Redução de Estresse Baseada em <i>Mindfulness</i> nos sintomas do câncer de mama: revisão sistemática e metanálise

Castanhel, Flavia Del; Liberali, Rafaela

doi:10.31744/einstein_journal/2018RW4383

Brasil

home Sumário navigate_before Anterior Atual Seguinte navigate_next

home Sumário

Revisão • EINSEinstein (São Paulo) 16 (4) • 2018 • https://doi.org/10.31744/einstein_journal/2018RW4383 linkcopiar

Redução de Estresse Baseada em Mindfulness nos sintomas do câncer de mama: revisão sistemática e metanálise

Autoria SCIMAGO INSTITUTIONS RANKINGS

RESUMO

A prática da Redução de Estresse Baseada em Mindfulness aumenta a capacidade de concentração e de atenção, sendo particularmente eficaz para pessoas com câncer de mama. O objetivo deste estudo foi analisar os efeitos da Redução de Estresse Baseada em Mindfulness nos sintomas de câncer de mama. Revisão sistemática e metanálise, na qual, para encontrar os estudos adequados, foi feita busca, no banco de dados PubMed/MEDLINE, usando as palavras-chave “breast cancer” e “mindfulness-based stress reduction”. Foram selecionados estudos em inglês publicados entre 2013 e 2017. Os estudos foram avaliados de acordo com sua qualidade metodológica pela escala PEDro (pontuação superior a 3), estudos que apresentaram evidências empíricas, desenho experimental (randomizado e não randomizado) e que estavam disponíveis na íntegra. Para a metanálise, utilizou-se um modelo de efeitos aleatórios com diferenças de médias padronizadas e intervalos de confiança de 95%. Sete estudos foram incluídos, sendo um não randomizado, contendo apenas um grupo de intervenção da Redução de Estresse Baseada em Mindfulness e seis estudos randomizados, divididos em amostras de dois grupos ou de três grupos. Os estudos não randomizados apresentaram escala PEDro de 6 pontos e os estudos randomizados de dois (de 6 a 7 pontos) e três grupos (7 pontos). Na metanálise, o resultado dos dois estudos randomizados selecionados, apesar de não significativo, revelou um efeito moderado da Redução de Estresse Baseada em Mindfulness sobre o desfecho da fadiga, com diferença média de −0,42 (IC95% −0,92- −0,07; p=0,09). A Redução de Estresse Baseada em Mindfulness apresenta-se como alternativa promissora para tratamento dessa doença.

Descritores: Meditação; Neoplasias da mama; Estresse psicológico; Intervenção psicológica; Qualidade de vida

ABSTRACT

Mindfulness-Based Stress Reduction practices increase the capacity for concentration and attention, and these practices are particularly effective for people with breast cancer. To analyze the effects of the application of Mindfulness-Based Stress Reduction on breast cancer symptoms. Systematic review and meta-analysis were carried out. To find suitable studies, the PubMed/ MEDLINE database was searched using the keywords “breast cancer” and “Mindfulness-Based Stress Reduction”. Studies included were published between 2013 and 2017, written in English and showed methodological quality through the PEDro scale (score greater than 3). They also presented empirical evidence, had an experimental study design (randomized or non-randomized), and had full text available. For the meta-analysis, we used a random-effects model, with standardized mean differences and 95% confidence intervals. Seven studies were included, one non-randomized and containing only an intervention group of Mindfulness-Based Stress Reduction, and six randomized including samples of two or three groups. The non-randomized study showed 6 points on the PEDro scale, the randomized studies of two groups 6 to 7 points and studies with three groups showed 7 points. In the meta-analysis of the two randomized studies, the results, although not significant, revealed a moderate effect for Mindfulness-Based Stress Reduction on the outcome of fatigue, with a mean difference of −0.42 (95%CI −0.92- −0.07; p=0.09). Mindfulness-Based Stress Reduction seems to be a promising alternative for treatment of this disease's symptoms.

Keywords: Meditation; Breast neoplasms; Stress, psychological; Psychosocial intervention; Quality of life

INTRODUÇÃO

O câncer de mama é uma doença complexa e heterogênea em termos de histologia, difusão, resposta terapêutica e diferença de resultados clínicos.⁽¹^–³⁾ Atualmente é o segundo tipo de câncer entre as mulheres⁽⁴^,⁵⁾ e representa 60% dos óbitos nos países desenvolvidos.⁽⁶⁾ A taxa de incidência da doença aumenta globalmente. Em 2008, por exemplo, aproximadamente 1,38 milhão de novos casos de câncer de mama foram diagnosticados⁽⁷⁾ e 1,7 milhão em 2012;⁽⁸^,⁹⁾ a expectativa é de 1,38 a 1,7 milhão de novos casos por ano,⁽¹⁰^,¹¹⁾ o que torna essa doença crônica um dos principais problemas de saúde pública.⁽¹²^,¹³⁾

A ocorrência do câncer de mama é atribuída a fatores hereditários e ambientais.⁽¹⁴⁾ Baixa taxa de incidência tem sido observada em países da África e Ásia, e altas taxas na Europa Setentrional e Ocidental, Austrália, Nova Zelândia e América do Norte.⁽¹⁵⁾ Além disso, diferenças raciais/étnicas observadas nas mulheres afro-americanas mostram que elas têm 41% mais chance de óbito devido ao câncer de mama do que mulheres brancas, embora a incidência da doença seja maior em mulheres brancas.⁽¹⁶⁾

O câncer de mama é caracterizado por aspectos negativos, incluindo sintomas físicos, mentais e psicológicos.⁽¹⁷⁾ Os sintomas psicológicos mais prevalentes são estresse, ansiedade, depressão e função cognitiva comprometida,⁽¹⁸^–²²⁾ além de sintomas físicos, como dor, distúrbios do sono e fadiga,⁽²³^–²⁵⁾ que podem desencadear o medo da morte, a recorrência, uma imagem corporal alterada, diminuição do bem-estar, entre outros.⁽²⁶^–²⁹⁾ A fadiga é definida como cansaço, exaustão ou falta de energia, que deixa o indivíduo desmotivado, compromete seu bem-estar⁽³⁰⁾ e afeta o indivíduo durante e após o tratamento, entre 40% e 80% dos casos.⁽³¹⁾

Muitos pacientes com câncer de mama adotam terapias complementares para lidar com sintomas da doença.⁽³²^,³³⁾ Um total de 33% a 47% das mulheres em todo mundo e 48% a 80% das mulheres americanas usam tais terapias,⁽³⁴⁾ sendo a meditação uma das alternativas complementares que influencia positivamente na reabilitação, reduzindo a dor, o estresse, a ansiedade, a depressão, a fadiga e até mesmo os efeitos adversos causados pelos tratamentos farmacológicos.⁽³⁵^,³⁶⁾ Originalmente proposta por Kabat-Zinn, a meditação tem sido incorporada com sucesso em diversas intervenções clínicas.⁽³⁷⁾

Atuamente a uma gama de abordagens terapêuticas baseadas na Mindfulness, tais como Treinamento em Consciência Alimentar Baseada na Mindfulness (MB-EAT - Mindfulness-Based Eating Awareness Training), Mindfulness-Based Relationship Enhancement (MBRE), Prevenção de Recaída Baseada na Mindfulness (MBRP - Mindfulness-Based Relapse Prevention), Terapia Cognitiva Baseada na Mindfulness (MBCT - Mindfulness-Based Cognitive Therapy) e Redução de Estresse Baseada na Mindfulness (MBSR - Mindfulness-Based Stress Reduction).⁽³⁸⁾ O MBSR é uma protocolo padrão que aborda múltiplas formas de prática de mindfulness com inclusão de elementos de hatha yoga.⁽³⁹⁾

Estudos mostram muitos benefícios da meditação para pacientes com câncer de mama, como redução do estresse e da ansiedade, e melhora dos fatores psicológicos, da qualidade do sono, da perspectiva de vida e dos sentimentos de autonomia, competência, força pessoal, senso de calma, serenidade e equilíbrio.⁽²³^,⁴⁰⁾

OBJETIVO

Analisar os efeitos da prática de Redução de Estresse Baseada em Mindfulness de sintomas como fadiga, depressão, ansiedade e aspectos cognitivos em mulheres com câncer de mama.

MÉTODOS

Estratégia de busca

Foi realizado levantamento bibliográfico na base de dados US National Library of Medicine/National Institutes of Health/MEDLINE (NLM/NIH/MEDLINE) − PubMed. Os procedimentos relacionados ao levantamento incluíram os seguintes passos:

–
Primeiro passo: identificar o descritor controlado pelo Medical Subject Headings (MeSH) “breast cancer” e o termo não controlado “MBSR mindfulness-based stress reduction”. Ambos foram pesquisados na base de dados MEDLINE, sendo eles: “breast neoplasms” OR “breast” AND “neoplasms” OR “breast neoplasm” OR “breast” AND “cancer” OR “breast cancer” AND “MBSR” AND “Mindfulness” OR “mindfulness” AND “based” AND “stress” OR “Stress” AND “reduction”.
–
Segundo passo: dois revisores independentes examinaram os relatos nas duas fases como proposto por Cook et al.⁽⁴¹⁾ Na primeira fase, artigos que apresentaram os descritores tiveram os títulos e os resumos examinados considerando a relevância. Após, na segunda fase, os textos completos dos artigos relevantes foram coletados para avaliar a elegibilidade.

Critério de inclusão e exclusão

Os critérios de inclusão para os artigos científicos foram: escritos em inglês disponíveis na base de dados PubMed/PMC; diretamente relacionados ao tema câncer de mama e MBSR; com evidência empírica, como desenho de estudo experimental (randomizado e não randomizado); com texto completo; que obtiveram escore maior do que 3 na Physiotherapy Evidence Database (PEDro; http://www.pedro.org.au); e período de estudo entre 2013 e 2017.

Foram excluídos artigos científicos contendo outros tipos de câncer que não câncer de mama; (contendo outras terapias (com MBSR somente aceito separadamente ou em comparação com outras terapias); contendo outros sintomas que não fadiga, depressão, ansiedade e aspectos cognitivos; e publicados em línguas diferentes do inglês.

Qualidade metodológica

A qualidade metodológica de todos os estudos foi avaliada utilizando a PEDro⁽⁴²⁾ (Tabela 1). Esta base de dados é gratuita e contém ensaios clínicos controlados, revisões sistemáticas e diretrizes de prática clínica em fisioterapia. A PEDro é baseada na lista de Delphi, e seu objetivo é ajudar seus usuários a identificar rapidamente qual dos ensaios clínicos randomizados conhecidos ou suspeitos (ensaios clínicos controlados ou ECCs) arquivados na base PEDro tem possibilidade de ser validado internamente (critério 2 a 9) e pode ter informação estatística suficiente para interpretar os resultados (critério 10-11).⁽⁴²⁾

Thumbnail

Tabela 1
Physiotherapy Evidence Database (PEDro)

Risco de viés na avaliação

A qualidade metodológica foi avaliada de modo independente por pelo menos dois revisores utilizando a ferramenta de risco da Cochrane, que considera sete domínios diferentes: adequação da geração de sequência; alocação da supressão da sequência; cegamento dos participantes e assistentes; cegamento da avaliação dos resultados; dados dos resultados incompletos; relato dos resultados seletivos; e presença de outras fontes potenciais de viés não consideradas para os outros seis domínios. O risco global estimado de viés para cada ensaio foi categorizado como baixo (se o risco de viés era baixo em todos os domínios-chaves), impreciso (se o risco de viés era baixo ou impreciso para todos os domínios-chaves) ou alto (se o risco de viés era alto em um ou mais domínios-chaves).⁽⁴³⁾

Análise de dados

Foi conduzida metanálise com dois estudos classificados como randomizados, ao passo que apresentavam taxa de fadiga com dados contínuos. O software Stata (versão 12.0; Stata Corp., College Station, EUA) foi utilizado para síntese e análise. Após a intervenção, os tamanhos do efeito do intergrupo foram calculados utilizando modelos de efeitos aleatórios (como tal efeito possibilita a generalização dos achados, além de um conjunto de estudos que foi incluído) e a variabilidade nas estimativas, com 95% de intervalo de confiança (IC95%), e estratificação pelo tipo de comparação de grupo (MBSR versus controle).

Após, utilizou-se a g de Hedges ajustada para calcular a proporção do efeito de cada estudo. A magnitude do g de Hedges pode ser interpretada utilizando a convenção de Cohen,⁽⁴⁴⁾ a saber: pequena (0,2), média (0,5) e extensa (0,8). Para estabelecer se os resultados dos estudos eram consistentes, os testes da heterogeneidade foram realizados utilizando estatísticas Q e I². A estatística Q calculou o valor da probabilidade para heterogeneidade dos estudos (heterogeneidade significante é indicada por valor de p≤0,05). O valor I² de 0% indica heterogeneidade não observada, enquanto os valores de 25%, 50% e 75% são considerados baixo, moderado, e alto.⁽⁴⁵⁾ O viés da publicação foi avaliado utilizando um gráfico de funil.

RESULTADOS

Características e resultados da pesquisa

A pesquisa localizou 370 estudos na base de dados MEDLINE (PubMed/PMC) utilizando os descritores “Mindfulness-Based Stress Reduction” AND “breast cancer”. Desta busca, sete estudos foram selecionados para análise devido ao preenchimento dos critérios de inclusão (Figura 1).

Figura 1
Fluxograma da pesquisa

Para descrever os estudos em tabelas, as seguintes categorias foram consideradas: ano de publicação, local onde o estudo foi conduzido, classificação da escala PEDro, escalas utilizadas como instrumentos de medição, publicação periódica, amostra (idade e sexo), intervenção (mindfulness), monitoramento da amostra e resultados obtidos.

Os países onde os estudos foram desenvolvidos foram os Estados Unidos [3 (42,8%)], Irã [2; (28,6%)], Inglaterra [1; (14,3%)] e Suécia [1; (14,3%)]. As publicações dos artigos ocorreram nos anos de 2013 [1; (14,3%)], 2014 [3 (42,8%)], 2015 [2; (28,6%)] e 2017 [1; (14,3%)]. Os artigos utilizaram diversas escalas para análise, como o European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC-QLQ-30), sendo esse um dos mais utilizados entre os estudos (Tabela 2).

Thumbnail

Tabela 2
Características dos estudos incluídos

Características populacionais

Como demonstrado na tabela 3, as amostras de sete estudos foram compostas apenas por mulheres, com idade entre 20 e 80 anos, totalizando 532 participantes. Todos os estudos utilizaram MBSR como intervenção, baseada no manual de Kabat-Zinn,⁽⁴⁶^–⁵²⁾ realizada com mulheres diagnosticadas com câncer de mama, estágio zero a III,⁽⁴⁷^,⁴⁹⁾ fase I e II,⁽⁴⁶⁾ fase I, II, III,⁽⁴⁸^,⁵¹⁾ e câncer com metástase.⁽⁵⁰⁾

Thumbnail

Tabela 3
Características de intervenções de estudos

Desenho dos estudos

As intervenções de estudos tiveram desenhos diferentes:

–
Estudos não randomizados [1; (14,3%)], contendo somente um Grupo MBSR.⁽⁵⁰⁾
–
Estudos randomizados [5; (83%)], com amostras divididas em dois grupos, comparando o Grupo MBSR com um controle ou Grupo Cuidado Habitual [3 (42,8%)];⁽⁴⁷^,⁴⁹^,⁵¹⁾ e exemplos divididos em três grupos, comparando o grupo MBSR com os Grupos Controle e o Grupo Tratamento Metacognitivo (GTM) [1; (14,3%)],⁽⁴⁸⁾ ou com Grupos Controle e MBSR + instrutor e sessões grupo semanalmente [1; (14,3%)].⁽⁵²⁾

Resultados de método qualitativo

O escore da escala PEDro variou de 6 a 7 (média total de todos os estudos de 6,71; desvio padrão de 0,48). O estudo não randomizado apresentou um escore PEDro de 6 pontos;⁽⁵⁰⁾ os estudos de três grupos randomizados, de 6 a 7 pontos;⁽⁴⁷^,⁴⁹^,⁵¹⁾ e os estudos de três grupos, 7 pontos.⁽⁴⁶^,⁴⁸^,⁵²⁾

Resultados da Redução de Estresse Baseada em Mindfulness

O estudo não randomizado de Eyles et al.,⁽⁵⁰⁾ demostrou, como resultado da prática de MBSR, melhoras significativas nos escores de depressão e ansiedade, e tendência para melhora no escore de fadiga. Os três estudos randomizados contendo dois grupos de intervenção mostraram resultado de que 8 semanas de prática de MBSR levaram à redução significante de escores para fadiga,⁽⁴⁷^,⁵¹⁾ ansiedade,⁽⁴⁹⁾ e aspectos cognitivos.⁽⁵¹⁾ Dois estudos randomizados contendo três grupos de intervenção mostraram que MBSR melhorou fadiga,⁽⁴⁸⁾ depressão,⁽⁵²⁾ ansiedade e depressão.⁽⁴⁶⁾

Viés em ensaios e qualidade da evidência

O risco de viés da Cochrane para cada citação é descrito na Figura 2. Somente um dos seis estudos mostrou escore de risco geral baixo do viés da Cochrane (Figura 3). Devido ao pequeno número de ensaios incluídos nesta metanálise, não foi possível examinar os gráficos de funil com base no viés da publicação.

Figura 2
Qualidade metodológica de ensaios utilizando ferramenta de risco de viés da Cochrane

Figura 3
Risco geral de viés utilizando a ferramenta de risco de viés da Cochrane

Resultados das metanálises

Dois estudos apresentaram dados contínuos para a metanálise. Os resultados, apesar de não significantes, mostraram efeito moderado de MBSR em fadiga com diferença média de −0,42 (IC95% −0,92- −0,07; p=0,09). O gráfico em floresta mostra IC95% para cada estudo. Observa-se que o IC95% dos artigos e o gráfico diamante não cruzaram a linha, indicando resultados estaticamente nulos em favor de MBSR, em relação ao escore de fadiga.

O resultado do tamanho do efeito (TE) de MBSR, em relação ao escore de fadiga, mostrou pequenos TE com o maior efeito no estudo por Reich et al.,⁽⁴⁷⁾ (0,46; IC95% −1,09-0,17), seguido por Rahmani et al.,⁽⁵¹⁾ (0,36; IC95%: −1,17-0,45), sem heterogeneidade, de acordo com análise do teste Q (p=0,85) e I²=0% (Figura 4).

Figura 4
Gráfico em floresta de Redução de Estresse Baseada em Mindfulness versus cuidado habitual (controle) para fadiga

DISCUSSÃO

Os resultados da revisão sistemática com meta-análise (modelo de efeitos aleatórios) e dos demais estudos (estudos randomizados e não randomizados) indicam que a MBSR é susceptível a reduzir os sintomas do câncer de mama em comparação aos demais tratamentos (controle, cuidados habituais, intervenção nutricional, metacognitivo), na melhora dos escores da depressão, fadiga e aspectos cognitivos. Supõe-se que, com a melhora de um sintoma do câncer de mama, tem-se a tendência de melhora de outros vários sintomas em conjunto. Com a melhora dos sintomas do câncer de mama, há tendência para melhorar diversos outros sintomas ao mesmo tempo. Nesta revisão, foram enfatizados alguns desses sintomas e seu relacionamento com outros, que poderia ser mencionado para entender o tratamento de indivíduos com câncer de mama.

Quatro estudos mostraram que MBSR pode beneficiar a diminuição de sintomas da fadiga.⁽⁴⁷^,⁴⁸^,⁵¹⁾ A fadiga é definida como a impossibilidade de iniciar e manter atividades que requerem atenção e automotivação,⁽⁵²^–⁵⁴⁾ sendo mais prevalentes os sintomas crônicos e debilitantes entre pacientes com câncer, levando à redução de funções físicas⁽⁵⁵⁾ e tornando-se o principal problema durante o tratamento de câncer de mama.⁽⁵⁶⁾

Armes et al.,⁽⁵⁷⁾ enfatizam que não há tratamentos farmacológicos para fadiga. Porém, as intervenções devem focar em terapias de suporte psicológico, educacional, social e em grupo, com o objetivo de permitir que os indivíduos interpretem a fadiga, respondam os sintomas com pensamento positivo e retornem às atividades diárias.⁽⁵⁷^,⁵⁸⁾ A prática de meditação parece ser benéfica ao tratamento de fadiga, sendo considerada uma terapia psicoeducacional⁽⁵⁹⁾ que combina cognição com treinamento intensivo de meditação,⁽³⁸⁾ focando em observação e trabalho em processos cognitivos e afetivos, com objetivo de ensinar os indivíduos a se tornarem conscientes e envolvidos consigo mesmo.⁽⁶⁰⁾

A relação positiva entre a prática de meditação e os sintomas de câncer de mama é consistente com diversos outros estudos. Alguns mostram redução de fadiga e aumento de vigor físico, como o estudo de Carlson et al.,⁽⁶¹⁾ que incluiu 89 sujeitos de ambos os sexos e diversos tipos de câncer, em 6 semanas de prática de meditação, e o estudo de Carlson et al.,⁽⁶²⁾ com 63 indivíduos de ambos os sexos com câncer (câncer de mama, ovário, linfoma e próstata), após 8 semanas de prática de MBSR. Outros estudos mostram redução da fadiga com melhora de energia física, como o de Carlson et al.,⁽⁶³⁾ com 49 mulheres com câncer de mama e 10 homens com câncer de próstata, em 8 semanas de prática de MBSR, e o de Lengacher et al.,⁽⁶⁴⁾ com 41 mulheres com câncer de mama, após 6 semanas de prática de MBSR.

Os aspectos cognitivos mostraram melhora com prática de MBSR⁽⁴⁸^,⁵¹⁾ e da terapia de grupo de metacognição.⁽⁴⁸⁾ Entre 17% e 75% dos pacientes com câncer de mama que realizaram quimioterapia mostraram estrutura cerebral alterada, e a função que sugere padrão de lesão cerebral difusa, que contorna os deficits cognitivos, pode ocorrer durante os 6 primeiros meses, seguida pela recuperação de 1 a 2 anos e/ou período de estabilização.⁽⁶⁵⁾ Funções executivas (como a memória de trabalho, por exemplo) e velocidade de processamento, processo cognitivo fortemente controlado pelos sistemas cerebrais frontais, foram dois dos mais relatados.⁽⁶⁶⁾

A memória tem a função de armazenar e manipular informação por um período curto, requerendo integração do córtex pré-frontal com outras conexões cerebrais.⁽⁶⁷⁾ A atenção é um modulador-chave de processamento cognitivo, possibilitando selecionar estímulos relevantes e inibir informações irrelevantes, mantendo o foco no desempenho cognitivo, dividindo a atenção, e ficando vigilante quando necessário.⁽⁶⁸⁾ A quimioterapia pode afetar a memória (verbal e visual), a atenção, a concentração, as tarefas de decisões múltiplas, a flexibilidade mental e a velocidade de processamento.⁽⁶⁹⁾

Portanto, MBSR é uma terapia promissora e está associada ao aumento de densidade nas regiões do cérebro relacionadas à atenção e ao processamento sensorial, incluindo córtex pré-frontal e ínsula anterior direita, levando ao aumento da ativação cerebral envolvida no processamento das emoções, no senso de bem-estar e na redução de recaída e recorrência.⁽⁷⁰^,⁷¹⁾ Esse modelo de mindfulness compreende dois componentes, a auto-regulação da atenção (mantida na experiência imediata) e a orientação atitudinal (curiosidade, abertura e aceitação).⁽⁶⁸⁾

O estudo de Schellekens et al.,⁽⁷²⁾ foi consistente em mostrar o ambiente do treinamento de MBSR experimentado por 37 mulheres com câncer de mama como seguro e com conteúdo disponível para os participantes que puderam conectar e confiar uma na outra, possibilitando aos pacientes um sentimento de aceitação e ajuda mútua, para facilitar os processos de aprendizagem, como reconhecer suas emoções e ganhar perspectivas distintas.

A terapia de grupo de metacognição também se mostrou promissora para melhora dos aspectos cognitivos no câncer de mama. A terapia de grupo de metacognição é similar ao MBSR, sendo baseada na premissa de que a avaliação negativa das doenças (como pensamentos negativos sobre câncer e suas consequências) instiga e mantém a angústia e, ainda, usa elementos de mindfulness para procurar o autoconhecimento, entender os sentimentos e as emoções, focando no pensamento negativo de interrupção.⁽⁷³^,⁷⁴⁾

Estudos mostram que MBSR melhorou a depressão e a ansiedade,⁽⁴⁶^,⁴⁹^,⁵⁰^,⁵²⁾ bem como a depressão, para intervenção de educação nutricional.⁽⁴⁶⁾ De 22% a 50% das mulheres com câncer de mama têm depressão, 3% a 19% estresse pós-traumático e 33%, estresse.⁽⁷⁵⁾ Huang et al.,⁽⁷⁶⁾ enfatizaram que quase 60% das pacientes com câncer de mama relatam alto níveis de ansiedade, enquanto 25,6% a 58% relatam conviver com depressão.

Mindfulness é um importante para combater sintomas psicológicos, pois leva o indivíduo a aceitar suas experiências internas sem julgamento, reduz a resposta cotidiana ou automática a experiências estressantes, e desenvolve uma visão dos acontecimentos de sua vida (que não podem mudar), portanto, reduzindo também o estresse de sintomas psicológicos.⁽⁷⁷⁾ Algumas metanálises confirmam que a prática de MBSR pode ajudar a reduzir os sintomas psicológicos, como distúrbios de humor e sono, depressão e ansiedade em mulheres com câncer de mama.⁽⁹^,⁵⁹^,⁷⁸⁾ Outros estudos randomizados são consistentes em mostrar a relação da prática de meditação e a melhora dos sintomas de depressão e ansiedade, com 6⁽⁶¹^,⁶⁴⁾ ou 8 semanas de prática.⁽⁶²^,⁶³⁾

A intervenção da educação nutricional também mostrou melhora na depressão, com o uso de elementos similares ao MBSR, em termos de ter grupo de terapia ao longo de 8 sessões com atividades de lição de casa (sem incluir elementos de meditação ou yoga), porém, com foco na educação nutricional e na mudança da dieta, por meio de preparação de grupo de refeição, seguindo os princípios da teoria cognitiva social e aconselhamento centrado no paciente.⁽⁴⁶^,⁷⁹⁾ A intervenção da educação nutricional é importante, como uma intervenção no estilo de vida, para reduzir a gordura ingerida na dieta, causar influência razoável no peso corporal, e melhorar a sobrevivência livre da doença de pacientes com câncer de mama.⁽⁸⁰⁾

LIMITAÇÕES

Algumas limitações desta metanálise se relacionam à qualidade dos estudos, que nem sempre alcançam o escore máximo na escala de PEDro e ao fato de os estudos não relatarem dados básicos de estatística descritiva e inferencial, disponibilizando somente valores de frequência. Outra limitação esteve associada à inclusão de ensaios clínicos não randomizados, sem a metanálise deles. Esta escolha se deu pela necessidade de se observarem, na literatura, artigos que disponibilizem resultados inovadores, apesar de não realizados randomicamente. Por fim, destacamos como limitação a escolha de artigos de uma única base de dados, o que pode ter causado falta de intervenção de estudos com excelente qualidade de outras bases de dados. O uso de uma única base foi por esta ter acesso livre e apresentar qualidade em suas publicações.

CONCLUSÃO

Esta revisão sistemática e metanálise sugere que a Redução de Estresse Baseada em Mindfulness pode ser considerada uma alternativa promissora para o tratamento de sintomas de câncer de mama. Os resultados mostram que a Redução de Estresse Baseada em Mindfulness, isolada ou combinada com outras intervenções cognitivas (intervenção de educação nutricional, terapia em grupo de metacognição), é efetiva para os principais sintomas de câncer de mama. Esses achados demostram a necessidade de maior disponibilidade de tratamentos alternativos para os sintomas de câncer de mama, e como isso poderia reduzir os custos de intervenção e, também, complementar o tratamento habitual.

Referências bibliográficas

¹ Prat A, Perou CM. Deconstructing the molecular portraits of breast cancer. Mol Oncol. 2011;5(1):5-23. Review.
² Eroles P, Bosch A, Pérez-Fidalgo JA, Lluch A. Molecular biology in breast cancer: Intrinsic subtypes and signaling pathways. Cancer Treat Rev. 2012; 38(6):698-707. Review.
³ Graveel CR, Calderone HM, Westerhuis JJ, Winn ME, Sempere LF. Critical analysis of the potential for microRNA biomarkers in breast cancer management. Breast Cancer (Dove Med Press). 2015;7:59-79. Review.
⁴ Kim HJ, Park TJ, Ahn KM. Bisphosphonate-related osteonecrosis of the jaw in metastatic breast cancer patients: a review of 25 cases. Maxillofac Plast Reconstr Surg. 2016;38(1):6.
⁵ Gao FF, Lv JW, Wang Y, Fan R, Li Q, Zhang Z, et al. Tamoxifen induces hepatotoxicity and changes to hepatocyte morphology at the early stage of endocrinotherapy in mice. Biomed Rep. 2016;4(1):102-6.
⁶ El-Deeb MM, El-Sheredy HG, Mohammed AF. The role of serum trace elements and oxidative stress in egyptian breast cancer patients. Adv Breast Cancer Res. 2016;5(1):37-47.
⁷ Teegarden D, Romieu I, Lelièvre SA. Redefining the impact of nutrition on breast cancer incidence: is epigenetics involved? Nutr Res Rev. 2012; 25(1):68-95. Review.
⁸ Youlden DR, Cramb SM, Yip CH, Baade PD. Incidence and mortality of female breast cancer in the Asia-Pacific region. Cancer Biol Med. 2014;11(2):101-15.
⁹ Zainal NZ, Booth S, Huppert FA. The efficacy of mindfulness-based stress reduction on mental health of breast cancer patients: a meta-analysis. Psychooncology. 2013;22(7):1457-65. Review.
¹⁰ Eccles SA, Aboagye EO, Ali S, Anderson AS, Armes J, Berditchevski F, et al. Critical research gaps and translational priorities for the successful prevention and treatment of breast cancer. Breast Cancer Res. 2013;15(5):R92. Review.
¹¹ Braithwaite D, Demb J, Henderson LM. Optimal breast cancer screening strategies for older women: current perspectives. Clin Interv Aging. 2016; 11:111-25. Review.
¹² Bodai BI, Tuso P. Breast Cancer Survivorship: a comprehensive review of long-term medical issues and lifestyle recommendations. Perm J. 2015;19(2):48-79.
¹³ Howell A, Anderson AS, Clarke RB, Duffy SW, Evans DG, Garcia-Closas M, et al. Risk determination and prevention of breast cancer. Breast Cancer Res. 2014;16(5):446. Review.
¹⁴ Davis NM, Sokolosky M, Stadelman K, Abrams SL, Libra M, Candido S, et al. Deregulation of the EGFR/PI3K/PTEN/Akt/mTORC1 pathway in breast cancer: possibilities for therapeutic intervention. Oncotarget. 2014;5(13):4603-50. Review.
¹⁵ Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D. Global Cancer Statistics. CA Cancer J Clin. 2011;61(2):69-90. Erratum in: CA Cancer J Clin. 2011;61(2):134.
¹⁶ Noel L, Connors SK, Goodman MS, Gehlert S. Improving breast cancer services for African-American women living in St. Louis. Breast Cancer Res Treat. 2015;154(1):5-12.
¹⁷ Hwang JH, Kim WY, Ahmed M, Choi S, Kim J, Han DW. The use of complementary and alternative medicine by korean breast cancer women: is it associated with severity of symptoms? Evid Based Complement Alternat Med. 2015;2015:182475.
¹⁸ Nowicki A, Krzemkowska E, Rhone P. Acceptance of illness after surgery in patients with breast cancer in the early postoperative period. Pol Przeglad Chir. 2015;87(11):539-50.
¹⁹ Dillard AJ, Scherer L, Ubel PA, Smith DM, Zikmund-Fisher BJ, McClure JB, et al. Breast cancer anxiety's associations with responses to a chemoprevention decision aid. Soc Sci Med. 2013;77:13-9.
²⁰ Vodermaier A, Linden W, Rnic K, Young SN, Ng A, Ditsch N, et al. Prospective associations of depression with survival: a population-based cohort study in patients with newly diagnosed breast cancer. Breast Cancer Res Treat. 2014;143(2):373-84.
²¹ Pinquart M, Duberstein PR. Depression and cancer mortality: a meta-analysis. Psychol Med. 2010;40(11):1797-810.
²² Kang HJ, Kim JM, Kim SY, Kim SW, Shin S, Kim HR, et al. A longitudinal study of bdnf promoter methylation and depression in breast cancer. Psychiatry Investig. 2015;12(4):523-31.
²³ Charlson ME, Loizzo J, Moadel A, Neale M, Newman C, Olivo E, et al. Contemplative self healing in women breast cancer survivors: a pilot study in underserved minority women shows improvement in quality of life and reduced stress. BMC Complement Altern Med. 2014;14:349.
²⁴ Hall DL, Antoni MH, Lattie EG, Jutagir DR, Czaja SJ, Perdomo D, et al. Perceived fatigue interference and depressed mood: comparison of chronic fatigue Syndrome/Myalgic encephalomyelitis patients with fatigued breast cancer survivors. Fatigue. 2015;3(3):142-55.
²⁵ Bower JE. Cancer-related fatigue: mechanisms, risk factors, and treatments. Nat Rev Clin Oncol. 2014;11(10):597-609. Review.
²⁶ Vahdaninia M, Omidvari S, Montazeri A. What do predict anxiety and depression in breast cancer patients? A follow-up study. Soc Psychiatry Psychiatr Epidemiol. 2010;45(3):355-61.
²⁷ Wurtzen H, Dalton SO, Elsass P, Sumbundu AD, Steding-Jensen M, Karlsen RV, et al. Mindfulness significantly reduces self-reported levels of anxiety and depression: Results of a randomised controlled trial among 336 Danish women treated for stage I-III breast cancer. Eur J Cancer. 2013;49(6):1365-73.
²⁸ Chaoul A, Milbury K, Sood AK, Prinsloo S, Cohen L. Mind-Body Practices in Cancer Care. Curr Oncol Rep. 2014;16(12):417. Review.
²⁹ Link AR, Gammon MD, Jacobson JS, Abrahamson P, Bradshaw PT, Terry MB, et al. Use of self-care and practitioner-based forms of complementary and alternative medicine before and after a diagnosis of breast cancer. Evid Based Complement Alternat Med. 2013;2013:301549.
³⁰ Vargas S, Antoni MH, Carver CS, Lechner SC, Wohlgemuth W, Llabre M, et al. Sleep quality and fatigue after a stress management intervention for women with early-stage breast cancer in southern Florida. Int J Behav Med. 2014;21(6):971-81.
³¹ Meneses-Echavez JF, Gonzalez-Jimenez E, Ramirez-Velez R. Effects of supervised exercise on cancer-related fatigue in breast cancer survivors: a systematic review and meta-analysis. BMC Cancer. 2015;15:77.
³² Cramer H, Lauche R, Paul A, Dobos G. Mindfulness-based stress reduction for breast cancer-a systematic review and meta-analysis. Curr Oncol. 2012;19(5):e343-52.
³³ Brahmi SA, El M'rabet FZ, Benbrahim Z, Akesbi Y, Amine B, Nejjari C, et al. Complementary medicine use among Moroccan patients with cancer: A descriptive study. Pan Afr Med J. 2011;10:36.
³⁴ Greenlee H, Balneaves LG, Carlson LE, Cohen M, Deng G, Hershman D, et al. Clinical practice Gguidelines on the use of integrative therapies as supportive care in patients treated for breast cancer. J Natl Cancer Inst Monogr. 2014;2014(50):346-58. Review.
³⁵ Kenne Sarenmalm E, Martensson LB, Holmberg SB, Andersson BA, Oden A, Bergh I. Mindfulness based stress reduction study design of a randomized controlled complementary intervention in women with breast cancer. BMC Complement Altern Med. 2013;13:248.
³⁶ Lamothe M, E, Malboeuf-Hurtubise C, Duval M, Sultan S. Outcomes of MBSR or MBSR-based interventions in health care providers: A systematic review with a focus on empathy and emotional competencies. Complement Ther Med. 2016;24:19-28. Review.
³⁷ Vago DR, Silbersweig DA. Self-awareness, self-regulation, and self-transcendence (S-ART): a framework for understanding the neurobiological mechanisms of mindfulness. Front Hum Neurosci. 2012;6:296.
³⁸ Crane RS, Kuyken W, Hastings RP, Rothwell N, Williams JM. Training teachers to deliver mindfulness-based interventions: learning from the UK experience. Mindfulness (NY). 2010;1(2):74-86.
³⁹ Kabat-Zinn J. Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness. New York: Dell Publishing; 1990.
⁴⁰ Nakamura Y, Lipschitz DL, Kuhn R, Kinney AY, Donaldson GW. Investigating efficacy of two brief mind-body intervention programs for managing sleep disturbance in cancer survivors: a pilot randomized controlled trial. J Cancer Surviv. 2013;7(2):165-82. Review.
⁴¹ Cook DA, West CP. Conducting systematic reviews in medical education: a stepwise approach. Med Educ. 2012;46:943-52.
⁴² PEDro. Physiotherapy Evidence Database [Internet]. Australian: The center for evidence-based physiotherapy; 1999 [cited 2015 June 26]. Available from: http://www.pedro.org.au/wp-content/uploads/PEDro_scale.pdf
» http://www.pedro.org.au/wp-content/uploads/PEDro_scale.pdf
⁴³ Higgins JPT, Altman DG, Gøtzsche PC, et al. The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ. 2011;343:d5928.
⁴⁴ Cohen J. Statistical power analysis for the behavioral sciences. 2a ed. Hillsdale: Lawrence Erlbaum Associates; 1988.
⁴⁵ Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003;327(7414): 557-60. Review.
⁴⁶ Henderson VP, Massion AO, Clemow L, Hurley TG, Druker S, Hébert JR. A randomized controlled trial of mindfulness-based stress reduction for women with early-stage breast cancer receiving radiotherapy. Integr Cancer Ther. 2013;12(5):404-13.
⁴⁷ Reich RR, Lengacher CA, Kip KE, Shivers SC, Schell MJ, Shelton MM, et al. Baseline immune biomarkers as predictors of MBSR(BC) treatment success in off-treatment breast cancer patients. Biol Res Nurs. 2014;16(4):429-37.
⁴⁸ Rahmani S, Talepasand S, Ghanbary-Motlagh A. Comparison of effectiveness of the metacognition treatment and the mindfulness-based stress reduction treatment on global and specific life quality of women with breast cancer. Iran J Cancer Prev. 2014;7(4):184-96.
⁴⁹ Lengacher CA, Shelton MM, Reich RR, Barta MK, Johnson-Mallard V, Moscoso M, S.et al. Mindfulness based stress reduction (MBSR(BC)) in breast cancer: evaluating fear of recurrence (FOR) as a mediator of psychological and physical symptoms in a randomized control trial (RCT). J Behav Med. 2014;37(2):185-95.
⁵⁰ Eyles C, Leydon GM, Hoffman CJ, Copson ER, Prescott P, Chorozoglou M, et al. Mindfulness for the self-Management of fatigue, anxiety, and depression in women with metastatic breast cancer: a mixed methods feasibility study. Integr Cancer Ther. 2015;14(1):42-56.
⁵¹ Rahmani S, Talepasand S. The effect of group mindfulness - based stress reduction program and conscious yoga on the fatigue severity and global and specific life quality in women with breast cancer. Med J Islam Repub Iran. 2015;29:175.
⁵² Sarenmalm EK, Martensson LB, Andersson BA, Karlsson P, Bergh I. Mindfulness and its efficacy for psychological and biological responses in women with breast cancer. Cancer Med. 2017;6(5):1108-22.
⁵³ Nakagawa S, Takeuchi H, Taki Y, Nouchi R, Kotozaki Y, Shinada T, et al. Basal ganglia correlates of fatigue in young adults. Sci Rep. 2016:6:21386.
⁵⁴ Chaudhuri A, Behan PO. Fatigue and basal ganglia. J Neurol Sci. 2000;179(S 1-2):34-42. Review.
⁵⁵ Hoffman AJ, Brintnall RA, Cooper J. Merging technology and clinical research for optimized post-surgical rehabilitation of lung cancer patients. Ann Transl Med. 2016;4(2):28.
⁵⁶ Minton O, Stone P. How common is fatigue in disease-free breast cancer survivors? A systematic review of the literature. Breast Cancer Res Treat. 2008;112(1):5-13. Review.
⁵⁷ Armes J, Chalder T, Addington-Hall J, Richardson A, Hotopf M. A randomized controlled trial to evaluate the effectiveness of a brief, behaviorally oriented intervention for cancer-related fatigue. Cancer. 2007;110(6):1385-95.
⁵⁸ Corbett T, Devane D, Walsh JC, Groarke A, McGuire BE. Protocol for a systematic review of psychological interventions for cancer-related fatigue in post-treatment cancer survivors. Syst Rev. 2015;4:174. Review.
⁵⁹ Smith JE, Richardson J, Hoffman C, Pilkington K. Mindfulness-based stress reduction as supportive therapy in cancer care: systematic review. J Adv Nurs. 2005;52(3):315-27. Review.
⁶⁰ van der Velden AM, Kuyken W, Wattar U, Crane C, Pallesen KJ, Dahlgaard J, et al. A systematic review of mechanisms of change in mindfulness-based cognitive therapy in the treatment of recurrent major depressive disorder. Clin Psychol Rev. 2015;37:26-39. Review.
⁶¹ Carlson LE, Ursuliak Z, Goodey E, Angen M, Speca M. The effects of a mindfulness meditation-based stress reduction program on mood and symptoms of stress in cancer outpatients: 6-month follow-up. Support Care Cancer. 2001;9(2):112-23.
⁶² Carlson LE, Garland SN. Impact of mindfulness-based stress reduction (MBSR) on sleep, mood, stress and fatigue symptoms in cancer outpatients. Int J Behav Med. 2005;12(4):278-85.
⁶³ Carlson LE, Speca M, Patel KD, Goodey, E. Mindfulness based stress reduction in relation to quality of life, mood, symptoms of stress, and immune parameters in breast and prostate cancer outpatients. Psychosom Med. 2003;65(4):571-81.
⁶⁴ Lengacher CA, Johnson-Mallard V, Post-White J, Moscoso MS, Jacobsen PB, Klein TW, et al. Randomized controlled trial of mindfulness-based stress reduction (MBSR) for survivors of breast cancer. Psychooncology. 2009; 18(12):1261-72.
⁶⁵ Kesler S, Hadi Hosseini SM, Heckler C, Janelsins M, Palesh O, Mustian K, et al. Cognitive training for improving executive function in chemotherapy-treated breast cancer survivors. Clin Breast Cancer. 2013;13(4):299-306.
⁶⁶ McDonald BC, Conroy SK, Smith DJ, West JD, Saykin AJ. Frontal gray matter reduction after breast cancer chemotherapy and association with executive symptoms: a replication and extension study. Brain Behav Immun. 2013;30 Suppl: S117-25.
⁶⁷ Scherling C, Collins B, MacKenzie J, Bielajew C, Smith A. Pre-chemotherapy differences in visuospatial working memory in breast cancer patients compared to controls: an FMRI study. Front Hum Neurosci. 2011;5:122.
⁶⁸ Sanger KL, Dorjee D. Mindfulness training for adolescents: a neuro developmental perspective on investigating modifications in attention and emotion regulation using event-related brain potentials. Cogn Affect Behav Neurosci. 2015;15(3):696-711. Review.
⁶⁹ Kaiser J, Bledowski C, Dietrich J. Neural correlates of chemotherapy-related cognitive impairment. Cortex. 2014;54:33-50. Review.
⁷⁰ Keng SL, Smoski MJ, Robins CJ. Effects of mindfulness on psychological health: a review of empirical studies. Clin Psychol Rev. 2011;31(6):1041-56. Review.
⁷¹ Alexander VL, Tatum BC. Effectiveness of cognitive therapy and mindfulness tools in reducing depression and anxiety: a mixed method study. Psychology. 2014;5:1702-13.
⁷² Schellekens MP, Jansen ET, Willemse HH, van Laarhoven HW, Prins JB, Speckens AE. A qualitative study on mindfulness-based stress reduction for breast cancer patients: how women experience participating with fellow patients. Support Care Cancer. 2016;24(4):1813-20.
⁷³ Wenn J, O'Connor M, Breen LJ, Kane RT, Rees CS. Efficacy of metacognitive therapy for prolonged grief disorder: protocol for a randomised controlled trial. BMJ Open. 2015;5(12):e007221.
⁷⁴ Cook SA, Salmon P, Dunn G, Holcombe C, Cornford P, Fisher P. A prospective study of the association of metacognitive beliefs and processes with persistent emotional distress after diagnosis of cancer. Cognit Ther Res. 2015; 39:51-60.
⁷⁵ Classen C, Butler LD, Koopma C, Miller E, DiMiceli S, Giese-Davis J, et al. Supportive-Expressive Group Therapy and Distress in patients With Metastatic Breast Cancer. A randomized clinical intervention trial. Arch Gen Psychiatry. 2001;58(5):494-501.
⁷⁶ Huang J, Shi L. The effectiveness of mindfulness-based stress reduction (MBSR) for survivors of breast cancer: study protocol for a randomized controlled trial. Trials. 2016;17(1):209.
⁷⁷ Witek-Janusek L, Albuquerque K, Chroniak KR, Chroniak C, Durazo-Arvizu R, Mathews HL. Effect of mindfulness based stress reduction on immune function, quality of life and coping in women newly diagnosed with early stage breast cancer. Brain Behav Immun. 2008;22(6):969-81.
⁷⁸ Shennan C, Payne S, Fenlon D. What is the evidence for the use of mindfulness-based interventions in cancer care? A review. Psychooncology. 2011;20(7):681-97.
⁷⁹ Henderson VP, Clemow L, Massion AO, Hurley TG, Druker S, Hébert JR. The effects of mindfulness-based stress reduction on psychosocial outcomes and quality of life in early-stage breast cancer patients: a randomized trial. Breast Cancer Res Treat. 2012;131(1):99-109.
⁸⁰ Chlebowski RT, Blackburn GL, Thomson CA, Nixon DW, Shapiro A, Hoy MK, et al. Dietary fat reduction and breast cancer outcome: interim efficacy results from the women's intervention nutrition study. J Natl Cancer Inst. 2006;98(24):1767-76.

Datas de Publicação

Publicação nesta coleção
06 Dez 2018
Data do Fascículo
2018

Histórico

Recebido
09 Jan 2018
Aceito
27 Jun 2018

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Todos os critérios	Sim/Não	Escore
Critérios de elegibilidade não especificados	Sim/Não	1/0
Indivíduos foram alocados aleatoriamente em grupos (em estudo transversal, os indivíduos foram alocados aleatoriamente pela ordem em que os tratamentos foram recebidos)	Sim/Não	1/0
A alocação foi suprimida	Sim/Não	1/0
Os grupos foram similares na linha de base em relação aos indicadores prognósticos mais importantes	Sim/Não	1/0
Cegamento de todos os indivíduos	Sim/Não	1/0
Cegamento de todos os terapeutas que administraram a terapia	Sim/Não	1/0
Cegamento de todos os assessores que mediram pelo menos um resultado-chave	Sim/Não	1/0
Medidas de pelo menos um resultado-chave foram obtidas de mais de 85% dos indivíduos inicialmente alocados nos grupos	Sim/Não	1/0
Todos os indivíduos cujos resultados medidos estavam disponíveis receberam tratamento ou condição de controle como quando alocado ou, se não foi o caso, os dados de pelo menos um resultado-chave foram analisados por “intenção de tratamento”	Sim/Não	1/0
Os resultados entre grupos de comparações estatísticas são relatados em pelo menos um resultado-chave	Sim/Não	1/0
O estudo disponibiliza tanto pontos de medição quanto modos de variabilidade de pelo menos um resultado-chave	Sim/Não	1/0
	Total	Total /11

Estudos	Local do estudo	Questionário
Henderson et al.,⁽⁴⁶⁾	4 locais práticos em Massachusetts, Estados Unidos	SCL-90-R, DWI
Reich et al.,⁽⁴⁷⁾	Universidade do Sul da Flórida em Tampa, Flórida, Estados Unidos	MDASI
Rahmani et al.,⁽⁴⁸⁾	Departamento de Oncologia e Radioterapia do Hospital Imam Hossein em Teerã, Irã	EORTC QLQ-30
Lengacher et al.,⁽⁴⁹⁾	Instituto de Pesquisa e Centro de Câncer H. Lee Moffitt Tampa, Flórida, Estados Unidos	STAI; CAMSR
Eyles et al.,⁽⁵⁰⁾	3 ambulários oncológicos (UK) Reino Unido	BFI; HADS
Rahmani et al.,⁽⁵¹⁾	Departamento de Oncologia e Radioterapia do Hospital Imam Hossein em Teerã, Irã	FSS; EORTC
Sarenmalm et al.,⁽⁵²⁾	Centro de Pesquisa e Desenvolvimento, Suécia	HADS

Author	PEDro scale criteria	Subjects	Intervention	Findings
Henderson et al.,⁽⁴⁶⁾	7/11	163 women with stage I or II of breast cancer (20 to 65 years old)	G1 = UC (n=58) G2 = MBSR (breast cancer) (n=53) G3 = NEP (n=52) Follow-up: 4 months	Anxiety - SCL-90-R mean (SD) p value Follow-up: 4 months MBSR versus UC = 0.14 (0.05) versus 0.28 (0.05); p≤0.05 Depression - SCL-90-R mean (SD) p value Follow-up: 4 months MBSR versus NEP = 0.31 (0.08) versus 0.58 (0.08); p≤0.05
Reich et al.,⁽⁴⁷⁾	6/11	41 women with stage 0, I, II, or III of breast cancer (mean, SD) 58.2 (9.5) years old)	G1 = UC (n=24) + standard clinic visits G2 = MBSR^* * MBSR: Kabat-Zinn's original 8-week program, weekly 2-hours sessions.(39) The program includes three components: (a) educational materials and exercises related to meditation practices and the mind-body connection, (b) practice time and a CD on which verbal support for four meditative practices was recorded (sitting meditation, walking meditation, body scan, and gentle hatha yoga), and (c) opportunity for group discussion, including time to answer questions related to barriers with formal and informal practice. Participants were asked to spend 15 to 45 minutes daily outside of the group sessions for formal and informal practice and to record their daily practice in a diary. Formal mindfulness practice includes sitting meditation, walking meditation, body scan, and yoga practice. Informal mindfulness meditation practices, or mindfulness in everyday life, incorporate an awareness of pleasant and unpleasant events, and encourage awareness of routine activities; (breast cancer) 6-week program (n=17)	Fatigue - MADSI mean (SD) p value Baseline to 6 weeks UC = 9.1 (7.1) to 7.3 (6.0) ns MBSR = 8.8 (6.9) to 4.6 (5.3); p≤0.05 Cognitive/psychological - MADSI mean (SD) p value Baseline to 6 weeks UC = 9.1 (8.7) to 7.8 (8.5) ns MBSR = 7.1(10.1) to 4.3 (5.1) ns
Rahmani et al.,⁽⁴⁸⁾	7/11	36 women with stages I, II, III of BC (38 to 49 years old)	G1= CG (n=12) G2= GTM (n=12) G1= MBSR (breast cancer) (n=12) Follow-up: 2 months	Fatigue - EORTC QLQ-C30 mean (SD) p value Baseline to 8 weeks to follow-up CG = 76.85 (5.72) to 71.29 (12.93)^† † GTM: 8-week program. Introducing the model/identifying rumination periods (metacognition enhancement)/practicing techniques of increasing attention/completing. Attention training technique form/homework; practicing detached mindfulness/showing the postponing of rumination in an experimental way for modifying uncontrollable beliefs/practicing attention training technique; checking homework, examining the rumination, positive thoughts and activity level/examining and extensive application of detached mindfulness/continuing to the challenge with positive thoughts about rumination/examining activity levels and increasing time of contemplation to reaction (sinking in thought), identifying and preventing harmful coping behavior (e.g. sleep or drinking alcohol)/practicing attention training technique/homework). to 72.22 (11.11); p≤0.00 GTM = 75.00 (8.37) to 64.81 (7.97)^† † GTM: 8-week program. Introducing the model/identifying rumination periods (metacognition enhancement)/practicing techniques of increasing attention/completing. Attention training technique form/homework; practicing detached mindfulness/showing the postponing of rumination in an experimental way for modifying uncontrollable beliefs/practicing attention training technique; checking homework, examining the rumination, positive thoughts and activity level/examining and extensive application of detached mindfulness/continuing to the challenge with positive thoughts about rumination/examining activity levels and increasing time of contemplation to reaction (sinking in thought), identifying and preventing harmful coping behavior (e.g. sleep or drinking alcohol)/practicing attention training technique/homework). to 76.85 (10.00); p≤0.00 MBSR = 77.77 (4.73) to 37.96 (8.81)^† † GTM: 8-week program. Introducing the model/identifying rumination periods (metacognition enhancement)/practicing techniques of increasing attention/completing. Attention training technique form/homework; practicing detached mindfulness/showing the postponing of rumination in an experimental way for modifying uncontrollable beliefs/practicing attention training technique; checking homework, examining the rumination, positive thoughts and activity level/examining and extensive application of detached mindfulness/continuing to the challenge with positive thoughts about rumination/examining activity levels and increasing time of contemplation to reaction (sinking in thought), identifying and preventing harmful coping behavior (e.g. sleep or drinking alcohol)/practicing attention training technique/homework). to 47.22 (11.72)^‡ ‡ The nutrition education intervention, led by registered dieticians, was a group intervention focused on dietary change through education and group meal preparation. Practices followed the principles of social cognitive theory and patient-centered counseling. The nutrition education intervention was equivalent to the MBSR in terms of contact time and homework assignments but did not contain any meditation or yoga. G1: group 1; UC: usual care (Control Group); G2: group 2; MBSR: Mindfulness-Based Stress Reduction; G3: group 3; NEP: nutrition education intervention; SCL-90-R: Symptom Checklist-90-Revised; SD: standard deviation; MADSI: MD Anderson Symptom Inventory; ns: no significant; CG: Control Group; GTM: metacognition group therapy; EORTC QLQ-C30: European Organization for Research and Treatment of Cancer Quality Life Questionnaire; CD: compact disc; BFI: Brief Fatigue Inventory; HADS: Hospital Anxiety and Depression Scale; FSS: Fatigue Severity Scale. ; p≤0.00, baseline to 8 weeks^† † GTM: 8-week program. Introducing the model/identifying rumination periods (metacognition enhancement)/practicing techniques of increasing attention/completing. Attention training technique form/homework; practicing detached mindfulness/showing the postponing of rumination in an experimental way for modifying uncontrollable beliefs/practicing attention training technique; checking homework, examining the rumination, positive thoughts and activity level/examining and extensive application of detached mindfulness/continuing to the challenge with positive thoughts about rumination/examining activity levels and increasing time of contemplation to reaction (sinking in thought), identifying and preventing harmful coping behavior (e.g. sleep or drinking alcohol)/practicing attention training technique/homework). /8 weeks to follow-up^‡ ‡ The nutrition education intervention, led by registered dieticians, was a group intervention focused on dietary change through education and group meal preparation. Practices followed the principles of social cognitive theory and patient-centered counseling. The nutrition education intervention was equivalent to the MBSR in terms of contact time and homework assignments but did not contain any meditation or yoga. G1: group 1; UC: usual care (Control Group); G2: group 2; MBSR: Mindfulness-Based Stress Reduction; G3: group 3; NEP: nutrition education intervention; SCL-90-R: Symptom Checklist-90-Revised; SD: standard deviation; MADSI: MD Anderson Symptom Inventory; ns: no significant; CG: Control Group; GTM: metacognition group therapy; EORTC QLQ-C30: European Organization for Research and Treatment of Cancer Quality Life Questionnaire; CD: compact disc; BFI: Brief Fatigue Inventory; HADS: Hospital Anxiety and Depression Scale; FSS: Fatigue Severity Scale. Cognitive/psychological - EORTC QLQ-C30 mean (SD) Baseline to 8 weeks to follow-up CG = 59.72 (8.58) to 59.72 (11.14) to 58.33 (15.07) GTM = 45.83 (10.36) to 61.11 (10.86) to 58.33 (8.71) MBSR = 62.50 (10.35) to 75.00 (11.23) to 72.22 (12.97)
Lengacher et al.,⁽⁴⁹⁾	7/11	82 women with stages 0, I, II, III of breast cancer (mean 57 years old)	G1 = UC (n=42) waitlisted Control Group were offered the MBSR (breast cancer) G2 = MBSR (breast cancer) 6-week program (n=40) Follow-up: 2 week	Depression - mean (SD) Baseline to 6 weeks UC =14.2 (8.5) to 4.0 (1.7) MBSR = 13.3 (12.0) to 7.2 (4.6) Anxiety - mean (SD) Baseline to 6 weeks UC = 40.4 (11.9) to 6.4 (12.1)^† † GTM: 8-week program. Introducing the model/identifying rumination periods (metacognition enhancement)/practicing techniques of increasing attention/completing. Attention training technique form/homework; practicing detached mindfulness/showing the postponing of rumination in an experimental way for modifying uncontrollable beliefs/practicing attention training technique; checking homework, examining the rumination, positive thoughts and activity level/examining and extensive application of detached mindfulness/continuing to the challenge with positive thoughts about rumination/examining activity levels and increasing time of contemplation to reaction (sinking in thought), identifying and preventing harmful coping behavior (e.g. sleep or drinking alcohol)/practicing attention training technique/homework). MBSR = 35.3 (12.0) to 7.8 (9.8)^† † GTM: 8-week program. Introducing the model/identifying rumination periods (metacognition enhancement)/practicing techniques of increasing attention/completing. Attention training technique form/homework; practicing detached mindfulness/showing the postponing of rumination in an experimental way for modifying uncontrollable beliefs/practicing attention training technique; checking homework, examining the rumination, positive thoughts and activity level/examining and extensive application of detached mindfulness/continuing to the challenge with positive thoughts about rumination/examining activity levels and increasing time of contemplation to reaction (sinking in thought), identifying and preventing harmful coping behavior (e.g. sleep or drinking alcohol)/practicing attention training technique/homework).
Eyles et al.,⁽⁵⁰⁾	6/11	19 women with metastatic breast cancer (37 to 65 years old)	G1 = MBSR = adapted (the class sessions were reduced to 2 hours in length (instead of 2 hours and 30 minutes) except the first and last, which lasted 2 hours and 30 minutes. The day of mindfulness in week 6 was 4 hours and 30 minutes (instead of 6-7 hours), and the mindfulness home practice using CDs of the above-mentioned mindfulness practices was 30 min/day, instead of 45 minutes/day) Follow-up: 24 week	Fatigue - BFI mean (SD) p value Baseline to 8 weeks = 4.19 (2.32) to 3.86 (2.45) ns 8 weeks to follow-up = 3.86 (2.45) to 3.28 (1.86) ns Baseline to follow-up = 4.19 (2.32) to 3.86 (2.45) ns Depression – HADS mean (SD) p value Baseline to 8 weeks = 5.74 (3.28) to 5.12 (4.46) ns 8 weeks to follow-up = 5.12 (4.46) to 3.79 (3.14) p≤0.04 Baseline to follow-up = 5.74 (3.28) to 3.79 (3.14) p≤0.04 Anxiety – HADS mean (SD) p value Baseline to 8 weeks = 9.42 (3.49) to 6.66 (3.63) 8 weeks to follow-up = 6.66 (3.63) to 5.79 (3.22) Baseline to follow-up = 9.42 (3.49) to 5.79 (3.22) p≤0.00
Rahmani et al.,(51)	7/11	24 women with stages I, II, III of BC (30 to 55 years old)	G1= CG (n=12) G2 = MBSR (breast cancer) + yoga (n=12) Follow-up: 2 months	Severe fatigue - FSS mean (SD) p value Baseline to 8 weeks to follow-up CG = 5.69 (1.58) to 5.60 (1.45) to 5.52 (3.07) ns MBSR = 5.85 (1.97) to 4.81 (2.60)^* * MBSR: Kabat-Zinn's original 8-week program, weekly 2-hours sessions.(39) The program includes three components: (a) educational materials and exercises related to meditation practices and the mind-body connection, (b) practice time and a CD on which verbal support for four meditative practices was recorded (sitting meditation, walking meditation, body scan, and gentle hatha yoga), and (c) opportunity for group discussion, including time to answer questions related to barriers with formal and informal practice. Participants were asked to spend 15 to 45 minutes daily outside of the group sessions for formal and informal practice and to record their daily practice in a diary. Formal mindfulness practice includes sitting meditation, walking meditation, body scan, and yoga practice. Informal mindfulness meditation practices, or mindfulness in everyday life, incorporate an awareness of pleasant and unpleasant events, and encourage awareness of routine activities; to 4.95 (2.61)^† † GTM: 8-week program. Introducing the model/identifying rumination periods (metacognition enhancement)/practicing techniques of increasing attention/completing. Attention training technique form/homework; practicing detached mindfulness/showing the postponing of rumination in an experimental way for modifying uncontrollable beliefs/practicing attention training technique; checking homework, examining the rumination, positive thoughts and activity level/examining and extensive application of detached mindfulness/continuing to the challenge with positive thoughts about rumination/examining activity levels and increasing time of contemplation to reaction (sinking in thought), identifying and preventing harmful coping behavior (e.g. sleep or drinking alcohol)/practicing attention training technique/homework). ; p≤0.00, baseline to 8 weeks^* * MBSR: Kabat-Zinn's original 8-week program, weekly 2-hours sessions.(39) The program includes three components: (a) educational materials and exercises related to meditation practices and the mind-body connection, (b) practice time and a CD on which verbal support for four meditative practices was recorded (sitting meditation, walking meditation, body scan, and gentle hatha yoga), and (c) opportunity for group discussion, including time to answer questions related to barriers with formal and informal practice. Participants were asked to spend 15 to 45 minutes daily outside of the group sessions for formal and informal practice and to record their daily practice in a diary. Formal mindfulness practice includes sitting meditation, walking meditation, body scan, and yoga practice. Informal mindfulness meditation practices, or mindfulness in everyday life, incorporate an awareness of pleasant and unpleasant events, and encourage awareness of routine activities; /8 weeks to Follow-up^† † GTM: 8-week program. Introducing the model/identifying rumination periods (metacognition enhancement)/practicing techniques of increasing attention/completing. Attention training technique form/homework; practicing detached mindfulness/showing the postponing of rumination in an experimental way for modifying uncontrollable beliefs/practicing attention training technique; checking homework, examining the rumination, positive thoughts and activity level/examining and extensive application of detached mindfulness/continuing to the challenge with positive thoughts about rumination/examining activity levels and increasing time of contemplation to reaction (sinking in thought), identifying and preventing harmful coping behavior (e.g. sleep or drinking alcohol)/practicing attention training technique/homework). Fatigue - EORTC QLQ-C30 mean (SD) p value Baseline to 8 weeks to follow-up CG = 76.85 (5.72) to 71.29 (12.93) to 72.22 (11.11) ns MBSR = 77.77 (4.73) to 37.96 (8.81)^* * MBSR: Kabat-Zinn's original 8-week program, weekly 2-hours sessions.(39) The program includes three components: (a) educational materials and exercises related to meditation practices and the mind-body connection, (b) practice time and a CD on which verbal support for four meditative practices was recorded (sitting meditation, walking meditation, body scan, and gentle hatha yoga), and (c) opportunity for group discussion, including time to answer questions related to barriers with formal and informal practice. Participants were asked to spend 15 to 45 minutes daily outside of the group sessions for formal and informal practice and to record their daily practice in a diary. Formal mindfulness practice includes sitting meditation, walking meditation, body scan, and yoga practice. Informal mindfulness meditation practices, or mindfulness in everyday life, incorporate an awareness of pleasant and unpleasant events, and encourage awareness of routine activities; to 47.22 (11.72)^† † GTM: 8-week program. Introducing the model/identifying rumination periods (metacognition enhancement)/practicing techniques of increasing attention/completing. Attention training technique form/homework; practicing detached mindfulness/showing the postponing of rumination in an experimental way for modifying uncontrollable beliefs/practicing attention training technique; checking homework, examining the rumination, positive thoughts and activity level/examining and extensive application of detached mindfulness/continuing to the challenge with positive thoughts about rumination/examining activity levels and increasing time of contemplation to reaction (sinking in thought), identifying and preventing harmful coping behavior (e.g. sleep or drinking alcohol)/practicing attention training technique/homework). ; p≤0.00, baseline to 8 weeks^* * MBSR: Kabat-Zinn's original 8-week program, weekly 2-hours sessions.(39) The program includes three components: (a) educational materials and exercises related to meditation practices and the mind-body connection, (b) practice time and a CD on which verbal support for four meditative practices was recorded (sitting meditation, walking meditation, body scan, and gentle hatha yoga), and (c) opportunity for group discussion, including time to answer questions related to barriers with formal and informal practice. Participants were asked to spend 15 to 45 minutes daily outside of the group sessions for formal and informal practice and to record their daily practice in a diary. Formal mindfulness practice includes sitting meditation, walking meditation, body scan, and yoga practice. Informal mindfulness meditation practices, or mindfulness in everyday life, incorporate an awareness of pleasant and unpleasant events, and encourage awareness of routine activities; /8 weeks to follow-up^† † GTM: 8-week program. Introducing the model/identifying rumination periods (metacognition enhancement)/practicing techniques of increasing attention/completing. Attention training technique form/homework; practicing detached mindfulness/showing the postponing of rumination in an experimental way for modifying uncontrollable beliefs/practicing attention training technique; checking homework, examining the rumination, positive thoughts and activity level/examining and extensive application of detached mindfulness/continuing to the challenge with positive thoughts about rumination/examining activity levels and increasing time of contemplation to reaction (sinking in thought), identifying and preventing harmful coping behavior (e.g. sleep or drinking alcohol)/practicing attention training technique/homework). Cognitive/psychological - EORTC QLQ-C30 mean (SD) Baseline to 8 weeks to follow-up CG = 59.72 (8.58) to 59.72 (11.14) to 61.11 (16.41) ns MBSR = 62.50 (10.35) to 75.00 (11.23) to 72.22 (12.97)
Sarenmalm et al.,⁽⁵²⁾	7/11	166 women diagnosed with cancer at (34 to 80 years old)	G1 = active control (8 weeks self-instructing MBSR program), n=52 G2=MBSR (8 weeks self-instructing MBSR program + instructor and weekly group sessions), n=62 G3=non MBSR n=52	Anxiety - HADS mean (SD) p value MBSR = 6.5 (4.3) to 6.0 (3.9) ns Non MBSR = 4.8 (3.6) to 5.5 (4.1) ns Active control = 5.6 (3.9) to 5.1 (3.9) ns Depression - HADS mean (SD) p value MBSR = 4.3 (3.7) to 3.3 (3.3) p≤0.00 Non MBSR = 3.5 (3.5) to 3.8 (3.8) ns Active control = 3.4 (3.4) to 3.8 (3.8) ns

^*
MBSR: Kabat-Zinn's original 8-week program, weekly 2-hours sessions.(39) The program includes three components: (a) educational materials and exercises related to meditation practices and the mind-body connection, (b) practice time and a CD on which verbal support for four meditative practices was recorded (sitting meditation, walking meditation, body scan, and gentle hatha yoga), and (c) opportunity for group discussion, including time to answer questions related to barriers with formal and informal practice. Participants were asked to spend 15 to 45 minutes daily outside of the group sessions for formal and informal practice and to record their daily practice in a diary. Formal mindfulness practice includes sitting meditation, walking meditation, body scan, and yoga practice. Informal mindfulness meditation practices, or mindfulness in everyday life, incorporate an awareness of pleasant and unpleasant events, and encourage awareness of routine activities;
^†
GTM: 8-week program. Introducing the model/identifying rumination periods (metacognition enhancement)/practicing techniques of increasing attention/completing. Attention training technique form/homework; practicing detached mindfulness/showing the postponing of rumination in an experimental way for modifying uncontrollable beliefs/practicing attention training technique; checking homework, examining the rumination, positive thoughts and activity level/examining and extensive application of detached mindfulness/continuing to the challenge with positive thoughts about rumination/examining activity levels and increasing time of contemplation to reaction (sinking in thought), identifying and preventing harmful coping behavior (e.g. sleep or drinking alcohol)/practicing attention training technique/homework).
^‡
The nutrition education intervention, led by registered dieticians, was a group intervention focused on dietary change through education and group meal preparation. Practices followed the principles of social cognitive theory and patient-centered counseling. The nutrition education intervention was equivalent to the MBSR in terms of contact time and homework assignments but did not contain any meditation or yoga. G1: group 1; UC: usual care (Control Group); G2: group 2; MBSR: Mindfulness-Based Stress Reduction; G3: group 3; NEP: nutrition education intervention; SCL-90-R: Symptom Checklist-90-Revised; SD: standard deviation; MADSI: MD Anderson Symptom Inventory; ns: no significant; CG: Control Group; GTM: metacognition group therapy; EORTC QLQ-C30: European Organization for Research and Treatment of Cancer Quality Life Questionnaire; CD: compact disc; BFI: Brief Fatigue Inventory; HADS: Hospital Anxiety and Depression Scale; FSS: Fatigue Severity Scale.

vertical_align_top file_download show_chart

more_horizclose
- image
- translate
- link
- article
- vertical_align_top
- file_download
- show_chart
- image
- translate
- link
- article

location_on

Instituto Israelita de Ensino e Pesquisa Albert Einstein Avenida Albert Einstein, 627/701 , 05651-901 São Paulo - SP, Tel.: (55 11) 2151 0904 - São Paulo - SP - Brazil
E-mail: revista@einstein.br

rss_feed Acompanhe os números deste periódico no seu leitor de RSS

Acessibilidade / Reportar erro

[1] ¹ Prat A, Perou CM. Deconstructing the molecular portraits of breast cancer. Mol Oncol. 2011;5(1):5-23. Review.

[2] ² Eroles P, Bosch A, Pérez-Fidalgo JA, Lluch A. Molecular biology in breast cancer: Intrinsic subtypes and signaling pathways. Cancer Treat Rev. 2012; 38(6):698-707. Review.

[3] ³ Graveel CR, Calderone HM, Westerhuis JJ, Winn ME, Sempere LF. Critical analysis of the potential for microRNA biomarkers in breast cancer management. Breast Cancer (Dove Med Press). 2015;7:59-79. Review.

[4] ⁴ Kim HJ, Park TJ, Ahn KM. Bisphosphonate-related osteonecrosis of the jaw in metastatic breast cancer patients: a review of 25 cases. Maxillofac Plast Reconstr Surg. 2016;38(1):6.

[5] ⁵ Gao FF, Lv JW, Wang Y, Fan R, Li Q, Zhang Z, et al. Tamoxifen induces hepatotoxicity and changes to hepatocyte morphology at the early stage of endocrinotherapy in mice. Biomed Rep. 2016;4(1):102-6.

[6] ⁶ El-Deeb MM, El-Sheredy HG, Mohammed AF. The role of serum trace elements and oxidative stress in egyptian breast cancer patients. Adv Breast Cancer Res. 2016;5(1):37-47.

[7] ⁷ Teegarden D, Romieu I, Lelièvre SA. Redefining the impact of nutrition on breast cancer incidence: is epigenetics involved? Nutr Res Rev. 2012; 25(1):68-95. Review.

[8] ⁸ Youlden DR, Cramb SM, Yip CH, Baade PD. Incidence and mortality of female breast cancer in the Asia-Pacific region. Cancer Biol Med. 2014;11(2):101-15.

[9] ⁹ Zainal NZ, Booth S, Huppert FA. The efficacy of mindfulness-based stress reduction on mental health of breast cancer patients: a meta-analysis. Psychooncology. 2013;22(7):1457-65. Review.

[10] ¹⁰ Eccles SA, Aboagye EO, Ali S, Anderson AS, Armes J, Berditchevski F, et al. Critical research gaps and translational priorities for the successful prevention and treatment of breast cancer. Breast Cancer Res. 2013;15(5):R92. Review.

[11] ¹¹ Braithwaite D, Demb J, Henderson LM. Optimal breast cancer screening strategies for older women: current perspectives. Clin Interv Aging. 2016; 11:111-25. Review.

[12] ¹² Bodai BI, Tuso P. Breast Cancer Survivorship: a comprehensive review of long-term medical issues and lifestyle recommendations. Perm J. 2015;19(2):48-79.

[13] ¹³ Howell A, Anderson AS, Clarke RB, Duffy SW, Evans DG, Garcia-Closas M, et al. Risk determination and prevention of breast cancer. Breast Cancer Res. 2014;16(5):446. Review.

[14] ¹⁴ Davis NM, Sokolosky M, Stadelman K, Abrams SL, Libra M, Candido S, et al. Deregulation of the EGFR/PI3K/PTEN/Akt/mTORC1 pathway in breast cancer: possibilities for therapeutic intervention. Oncotarget. 2014;5(13):4603-50. Review.

[15] ¹⁵ Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D. Global Cancer Statistics. CA Cancer J Clin. 2011;61(2):69-90. Erratum in: CA Cancer J Clin. 2011;61(2):134.

[16] ¹⁶ Noel L, Connors SK, Goodman MS, Gehlert S. Improving breast cancer services for African-American women living in St. Louis. Breast Cancer Res Treat. 2015;154(1):5-12.

[17] ¹⁷ Hwang JH, Kim WY, Ahmed M, Choi S, Kim J, Han DW. The use of complementary and alternative medicine by korean breast cancer women: is it associated with severity of symptoms? Evid Based Complement Alternat Med. 2015;2015:182475.

[18] ¹⁸ Nowicki A, Krzemkowska E, Rhone P. Acceptance of illness after surgery in patients with breast cancer in the early postoperative period. Pol Przeglad Chir. 2015;87(11):539-50.

[19] ¹⁹ Dillard AJ, Scherer L, Ubel PA, Smith DM, Zikmund-Fisher BJ, McClure JB, et al. Breast cancer anxiety's associations with responses to a chemoprevention decision aid. Soc Sci Med. 2013;77:13-9.

[20] ²⁰ Vodermaier A, Linden W, Rnic K, Young SN, Ng A, Ditsch N, et al. Prospective associations of depression with survival: a population-based cohort study in patients with newly diagnosed breast cancer. Breast Cancer Res Treat. 2014;143(2):373-84.

[21] ²¹ Pinquart M, Duberstein PR. Depression and cancer mortality: a meta-analysis. Psychol Med. 2010;40(11):1797-810.

[22] ²² Kang HJ, Kim JM, Kim SY, Kim SW, Shin S, Kim HR, et al. A longitudinal study of bdnf promoter methylation and depression in breast cancer. Psychiatry Investig. 2015;12(4):523-31.

[23] ²³ Charlson ME, Loizzo J, Moadel A, Neale M, Newman C, Olivo E, et al. Contemplative self healing in women breast cancer survivors: a pilot study in underserved minority women shows improvement in quality of life and reduced stress. BMC Complement Altern Med. 2014;14:349.

[24] ²⁴ Hall DL, Antoni MH, Lattie EG, Jutagir DR, Czaja SJ, Perdomo D, et al. Perceived fatigue interference and depressed mood: comparison of chronic fatigue Syndrome/Myalgic encephalomyelitis patients with fatigued breast cancer survivors. Fatigue. 2015;3(3):142-55.

[25] ²⁵ Bower JE. Cancer-related fatigue: mechanisms, risk factors, and treatments. Nat Rev Clin Oncol. 2014;11(10):597-609. Review.

[26] ²⁶ Vahdaninia M, Omidvari S, Montazeri A. What do predict anxiety and depression in breast cancer patients? A follow-up study. Soc Psychiatry Psychiatr Epidemiol. 2010;45(3):355-61.

[27] ²⁷ Wurtzen H, Dalton SO, Elsass P, Sumbundu AD, Steding-Jensen M, Karlsen RV, et al. Mindfulness significantly reduces self-reported levels of anxiety and depression: Results of a randomised controlled trial among 336 Danish women treated for stage I-III breast cancer. Eur J Cancer. 2013;49(6):1365-73.

[28] ²⁸ Chaoul A, Milbury K, Sood AK, Prinsloo S, Cohen L. Mind-Body Practices in Cancer Care. Curr Oncol Rep. 2014;16(12):417. Review.

[29] ²⁹ Link AR, Gammon MD, Jacobson JS, Abrahamson P, Bradshaw PT, Terry MB, et al. Use of self-care and practitioner-based forms of complementary and alternative medicine before and after a diagnosis of breast cancer. Evid Based Complement Alternat Med. 2013;2013:301549.

[30] ³⁰ Vargas S, Antoni MH, Carver CS, Lechner SC, Wohlgemuth W, Llabre M, et al. Sleep quality and fatigue after a stress management intervention for women with early-stage breast cancer in southern Florida. Int J Behav Med. 2014;21(6):971-81.

[31] ³¹ Meneses-Echavez JF, Gonzalez-Jimenez E, Ramirez-Velez R. Effects of supervised exercise on cancer-related fatigue in breast cancer survivors: a systematic review and meta-analysis. BMC Cancer. 2015;15:77.

[32] ³² Cramer H, Lauche R, Paul A, Dobos G. Mindfulness-based stress reduction for breast cancer-a systematic review and meta-analysis. Curr Oncol. 2012;19(5):e343-52.

[33] ³³ Brahmi SA, El M'rabet FZ, Benbrahim Z, Akesbi Y, Amine B, Nejjari C, et al. Complementary medicine use among Moroccan patients with cancer: A descriptive study. Pan Afr Med J. 2011;10:36.

[34] ³⁴ Greenlee H, Balneaves LG, Carlson LE, Cohen M, Deng G, Hershman D, et al. Clinical practice Gguidelines on the use of integrative therapies as supportive care in patients treated for breast cancer. J Natl Cancer Inst Monogr. 2014;2014(50):346-58. Review.

[35] ³⁵ Kenne Sarenmalm E, Martensson LB, Holmberg SB, Andersson BA, Oden A, Bergh I. Mindfulness based stress reduction study design of a randomized controlled complementary intervention in women with breast cancer. BMC Complement Altern Med. 2013;13:248.

[36] ³⁶ Lamothe M, E, Malboeuf-Hurtubise C, Duval M, Sultan S. Outcomes of MBSR or MBSR-based interventions in health care providers: A systematic review with a focus on empathy and emotional competencies. Complement Ther Med. 2016;24:19-28. Review.

[37] ³⁷ Vago DR, Silbersweig DA. Self-awareness, self-regulation, and self-transcendence (S-ART): a framework for understanding the neurobiological mechanisms of mindfulness. Front Hum Neurosci. 2012;6:296.

[38] ³⁸ Crane RS, Kuyken W, Hastings RP, Rothwell N, Williams JM. Training teachers to deliver mindfulness-based interventions: learning from the UK experience. Mindfulness (NY). 2010;1(2):74-86.

[39] ³⁹ Kabat-Zinn J. Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness. New York: Dell Publishing; 1990.

[40] ⁴⁰ Nakamura Y, Lipschitz DL, Kuhn R, Kinney AY, Donaldson GW. Investigating efficacy of two brief mind-body intervention programs for managing sleep disturbance in cancer survivors: a pilot randomized controlled trial. J Cancer Surviv. 2013;7(2):165-82. Review.

[41] ⁴¹ Cook DA, West CP. Conducting systematic reviews in medical education: a stepwise approach. Med Educ. 2012;46:943-52.

[42] ⁴² PEDro. Physiotherapy Evidence Database [Internet]. Australian: The center for evidence-based physiotherapy; 1999 [cited 2015 June 26]. Available from: http://www.pedro.org.au/wp-content/uploads/PEDro_scale.pdf
» http://www.pedro.org.au/wp-content/uploads/PEDro_scale.pdf

[43] ⁴³ Higgins JPT, Altman DG, Gøtzsche PC, et al. The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ. 2011;343:d5928.

[44] ⁴⁴ Cohen J. Statistical power analysis for the behavioral sciences. 2a ed. Hillsdale: Lawrence Erlbaum Associates; 1988.

[45] ⁴⁵ Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003;327(7414): 557-60. Review.

[46] ⁴⁶ Henderson VP, Massion AO, Clemow L, Hurley TG, Druker S, Hébert JR. A randomized controlled trial of mindfulness-based stress reduction for women with early-stage breast cancer receiving radiotherapy. Integr Cancer Ther. 2013;12(5):404-13.

[47] ⁴⁷ Reich RR, Lengacher CA, Kip KE, Shivers SC, Schell MJ, Shelton MM, et al. Baseline immune biomarkers as predictors of MBSR(BC) treatment success in off-treatment breast cancer patients. Biol Res Nurs. 2014;16(4):429-37.

[48] ⁴⁸ Rahmani S, Talepasand S, Ghanbary-Motlagh A. Comparison of effectiveness of the metacognition treatment and the mindfulness-based stress reduction treatment on global and specific life quality of women with breast cancer. Iran J Cancer Prev. 2014;7(4):184-96.

[49] ⁴⁹ Lengacher CA, Shelton MM, Reich RR, Barta MK, Johnson-Mallard V, Moscoso M, S.et al. Mindfulness based stress reduction (MBSR(BC)) in breast cancer: evaluating fear of recurrence (FOR) as a mediator of psychological and physical symptoms in a randomized control trial (RCT). J Behav Med. 2014;37(2):185-95.

[50] ⁵⁰ Eyles C, Leydon GM, Hoffman CJ, Copson ER, Prescott P, Chorozoglou M, et al. Mindfulness for the self-Management of fatigue, anxiety, and depression in women with metastatic breast cancer: a mixed methods feasibility study. Integr Cancer Ther. 2015;14(1):42-56.

[51] ⁵¹ Rahmani S, Talepasand S. The effect of group mindfulness - based stress reduction program and conscious yoga on the fatigue severity and global and specific life quality in women with breast cancer. Med J Islam Repub Iran. 2015;29:175.

[52] ⁵² Sarenmalm EK, Martensson LB, Andersson BA, Karlsson P, Bergh I. Mindfulness and its efficacy for psychological and biological responses in women with breast cancer. Cancer Med. 2017;6(5):1108-22.

[53] ⁵³ Nakagawa S, Takeuchi H, Taki Y, Nouchi R, Kotozaki Y, Shinada T, et al. Basal ganglia correlates of fatigue in young adults. Sci Rep. 2016:6:21386.

[54] ⁵⁴ Chaudhuri A, Behan PO. Fatigue and basal ganglia. J Neurol Sci. 2000;179(S 1-2):34-42. Review.

[55] ⁵⁵ Hoffman AJ, Brintnall RA, Cooper J. Merging technology and clinical research for optimized post-surgical rehabilitation of lung cancer patients. Ann Transl Med. 2016;4(2):28.

[56] ⁵⁶ Minton O, Stone P. How common is fatigue in disease-free breast cancer survivors? A systematic review of the literature. Breast Cancer Res Treat. 2008;112(1):5-13. Review.

[57] ⁵⁷ Armes J, Chalder T, Addington-Hall J, Richardson A, Hotopf M. A randomized controlled trial to evaluate the effectiveness of a brief, behaviorally oriented intervention for cancer-related fatigue. Cancer. 2007;110(6):1385-95.

[58] ⁵⁸ Corbett T, Devane D, Walsh JC, Groarke A, McGuire BE. Protocol for a systematic review of psychological interventions for cancer-related fatigue in post-treatment cancer survivors. Syst Rev. 2015;4:174. Review.

[59] ⁵⁹ Smith JE, Richardson J, Hoffman C, Pilkington K. Mindfulness-based stress reduction as supportive therapy in cancer care: systematic review. J Adv Nurs. 2005;52(3):315-27. Review.

[60] ⁶⁰ van der Velden AM, Kuyken W, Wattar U, Crane C, Pallesen KJ, Dahlgaard J, et al. A systematic review of mechanisms of change in mindfulness-based cognitive therapy in the treatment of recurrent major depressive disorder. Clin Psychol Rev. 2015;37:26-39. Review.

[61] ⁶¹ Carlson LE, Ursuliak Z, Goodey E, Angen M, Speca M. The effects of a mindfulness meditation-based stress reduction program on mood and symptoms of stress in cancer outpatients: 6-month follow-up. Support Care Cancer. 2001;9(2):112-23.

[62] ⁶² Carlson LE, Garland SN. Impact of mindfulness-based stress reduction (MBSR) on sleep, mood, stress and fatigue symptoms in cancer outpatients. Int J Behav Med. 2005;12(4):278-85.

[63] ⁶³ Carlson LE, Speca M, Patel KD, Goodey, E. Mindfulness based stress reduction in relation to quality of life, mood, symptoms of stress, and immune parameters in breast and prostate cancer outpatients. Psychosom Med. 2003;65(4):571-81.

[64] ⁶⁴ Lengacher CA, Johnson-Mallard V, Post-White J, Moscoso MS, Jacobsen PB, Klein TW, et al. Randomized controlled trial of mindfulness-based stress reduction (MBSR) for survivors of breast cancer. Psychooncology. 2009; 18(12):1261-72.

[65] ⁶⁵ Kesler S, Hadi Hosseini SM, Heckler C, Janelsins M, Palesh O, Mustian K, et al. Cognitive training for improving executive function in chemotherapy-treated breast cancer survivors. Clin Breast Cancer. 2013;13(4):299-306.

[66] ⁶⁶ McDonald BC, Conroy SK, Smith DJ, West JD, Saykin AJ. Frontal gray matter reduction after breast cancer chemotherapy and association with executive symptoms: a replication and extension study. Brain Behav Immun. 2013;30 Suppl: S117-25.

[67] ⁶⁷ Scherling C, Collins B, MacKenzie J, Bielajew C, Smith A. Pre-chemotherapy differences in visuospatial working memory in breast cancer patients compared to controls: an FMRI study. Front Hum Neurosci. 2011;5:122.

[68] ⁶⁸ Sanger KL, Dorjee D. Mindfulness training for adolescents: a neuro developmental perspective on investigating modifications in attention and emotion regulation using event-related brain potentials. Cogn Affect Behav Neurosci. 2015;15(3):696-711. Review.

[69] ⁶⁹ Kaiser J, Bledowski C, Dietrich J. Neural correlates of chemotherapy-related cognitive impairment. Cortex. 2014;54:33-50. Review.

[70] ⁷⁰ Keng SL, Smoski MJ, Robins CJ. Effects of mindfulness on psychological health: a review of empirical studies. Clin Psychol Rev. 2011;31(6):1041-56. Review.

[71] ⁷¹ Alexander VL, Tatum BC. Effectiveness of cognitive therapy and mindfulness tools in reducing depression and anxiety: a mixed method study. Psychology. 2014;5:1702-13.

[72] ⁷² Schellekens MP, Jansen ET, Willemse HH, van Laarhoven HW, Prins JB, Speckens AE. A qualitative study on mindfulness-based stress reduction for breast cancer patients: how women experience participating with fellow patients. Support Care Cancer. 2016;24(4):1813-20.

[73] ⁷³ Wenn J, O'Connor M, Breen LJ, Kane RT, Rees CS. Efficacy of metacognitive therapy for prolonged grief disorder: protocol for a randomised controlled trial. BMJ Open. 2015;5(12):e007221.

[74] ⁷⁴ Cook SA, Salmon P, Dunn G, Holcombe C, Cornford P, Fisher P. A prospective study of the association of metacognitive beliefs and processes with persistent emotional distress after diagnosis of cancer. Cognit Ther Res. 2015; 39:51-60.

[75] ⁷⁵ Classen C, Butler LD, Koopma C, Miller E, DiMiceli S, Giese-Davis J, et al. Supportive-Expressive Group Therapy and Distress in patients With Metastatic Breast Cancer. A randomized clinical intervention trial. Arch Gen Psychiatry. 2001;58(5):494-501.

[76] ⁷⁶ Huang J, Shi L. The effectiveness of mindfulness-based stress reduction (MBSR) for survivors of breast cancer: study protocol for a randomized controlled trial. Trials. 2016;17(1):209.

[77] ⁷⁷ Witek-Janusek L, Albuquerque K, Chroniak KR, Chroniak C, Durazo-Arvizu R, Mathews HL. Effect of mindfulness based stress reduction on immune function, quality of life and coping in women newly diagnosed with early stage breast cancer. Brain Behav Immun. 2008;22(6):969-81.

[78] ⁷⁸ Shennan C, Payne S, Fenlon D. What is the evidence for the use of mindfulness-based interventions in cancer care? A review. Psychooncology. 2011;20(7):681-97.

[79] ⁷⁹ Henderson VP, Clemow L, Massion AO, Hurley TG, Druker S, Hébert JR. The effects of mindfulness-based stress reduction on psychosocial outcomes and quality of life in early-stage breast cancer patients: a randomized trial. Breast Cancer Res Treat. 2012;131(1):99-109.

[80] ⁸⁰ Chlebowski RT, Blackburn GL, Thomson CA, Nixon DW, Shapiro A, Hoy MK, et al. Dietary fat reduction and breast cancer outcome: interim efficacy results from the women's intervention nutrition study. J Natl Cancer Inst. 2006;98(24):1767-76.