Randomized controlled trial of mindfulness program to enhance body image in patients with breast cancer

Accepted Manuscript Title: Randomized controlled trial of mindfulness program to enhance body image in patients with breast cancer Authors: Sheila Pintado, Sandra Andrade PII: DOI: Reference:

S1876-3820(17)30107-5 http://dx.doi.org/doi:10.1016/j.eujim.2017.05.009 EUJIM 683

To appear in: Received date: Revised date: Accepted date:

23-2-2017 29-5-2017 29-5-2017

Please cite this article as: Pintado Sheila, Andrade Sandra.Randomized controlled trial of mindfulness program to enhance body image in patients with breast cancer.European Journal of Integrative Medicine http://dx.doi.org/10.1016/j.eujim.2017.05.009 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Title: Randomized controlled trial of mindfulness program to enhance body image in patients with breast cancer

Author names Sheila Pintado, PhD; Sandra Andrade, BA

Author Affiliations: Department of Psychology, Universidad de las Américas Puebla (UDLAP)

Correspondence: Sheila Pintado, PhD, Department of Psychology, Universidad de las Américas Puebla (UDLAP). Ex Hacienda Sta Catarina Mártir, San Andrés Cholula, 72810 Puebla, México ([email protected])

Informed consent: Informed consent was obtained from all individual participants included in the study.

ABSTRACT

Introduction: Breast cancer affects the thoughts and emotions related to patients´ body image and it has a negative impact in their quality of life. The purpose of this study was to conduct a randomized controlled trial in patients with breast cancer comparing mindfulness training to improve body image with a program based on personal image advice. Method: A total of 29 women with breast cancer were randomly allocated into one of 2 groups: an experimental (mindfulness program) and control (personal image advice) group. The assessment tools were semi-structured interviews and the BIS and SBC questionnaires. Data was analyzed using quantitative techniques. Results: The mindfulness program was effective in decreasing negative thoughts and emotions related to body image and dissociation (p<.01), and in increasing positive

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thoughts and body awareness (p<.01). Moreover, there were significant differences in body image between control and experimental group (F(1,28)=12.616; p<.01; ηp2=.335). Conclusion: The mindfulness program was useful in improving psychological and emotional changes related to body image in breast cancer patients. Changes in body image are a key component in the treatment of breast cancer patients with the ability to improve the patients´ quality of life.

Keywords: Breast cancer; mindfulness; body image; clinical trial

Introduction Breast cancer is the most frequent neoplasm in women and has a negative impact on the emotional well-being of patients. On the one hand, the diagnosis and treatment of breast cancer have been related to symptoms of anxiety and depression, and to worsening quality of life. On the other hand, breast cancer is one of the diseases in which physical changes are more visibly apparent, contributing to an increase in the levels of alterations in the body image [1]. Moreover, treatment and its side effects are related to physical breast changes, be it deformity, loss of hair, decline in sexuality, reduced sense of femininity and physical attraction, and in some cases, loss of fertility [2,3]. Because of this, emotional well-being is negatively affected [4-9] with this disruption in the normal psychological function related to alterations in the body image [10-18] and there are few specific interventions that deal with these issues.

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Alterations of body image in breast cancer patients Body image is a complex concept understood through the perceptions and judgements that one has about oneself. Because of this, it is difficult to evaluate it; therefore it is deemed necessary to thoroughly analyze the real impact of the alterations of the body image in cancer [19]. Despite this, in the past decade, results of numerous applied studies appear to help an appreciation of how body image is affected in this illness. For example, in a study, results showed that the negative perceptions of body image in breast cancer include dissatisfaction with self-appearance, a reduced sense of femininity, and the appearance of certain behaviors, such as the avoidance of seeing themselves naked, or the avoidance of people because of fear of being rejected; and almost the 50% of patients with breast cancer had problems with their body image. [16]. In another study, this number increased to 77% of the women [11]. Despite the severity of this illness and its repercussions in physical and psychological wellbeing, survival of breast cancer patients has increased in the last 20 years [20] and this fact has triggered a greater interest in the improvement of the quality of life of these patients. In this sense, to treat the alterations of body image of breast cancer patients, two types of interventions have been implemented: on the one hand, the traditional psychotherapy, above all, cognitive behavioral therapy (CBT) in order to change maladaptive cognitions and behaviors. And on the other hand, some non-invasive techniques to improve the physical body image, as the use of external prosthesis, or counseling programs which provide cosmetic help, including makeup tips, care of skin and recommendations to cover the head [21].

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In relation to the interventions based on CBT, some studies have investigated its efficacy in improving body image in cancer patients. For example, Fadaei et al. (2011) implemented an intervention based on Ellis rational emotive behavior therapy for 72 patients diagnosed with breast cancer and after intervention, they observed that the alterations of body image, measured by the Body Image Scale (BIS), were significantly lower in the intervention group compared with the control group [22]. Duijts et al. (2012) evaluated the effect of cognitive behavioral therapy (CBT), physical exercise and these two interventions combined on menopausal symptoms, body image, sexual functioning, psychological well-being, and health-related quality of life in 422 patients with breast cancer. Results showed no significant overall group differences for body image [23]. Fingeret, Teo and Epner (2014) provided information about CBT interventions studies focused on body image difficulties of adult cancer patients from 2003-2013, and they found four studies with a randomized control trial design that used CBT. Components of CBT included psycho-education, stress management, problem solving, cognitive reframing and communication skills training. Three studies reported statistically significant improvements in body image, however, it is not clear what component is more effective. So intervention research was limited [24]. Nevertheless, nowadays it is not enough to provide patients the medical treatment or the superficial techniques; it is necessary to include integral and multidisciplinary rehabilitation to deal with all the complications that may arise after diagnosis and treatment [25]. Mindfulness programs in cancer patients Mindfulness is a practice that allows the mind to concentrate on the present moment and it can be defined as the awareness of an event without judging the moment [26].

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Mindfulness training includes the consciousness of the body. This consciousness is considered an interactive and dynamic process that includes the perception about the states, processes, acts and sensations of the corporal entity [27] and it can be modified by different mental processes as attention, interpretation, values, memories, aptitudes, conditioning and affection [28]. Regarding this, mindfulness training is used as a complementary therapy with favorable results. Mindfulness training allows people pause ruminations and autopilot, and instead, permits the awareness of mental habits and consciousness of the present moment, accepting the experience as it is [29]. Mindfulness it is also an ability that can be improved through practice [30]. Despite mindfulness was applied more than 30 years ago to reduce stress and depression of chronic pain patients [31], nowadays it is been used in patients with cancer [32-37], showing a reduction in stress, depression, anxiety, fear of recurrence, and improving physical function and energy levels [38,39]. In a study performed with 271 breast cancer survivors, the Mindfulness-Based Cancer Recovery program (MBCR) was applied based on Mindfulness-based Stress Reduction (MBSR) by Kabat-Zinn (1990) and adapted to cancer patients. Results showed that practitioners of the MBCR group reduced more stress symptoms and improved quality of life, compared with the group therapy [40]. So, although mindfulness is effective in improving the emotional well-being, the physical functions and the quality of life, it is necessary to analyze if these programs are effective in treating and improving the alteration of body image in breast cancer patients.

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As noted previously, due to the increment of survivor rate of breast cancer, a greater interest in providing patients with a better quality of life is necessary to reduce the side effects (physical and psychologically) through the application of integral rehabilitation models, as Campbell et al. (2005) proposed. Following this, to treat the alterations of body image in breast cancer is a challenge that a multidisciplinary oncological team has to attend. There are a few scientific investigations that have studied the efficacy of mindfulness programs for body image alterations treatment. The majority of them have studied its efficacy in relation to eating disorders and preoccupation with weight [41-43], finding that mindfulness can be effective to improve body image in women. However, despite the problems that breast cancer patients have in body image, there are not specific programs based on mindfulness to treat this. To close this gap, the purpose of this study was to conduct a randomized controlled trial in patients with breast cancer comparing mindfulness training to improve body image with a program based on personal image advice. The hypotheses are: H1: Mindfulness training will be effective to reduce negative thoughts and emotions related to body image in patients with breast cancer. H2: Mindfulness training will be more effective in reducing negative thoughts and emotions related to body image of patients with breast cancer, compared with the control group. MATERIAL AND METHODS Participants

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Twenty-nine patients were recruited from outpatient Oncology Unit at one public hospital in Mexico. Inclusion criteria were that patients were diagnosed with breast cancer in the stages I or II, over 18 years old, hadn’t received an active adjuvant therapy at the moment of the study and who did not practice meditation or mindfulness currently. Exclusion criteria were: younger than 18 years old, in palliative care, receiving adjuvant therapy or some intervention based on meditation and not attend all program sessions. A total of 35 women who complied with inclusion criteria were interested participating on the program but 6 were excluded because they could not attend the sessions in the time programmed. Only 14% (n=4) of the participants had previous experience with meditation or similar practices, indicating that 86% were not familiar with this aspect. However, 100% of study participants did not perform any kind of meditation or similar at the time of the study. Assessment Tools To measure the alterations in appearance, the Body Image Scale (BIS) [44] adapted in Spanish was used [45]. The scale contains 10 items that assess emotional and cognitive aspects, rated on a Likert scale of 4 points (0="nothing" and 3="a lot"); and higher scores indicate higher symptoms/distress to the body image. Its reliability is .93.

The second instrument applied was the Scale of Body Connection (SBC [46] adapted in Spanish [47]). The scale consists of 20 items and two subscales: Body Awareness (12 items) and Bodily Dissociation (8 items). The response format is Likert of 5 alternatives

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(0="not at all, or never" and 5= "all the time"). The body awareness subscale has a Cronbach’s alpha of .83 and the bodily dissociation subscale .78. Procedure First of all, the authors presented a protocol of the study to the Ethic Committee on Human Investigation, in accordance with the 1964 Helsinki declaration, at the University of las Americas Puebla and permission was received. Then, patients were informed about the investigation, and after informed consent was accepted and signed, they were interviewed. Thereafter, participants were designated randomly to the experimental or control groups, women with odd number in the list of participants were allocated in the control group, and women with even number, in the experimental group. The BIS and SBS questionnaires were applied to both groups, once before performing the experimental sessions (pre), and once again at the end of the project (post) to evaluate the variable of body image and its changes. Thus the participant sample was divided into: - Experimental group (n=15) practiced mindfulness based in the MBSR program [29] and following an adaptation for cancer patients [33] for two months, in a total of 8 sessions divided as:  Sessions 1/2: included Body Scan technique and a sitting meditation.  Sessions 3/4: Body Scan and yoga exercises.  Sessions 5/6: yoga exercises and sitting meditation (mountain meditation).  Sessions 7: yoga exercises and kindness and forgiveness guided meditation.  Session 8: consisted on mild yoga exercises practice, followed by body scan and the meditation of kindness and forgiveness.

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At the end of each session, time was given to share personal experiences with the group. Physical exercises were adapted to flexibility characteristics of the participants. And some tasks were assigned to participants, which should be performed at home throughout the week. - Control group (n=14) received five group sessions of "personal image advice", one session per week. The detailed program was:  1st session: participants were advised about the adequate choice of a wig, and about some hairstyles for short hair.  2nd session: counseling about turbans and the different ways to tie and fold them.  3rd session: advice on makeup basic techniques were given.  4th session: counseling about clothing was given, according to complexion and skin tone.  5th session: advice was given on nail care and its basic decorative designs. This program was based on and adapted to following previous similar interventions [48] which provide advices for the physical improvement for patients against breast cancer. Finally, to analyze the results, the Statistical Package for the Social Sciences (SPSS) 23.0. Version was used. Non-parametric tests used were Mann-Whitney U test to compare the differences between control and experimental group at baseline, and Wilcoxon SignedRank test, on the one hand, to calculate the efficacy of the MBSR training in the experimental group; and the other hand, to calculate the efficacy of the personal image advice intervention in the control group. Moreover, analysis of covariance (ANCOVA) was

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used to compare differences between groups in the post-treatment, adjusting for baseline differences between both in the pre-treatment condition. -------------------Figure 1. Study flow chart---------------------------------------------------------RESULTS Sample characteristics The sample of this study consisted of 29 women diagnosed with breast cancer, with an average age of 49.34 years (SD = 8.913) ranging from 31 to 66 years of age. The type of surgery was mastectomy in 55.2% of the cases and breast conserving surgery in 44.8%; and a majority of women (96.5%) received combined treatment including chemotherapy, radiotherapy and hormonal treatment (Table 1). ----------Table 1. Sociodemographic and Clinical data of the Study Sample---------Sample characteristics comparing experimental and control group As it can been seen at Table 2, sociodemographic and clinical variables (age, relationship status, time since diagnosis, type of surgery and adjuvant treatment) were very similar in both groups. ----------Table 2. Sociodemographic and Clinical data comparing both groups---------The mean score of body image measured by BIS was equal in both. However, the groups were different in awareness and bodily dissociation. Results showed that control group presented more body awareness and less bodily dissociation than experimental group, and these differences were statistically significant using Mann-Whitney U test (p<.05 in both variables).

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Mindfulness program´s efficacy (experimental group) Data analyzed by Wilcoxon Signed-Rank test showed significant differences in body image between pre and post treatment in the experimental group measured by BIS (p<.01). Moreover, the intervention program increased the body awareness and decreased the dissociation, measured by SBC (both with p< .01). These results indicate that the mindfulness program was useful in decreasing the alterations and negatives thoughts related to body image. Efficacy of the program based in personal image advice (control group) There were not significant differences, analyzed by Wilcoxon Signed-Rank test (p > .05), in body image observed between pre and post treatment based in personal image advice measured by BIS (p= .055), SBC body awareness subscale (p= .138) or SBC dissociation subscale (p= .719). Comparison of mindfulness and personal image advice group To compare the differences between the group that received mindfulness program (Program A) and the group that received personal image advice program (Program B), the analysis of covariance (ANCOVA) was used, excluding the influences generated by the conditions before starting the program, so the pre-treatment was the covariate variable. The results showed that there were not significant differences between both groups in the body image measured by BIS: F(1,28)=.055; p>.05; ηp2=.002. However, the corrected model showed significant differences in body image in favor of the experimental group: F(1, 28)=12.616; p<.01; ηp2=.335.

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The results obtained in the SBC questionnaire initially showed significant differences in the subscale of Body Awareness: F(1,28)=12.047; p<01; ηp2=.325. However, when the model was corrected, the differences disappeared F(1,28)=2.475; p>.05; ηp2=.090. And in the Dissociation subscale, there were no significant differences between both groups, before or after the correction of the model (F(1,28)=2.163; p>.05; ηp2=.080, and F(1,28)=.018; p>.05; ηp2=.001, respectively). So, it is clear that the mindfulness program was more effective than the personal image advice program in decreasing negative emotions and thoughts related to body image, measured by BIS. But in relation to body awareness (BAAW) and body dissociation (BADIS), both programs had similar results (Figure 2). ---------Figure 2. Comparison between groups on different scales------------------------------DISCUSSION The survival of breast cancer patients has encouraged researchers to stop and observe the needs of the former and to discover the variables associated with distress and emotional well-being. Body image has been related with the emotional well-being in breast cancer patients. The alterations and changes in the body image, due to the illness, treatment and its side effects, promote emotional, psychological and behavioral disruptions as symptoms of anxiety and depression, avoidance of themselves or of some parts of the body, reduction in the sense of femininity, low self-esteem and self-efficacy, and more [2,3,10-18]. However, the majority of the studies have treated breast cancer patients´ emotional wellbeing but not the alterations in body image. For example, there are a few CBT-based

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intervention studies that report improvement in body image but it is not clear what component is determinant because the studies analyze different types of CBT interventions and they treat more variables beyond body image [24]. So, the present study contributes to improve the body image in these patients by implementing a mindfulness program. On the one hand, the mindfulness program was effective to decrease negative emotions and thoughts related to body image and the dissociation; and to increase the positive thoughts related to patient´s appearance and body awareness. So the first above mentioned hypotheses can be accepted. It could be due to the attention on present moment and accepting it without judging that this program helped increase body awareness and decrease ruminations about body image [26, 29]. Body image is part of self-concept and this self-concept affects emotional well-being. How people see, love and think about themselves has an impact on psychological function. As it was said in the introduction, alterations in body image are related to low self-esteem, dissatisfaction with appearance and to negative behavior and emotions that could allow psychological disorders, such as depression or some eating disorders like anorexia or bulimia [1,10-18, 41-43]. On the other hand, comparing experimental and control groups after the correction of the model to control the differences before the intervention, the results showed that the mindfulness program was more effective than personal image advice program to treat emotional and psychological body image alterations. But both programs had similar results in treating body awareness and body dissociation. In this case, the second hypotheses may be partially accepted.

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At this point, it is important to say that the groups were very different concerning body awareness and body dissociation variables at baseline. The control group had higher levels of body awareness and lower levels of body dissociation than experimental group before the program application and, although the ANCOVA corrected this variability, the final result can be biased due to differences. The main limitations observed in this study are the small number of participants, the differences in the pre-treatment condition, and the differences between the duration in both programs (five days for the control group and eight for the experimental group), so these results should not be generalized. To overcome these limitations, it is necessary to increase the sample size, to equalize the program duration in both groups in order to avoid the time variable of influencing the results. And along the same path, to equalize the groups concerning the variables analyzed at baseline to homogenize the samples. Moreover, it could be useful to study the cultural influences that can mediate the results, because extracting mindfulness from the context in which it originates can change the effects of the practice [49]. In this sense, this program was exposed for breast cancer patients at the hospital and women who decided take it are part of the sample, but we do not know why other patients decided not to participate; maybe there was influencing cultural or religious ideas about meditation and it would be worthwhile analyzing them. For example, some catholic people hear the word meditation and they associate it with Buddhism or Hinduism, so they reject this practice thinking that it is contrary with their faith. A recommendation for future investigations in this area is to homogenize the sample to apply mindfulness programs and adapt them to the needs of patients. For example, adapting

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yoga exercises to capacities or difficulties of sample if some patients have had a recent operation. Finally, it could be interesting to apply programs based on mindfulness and full attention to the medical team in different clinical divisions because these practices could prevent burnout or compassion fatigue syndrome. And this awareness about the own sensations and feelings could allow healthcare professionals to be more emphatic and more open to their patient’s necessities. CONCLUSION Breast cancer affects and promotes the alterations in body image and it deteriorates the well-being and women´s quality of life. There are some programs that promote body image in breast cancer patients, but they are limited to the physical aspect (hair, clothing, skin and makeup). In this sense, in our study, the mindfulness program helped to recognize, accept and improve the thoughts and emotions related to the body.

Ethical approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The research ethical approval was provided by a committee at Universidad

de

las

Americas

Puebla

Conflict of Interest and source of funding: The authors have no conflicts of interest to disclose and they have no source of funding.

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REFERENCES 1. Pintado S. Emotional well-being, body image, self-esteem and sexuality in women with breast cancer (in Spanish). PhD Thesis. Spain: University of Valencia, 2013. 2. Baize N, Mounier N, Bongain A, Spano J. Femininity and breast cancer, original approach of announcement in Oncology. Bull Cancer, 95(9) (2008), pp. 49-57. doi: 10.1684/bdc.2008.0702. 3. Knobf MT. The influence of endocrine effects of adjuvant therapy on quality of life outcomes in younger breast cancer survivors. Oncologist, 11(2) (2006), pp. 96-110. 4. Al-Ghazal S, Fallowfield L, Blamey R. Comparison of psychological aspects and patient satisfaction following breast conserving surgery, simple mastectomy and breast reconstruction. Eur. J. Cancer, 36 (2000), pp. 1938-1943. 5. Arora N, Gustafson D, Hawkins R, et al. Impact of surgery and chemotherapy on the quality of life of younger women with breast carcinoma: a prospective study. Cancer, 92 (5) (2001), pp. 1288–1298. 6. Compas B, Luecken L. Psychological adjustment to breast cancer. Curr. Dir. Psychol. Sci., 11(3) (2002), pp. 111-114. 7. Ganz P, Desmond K, Leedham B, Rowland J, Meyerowitz B, Belin T. Quality of life in long-term, disease-free survivors of breast cancer: a follow-up study. J. Natl. Cancer Inst., 94 (1) (2002), pp. 39-49. 8. Schmid-Büchi S, Halfens R, Dassen T, van den Borne B. Psychosocial problems and needs of post-treatment patients with breast cancer and their relatives. Eur. J. Oncol.Nurs., 15 (3) (2011), pp. 260–266.

17

9. Wimberly S, Carver C, Antoni M. Effects of optimism, interpersonal relationships, and distress on psychosexual well-being among women with early stage breast cancer. Psychol. Health, 23 (1) (2008), pp. 57-72. 10. Anillo L. Sexual life after breast cancer. J. Sex Marital Ther., 26 (2000), pp. 241– 248. 11. Avis N, Crawford S, Manuel J. Psychosocial problems among younger women with breast cancer. Psycho-oncology, 13 (2004), pp. 295-308. 12. Brandberg Y, Sandelin K, Erikson S, et al. Psychological reactions, quality of life, and body image after bilateral prophylactic mastectomy in women at high risk for breast cancer: A prospective 1-year follow-up study. J. Clin. Oncol., 26 (24) (2008), pp. 3943-3949. 13. Chang O, Choi E, Kim I, et al. Association between socioeconomic status and altered appearance distress, body image, and quality of life among breast cancer patients. Asian Pac. J. Cancer Prev., 15 (20) (2014), pp. 8607-8612. 14. Collins K, Liu Y, Schootman M, et al. Effects of breast cancer surgery and surgical side effects on body image over time. Breast Cancer Res. Treat., 126 (1) (2011), pp. 167–176. 15. Falk CA, Reinertsen KV, Nesvold IL, Fossa SD, Dahl AA. A study of body image in long-term breast cancer survivors. Cancer, 116 (15) (2010), pp. 3549-57. doi: 10.1002/cncr.25251. 16. Fobair P, Stewart S, Chang S, D’Onofrio C, Banks P, Bloom J. Body image and sexual problems in young women with breast cancer. Psycho-oncology, 15 (2006), pp. 579-594.

18

17. Helms R, O’Hea E, Corso M. Body image issues in women with breast cancer. Psychol Health Med, 13 (3) (2008), pp. 313-25. 18. Przezdziecki A, Sherman K, Baillie A, Taylor A, Foley E, Stalgis-Bilinski K. My changed body: breast cancer, body image, distress and self-compassion. PsychoOncology, 22 (8) (2013), pp. 1872-1879. DOI: 10.1002/pon.3230 19. Cash T, Smolak L. Body image: a handbook of science, practice, and prevention. New York: Gulford Press; 2011. 20. American

Cancer

Society

http://www.cancer.org/acs/groups/content/@research/documents/webcontent/acspc-042151.pdf, 2010 (accessed 07.03.2016)

21. American Cancer Society http://www.cancer.org/acs/groups/content/@nho/documents/document/f861009final90809pdf.pdf., 2010 (accessed 09.01.2016)

22. Fadaei S, Janighorban M, Mehrabi T, et al. Effects of cognitive behavioral counseling on body Image following mastectomy. Journal of Research in Medical Sciences, 16(8), (2011), pp. 1047-1054. 23. Duijts S, van Beurden M, Oldenburg H, et al. Efficacy of cognitive behavioral therapy and physical exercise in alleviating treatment-induced menopausal symptoms in patients with breast cancer: results of a randomized, controlled, multicenter trial. Journal of Clinical Oncology, 30(33) (2012), pp. 4124-4133. 24. Fingeret M, Teo I, Epner D. Managing body image difficulties of adult cancer patients: lessons from available research. Cancer, 120(5) (2014), pp. 633-641.

19

25. Campbell A, Mutrie N, White F, McGuire F, Kearney N. A pilot study of supervised group exercise program as a rehabilitation treatment for women with breast cancer receiving adjuvant treatment. Eur. J. Oncol. Nur, 9 (2005), pp. 56–63. 26. Brown K, Ryan R, Creswell J. Mindfulness: Theoretical foundations and evidence for

its

salutory

effects.

Psychol.

Inq.,

18(4)

(2007),

pp.

211-237.

doi:10.1080/104784000701598298 27. Mehling WE, Gopisetty V, Daubenmier J, Price CJ, Hecht FM, Stewart A. Body Awareness: Construct and self-report measures. PLoS One, 4 (5) (2009), pp. 1-18. Doi:10.1371/journal.pone.0005614 28. Mehling WE, Wrubel J, Daubenmier JJ, et al. Body Awareness: A phenomenological inquiry into the common ground of mind-body therapies. Philos., Ethics Humanit. Med., 6 (2011), pp. 6. Doi: 10.1186/1747-5341-6-6 29. Kabat-Zinn J. MBSR interventions in context: Past, Present and Future. Clin. Psychol.Sci. Pr., 10 (2003), pp. 144-156. 30. Bishop S, Lau M, Shapiro S, et al. Mindfulness: a proposed operational definition. Clin. Psychol.Sci. Pr., 11 (3) (2004), pp. 230-241. 31. Kabat-Zinn, J. Full catastrophe living: Using the wisdom if your body and mind to face stress, pain and illness. Nueva York: Delta; 1990. 32. Carlson L, Brown K. Validation of the Mindful Attention Awareness Scale in a cancer population. J. Psychosom. Res., 58 (2005), pp. 29-33. 33. Carlson LE, Speca M, Segal ZV. Mindfulness-based cancer recovery. Oakland, CA: New Harbinger; 2010. 34. Galantino ML. Influence of Yoga, walking and Mindfulness meditation on fatigue and body mass index in women living with breast cancer. Seminars in Integrative Medicine, 1 (2003), pp. 151-157.

20

35. Tacón AM, Caldera YM, Ronaghan C. Mindfulness-based stress reduction in women with breast cancer. Fam.Syst. Health, 22 (2004), pp. 193-203. 36. Schellekens M, van den Hurk D, Prins J, et al. Study protocol of a randomized controlled trial comparing Mindfulness-Based Stress Reduction with treatment as usual in reducing psychological distress in patients with lung cancer and their partners: the MILON study. BMC Cancer, 14 (2014), pp. 1. doi: 10.1186/14712407-14-3. 37. Shennan C, Payne S, Fenlon D. What is the evidence for the use of mindfulness based interventions in cancer care? A review, Psycho-Oncology, 20 (2010), pp. 681–697. 38. Kvillemo P, Bränström R. Experiences of a mindfulness-based stress reduction intervention among patients with cancer. Cancer Nursing: An International Journal for Cancer Care, 24 (1) (2011), pp. 24–31. 39. Lengacher C, Johnson-Mallard V, Post-White J, et al. Randomized controlled trial of mindfulness-based stress reduction (MBSR) for survivors of breast cancer. Psycho-Oncology, 18 (2009), pp. 1261–1272. 40. Carlson L, Doll R, Stephen J, et al. Randomized controlled trial of mindfulnessbased cancer recovery versus supportive expressive group therapy for distressed survivors of breast cancer. J. Clin. Oncol., 31 (25) (2013), pp. 3119-26. 41. Pidgeon A, Appleby L. Investigating the role of dispositional mindfulness as a protective factor for body image dissatisfaction among women. Current Research in Psychology, 5(2) (2014), pp. 96-103. 42. Albertson E, Neff K, Dill-Shackleford K. Self-compassion and body dissatisfaction in

women:

A

randomized

controlled

trial

of

a

brief

meditation

21

intervention. Mindfulness, 6(3) (2015), pp. 444-454. DOI 10.1007/s12671-0140277-3 43. Alberts H, Thewissen R, Raes L. Dealing with problematic eating behaviour. The effects of a mindfulness-based intervention on eating behaviour, food cravings, dichotomous thinking and body image concern. Appetite, 58(3) (2012), pp. 847851. 44. Hopwood P, Fletcher I, Lee A, Al Ghazal S. A body image scale for use with cancer patients. Eur. J. Cancer, 37 (2001), pp. 189-197. 45. Gómez-Campelo

P, Bragado-Álvarez

C, Hernández-Lloreda

MJ, Sánchez-

Bernardos ML. The Spanish version of the Body Image Scale (S-BIS): psychometric properties in a sample of breast and gynecological cancer patients. Support Care Cancer, 23(2) (2015), pp. 473-81. doi: 10.1007/s00520-014-2383-0. 46. Price C, Thompson E. Measuring Dimensions of Body Connection: Body Awareness and Bodily Dissociation. J Altern Comp Med, 13 (2007), pp. 945-53. 47. Quezada-Berumen LD, González-Ramírez MT, Cebolla AJ, Soler J. Body awareness and mindfulness: Validation of the Spanish version of the Scale of Body Connection. Actas Esp Psiquiatr, 42(2) (2014), pp. 57-67. 48. García C. Your best image in cancer (in Spanish). México: Porrúa; 2011. 49. Kirmayer LJ. Mindfulness in cultural context. Transcultural Psychiatry, 52(4) (2015), pp. 447-69. DOI: 10.1177/1363461515598949

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Figure 1. Study flow chart Ethic Committee approval

Total participants (N=35)

Final sample (N=29)

Randomly designation to control (N=15) and experimental group (N=14)

Pre-treatment assessment

Application programs

Post-treatment assessment

Data analysis

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Figure 2. Comparison between groups on different scales 25

p > .05 20 15

p > .05

p<.01 10 5 0 BIS

BAAW

BADIS

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Table 1. Sociodemographic and Clinical data of the Study Sample Characteristic

% or Mean

Range (SD)

Age

49.34 years

8.913 years

Relationship status Married

45% (13)

Divorced/separated

31% (9)

Open relationship

10% (3)

Single

10% (3)

Widow

3% (1)

Time since diagnostic

4.79 years

Type of surgery Mastectomy

55.2% (16)

Breast conserving surgery

44.8% (13)

Adjuvant treatment Chemotherapy

3.5% (1)

Chemotherapy+radiotherapy+hormonal treatment

96.5% (28)

3.745 years

25

Table 2. Sociodemographic and Clinical data comparing both groups

Characteristic

Control group

Experimental group

Age

50.71 years (SD=7.829)

48.05 years (SD=9.917)

Married

42.9% (6)

46.7% (7)

Divorced/separated

28.6% (4)

33.3% (5)

Open relationship

14.3% (2)

6.7% (1)

Single

7.1% (1)

13.3% (2)

Widow

7.1% (1)

Relationship status

Time since diagnostic

5.07 years

4.53 years

57.2% (8)

60% (9)

Breast conserving surgery 42.8% (6)

40% (6)

Type of surgery Mastectomy

Adjuvant treatment Chemotherapy

7.1% (1)

6.7% (1)

Combined

92.9% (13)

93.3% (14)

BIS

7.93

7.93

SBC Awareness

20.79

15.47

SBC Bodily Dissociation

10.07

12.73