Interventions relieve depression in younger breast cancer survivors


A mindfulness intervention and a survivorship education intervention both reduced depressive symptoms in younger breast cancer survivors in a phase 3, randomized trial. The mindfulness intervention also reduced fatigue, hot flash severity, and sleep disturbances.

These results, from the Pathways to Wellness trial, were reported at the 2020 San Antonio Breast Cancer Symposium (Abstract GS2-10).

“Younger breast cancer survivors represent a vulnerable population with well-documented side effects from breast cancer treatments and notable increases in depressive symptoms,” said the trial’s principal investigator Patricia Ganz, MD, of the University of California, Los Angeles. “These lasting effects of breast cancer treatments can have a negative impact on quality of life in the survivorship period.”

With this in mind, Dr. Ganz and colleagues conducted the Pathways to Wellness trial. The researchers enrolled and randomized 247 women with stage 0 to III breast cancer.

All patients were younger than 50 years of age at diagnosis. Their mean age was 45.4 years. Patients were 6 months to 5 years out from primary treatment at baseline. The mean time from diagnosis was 2.6 years.

All patients had at least mild depressive symptoms on the 8-item Patient Health Questionnaire.

The patients were randomized to a wait list control group or to one of two 6-week interventions: a mindfulness awareness practices (MAPS) intervention or a survivorship education intervention. Both interventions followed a standardized curriculum and entailed weekly 2-hour, in-person group sessions.

Dr. Patricia Ganz
The MAPS intervention was delivered by community mindfulness instructors who received formal training, Dr. Ganz said. The intervention focused on building skills in areas such as working with pain and difficult emotions, and it included homework assignments.

The survivorship education intervention was delivered by trained oncology nurses. It used written materials provided in a notebook and slides that covered topics such as nutrition, genetic testing, relationships, and body image. Sessions allowed time for questions and group discussion.

Results and implications

Attendance for the MAPS intervention was better than attendance for the survivorship education intervention, Dr. Ganz reported.

At baseline, all three study groups had mean scores on the Center for Epidemiologic Studies Depression Scale (CES-D) of about 17-18, which is higher than the cutoff of 16 that indicates moderately severe depressive symptoms.

In a controlled intention-to-treat analysis, the mean CES-D score at the end of the intervention was significantly lower, at about 13, in both the MAPS group (P < .001) and the survivorship education group (P < .01) than in the control group. The mean CES-D score was essentially unchanged in the control group.

Scores were still significantly better for both interventions at 3 months of follow-up, with roughly the same magnitude of difference. However, only the MAPS intervention was significantly better than control at 6 months (P < .027).

Both interventions netted significantly lower scores on the Generalized Anxiety Disorder–7 scale relative to the wait list control at the end of the intervention (P < .001 for MAPS and P < .01 for education). However, the benefit was not sustained with either intervention over time.

The MAPS intervention group alone had a significantly lower score than the wait list control group on the Fatigue Symptom Inventory at the end of the intervention, with a significant difference still evident at 6 months (P < .001).

Hot flash severity, assessed via the Breast Cancer Prevention Trial Hot Flashes scale score, decreased with MAPS and was significantly less with this intervention than with control at 3 months (P < .01) and 6 months (P < .001).

Finally, sleep disturbance, as measured with the Insomnia Severity Index, decreased with both interventions. The difference comparing MAPS with control was significant at the end of the intervention (P < .001), at 3 months (P < .001), and at 6 months (P < .01). The difference for survivorship education was significant only at 3 months (P < .01).

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“The Pathways to Wellness participants had high levels of depression, anxiety, fatigue, sleep disturbance, and other symptoms an average of 2.6 years after diagnosis,” Dr. Ganz summarized. “Both interventions significantly reduced depression, with additional reduction in other symptoms only in the MAPS group.”

Feedback from the women given survivorship education suggested they would have preferred receiving that intervention’s educational content and group support earlier in the course of their care, Dr. Ganz noted.

On the other hand, she said, “MAPS is a skill-building and training-practice intervention, which has skills that could be used anywhere in the cancer continuum. I wouldn’t be surprised if there would be benefit also in metastatic disease patients.

“Further dissemination and evaluation of these interventions is warranted to address the unmet psychosocial needs of younger breast cancer survivors,” Dr. Ganz concluded, noting that the MAPS program is available online through the UCLA Mindful Awareness Research Center.

Dr. Ganz disclosed relationships with Up-To-Date, Blue Note Therapeutics, and Intrinsic Life Sciences. The trial was funded by the National Cancer Institute and the Breast Cancer Research Foundation.