awareness and other intractable problems for psychology’s (re) invention of
mindfulness: Comment on Brown et al.(2011). Psychological Assessment, 23(4), 1034-
1040.
Haenlein, M., & Kaplan, A. M. (2004). A beginner’s guide to partial least squares analysis.
Understanding Statistics, 3(4), 283–297.
Hair, J., Black, W. C., Babin, B. J., & Anderson, R. E. (2009). Multivariate Data Analysis (7
edition.). Upper Saddle River, NJ: Prentice Hall.
Hann, D., Winter, K., & Jacobsen, P. (1999). Measurement of depressive symptoms in cancer
patients: Evaluation of the Center for Epidemiological Studies Depression Scale (CES-
D). Journal of Psychosomatic Research, 46(5), 437–443.
Härter, M., Reuter, K., Aschenbrenner, A., Schretzmann, B., Marschner, N., Hasenburg, A., &
Weis, J. (2001). Psychiatric disorders and associated factors in cancer: Results of an
interview study with patients in inpatient, rehabilitation and outpatient treatment.
European Journal of Cancer, 37(11), 1385–1393.
MINDFULNESS IN ADVANCED CANCER 62
Hayes, A. M., & Feldman, G. (2004). Clarifying the construct of mindfulness in the context of
emotion regulation and the process of change in therapy. Clinical Psychology: Science
and Practice, 11(3), 255–262.
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and Commitment Therapy: An
Experiential Approach to Behavior Change. (2nd edition.). New York: The Guilford
Press.
Hjermstad, M. J., Fayers, P. M., Bjordal, K., & Kaasa, S. (1998). Using reference data on quality
of life—The importance of adjusting for age and gender, exemplified by the EORTC
QLQ-C30 (+ 3). European Journal of Cancer, 34(9), 1381–1389.
Horowitz, M. J. (1975). Intrusive and repetitive thoughts after experimental stress: A summary.
Archives of General Psychiatry, 32(11), 1457–1463.
Horowitz, M. J. (1986). Stress-response syndromes: A review of posttraumatic and adjustment
disorders. Psychiatric Services, 37(3), 241–249.
Hotopf, M., Chidgey, J., Addington-Hall, J., & Ly, K. L. (2002). Depression in advanced
disease: A systematic review Part 1. Prevalence and case finding. Palliative Medicine,
16(2), 81–97.
Johnsen, A. T., Petersen, M. A., Pedersen, L., & Groenvold, M. (2009). Symptoms and problems
in a nationally representative sample of advanced cancer patients. Palliative Medicine,
23(6), 491–501. doi:10.1177/0269216309105400
Jones, S. L., Hadjistavropoulos, H. D., & Gullickson, K. (2013). Understanding health anxiety
following breast cancer diagnosis. Psychology, Health & Medicine, 1–11.
doi:10.1080/13548506.2013.845300
MINDFULNESS IN ADVANCED CANCER 63
Kabat-Zinn, J. (1990). Full Catastrophe Living: Using the Wisdom of Your Body and Mind to
Face Stress, Pain, and Illness. New York, NY: Delacorte.
Kabat-Zinn, J. (1994). Wherever You Go, There You Are (10th ed.). New York, NY: Hyperion.
Kabat-Zinn, J. (2003). Mindfulness-based interventions in context: Past, present, and future.
Clinical Psychology: Science and Practice, 10(2), 144–156.
Kaiser, H. F. (1960). The application of electronic computers to factor analysis. Educational and
Psychological Measurement, 20, 141-151.
Kaiser, H. F. (1974). An index of factorial simplicity. Psychometrika, 39, 31–36.
Keller, M., & Henrich, G. (1999). Illness-related distress: Does it mean the same for men and
women? Acta Oncologica, 38(6), 747–755. doi:10.1080/028418699432905
Kershaw, T., Northouse, L., Kritpracha, C., Schafenacker, A., & Mood, D. (2004). Coping
strategies and quality of life in women with advanced breast cancer and their family
caregivers. Psychology & Health, 19(2), 139–155. doi:10.1080/08870440310001652687
Kindler, H. L., & Shulman, K. L. (2001). Metastatic colorectal cancer. Current Treatment
Options in Oncology, 2(6), 459–471. doi:10.1007/s11864-001-0068-7
Kissane, D. W., Grabsch, B., Love, A., Clarke, D. M., Bloch, S., & Smith, G. C. (2004).
Psychiatric disorder in women with early stage and advanced breast cancer: A
comparative analysis. Australian and New Zealand Journal of Psychiatry, 38(5), 320–
326. doi:10.1111/j.1440-1614.2004.01358.x
Knight, R. G., Williams, S., McGee, R., & Olaman, S. (1997). Psychometric properties of the
Centre for Epidemiologic Studies Depression Scale (CES-D) in a sample of women in
middle life. Behaviour Research and Therapy, 35(4), 373–380. doi:10.1016/S0005-
7967(96)00107-6
MINDFULNESS IN ADVANCED CANCER 64
Kock, N. (2013). WarpPLS 4.0 User Manual. Laredo, TX: Script Warp Systems.
Kurtz, M. E., Kurtz, J. C., Stommel, M., Given, C. W., & Given, B. (2001). Physical functioning
and depression among older persons with cancer. Cancer Practice, 9(1), 11–18.
doi:10.1111/j.1523-5394.2001.91004.pp.x
Labelle, L. E. (2013). How does mindfulness-based stress reduction (MBSR) improve
psychological functioning in cancer patients? Dissertation Abstracts International:
Section B: The Sciences and Engineering, 73(12-B(E)).
Lam, K., Chow, E., Zhang, L., Wong, E., Bedard, G., Fairchild, A., … Bottomley, A. (2013).
Determinants of quality of life in advanced cancer patients with bone metastases
undergoing palliative radiation treatment. Supportive Care in Cancer, 21(11), 3021–
3030. doi:10.1007/s00520-013-1876-6
Ledesma, D., & Kumano, H. (2009). Mindfulness-based stress reduction and cancer: A meta-
analysis. Psycho-Oncology, 18(6), 571–579.
Lepore, S. J. (2001). A social–cognitive processing model of emotional adjustment to cancer. In
A. Baum & B. L. Andersen (Eds.), Psychosocial Interventions for Cancer (pp. 99-116).
Washington, DC: American Psychological Association.
Lewis, J. A., Manne, S. L., DuHamel, K. N., Vickburg, S. M. J., Bovbjerg, D. H., Currie, V., …
Redd, W. H. (2001). Social support, intrusive thoughts, and quality of life in breast
cancer survivors. Journal of Behavioral Medicine, 24(3), 231–245.
Linehan, M. (1993). Cognitive-Behavioral Treatment of Borderline Personality Disorder. New
York: The Guilford Press.
MINDFULNESS IN ADVANCED CANCER 65
Lloyd-Williams, M., Shiels, C., Taylor, F., & Dennis, M. (2009). Depression—An independent
predictor of early death in patients with advanced cancer. Journal of Affective Disorders,
113(1), 127–132.
Luecken, L. J., & Compas, B. E. (2002). Stress, coping, and immune function in breast cancer.
Annals of Behavioral Medicine, 24(4), 336–344.
Luoma, M., & Hakamies-Blomqvist, L. (2004). The meaning of quality of life in patients being
treated for advanced breast cancer: A qualitative study. Psycho ‐Oncology, 13(10), 729–
739. doi:10.1002/pon.788
Matousek, R. H., Dobkin, P. L., & Pruessner, J. (2010). Cortisol as a marker for improvement in
mindfulness-based stress reduction. Complementary Therapies in Clinical Practice,
16(1), 13–19.
McCracken, L. M., Gauntlett-Gilbert, J., & Vowles, K. E. (2007). The role of mindfulness in a
contextual cognitive-behavioral analysis of chronic pain-related suffering and disability.
Pain, 131(1), 63–69.
Meyer, H. M., Sinnott, C., & Seed, P. T. (2003). Depressive symptoms in advanced cancer. Part
1. Assessing depression: The Mood Evaluation Questionnaire. Palliative Medicine, 17(7),
596–603.
Michalak, J., Heidenreich, T., Meibert, P., & Schulte, D. (2008). Mindfulness predicts
relapse/recurrence in major depressive disorder after mindfulness-based cognitive
therapy. The Journal of Nervous and Mental Disease, 196(8), 630–633.
Mitchell, A. J., Chan, M., Bhatti, H., Halton, M., Grassi, L., Johansen, C., & Meader, N. (2011).
Prevalence of depression, anxiety, and adjustment disorder in oncological,
MINDFULNESS IN ADVANCED CANCER 66
haematological, and palliative-care settings: A meta-analysis of 94 interview-based
studies. The Lancet Oncology, 12(2), 160–174. doi:10.1016/S1470-2045(11)70002-X
Mock, V., Atkinson, A., Barsevick, A., Cella, D., Cimprich, B., Cleeland, C., … Hinds, P.
(2000). NCCN practice guidelines for cancer-related fatigue. Oncology, 14(11A), 151–
161.
Morgan, S. C., & Parker, C. C. (2011). Local treatment of metastatic cancer—Killing the seed or
disturbing the soil? Nature Reviews Clinical Oncology, 8(8), 504–506.
doi:10.1038/nrclinonc.2011.88
National Comprehensive Cancer Network. (2010). Clinical Practice Guidelines in Oncology for
Adult Cancer Pain. Fort Washington, PA: National Comprehensive Cancer Network.
Retrieved from www.nccn.org
National Institutes of Health. (2012). Coping with Advanced Cancer, NIH Publication 12-0856.
Washington, D.C.: U.S. Department of Health and Human Services, National Institutes of
Health.
National Institutes of Health State-of-the-Science Panel. (2003). Symptom management in
cancer: Pain, depression, and fatigue. Journal of the National Cancer Institute, 95(15),
1110–1117.
Neuman, H. B., Schrag, D., Cabral, C., Weiser, M. R., Paty, P. B., Guillem, J. G., … Temple, L.
K. (2007). Can differences in bowel function after surgery for rectal cancer be identified
by the European Organization for Research and Treatment of Cancer quality of life
instrument? Annals of Surgical Oncology, 14(5), 1727–1734.
Norum, J. (1997). Adjuvant chemotherapy in Dukes’ B and C colorectal cancer has only a minor
influence on psychological distress. Supportive Care in Cancer, 5(4), 318–321.
MINDFULNESS IN ADVANCED CANCER 67
Oken, M. M., Creech, R. H., Tormey, D. C., Horton, J., Davis, T. E., McFadden, E. T., &
Carbone, P. P. (1982). Toxicity and response criteria of the Eastern Cooperative
Oncology Group. American Journal of Clinical Oncology, 5(6), 649–656.
Osse, B., Vernooij-Dassen, M., Schadé, E., & Grol, R. (2005). The problems experienced by
patients with cancer and their needs for palliative care. Supportive Care in Cancer, 13(9),
722–732. doi:10.1007/s00520-004-0771-6
Peppercorn, J. M., Smith, T. J., Helft, P. R., DeBono, D. J., Berry, S. R., Wollins, D. S., …
Schnipper, L. E. (2011). American Society of Clinical Oncology statement: Toward
individualized care for patients with advanced cancer. Journal of Clinical Oncology,
29(6), 755–760. doi:10.1200/JCO.2010.33.1744
Piet, J., Würtzen, H., & Zachariae, R. (2012). The effect of mindfulness-based therapy on
symptoms of anxiety and depression in adult cancer patients and survivors: A systematic
review and meta-analysis. Journal of Consulting and Clinical Psychology, 80(6), 1007–
1020. doi:http://dx.doi.org.libproxy.usc.edu/10.1037/a0028329
Radloff, L. S. (1977). The CES-D scale: A self-report depression scale for research in the general
population. Applied Psychological Measurement, 1(3), 385–401.
Roesch, S. C., Adams, L., Hines, A., Palmores, A., Vyas, P., Tran, C., … Vaughn, A. A. (2005).
Coping with prostate cancer: A meta-analytic review. Journal of Behavioral Medicine,
28(3), 281–293.
Shapiro, S. L., Carlson, L. E., Astin, J. A., & Freedman, B. (2006). Mechanisms of mindfulness.
Journal of Clinical Psychology, 62(3), 373–386.
MINDFULNESS IN ADVANCED CANCER 68
Simon, A. E., Thompson, M. R., Flashman, K., & Wardle, J. (2009). Disease stage and
psychosocial outcomes in colorectal cancer. Colorectal Disease, 11(1), 19–25.
doi:10.1111/j.1463-1318.2008.01501.x
Stanton, A. L., Danoff-Burg, S., Cameron, C. L., Bishop, M., Collins, C. A., Kirk, S. B., …
Twillman, R. (2000). Emotionally expressive coping predicts psychological and physical
adjustment to breast cancer. Journal of Consulting and Clinical Psychology, 68(5), 875.
Stanton, A. L., & Snider, P. R. (1993). Coping with a breast cancer diagnosis: A prospective
study. Health Psychology, 12(1), 16.
Stark, D., Kiely, M., Smith, A., Velikova, G., House, A., & Selby, P. (2002). Anxiety disorders
in cancer patients: Their nature, associations, and relation to quality of life. Journal of
Clinical Oncology, 20(14), 3137–3148.
Steinhauser, K. E., Clipp, E. C., Hays, J. C., Olsen, M., Arnold, R., Christakis, N. A., … Tulsky,
J. A. (2006). Identifying, recruiting, and retaining seriously-ill patients and their
caregivers in longitudinal research. Palliative Medicine, 20(8), 745–754.
Step, M. M., Kypriotakis, G. M., & Rose, J. H. (2013). An exploration of the relative influence
of patient’s age and cancer recurrence status on symptom distress, anxiety, and
depression over time. Journal of Psychosocial Oncology, 31(2), 168–190.
doi:10.1080/07347332.2012.761318
Tabachnick, B. G., & Fidell, L. S. (2001). Using Multivariate Statistics. Boston, MA: Pearson
Education, Inc.
Taylor, S. E., & Stanton, A. L. (2007). Coping resources, coping processes, and mental health.
Annual Review of Clinical Psychology, 3(1), 377–401.
doi:10.1146/annurev.clinpsy.3.022806.091520
MINDFULNESS IN ADVANCED CANCER 69
Taylor-Ford, M. (2014). Clinical considerations for working with patients with advanced cancer.
Journal of Clinical Psychology in Medical Settings.
doi:http://dx.doi.org/10.1007/s10880-014-9398-z
Teasdale, J. D., Moore, R. G., Hayhurst, H., Pope, M., Williams, S., & Segal, Z. V. (2002).
Metacognitive awareness and prevention of relapse in depression: Empirical evidence.
Journal of Consulting and Clinical Psychology, 70(2), 275.
Teunissen, S. C., Wesker, W., Kruitwagen, C., de Haes, H. C., Voest, E. E., & de Graeff, A.
(2007). Symptom prevalence in patients with incurable cancer: A systematic review.
Journal of Pain and Symptom Management, 34(1), 94–104.
Tuinstra, J., Hagedoorn, M., van Sonderen, E., Ranchor, A. V., van den Bos, G. A. M., Nijboer,
C., & Sanderman, R. (2004). Psychological distress in couples dealing with colorectal
cancer: Gender and role differences and intracouple correspondence. British Journal of
Health Psychology, 9(4), 465–478. doi:10.1348/1359107042304588
van Dam, N. T., Earleywine, M., & Danoff-Burg, S. (2009). Differential item function across
meditators and non-meditators on the Five Facet Mindfulness Questionnaire. Personality
and Individual Differences, 47(5), 516–521. doi:10.1016/j.paid.2009.05.005
van den Beuken-van Everdingen, M. H. J., de Rijke, J. M., Kessels, A. G., Schouten, H. C., van
Kleef, M., & Patijn, J. (2009). Quality of life and non-pain symptoms in patients with
cancer. Journal of Pain and Symptom Management, 38(2), 216–233.
doi:http://dx.doi.org.libproxy.usc.edu/10.1016/j.jpainsymman.2008.08.014
van den Beuken-van Everdingen, M. H. J., De Rijke, J. M., Kessels, A. G., Schouten, H. C., van
Kleef, M., & Patijn, J. (2007). Prevalence of pain in patients with cancer: A systematic
review of the past 40 years. Annals of Oncology, 18(9), 1437–1449.
MINDFULNESS IN ADVANCED CANCER 70
van der Lee, M. L., van der Bom, J. G., Swarte, N. B., Heintz, A. P. M., de Graeff, A., & van den
Bout, J. (2005). Euthanasia and depression: A prospective cohort study among terminally
ill cancer patients. Journal of Clinical Oncology, 23(27), 6607–6612.
van Laarhoven, H. W. M., Schilderman, J., Verhagen, C. A., Vissers, K. C., & Prins, J. (2011).
Perspectives on death and an afterlife in relation to quality of life, depression, and
hopelessness in cancer patients without evidence of disease and advanced cancer patients.
Journal of Pain and Symptom Management, 41(6), 1048–1059.
doi:10.1016/j.jpainsymman.2010.08.015
Vinzi, V. E., Trinchera, L., & Amato, S. (2010). PLS path modeling: From foundations to recent
developments and open issues for model assessment and improvement. In V. E. Vinzi,
W. W. Chin, J. Henseler, & H. Wang (Eds.), Handbook of Partial Least Squares (pp. 47–
82). Berlin: Springer-Verlag.
Volkers, N. (1999). In coping with cancer, gender matters. Journal of the National Cancer
Institute, 91(20), 1712–1714.
Warmenhoven, F., van Rijswijk, E., van Weel, C., Prins, J., & Vissers, K. (2012). Low
prevalence of depressive disorder in ambulatory advanced cancer patients using the
Schedules for Clinical Assessment in Neuropsychiatry (SCAN 2.1). Journal of Affective
Disorders, 136(3), 1209–1211. doi:10.1016/j.jad.2011.11.017
Weinstein, N., Brown, K. W., & Ryan, R. M. (2009). A multi-method examination of the effects
of mindfulness on stress attribution, coping, and emotional well-being. Journal of
Research in Personality, 43(3), 374–385.
doi:http://dx.doi.org.libproxy.usc.edu/10.1016/j.jrp.2008.12.008
MINDFULNESS IN ADVANCED CANCER 71
Weiss, D. S., & Marmar, C. R. (1997). The impact of event scale-revised. In J. P Wilson & T. M.
Keane (Eds.) Assessing psychological trauma and PTSD (pp. 399–411). New York:
Guilford Press.
Wessels, H., de Graeff, A., Wynia, K., de Heus, M., Kruitwagen, C. L. J. J., Woltjer, G. T. G. J.,
… Voest, E. E. (2010). Gender-related needs and preferences in cancer care indicate the
need for an individualized approach to cancer patients. The Oncologist, 15(6), 648–655.
doi:10.1634/theoncologist.2009-0337
Whistance, R. N., Conroy, T., Chie, W., Costantini, A., Sezer, O., Koller, M., … Blazeby, J.M.
(2009). Clinical and psychometric validation of the EORTC QLQ-CR29 questionnaire
module to assess health-related quality of life in patients with colorectal cancer.
European Journal of Cancer, 45(17), 3017–3026.
Williams, P. G., & Wiebe, D. J. (2000). Individual differences in self-assessed health: Gender,
neuroticism and physical symptom reports. Personality and Individual Differences, 28(5),
823–835. doi:10.1016/S0191-8869(99)00140-3
Wizemann, T. M., & Pardue, M. L. (2001). Executive summary: Exploring the biological
contributions to human health: Does sex matter? J Womens Health Gend Based Med, 10,
433–9.
Zernicke, K. A., Campbell, T. S., Speca, M., McCabe-Ruff, K., Flowers, S., Dirkse, D. A., &
Carlson, L. E. (2013). The eCALM Trial-eTherapy for cancer appLying mindfulness:
Online mindfulness-based cancer recovery program for underserved individuals living
with cancer in Alberta: Protocol development for a randomized wait-list controlled
clinical trial. BMC Complementary and Alternative Medicine, 13(1), 34.
MINDFULNESS IN ADVANCED CANCER 72
Zigmond, A. S., & Snaith, R. P. (1983). The Hospital Anxiety and Depression Scale. Acta
Psychiatrica Scandinavica, 67(6), 361–370. doi:10.1111/j.1600-0447.1983.tb09716.x
MINDFULNESS IN ADVANCED CANCER 73
Tables
Table 1
Demographic Characteristics
% M(SD) Median Observed Range
Age
55.07(11.24) 54 29 - 83
Sex
Male 48
Ethnicity
White 69
Black 3
Hispanic 13
Asian 12
Other 3
Partner status
Partnered 83
Not partnered 17
Highest level of education
Some high school 2
High school graduate/GED 16
Vocational training 7
Associate degree 24
Bachelors degree 26
Masters degree 14
Doctoral degree 11
Income
Under 20,000 13
20,001-50,000 17
50,001-80,000 14
80,001-110,000 19
110,001-140,000 10
140,001-170,000 7
170,001-200,000 4
Over 200,000 16
MINDFULNESS IN ADVANCED CANCER 74
Table 2
Medical Characteristics
% M(SD) Median
Observed
Range
Performance status
0.71(0.55) 1 0 - 3
Days since diagnosis
821(941) 516 42 - 5,072
Cancer diagnosis
Colon 66
Rectal 34
Current treatment
a
Chemotherapy 94
Radiation 1
Other 8
Past treatment
a
Chemotherapy 87
Radiation 25
Surgery 81
Other 2
a
Patients may receive more than one treatment.
MINDFULNESS IN ADVANCED CANCER 75
Table 3
Measures
Domain Measure Items
Chronbach's
Alpha
Possible
Range
M(SD) Median
Observed
Range
Mindfulness MAAS 14 items 0.88 1 – 6 4.92(0.70) 4.99 3.21 – 6
Depressive
Symptoms
CES-D 20 items 0.88 0 – 60 16.37(9.50) 14.00 0 – 43
Anxiety
Symptoms
HADS-A 7 items 0.76 0 – 21 5.29(3.28) 5.00 0 – 13
Emotional
Dysfunction
EORTC QLQ-
C30
4 items 0.79 1 – 4 2.03(0.60) 2.00 1 – 4
Physical
Symptoms
EORTC QLQ-
C30
3 subscales assessing fatigue,
pain, and nausea/vomiting, and 4
items assessing dyspnea, appetite
loss, constipation, and diarrhea
0.75 1 – 4 2.07(0.56) 2.00 1 – 3.64
Cancer-
related
Intrusive
Thoughts
IES-R
8 items comprising the intrusion
subscale
0.87 0 – 4 1.08(0.74) 1.11 0 – 3.13
Cancer-
related
Coping
Brief COPE
Active Coping: 8 items assessing
positive reframing, planning, self
distraction, and active coping
0.78 1 – 4 2.71(0.64) 2.75 1 – 4
Avoidant Coping: 4 items
assessing denial and behavioral
disengagement
0.69 1 – 4 1.31(0.48) 1.00 1 – 3
Neuroticism
EPQR-N 12 items 0.79 0 –12 3.34(2.83) 3.00 0 – 11
Note: For all measures, higher scores reflect higher levels of the domain being measured. MAAS = Mindful Attention Awareness Scale.
CES-D = Center for Epidemiological Studies - Depression Scale. HADS-A = Hospital Anxiety and Depression Scale - Anxiety Subscale. EORTC
QLQ-C30 = European Organization for Research and Treatment of Cancer Quality of Life Questionnaire. IES-R = Impact of Event Scale-Revised.
COPE = Coping Orientations to Problems Experienced. EPQR-N = Short-Scale Eysenck Personality Questionnaire-Revised Neuroticism Subscale.
MINDFULNESS IN ADVANCED CANCER 76
Table 4
Correlations Among Key Study Variables
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
1 Mindfulness - -
2 Depressive symptoms -0.33 - -
3 Anxiety symptoms -0.45 0.69 - -
4 Emotional dysfunction -0.49 0.70 0.71 - -
5 Physical symptoms
a
-0.21 0.45 0.24 0.37 - -
6 Intrusive thoughts -0.49 0.58 0.65 0.70 0.20 - -
7 Active coping -0.11 -0.24 -0.07 -0.11 -0.19 0.16 - -
8 Planning coping -0.28 -0.02 0.17 0.18 0.06 0.26 0.57 - -
9 Positive reframing coping -0.09 -0.12 -0.06 -0.14 -0.06 0.03 0.40 0.30 - -
10 Self distraction coping -0.14 -0.10 0.17 0.01 -0.14 0.14 0.28 0.26 0.42 - -
11 Denial coping -0.04 0.28 0.25 0.31 0.14 0.25 -0.27 0.00 -0.14 -0.05 - -
12 Behavioral disengagement coping -0.19 0.39 0.29 0.37 0.20 0.27 -0.22 -0.15 -0.14 -0.03 0.44 - -
13 Neuroticism -0.44 0.48 0.54 0.65 0.16 0.56 -0.12 0.20 -0.12 0.12 0.33 0.28 - -
14 Age 0.10 -0.10 -0.14 -0.04 -0.01 -0.06 -0.35 -0.18 -0.27 -0.04 0.19 0.15 0.00 - -
15 Male 0.12 -0.27 -0.27 -0.21 0.06 -0.27 -0.06 -0.05 -0.09 -0.02 0.01 -0.14 -0.23 0.25 - -
16 White -0.08 -0.06 0.08 0.04 0.04 0.14 0.09 0.19 -0.01 -0.11 -0.16 -0.15 0.09 0.03 0.02 - -
17 Partnered 0.11 -0.17 -0.08 -0.13 0.04 -0.06 0.13 0.07 0.14 0.13 0.03 -0.17 -0.10 -0.05 0.17 0.15 - -
18 Education -0.21 -0.22 -0.14 -0.06 -0.12 0.02 0.33 0.17 0.02 -0.14 -0.14 0.01 -0.09 -0.30 -0.07 0.23 0.04 - -
19 Rectal cancer 0.05 -0.12 -0.04 -0.09 -0.09 -0.19 0.06 -0.07 -0.05 0.09 0.09 0.06 -0.08 0.02 0.02 -0.07 -0.10 -0.03 - -
20 Chemotherapy - current -0.12 0.03 0.05 0.05 -0.06 0.11 0.06 0.00 0.07 0.19 -0.15 0.00 0.16 0.11 -0.01 0.01 0.00 -0.07 0.10 - -
21 Radiation - current 0.03 -0.08 -0.07 -0.17 -0.12 -0.13 -0.05 -0.12 -0.03 -0.19 -0.06 -0.05 -0.12 0.06 0.10 0.07 -0.22 0.04 0.13 0.03 - -
22 Surgery -0.19 0.08 0.12 0.21 0.05 0.09 -0.19 -0.21 -0.10 -0.01 0.03 0.05 0.12 0.06 0.06 -0.11 0.07 -0.07 -0.15 -0.02 -0.21 - -
23 Days since diagnosis -0.01 -0.06 -0.09 -0.10 0.09 -0.04 -0.07 -0.01 -0.03 -0.10 -0.14 -0.03 -0.06 0.09 0.00 0.02 0.00 0.06 -0.12 0.03 -0.04 0.13 - -
24 Performance status 0.11 0.17 0.03 0.10 0.27 0.08 -0.13 -0.06 0.07 -0.11 0.04 0.10 0.08 0.02 -0.02 0.08 -0.03 -0.24 -0.09 -0.14 0.00 -0.01 -0.07 - -
a
Correlations between individual indicators of the physical symptoms latent variable (e.g., fatigue, pain) and all other study variables were omitted for ease of presentation. There were no departures in these
omitted correlations from the pattern of correlations between the physical symptom latent variable and other study variables presented here.
Note: Bold indicates significance at the p < 0.05 level. Bold italics indicates signifiance at the p < 0.01 level. Pearson correlations are provided for continuous variables and point biserial correlations are
provided for dichotomous variables.
MINDFULNESS IN ADVANCED CANCER 77
Table 5
Indicator Weights for Formative Latent Variables
Latent & Indicator Variables Weight VIF
Physical Symptoms
Pain 0.20 1.43
Fatigue 0.26 1.81
Dyspnea 0.19 1.29
Diarrhea 0.19 1.44
Constipation 0.14 1.15
Loss of appetite 0.26 1.82
Nausea & vomiting 0.26 1.84
Active Coping
Active 0.37 1.64
Planning 0.35 1.51
Self distraction 0.30 1.26
Positive reframing 0.34 1.37
Avoidant Coping
Denial 0.59 1.23
Behavioral disengagement 0.59 1.23
MINDFULNESS IN ADVANCED CANCER 78
Table 6
Correlations Among Latent Variables (with Square Roots of AVEs)
1 2 3 4 5 6
1 Mindfulness (1.00)
2 Emotional distress -0.48 (0.89)
3 Physical symptoms -0.21 0.40 (0.66)
4 Intrusive thoughts -0.49 0.72 0.20 (1.00)
5 Active coping -0.21 -0.05 -0.11 0.15 (0.73)
6 Avoidant coping -0.14 0.42 0.20 0.31 -0.21 (0.85)
MINDFULNESS IN ADVANCED CANCER 79
Table 7
Comparison of Full and Trimmed Models (N=102)
Outcome Variable Model R
2
(df) ∆R
2
full - trimmed
F
diff
p-value
Emotional distress
Full 0.65 (6, 95)
Trimmed 0.64 (5, 96)
0.01 2.71 0.10
Physical symptoms
Full 0.10 (5, 96)
Trimmed 0.08 (3, 98)
0.02 1.07 0.35
MINDFULNESS IN ADVANCED CANCER 80
Table 8
Effects of Mindfulness on Emotional Distress and Physical Symptoms (with Effect Sizes)
Sample Path
Direct
Effects
Indirect
Effects
Total
Effects
Full
Mindfulness Emotional Distress -0.17 (0.08) -0.25 (0.12) -0.42 (0.20)
Mindfulness Physical Symptoms -0.15 (0.03) -0.06 (0.01) -0.21 (0.04)
Women
Mindfulness Emotional Distress -0.31 (0.18) -0.20 (0.12) -0.51 (0.30)
Mindfulness Physical Symptoms -0.24 (0.06) -0.04 (0.01) -0.28 (0.07)
Men
Mindfulness Emotional Distress - - -0.24 (0.07) -0.24 (0.07)
Mindfulness Physical Symptoms - - -0.13 (0.02) -0.13 (0.02)
MINDFULNESS IN ADVANCED CANCER 81
Table 9
Correlations Among Latent Variables - Female Sub-Sample (n=53)
1 2 3 4 5 6
1 Mindfulness
- -
2 Emotional distress -0.58
- -
3 Physical symptoms -0.27 0.39
- -
4 Intrusive thoughts -0.54 0.68 0.13
- -
5 Active coping -0.28 -0.14 -0.10 0.11
- -
6 Avoidant coping -0.24 0.48 0.23 0.29 -0.22
- -
MINDFULNESS IN ADVANCED CANCER 82
Table 10
Correlations Among Latent Variables - Male Sub-Sample (n=49)
1 2 3 4 5 6
1 Mindfulness
- -
2 Emotional distress -0.28
- -
3 Physical symptoms -0.18 0.51
- -
4 Intrusive thoughts -0.38 0.73 0.34
- -
5 Active coping -0.12 0.01 -0.14 0.16
- -
6 Avoidant coping 0.03 0.31 0.17 0.32 -0.22
- -
MINDFULNESS IN ADVANCED CANCER 83
Figures
Figure 1
Hypothesized Model
Emotional
Distress
Mindfulness
Avoidant
Coping
Active
Coping
Physical
Symptoms
Cancer-Related
Intrusive Thoughts
-
-
-
+
+
+
-
+ +
+
-
-
-
Covariates
MINDFULNESS IN ADVANCED CANCER 84
Figure 2
Recruitment Flow Chart
9 refused 136 patients recruited
127 patients consented 22 “soft declines”
3 withdrew
102 returned questionnaires
MINDFULNESS IN ADVANCED CANCER 85
Figure 3
Measurement Model
Emotional
Distress
MAAS
Avoidant
Coping
Behavioral
Disengagement
(Brief COPE)
Denial (Brief COPE)
Active
Coping
Self distraction
(Brief COPE)
Positive reframing
(Brief COPE )
Planning (Brief COPE)
Active (Brief COPE)
Physical
Symptoms
Pain (EORTC)
Dyspnea (EORTC)
Fatigue (EORTC)
Constipation (EORTC)
Loss of appetite
(EORTC)
Nausea & vomiting
(EORTC)
Diarrhea (EORTC)
IES-R
Emotional dysfunction
(EORTC)
Depressive symptoms
(CES-D)
Anxiety symptoms
(HADS-A)
Cancer-Related
Intrusive
Thoughts
Mindfulness
MINDFULNESS IN ADVANCED CANCER 86
Figure 4
Trimmed Model with Path Weights and the Amount of Variance Accounted for by Each Path
Full Sample (N=102)
Emotional
Distress
Mindfulness
Avoidant
Coping
Active
Coping
Physical
Symptoms
Cancer-Related
Intrusive Thoughts
Education
Neuroticism
-0.49
(24%)
-0.17
(8%)
-0.15
(3%)
-0.21
(4%)
0.48
(34%)
0.07
(2%)
0.31
(10%)
0.16
(7%) 0.16
(3%)
0.21
(13%)
-0.17
(3%)
Note: Bold italics signifies p<0.01. Bold signifies p<0.05.
MINDFULNESS IN ADVANCED CANCER 87
Figure 5
Trimmed Model with Path Weights and the Amount of Variance Accounted for by Each Path
Female Sample (n=53)
Emotional
Distress
Mindfulness
Avoidant
Coping
Active
Coping
Physical
Symptoms
Cancer-Related
Intrusive Thoughts
Education
Neuroticism
-0.54
(29%)
-0.31
(18%)
-0.24
(6%)
-0.12
(3%)
0.41
(28%)
0.22
(6%)
0.18
(9%)
0.15
(3%)
-0.23
(3%) -0.27
(2%)
0.12
(8%)
Surgery
Age
-0.28
(8%)
-0.35
(7%)
-0.18
(2%)
Note: Bold italics signifies p<0.01. Bold signifies p<0.05.
MINDFULNESS IN ADVANCED CANCER 88
Figure 6
Trimmed Model with Path Weights and the Amount of Variance Accounted for by Each Path
Male Sample (n=49)
Emotional
Distress
Mindfulness
Avoidant
Coping
Active
Coping
Physical
Symptoms
Cancer-Related
Intrusive Thoughts
Education
Neuroticism
-0.38
(15%)
0.63
(46%)
0.38
(13%)
0.16
(3%)
0.32
(10%) -0.24
(3%)
0.25
(13%)
-0.16
(2%)
Time since diagnosis
Rectal cancer
-0.23
(4%)
-0.08
(2%)
Note: Bold italics signifies p<0.01. Bold signifies p<0.05.
MINDFULNESS IN ADVANCED CANCER 89
Appendices
Appendix 1:
Qualitative Interviews
A subset of patients was administered brief (<15 minutes) unstructured interviews to
assess their understanding and interpretation of four items in the questionnaire. Two items from
both the Impact of Event Scale – Revised (IES-R) Intrusive Thoughts subscale and the Mindful
Attention Awareness Scale (MAAS) were selected. The items in question included
Item 4 from the MAAS, “I tend to walk quickly to get where I’m going without
paying attention to what I experience along the way.”
Item 8 from the MAAS, “I rush through activities without being really attentive to
them.”
Item 9 from the IES-R, “Pictures about [my colorectal cancer] popped into my
mind.”
Item 20 from the IES-R, “I had dreams about [my colorectal cancer].”
Talking points of the interviews included
“As you answered this question, what went through your mind?”
“How did you interpret this item?”
“What does a score of ___ [e.g., 2] mean to you on this question?”
“Was this question easy for you to answer? Why or why not?”
In total, eighteen patients were queried. The demographic and medical characteristics of
this subset of the participants generally matched those of the whole sample. The average age of
the 18 patients was 57.6 years. Half of the interviewees were female, half of the interviewees
MINDFULNESS IN ADVANCED CANCER 90
were college educated, 61% (n=11) were white, and 83% (n=15) were married. 78% (n=14) had
colon cancer and the remaining 22% (n=4) had rectal cancer, and all were currently receiving
chemotherapy.
On both of the MAAS items, nearly all of the 18 patients stated that they had experienced
each item infrequently or almost never in the past month (a score of 3 or lower). The exception
was two patients who endorsed item 4 at the “somewhat frequently” level. In regards to these
items on the MAAS, one concern was that their double-barreled structure would make them
difficult for patients to answer. For example, if just the first part of an item was true (e.g., “I
tend to walk quickly”), would a patient endorse the item even if the second part (e.g., “without
paying attention to what I experience along the way”) was not true, or vice versa? Interviews
with patients revealed that patients read the items as single experiences (as opposed to two
separate experiences in one item), and both parts of the question had to be true in order for them
to endorse it. Furthermore, all of the patients interviewed indicated that they understood the
items on the MAAS to be assessing their state of awareness and attention.
There was also concern that some of the items on the IES-R would be difficult for
patients to respond to. For instance, it was unclear what dreams or pictures of the cancer would
look like to the patient answering these items. Eleven patients reported that “pictures of it [my
colorectal cancer] popped into my mind” at least “a little bit” (scores ≥ 1) and six reported that
they “had dreams about it [my colorectal cancer].” Of these patients who endorsed items 9 and
20 to some extent, most of them (n=17) indicated that cognitive representations of their cancer
experience (in the form of dreams or pictures that popped into their mind) ranged from thoughts
related to the moment they were diagnosed to a recent cancer treatment they received, or a
meeting they had with their doctor. One patient could not recall the content of her dreams or
MINDFULNESS IN ADVANCED CANCER 91
cancer-related thoughts, but endorsed the item anyway. These findings are consistent with
qualitative data reported by Cordova et al. (1995) in which 55 breast cancer survivors were
interviewed and administered the IES. The women indicated that the most common intrusive
thoughts and dreams were related to side effects, treatment, and dying.
In general, the information obtained through these interviews lent support to the use of
the MAAS and the IES-R as measures of mindful attention/awareness and intrusive thoughts,
respectively, in the present study.
MINDFULNESS IN ADVANCED CANCER 92
Appendix 2:
Measures
DEMOGRAPHIC INFORMATION
Please fill out the following information to the best of your knowledge.
1. Age: _______ years old
2. Sex: [ ] Female [ ] Male
3. Check the box that most closely represents your ethnic identification?
[ ] Black (African) American, NOT Hispanic [ ] Asian/Asian American
[ ] White, Hispanic [ ] Native American
[ ] Black, Hispanic
[ ] Mixed race, Hispanic
[ ] White (Anglo/Caucasian/European),
NOT Hispanic
[ ] Caribbean Islander (NOT Hispanic) [ ] Other (specify) __________
4. Please check the highest level of education you have completed. (check one)
[ ] Grade school (1-8 yrs) [ ] Associate Degree earned (AA or AD)
[ ] Some high school (9-11 yrs) [ ] Bachelors Degree earned (BA or BS)
[ ] High School Graduate or GED [ ] Masters Degree earned (MA, MS,
MBA, MSW, etc.)
[ ] Vocational or training school after
high school graduation
[ ] Doctoral Degree earned (MD, PhD,
JD, etc.)
5. What is your marital status?
[ ] Single/Separated/Divorced/Widowed [ ] Married/Partnered
MINDFULNESS IN ADVANCED CANCER 93
MEDICAL INFORMATION (To be completed by medical personnel)
1. Primary cancer site
[ ] colon
[ ] rectum
[ ] other:__________________________________________________________
2. Date first diagnosed with advanced disease: ____(mo.)/ ____(day) / _______(yr.)
3. Current treatment (check all that apply):
[ ] chemotherapy (please specify type):______________________________________
[ ] radiation
[ ] other (please specify type): _____________________________________________
4. Past treatment (check all that apply):
[ ] chemotherapy (please specify type):______________________________________
[ ] radiation
[ ] surgery
[ ] other (please specify type): _____________________________________________
5. Performance status (0-5): _________________________________________________
MINDFULNESS IN ADVANCED CANCER 94
MINDFULNESS (MAAS)
Below is a collection of statements about your everyday experience. Please indicate how
frequently or infrequently you have experienced each in the past month. Please answer according
to what really reflects your experience rather than what you think your experience should be.
In the past month
Almost
Never
Very
infrequently
Somewhat
infrequently
Somewhat
frequently
Very
Frequently
Almost
always
1. I could be experiencing some emotion and not be
conscious of it until some time later.
1 2 3 4 5 6
2. I break or spill things because of carelessness, not
paying attention, or thinking of something else.
1 2 3 4 5 6
3. I find it difficult to stay focused on what’s
happening in the present.
1 2 3 4 5 6
4. I tend to walk quickly to get where I’m going
without paying attention to what I experience
along the way.
1 2 3 4 5 6
5. I tend not to notice feelings of physical tension or
discomfort until they really grab my attention.
1 2 3 4 5 6
6. I forget a person’s name almost as soon as I’ve
been told it for the first time.
1 2 3 4 5 6
7. It seems I am “running on automatic” without
much awareness of what I’m doing.
1 2 3 4 5 6
8. I rush through activities without being really
attentive to them.
1 2 3 4 5 6
9. I get so focused on the goal I want to achieve that
I lose touch with what I am doing right now to get
there.
1 2 3 4 5 6
10. I do jobs or tasks automatically, without being
aware of what I’m doing.
1 2 3 4 5 6
11. I find myself listening to someone with one ear,
doing something else at the same time.
1 2 3 4 5 6
12. I drive places on “automatic pilot” and then
wonder why I went there.
1 2 3 4 5 6
13. I find myself preoccupied with the future or the
past.
1 2 3 4 5 6
14. I find myself doing things without paying
attention.
1 2 3 4 5 6
15. I snack without being aware that I’m eating.
1 2 3 4 5 6
MINDFULNESS IN ADVANCED CANCER 95
DEPRESSIVE SYMPTOMS (CES-D)
Circle the number of each statement that best describes how often you felt or behaved during
the past month.
During the past month…
Rarely or
none of the
time
Some or a
little of the
time
Occasionally
or a moderate
amount of the
time
Most or
all of the
time
1. I was bothered by things that usually don’t
bother me*
0 1 2 3
2. I did not feel like eating; my appetite was poor* 0 1 2 3
3. I felt that I could not shake off the blues even
with help from my family and friends
0 1 2 3
4. I felt that I was just as good as other people
0 1 2 3
5. I had trouble keeping my mind on what I was
doing
0 1 2 3
6. I felt depressed
0 1 2 3
7. I felt that everything I did was an effort*
0 1 2 3
8. I felt hopeful about the future
0 1 2 3
9. I thought my life had been a failure
0 1 2 3
10. I felt fearful
0 1 2 3
11. My sleep was restless*
0 1 2 3
12. I was happy
0 1 2 3
13. I talked less than usual
0 1 2 3
14. I felt lonely
0 1 2 3
15. People were unfriendly
0 1 2 3
16. I enjoyed life
0 1 2 3
17. I had crying spells
0 1 2 3
18. I felt sad
0 1 2 3
19. I felt that people disliked me
0 1 2 3
20. I could not get “going”*
0 1 2 3
*Somatic symptom item
MINDFULNESS IN ADVANCED CANCER 96
ANXIETY SYMPTOMS (HADS-A)
Please read each group of statements carefully, and then pick out the one statement in each group
that best describes the way you have been feeling during the past month. Circle the number
beside the statement you picked. Be sure to read all the statements in each group before making
your choice.
1) I feel tense or "wound up."
0 Most of the time
1 A lot of the time
2 From time to time, occasionally
3 Not at all
2) I get a sort of frightened feeling as if something awful is about to
happen.
0 Very definitely and quite badly
1 Yes, but not too badly
2 A little, but it doesn't worry me
3 Not at all
3) Worrying thoughts go through my mind.
0 A great deal of the time
1 A lot of the time
2 From time to time but not too often
3 Only occasionally
4) I can sit at ease and feel relaxed.
0 Definitely
1 Usually
2 Not often
3 Not at all
5) I get a sort of frightened feeling like "butterflies" in the stomach.
0 Not at all
1 Occasionally
2 Quite often
3 Very often
6) I feel restless as if I have to be on the move.
0 Very much indeed
1 Quite a lot
2 Not very much
3 Not at all
7) I get sudden feelings of panic.
0 Very often indeed
1 Quite often
2 Not very often
3 Not at all
MINDFULNESS IN ADVANCED CANCER 97
EMOTIONAL DYSFUNCTION (EORTC QLQ-C30)
We are interested in some things about you and your health during the past month. Please
answer all of the questions yourself by circling the number that best applies to you.
Not
at all
A
little
Quite
a bit
Very
Much
1. Did you feel tense?
1 2 3 4
2. Did you worry?
1 2 3 4
3. Did you feel irritable?
1 2 3 4
4. Did you feel depressed?
1 2 3 4
MINDFULNESS IN ADVANCED CANCER 98
CANCER-RELATED PHYSICAL SYMPTOMS (EORTC QLQ-C30)
We are interested in some things about you and your health during the past month. Please
answer all of the questions yourself by circling the number that best applies to you.
In the past month …
Not
at all
A
little
Quite
a bit
Very
Much
1. Were you short of breath?
1 2 3 4
2. Have you had pain?
1 2 3 4
3. Did you need to rest?
1 2 3 4
4. Have you felt weak?
1 2 3 4
5. Have you lacked appetite?
1 2 3 4
6. Have you felt nauseated?
1 2 3 4
7. Have you vomited?
1 2 3 4
8. Have you been constipated?
1 2 3 4
9. Have you had diarrhea?
1 2 3 4
10. Were you tired?
1 2 3 4
11. Did pain interfere with your daily activities?
1 2 3 4
MINDFULNESS IN ADVANCED CANCER 99
INTRUSIVE THOUGHTS (IES-R)
Below is a list of difficulties people sometimes have after stressful life events. Please read each
item, and then indicate how distressing each difficulty has been for you during the past month
with respect to your colorectal cancer.
Not at all
A little bit
Moderately
Quite a bit
Extremely
1. Any reminder brought back feelings about it.
0 1 2 3 4
2. I had trouble staying asleep.
0 1 2 3 4
3. Other things kept making me think about it.
0 1 2 3 4
4. I thought about it when I didn’t mean to.
0 1 2 3 4
5. Pictures about it popped into my mind.
0 1 2 3 4
6. I found myself acting or feeling like I was back
at that time.
0 1 2 3 4
7. I had waves of strong feelings about it.
0 1 2 3 4
8. I had dreams about it.
0 1 2 3 4
MINDFULNESS IN ADVANCED CANCER 100
COPING (Brief COPE)
Below are some statements that deal with ways you've been coping with worries or thoughts you
may have about your experience with colorectal cancer during the past month. Try to rate
each item separately from the others. Make your answers as true for you as you can.
In the past month…
I haven’t
been doing
this at all
I’ve been
doing this
a little bit
I’ve been
doing this
a medium
amount
I’ve
been
doing
this a lot
1. I've been turning to work or other activities to
take my mind off things.
1 2 3 4
2. I've been concentrating my efforts on doing
something about the situation I'm in.
1 2 3 4
3. I've been saying to myself "this isn't real".
1 2 3 4
4. I've been using alcohol or other drugs to make
myself feel better.
1 2 3 4
5. I've been getting emotional support from
others.
1 2 3 4
6. I've been giving up trying to deal with it.
1 2 3 4
7. I've been taking action to try to make the
situation better.
1 2 3 4
8. I've been refusing to believe that it has
happened.
1 2 3 4
9. I've been saying things to let my unpleasant
feelings escape.
1 2 3 4
10. I’ve been getting help and advice from other
people.
1 2 3 4
11. I've been using alcohol or other drugs to help
me get through it.
1 2 3 4
12. I've been trying to see it in a different light, to
make it seem more positive.
1 2 3 4
13. I’ve been criticizing myself.
1 2 3 4
14. I've been trying to come up with a strategy
about what to do.
1 2 3 4
15. I've been getting comfort and understanding
from someone.
1 2 3 4
16. I've been giving up the attempt to cope.
1 2 3 4
17. I've been looking for something good in what
is happening.
1 2 3 4
18. I've been making jokes about it.
1 2 3 4
MINDFULNESS IN ADVANCED CANCER 101
In the past month…
I haven’t
been doing
this at all
I’ve been
doing this
a little bit
I’ve been
doing this
a medium
amount
I’ve
been
doing
this a lot
19. I've been doing something to think about it
less, such as going to movies, watching TV,
reading, daydreaming, sleeping, or shopping.
1 2 3 4
20. I've been accepting the reality of the fact that
it has happened.
1 2 3 4
21. I've been expressing my negative feelings.
1 2 3 4
22. I've been trying to find comfort in my religion
or spiritual beliefs.
1 2 3 4
23. I’ve been trying to get advice or help from
other people about what to do.
1 2 3 4
24. I've been learning to live with it.
1 2 3 4
25. I've been thinking hard about what steps to
take.
1 2 3 4
26. I’ve been blaming myself for things that
happened.
1 2 3 4
27. I've been praying or meditating.
1 2 3 4
28. I've been making fun of the situation.
1 2 3 4
Note: Avoidant Coping = Items 3, 6, 8,16. Active Coping = Items 1, 2, 7, 12, 14, 17, 19, 25.
MINDFULNESS IN ADVANCED CANCER 102
NEUROTICISM (EPQR-N)
Are the following statements characteristic of you?
1. Does your mood often go up and down?
Yes No
2. Do you ever feel ‘just miserable’ for no reason?
Yes No
3. Do you often feel ‘fed-up’?
Yes No
4. Would you call yourself a nervous person?
Yes No
5. Are you a worrier?
Yes No
6. Would you call yourself tense or ‘highly strung’?
Yes No
7. Do you worry too long after an embarrassing experience?
Yes No
8. Do you suffer from ‘nerves’?
Yes No
9. Do you often feel lonely?
Yes No
10. Are you often troubled about feelings of guilt?
Yes No
11. Are you an irritable person?
Yes No
12. Are your feelings easily hurt?
Yes No
MINDFULNESS IN ADVANCED CANCER 103
Appendix 3:
Factor Analyses of Key Study Variables
Exploratory Factor Analyses (EFA) were conducted with principal axis factor extraction
and promax rotation in SPSS. Kaiser’s measure of sampling adequacy (KMO; Kaiser, 1974) was
used to determine factorability (values > 0.60; Tabachnick & Fidell, 2001). The scree test
(Cattell, 1966) was used to inform factor extraction, and when results from the scree test were
equivocal, inspection of eigenvalues greater than one (Kaiser, 1960) was also employed. Items
with loadings greater than 0.30 were considered satisfactory (Costello & Osborne, 2005).
MINDFULNESS IN ADVANCED CANCER 104
Mindful Attention Awareness Scale (MAAS)
In an EFA of the 14-item MAAS scale, the KMO measure of sampling adequacy
indicated that the data were suitable for analyses (KMO=0.85). The EFA revealed a single-
factor structure, consistent with previously-published EFAs of the scale (Black, Sussman, Steve,
Johnson, Anderson, & Milam, 2011; Brown & Ryan, 2003; Carlson & Brown, 2005). Inspection
of the scree plot (see below) showed that the first factor clearly existed on a separate slope than
the remaining factors. In the single-factor solution, factor loadings ranged from 0.46 to 0.78 (see
below).
Scree Plot for MAAS
MINDFULNESS IN ADVANCED CANCER 105
Factor Loadings for MAAS (N=102)
Item Loading
I find myself doing things without paying attention.
0.78
I rush through activities without being really attentive to them.
0.74
I do jobs or tasks automatically, without being aware of what I’m doing.
0.72
It seems I am “running on automatic” without much awareness of what I’m
doing.
0.66
I get so focused on the goal I want to achieve that I lose touch with what I am
doing right now to get there.
0.65
I find it difficult to stay focused on what’s happening in the present.
0.64
I tend to walk quickly to get where I’m going without paying attention to
what I experience along the way.
0.62
I find myself listening to someone with one ear, doing something else at the
same time.
0.58
I drive places on “automatic pilot” and then wonder why I went there.
0.57
I find myself preoccupied with the future or the past.
0.57
I break or spill things because of carelessness, not paying attention, or
thinking of something else.
0.55
I forget a person’s name almost as soon as I’ve been told it for the first time.
0.47
I could be experiencing some emotion and not be conscious of it until some
time later.
0.46
I snack without being aware that I’m eating.
0.46
MINDFULNESS IN ADVANCED CANCER 106
Center for Epidemiological Studies - Depression Scale (CES-D)
The KMO measure of sampling adequacy indicated that the 20 items that comprise the
CES-D were suitable for an EFA (KMO = 0.81). Although a four-factor solution for the CES-D
has been reported in the literature (e.g., Knight, Williams, McGee, & Olaman, 1997; Radloff,
1977), the scree test from the EFA clearly indicated a one-factor solution in the present study
(see below). Loadings of the single factor are presented below.
Scree Plot for CES-D
MINDFULNESS IN ADVANCED CANCER 107
Factor Loadings for CES-D (N=102)
Item Loading
I felt sad
0.79
I felt that I could not shake off the blues even with
help from my family and friends
0.76
I talked less than usual
0.67
I felt depressed
0.65
I felt lonely
0.60
I had crying spells
0.57
I felt fearful
0.56
I was happy
0.55
I could not get “going”
0.53
I felt that everything I did was an effort
0.50
I was bothered by things that usually don’t bother
me
0.48
I had trouble keeping my mind on what I was doing
0.48
I thought my life had been a failure
0.47
I enjoyed life
0.47
My sleep was restless
0.44
People were unfriendly
0.44
I did not feel like eating; my appetite was poor
0.44
I felt that I was just as good as other people
0.39
I felt hopeful about the future
0.34
I felt that people disliked me
0.32
MINDFULNESS IN ADVANCED CANCER 108
Hospital Anxiety and Depression Scale – Anxiety Subscale (HADS-A)
The seven items of the HADS-A demonstrated adequate factorability (KMO=0.78).
Inspection of the scree plot (see below) suggested a one factor solution. All loadings on the
single factor were greater than 0.38 (see below).
Scree Plot for HADS-A
MINDFULNESS IN ADVANCED CANCER 109
Factor Loadings for the HADS-A (N=102)
Item Loading
I get a sort of frightened feeling as if something awful is about to happen.
0.70
Worrying thoughts go through my mind.
0.68
I get sudden feelings of panic.
0.66
I get a sort of frightened feeling like butterflies in my stomach.
0.60
I can sit at ease and feel relaxed.
0.45
I feel tense or wound up.
0.41
I feel restless as if I have to be on the move.
0.39
MINDFULNESS IN ADVANCED CANCER 110
European Organization for Research and Treatment of Cancer Quality of Life
Questionnaire (EORTC QLQ-C30) Emotional Dysfunction Subscale
The four items that comprise the emotional dysfunction subscale of the EORTC QLQ-
C30 demonstrated adequate factorability (KMO=0.78) in an EFA. The scree test indicated a
one-factor solution (see below). All loadings on the single factor were greater than 0.60 (see
below).
Scree Plot for EORTC QLQ-C30 Emotional Dysfunction Subscale
MINDFULNESS IN ADVANCED CANCER 111
Factor Loadings for the Emotional Dysfunction Subscale of the EORTC (N=102)
Item Loading
Did you feel tense? 0.77
Did you worry? 0.73
Did you feel irritable? 0.68
Did you feel depressed? 0.61
MINDFULNESS IN ADVANCED CANCER 112
Impact of Event Scale Revised – Intrusive Thoughts Subscale (IES-R)
The KMO measure of sampling adequacy indicated that the 8 items that comprise the
intrusive thoughts subscale of the IES-R were suitable for an EFA (KMO=0.85). Inspection of
the scree plot showed that the first factor was on a separate slope than the remaining factors (see
below), thereby suggesting a single-factor structure. In this single-factor solution, factor
loadings ranged from 0.51 to 0.79 (see below).
Scree Plot for the IES-R
MINDFULNESS IN ADVANCED CANCER 113
Factor Loadings for the Intrusive Thoughts Subscale of the IES-R (N=102)
Item Loading
I had waves of strong feelings about it. 0.79
I thought about it when I didn't mean to. 0.77
Other things kept making me think about it. 0.76
Any reminder brought back feelings about it. 0.74
I found myself acting or feeling like I was back at that time. 0.64
Pictures about it popped into my mind. 0.56
I had trouble staying asleep. 0.52
I had dreams about it. 0.51
MINDFULNESS IN ADVANCED CANCER 114
Brief COPE
The twelve items from the Brief COPE demonstrated adequate factorability (KMO=
0.72). The scree test was ambiguous (see below), and inspection of eigenvalues greater than 1
(eigenvalues = 3.41, 1.98, 1.37, and 1.02) suggested four factors. Of these four factors, however,
two factors were two-item factors (one made up of the two items from the behavioral
disengagement subscale and one made up of the two items from the denial subscale). While
extracting more factors increased the variance explained, it also made the solution less
parsimonious. Additionally, extracting factors with fewer than three items is not recommended
(Tabachnick & Fidell, 2001). So, the factor analysis was rerun, restricting it to a two factor
solution. This yielded one factor comprised of items reflecting active coping strategies (i.e.,
items from the planning, positive reframing, active, and self distraction subscales) and one factor
comprised of items reflecting avoidant coping strategies (i.e., items from the denial and
behavioral disengagement subscales). The factor loadings are included below.
MINDFULNESS IN ADVANCED CANCER 115
Scree Plot for the Brief COPE
MINDFULNESS IN ADVANCED CANCER 116
Factor Loadings for the Brief COPE (N=102)
Item Subscale Loadings
Active
Coping
Factor
Avoidant
Coping
Factor
Trying to come up with a strategy of what to
do
Planning
0.71 0.03
Trying to see it in a different light, to make it
seem more positive
Positive reframing
0.62 -0.02
Turning to work or other activities to take my
mind off things
Self distraction
0.60 0.08
Taking action to try to make the situation
better
Active
0.55 -0.28
Concentrating on doing something about the
situation
Active
0.51 -0.07
Looking for something good in what is
happening
Positive reframing
0.50 -0.04
Thinking hard about what steps to take Planning
0.48 0.06
Think about it less by going to movies,
watching TV, reading, sleeping, daydreaming
Self distraction
0.44 0.16
Saying "this isn't real" Denial
0.10 0.85
Giving up the attempt to cope Behavioral
disengagement -0.03 0.63
Refusing to believe that it has happened Denial
0.05 0.59
Giving up trying to deal Behavioral
disengagement -0.02 0.37
MINDFULNESS IN ADVANCED CANCER 117
Appendix 4:
Full Model with Path Weights and the Amount of Variance Accounted for by Each Path
Full Sample (N=102)
Emotional
Distress
Mindfulness
Avoidant
Coping
Active
Coping
Physical
Symptoms
Cancer-Related
Intrusive Thoughts
Education
Neuroticism
-0.49
(24%)
-0.18
(9%)
-0.18
(4%)
-0.18
(4%)
0.50
(36%)
0.10
(2%)
0.06
(<1%)
0.32
(10%)
0.13
(5%)
0.12
(3%)
-0.11
(<1%)
0.20
(13%)
-0.16
(2%)
0.02
(<1%)
-0.14
(1%)
-0.02
(<1%)
MINDFULNESS IN ADVANCED CANCER 118
Appendix 5:
Means and Standard Deviations of Key Study Variables for Men (n=49) and Women
(n=53) and t-tests Comparing Key Study Variables between Sexes
Variable Sex M SD t df
Mindfulness
Men 5.01 0.64 1.17 100
Women 4.84 0.75
Depressive Symptoms
Men 13.76 7.67 2.75
**
100
Women 18.78 10.43
Anxiety Symptoms
Men 4.39 2.74 2.76
**
100
Women 6.12 3.53
Emotional Dysfunction
Men 1.90 0.56 2.10
*
100
Women 2.15 0.61
Physical Symptoms
Men 2.12 0.56 0.55 100
Women 2.06 0.54
Intrusive Thoughts
Men 0.88 0.66 2.75
**
100
Women 1.27 0.77
Active Coping
Men 2.66 0.68 0.78 100
Women 2.76 0.60
Avoidant Coping
Men 1.28 0.47 0.61 100
Women 1.33 0.49
*
significant at the 0.05 level
**
significant at the 0.01 level
Abstract (if available)
Linked assets
University of Southern California Dissertations and Theses
Conceptually similar
PDF
Psychosocial adjustment among patients with metastatic colorectal cancer
PDF
Role of age and comorbidities in the quality of life of newly diagnosed prostate cancer patients
PDF
Psychosexual adjustment among low-income Latinas with cervical cancer
PDF
Psychosocial adjustment of Latina cervical cancer patients
PDF
Social support, constraints, and protective buffering in prostate cancer patients and their partners
PDF
Health-related quality of life correlates of the treatment decision making process of newly diagnosed prostate cancer patients
PDF
The effects of physical functioning and public stigma on psychological distress as mediated by cognitive and social factors among Korean survivors of childhood cancer
PDF
Investigating racial and ethnic disparities in patient experiences with care and health services use following colorectal cancer diagnosis among older adults with comorbid chronic conditions
PDF
The influences of anxiety, coping, and social support on physical functioning among heart failure patients
PDF
The effects of health-related spousal influence on couples coping with chronic heart failure: an application of the actor-partner interdependence model
PDF
Crosscultural differences in dementia diagnosis and care-seeking in Hispanic and non-Hispanic white outpatients
PDF
Racial/ethnic differences in colorectal cancer patient experiences, health care utilization and their association with mortality: findings from the SEER-CAHPS data
PDF
The effect of renal function on toxicity of E7389 (eribulin) among patients with bladder cancer
PDF
Eribulin in advanced bladder cancer patients: a phase I/II clinical trial
PDF
Exploring the effects of mindfulness on psychosocial factors for patients receiving hand therapy
PDF
Eliciting perspectives on palliative care: outpatient visits, advance care planning, and the impact of COVID-19
PDF
The effects of mindfulness meditation on stress levels among student registered nurse anesthetists: a pilot study
PDF
Sources of stability and change in the trajectory of openness to experience across the lifespan
PDF
Investigating a physiological pathway for the effect of guided imagery on insulin resistance
PDF
A theory-informed approach to understanding family correlates of treatment use among Latinxs with psychotic symptoms
Asset Metadata
Creator
Taylor-Ford, Megan
(author)
Core Title
Mindfulness among patients with advanced colorectal cancer
School
College of Letters, Arts and Sciences
Degree
Doctor of Philosophy
Degree Program
Psychology
Publication Date
12/01/2014
Defense Date
08/07/2014
Publisher
University of Southern California
(original),
University of Southern California. Libraries
(digital)
Tag
advanced cancer,colorectal cancer,emotional distress,mindfulness,OAI-PMH Harvest,physical symptoms,sex differences
Format
application/pdf
(imt)
Language
English
Contributor
Electronically uploaded by the author
(provenance)
Advisor
Meyerowitz, Beth E. (
committee chair
), John, Richard S. (
committee member
), Enguidanos, Susan M. (
committee member
), Knight, Bob G. (
committee member
)
Creator Email
megan.taylorford@gmail.com,taylorfo@usc.edu
Permanent Link (DOI)
https://doi.org/10.25549/usctheses-c3-518027
Unique identifier
UC11297566
Identifier
etd-TaylorFord-3101.pdf (filename),usctheses-c3-518027 (legacy record id)
Legacy Identifier
etd-TaylorFord-3101.pdf
Dmrecord
518027
Document Type
Dissertation
Format
application/pdf (imt)
Rights
Taylor-Ford, Megan
Type
texts
Source
University of Southern California
(contributing entity),
University of Southern California Dissertations and Theses
(collection)
Access Conditions
The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...
Repository Name
University of Southern California Digital Library
Repository Location
USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA
Tags
advanced cancer
colorectal cancer
emotional distress
mindfulness
physical symptoms
sex differences