at SciVerse ScienceDirect

Complementary Therapies in Clinical Practice 18 (2012) 221e226

Contents lists available

Complementary Therapies in Clinical Practice

journal homepage: www.elsevier .com/locate/ctcp

Mindfulness-based stress reduction in breast cancer: A qualitative analysis

Caroline J. Hoffman a,*, Steven J. Ersser b, Jane B. Hopkinson c

a The Haven, Effie Road, London SW6 1TB, UKbUniversity of Hull, UKcCardiff University, UK

Keywords:Mindfulness-based stress reductionMBSRBreast cancerThe HavenQualitative

* Corresponding author. Tel.: þ44 (0) 20 7384 0007E-mail address: caroline.hoffman@thehaven.org.uk

1744-3881/$ e see front matter � 2012 Elsevier Ltd.http://dx.doi.org/10.1016/j.ctcp.2012.06.008

a b s t r a c t

There have been few qualitative investigations evaluating Mindfulness-Based Stress Reduction (MBSR) inbreast cancer populations. The nested qualitative analysis reported here explores the acceptability andthe perceived effect of MBSR. As part of a larger randomised controlled evaluative trial, 92 participantswith stages 0 to III breast cancer completed a short proforma following week 8 of a MBSR programmeconducted at The Haven, an integrated cancer support centre in London, UK in 2005e2006. Followingthematic analysis, the most positive experiences from participants (n ¼ 92) were reported to be; 1) beingcalmer, centred, at peace, connected and more confident; 2) the value of mindfulness practice; 3) beingmore aware; 4) coping with stress, anxiety and panic; 5) accepting things as they are, being lessjudgemental of myself and others; 6) improved communication and personal relationships and 7)making time and creating space for myself. All participants asked (n ¼ 39) said that following MBSRtraining they had become more mindful. These understandings will be able to help shape the futureteaching of MBSR in breast cancer.

� 2012 Elsevier Ltd. All rights reserved.

1. Background

1.1. Breast cancer

Breast cancer is the most common cancer in the UK; over550,000 women live with the disease in the UK.1 Lifetime risk ofbreast cancer in the UK is 1 in 8, the same as the USA.2Its diagnosisand treatment is known to have negative physical and psycholog-ical sequelae that can persist well after hospital treatment.3e9 In theUK, the amount of physical and emotional support received and theopportunity to learn self-management skills for breast cancerpatients beyond medical treatment remains a postcode lottery.10

The UK’s National Cancer Survivorship Initiative is examiningappropriate ways of helping people live well with and beyondcancer. The breast cancer charity, The Haven11 provides free infor-mation, support and mind-body therapies to help people alongsideand after their medical treatments both in their centres and viatheir film, audio and web-based outreach programme called TheHaven at Home.12

Before commencing this research, there was no publishedqualitative cancer and MBSR data. Subsequently two studies havebeen published. In cancer outpatients, Mackenzie13 found five

; fax: þ44 (0) 20 7384 0001.(C.J. Hoffman).

All rights reserved.

themes: opening to change, self-control, shared experience,personal growth, and spirituality whilst in breast cancer, Dobkin14

found themes of acceptance, regaining and sustaining mindfulcontrol, taking responsibility for what could change, openness andconnectedness. The limited number of studies offered this oppor-tunity to further research.

1.2. Mindfulness-based stress reduction

The MBSR programme started over 30 years ago by Dr JonKabat-Zinn in USA; it is now being taught worldwide. It aims toteach people a way of being that can help reduce stress and otherphysical and emotional symptoms and help people lead happierand healthier lives. Mindfulness is described as bringing attentionand awareness to each moment on purpose, in a particular way andnon-judgementally. It is ‘a way of being’.15 In its original format,MBSR is run as an 8-week programme of 2.5 h per week with anadditional day of mindfulness practice in week 6 of theprogramme.15

1.3. Aim

To explore the acceptability and perceived effects of partici-pating in MBSR using qualitative data nested within an evaluativerandomised controlled trial (RCT).

C.J. Hoffman et al. / Complementary Therapies in Clinical Practice 18 (2012) 221e226222

1.4. Methodology

The RCT (N ¼ 229) reported elsewhere,16 was supplemented byadditional qualitative data collected by the completion of a shortproforma (See Fig. 1). Semi-structured questions were used toexplore the participants’ experience of MBSR with one closed andfour open questions given to those who completed the MBSRprogramme. Of note, the first question 1.1, relating directly tomindfulness, was introduced part-way through the study when theimportance of capturing this data became evident.

Name……………………………………………………

Date………………………………………………………

1. As stated in class, Mindfulness is described a

the present moment in a non-judgemental way’

1.1.Do you believe you have experienced a greateparticipating in the stress reduction programme?

Yes No (Please circle the ans

1.2. Can you give some examples in your life wher

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

2. Please write down the most positive effect that tpractice has had in your life?

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

3. Please write down what you found the most chamindfulness practice

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

4. Please add any other comments about the prog

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Fig. 1. Feedback form given out a

Capturing open-ended qualitative data to obtain breadth ofknowledge allowed personal views and experiences to be gatheredthat would not be revealed through quantitative trial data. Thisenabled a better understand the experience of participating in MBSR,gave insights into the interaction ofwomenwith the intervention, thebenefits and challenges to the cultivation of mindfulness from theperspectiveof thesewomentreated forbreastcancerwhoparticipatedin thestudy.Atanexplanatory level, it allowed theclinician-researcherto understand the acceptability and perceived effects of undergoingthe MBSR intervention and their experience of mindfulness.

……………

…………..

s ‘bringing our attention and awareness to

.

r degree of Mindfulness as a result of

wer)

e this has occurred?

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………

his eight-week programme and mindfulness

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………

llenging about the programme and the

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………

ramme that you would like in the space below

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………...........................................

t week 8 (final MBSR class).

Table 1Inclusion and exclusion criteria for the study.

Inclusion criteria Exclusion criteria

Female MaleDiagnosis of stages

0 to III breast cancerDiagnosis of stageIV breast cancer

Age 18e80 years Non-English speakingAbility to complete a

questionnaireSubstance misuse

Aware of their cancerdiagnosis

Suicidal thoughts

Within 2 months to2 years following thecompletion of surgery,chemotherapy and/orradiotherapy

Unable to give informedconsent due to currentpsychosis or apparentserious intellectualimpairment

Table 2Main qualitative themes from MBSR participants from what was most positiveeffects or most challenging.

Percentage (N ¼ 92) asan indicator of saliency

Theme 1 Being calmer, centred, atpeace, connected andmore confident

33% (n ¼ 30)

Theme 2 The value and challengesof mindfulness practice

30% (n ¼ 28)

Theme 3 Being more aware 29% (n ¼ 27)Theme 4 Coping with stress,

anxiety and panic29% (n ¼ 27)

Theme 5 Accepting things as theyare, being less judgementalof myself and others

20% (n ¼ 18)

Theme 6 Improved communicationand personal relationships

17% (n ¼ 16)

Theme 7 Making time and creatingspace for myself

16% (n ¼ 15)

C.J. Hoffman et al. / Complementary Therapies in Clinical Practice 18 (2012) 221e226 223

1.5. Ethics

This study was given ethical approval by the London RiversideResearch Ethics Committee. This was granted in August 2004, RECreference number: 04/Q0401/58.

1.6. Research question

The research question to be answered by the qualitative datawas ‘What is 1) the acceptability and 2) the perceived effect ofMBSR?’

1.7. Recruitment

Eligible women were invited to attend a recruitment interview.Consent was given, then they were randomised using a blockdesign. Inclusion and exclusion criteria are found in Table 1. For thequantitative data, 229 women were recruited into the study, 114 inMBSR intervention group and 115 in control group (who wereoffered MBSR after the study). In the intervention group, mostparticipants (n¼ 92) completed the qualitative data proforma. Theyjoined the study a mean of 18 months post diagnosis and 9 monthspost radiotherapy. The mean age of participants in years was 49.

1.8. Participant characteristics

Participant’ predominant socio-economic status was high withapproximately 75% of participants in AB and 15% in C1 groupings.Participants with stages 0 to III breast cancer were recruited; mostpresented with stage II breast cancer (n ¼ 47), then stage I, stage IIIand stage 0 respectively. Amongst the 92 participants, their medicaltreatment was as follows: 59% percentage of participants hadbreast conserving surgery, 46% mastectomy (some of whom hadalready had breast conserving surgery), 59% chemotherapy, 80%radiotherapy and 20% breast reconstruction. These treatmentfigures are typical of women attending The Haven in London.

1.9. Intervention: MBSR programme

The 8-weekMBSR programme closely followed the University ofMassachusetts Centre for Mindfulness (UMCM) programme withclasses 1 and8: 2.25h and classes 2e6: 2hperweek. Therewas a6-hday of mindfulness inweek six on a Saturday. Home Practice for thecourse consisted of a structured PracticeManual including photos ofmindful stretching exercises, meditation sitting positions, infor-mation on ways of seeing, pleasant and unpleasant events, stress,some stories/poems, and short exercises, and 4 � 45 min mindful-ness CDs: body scan, lying stretches, sitting meditation, standingstretches. Home practice sheets were given out each week and

a record of formal home mindfulness practice was kept. An averageof 33minperdayofmindfulness practicewasdoneover the8weeks.

Between 12 and 20 participants attended each MSBR group andclinical supervision for the clinician-researcher delivering MBSRwas received from UMCM.

1.10. Data analysis

Data from the intervention group’s short proforma (n ¼ 92)were analysed in a series of analytic steps using content andthematic analysis. The counting of items in categories identifiedconsistency of findings and their saliency. Through noting patterns,clustering, subsuming particulars into the general, discrete items ofinformation were integrated to build a chain of evidence.17 Ifpresent, any key negative cases were noted.

2. Results

There were 92 qualitative short proforma completed froma possible 95 intervention group participants who completed theMBSR programme. The three participants who did not complete theform left the course due to work, being too busy and one who didnot find the course suitable.

2.1. Becoming more mindful

Only 42% (n ¼ 39) participants from the intervention groupcompleted question 1.1: whether they had experienced a greaterdegree of mindfulness as a result of participating in the stressreduction programme and all replied ‘yes’.

2.1.1. Main themes from qualitative analysisThe qualitative results show the diverse nature of impact that

practising mindfulness can have. The frequency of commentaryindicates salience for the themes identified. A degree of saturationwas achieved in the main themes and data is presented across therange of the sample. The additional themes presented here showhow participants experienced mindfulness and understood itsnature. The following data also gives further information as to theprocess and consequences of cultivating mindfulness from partic-ipation in the MBSR course and home practice. Table 2 lists themain qualitative themes derived from MBSR participants.

2.1.1.1. Theme 1. Being calmer, centred, at peace, connected and moreconfident. One of the key themes that emerged was ‘being calmer,centred, at peace, connected and more confident’. There were 33%

C.J. Hoffman et al. / Complementary Therapies in Clinical Practice 18 (2012) 221e226224

(n¼ 30) participants who commented on this. Participants perceivedthemselves to be calmer, and were also perceived by others to be soboth in mind and body. Participants were able to connect better withthemselves and get in touchwith the central, calm and peaceful placewithin, releasing their attention fromthedistractions of thebusyouterlife:

� ‘I am much more confident and self-assured than I was in the begin-ning. With this confidence I have the courage of my convictions tochange certain aspects ofmy lifewhich I wouldn’t have done beforeein my job, I’mvery much aware of what is good for me (mentally andphysically) and will actively change things’ (Participant 197SU17).

� ‘people are commentingabout how I seemcalmereven though theydon’t know I have been on the course.’ (Participant 168SP16).

� ‘I feel more centred, watch less TV and drink less’ (Participant009SP15).

� ‘I feel both physical and mental peace. I am now a lot calmer ineveryday life’ (Participant 196SU17).

� ‘I feel more at peace and at home with myself and my body than Ihave in a very long time’ (Participant 167SP16).

2.1.1.2. Theme 2. The value and challenges of mindfulness practi-ce. There were 30% (n ¼ 28) participants who commented on thevalue and challenges of mindfulness practice. Having a scheduledprogramme of mindfulness helped motivate participants to prac-tise, gave them the opportunity to experience meditation ona deeper level, to appreciate the value of meditation in life, and topractise without interruption. There was a particular gratitudeexpressed for having the CDs to practise with as ongoing resourcesboth during and after the course:

� ‘The CDs provide my backup to rebalance myself whenever I wante almost like an insurance policy for getting overstressed’(Participant 006SP15).

� ‘The resources that we can keep will make it easier to at least tryand keep up with the practice at home and in our daily lives’(Participant 002SP15).

The process of cultivating mindfulness through formal practiceraises various challenges for most people. The introduction of newexperiences such as the formal practice of mindfulness into thelives of participants brought attention to behaviours and physicalstates of which they were not aware. These included noticing theway the mind wanders and the challenge of keeping the mindpresent, physical discomfort and stiffness in the body, tirednessthat became apparent when participants found themselves fallingasleep during the body scan. Other issues can include motivation,intention and preferences (wanting to do something else or notwanting to practise). These are commonly experienced in thepractice of mindfulness and so are not unique to these participants;they are inherently part of the process of developing mindfulnessthrough noticing what arises in the present moment.

Challenges included 9% (n ¼ 8) participants who found stayingawake during the body scan one of the most challenging aspects ofmindfulness practice. Some participants, 21.7% (n ¼ 20), found themeditationpractice verydifficult eitherdue to the difficulties of sittingfor a period of time or because they noticed themindwandering a lot:

� ‘Sitting meditation was something that I really struggled with e

and sometimes still do e a combination of “monkey mind” andphysical discomfort’ (Participant 200SU17).

� ‘In practising the mindful body scan which was usually done lyingdown, staying awake was the biggest challenge’ (Participant167SP16).

Only one participant commented that she struggled to engagewith mindfulness practice in the following way:

� ‘I hated the first two to three sessions and felt very anti, but didappreciate it from then and I feel like it has made me a calmerperson’ (Participant 011SP15).

2.1.1.3. Theme 3. Being more aware. Participants found that comingback to the present, being mindful, was very useful when they orsituations felt out of control. Coming back to the awareness ofbreathingwas taughton thecourseasawayofbringingattentionbackto the present moment and participants commented on this as awayof regaining calm and control in a situation. It was noted that comingback to the present through awareness of breathing eased theperceived difficulty in any given situation. In the cultivation ofmindfulness, bringing attention and awareness to present momentexperiences is central to this process. Once it is recognised that theattention is no longer present, the practitioner can bring the mindback; this process helps develop mindfulness. Enhanced mind andbodyawareness can result, bringing discernment to life choices. Afterattending theMBSR programme and doingmindfulness practice, themost positive effect experienced was participants being more awareof the present moment (29%, n ¼ 27). Being more aware related toboth participants experience of themselves, in terms of awareness ofthe body andmind, as well as more awareness of life around them. Apart of this was the ability to choose where the attention goes:

� ‘an awareness of how I was living my life and the desire to changeit’ (Participant 021SP15).

� ‘Made me more aware of the necessity to slow down, to take timeout’ (Participant 133WT16).

Through enhanced awareness, participants found a desire andability to change situations that were seen as negative. Also,participants described the ability to see things as they are, ratherthan via the filters through which we normally perceive:

� ‘allowing for time to be was invaluable’ (Participant 067SU16).� ‘I am mindful of how my thoughts can take up an awful lot ofnegative energy. It is as if I can stand back and now see the wholepicture’ (Participant 170SP16).

� ‘The most positive effect has been the ability to stand back andview situations, thoughts and events in their true context’(Participant 170SP16).

This gave more clarity to viewing life and being able to see thewhole picture with thoughts and events in their true context. Beingmore aware also led to a greater appreciation of life’s beauty and itsquality:

� ‘simply noticing beauty in everyday life is a treasure’ (Participant167SP16).

This notion of increased clarity in the perception of life and ofa greater quality of life can be related to enhancements inwellbeing.

2.1.1.4. Theme 4. Coping better with stress, anxiety and panic. In thequalitative data 29% (n ¼ 27) of participants commented that theywere coping better with stress, anxiety and panic examples ofwhich are below:

� ‘I now feel that I have a way of understanding and dealing withstress which is available to me every moment of my life’ (Partic-ipant 200SU17).

C.J. Hoffman et al. / Complementary Therapies in Clinical Practice 18 (2012) 221e226 225

Returning to the awareness of breathing was one used inmoments of stress and commented on by 9% (n ¼ 8) participants:

� ‘using breath to regain calm at difficult moments’ (Participant016SP15).

2.1.1.5. Theme 5. Accepting things as they are, being less judgementalof myself and others. In the cultivation of mindfulness or presentmoment awareness, the development of non-judgemental or non-discriminatory awareness enables a direct contact with realitywithout the filters of judgement clouding situations to such a greatextent. Accepting things as they are is one way of describing thisform or awareness. Judgements are naturally made all the time,however, in the cultivation of mindfulness, they are seen for whatthey are, as ‘thoughts’ rather than as being fixed or permanent,right or wrong.

Non-judgemental awareness allows a degree of simplicity in theview of life, where occurrences are allowed to be as they are,including thoughts, emotions, the body, other people and situa-tions. This is in contrast to the constant battle or drive that exists ineveryday life where much time and energy are wasted wantingsituations and people to be different from how they are. This is notto be confusedwith enabling appropriate change in life, butmore ofa way of living with a greater degree of ease and reducing stress.

Through becoming more mindful, 20% (n ¼ 18) participants saidthat they became more aware of how judgemental they were ofthemselves and others, and began to be less judgemental; that is,learning to accept things as they are. Through accepting life andthemselves, including their bodies, participants found that therewasmore peace and less struggle in their lives. They noticed that theywere less judgemental of themselves andothers. Therewas alsomoreacceptance of self including the bodyand of otherswhich led them tofeel more at home with themselves. Illustrative examples include:

� ‘less judgemental and awareness of how judgemental I used to be’(Participant 198SU17).

� ‘more accepting of my body with all its faults’ (Participant130WT16).

2.1.1.6. Theme 6. Improved communication and personal relation-ships. Mindfulness enhanced the quality of attention given torelationships and this in turn enabled participants to be aware ofhabitual reactions resulting in the ability to respond in a moreappropriate and healthy way. It was observed that creating timeand space for mindfulness practice enabled a better quality incommunication on both sides of relationships both with adults andchildren. Comments on this came from 17% (n ¼ 16) participants:

� ‘I have noticed I am much more ‘present’ with my children’(Participant 157SP16).

� ‘It has enabled me to create some space and time for myself awayfrommy children (pre-school and inevitably demanding) and I feelI cope better with them as a result and they in turn respond betterto me.’ (Participant 130WT16).

2.1.1.7. Theme 7. Making time and creating space for myself. Manyparticipants found that making time for themselves was a chal-lenge. Some found that this led to making time for other things.Bringing awareness to the creation of space and time, and the needto slow down and take time out, actually created more time as oneparticipant put it ‘making time in my head’. Participation in thecourse and the request for home practice raised issues of theirrelationship with time itself.

Finding ways to participate in self-management is central tofinding ways to promote health and wellbeing. In the cultivation of

mindfulness, formal mindfulness practice necessitates participantsto reflect on creating time and space for their own health anddevelopment. In the study, formal home practice of 45 min per daywas suggested. For many participants who perceive their lives to bealready busy, this was a challenge.

The qualitative data revealed that making time and space formyself was important to participants; 16% (n ¼ 15) commenteddirectly about this. Furthermore, attendance of MBSR sessions andhome practice gave participants permission to give themselves moretime and space:

� ‘It has opened up a sense of space both physical and in time for me.And I feel I’ve got more space because the practice has given mea way of taking time for myself without pushing others in my lifeaway. And the non-judgemental ’permission’ concept has madespace from the critical part of my mind which has often over-whelmed me in the past’ (Participant 168SP15).

Making or finding time to do mindfulness practice was one ofthe biggest challenges for participants with 49% (n ¼ 45) directlycommenting on this, although it was acknowledged by some thatthis might be overcome by a change in thinking or perspective:

� ‘I found it very difficult to do the practical. Sometimes this was justabout making time in my head’ (Participant 133WT16).

� ‘When given the CD and told they lasted 45 min e thinking whencan I fit this in, but as you practise, to make time was not a chal-lenge e Not only have I found the time to do the practice and havealso found the time to swim each day which I haven’t done inyears.’ (Participant 202SU17).

2.2. Negative cases

It is important to note where the intervention was reported tobe unhelpful. This data was minimal with very few negativecomments, but one participant did not find MBSR helped withfeelings of desperation:

‘I enjoyed the course but it didn’t help with the things I hoped itwould, i.e. insomnia, fatigue, despair’ (Participant 024SP15).

This participant had spoken to the clinician-researcher in themiddle of the eight-week MBSR programme about feeling low andit was agreed that she could continue to come to the classes for thesocial support but not do the home practice as she was strugglingwith that. She was also under the care of her doctor.

2.3. Overall summary of qualitative data

From the process of simply being mindful or more aware, therewere skills thatwere developedwhich helped participants to achievethe following outcomes: accepting things as they are, being lessjudgemental, being calmer, more centred, at peace, connected andconfident. Making time and creating space for self was an importantpart of cultivating mindfulness and helped participants cope withstress, anxiety and panic. Improved communication and personalrelationships, coping with physical and mental symptoms includingpain were benefits of practice but not as frequently mentioned asthose above. Mindfulness is seen to have been beneficial but alsoa challenge for many participants to practise. The value and chal-lenges of mindfulness practice included having on going skills andresources to continue this practice over time. Frequency or propor-tions canbean indication of saliency inqualitative researchaccordingto Silverman (2006)22; the themes identified in this study were

Table 3Comparisons of themes from qualitative data measuring mindfulness in cancerpopulations.

Current study, (n ¼ 92) Mackenzieat al’s (2007)study, mixedcancer patients(n ¼ 9)

Dobkin’s (2008)study, completedmedical treatmentfor breast cancer(n ¼ 13)

Being more aware Opening to change Spirit of opennessand connectedness

Being calmer, centred, atpeace, connected andmore confident

Self-control, sharedexperience

Regaining andsustaining mindfulcontrol

Accepting things as theyare, being less judgementalof myself and others

Not specified Acceptance

Coping with stress, anxietyand panic

Personal growth Taking responsibilityfor what could change

Improved communicationand personal relationships

Spirituality Not specified

Making time and creatingspace for myself

Not specified Not specified

The value and challengesof mindfulness practice

Not specified Not specified

C.J. Hoffman et al. / Complementary Therapies in Clinical Practice 18 (2012) 221e226226

attributed to between 16% and 33% of respondents, suggestinga degree of saliency had been achieved.

2.4. Limitations of the qualitative data

The limitations of the study include: 1) the method of datacollection, for example, semi-structured interviews are likely tohave captured greater depth and breadth of experience 2) missingdata, some participants were not asked one of the questions, whichhas implications for the meaning of the frequencies reported and 3)social desirability may have influenced responses.

3. Discussion

MBSR and practising mindfulness reinforced some existingfindings and provided new insights compared to other two othermindfulness studies in cancer13,14 (see Table 3). Increased aware-ness, described as openness to change and the spirit of connected-ness, were common amongst all three studies. This is alsoacknowledged in the teachingofMBSRasmindfulness has increasedawareness as a keycomponent,18 althoughmindfulness ismore thanawareness alone.19 Seeing things differently enables participants tosee their habitual reactions and ruminative mental patterns, there-fore giving more control and choice to act in a more adaptive way.

Through MBSR and mindfulness practice, giving time to beobjectively aware of the experience of life as well as living itmoment to moment allowed increased acceptance, calm, confi-dence and ability to cope, all valuable for women facing an uncer-tain future. This was identified in other breast cancer studies and isnoted in mindfulness literature.14,20

Unique to this study were findings that confirmed the need forpeople treated for breast cancer to make time and space to care forthemselves and MBSR does this. It is an important key to improvingself-management and congruent with Bandura’s construct of self-efficacy.21

Ensuring that the possible challenges of mindfulness practice arehighlighted at the beginning of MBSR can help ensuring betteradherence to the programme but as this study showed, it does noteradicate them.

4. Conclusion

These qualitative results suggest that MBSR and mindfulnesspractice can enhance the quality of life in breast cancer survivors by

teaching a way of being and coping that can be used in differentaspects of their lives. A key new finding is that MBSR gives womentime and space for themselves and permission to engage in self-care, thereby enhancing self-management.

Funding sourcesThe Girdlers’ Company through the Florence Nightingale

Foundation, Mr Harvey White. The study sponsors have had noinvolvement in the study design, in the collection, analysis orinterpretation of data; in the writing of the manuscript; and in thedecision to submit the manuscript for publication.

Conflict of interestThe three authors on this paper had no conflict of interests with

any people, organisations or funders that might have inappropri-ately influenced (biased) this work.

References

1. Cancer Research UK. Prevalence of breast cancer. Cancer Research UK. Availablefrom: URL: http://info.cancerresearchuk.org/cancerstats/types/breast/incidence/#prev; 2011.

2. Breast Cancer Org. Lifetime risk of breast cancer in USA. Breast Cancer Org.Available from: URL: http://www.breastcancer.org/symptoms/understand_bc/statistics.jsp?gclid¼CO7f5PO7pqsCFQIYzQod92dW4Q; 2011.

3. Andersen BL, Farrar WB, Golden-Kreutz D, Kutz LA, MacCallum R, Courtney ME,et al. Stress and immune responses after surgical treatment for regional breastcancer. J Natl Cancer Inst 1998;90(1):30e62.

4. Andrykowski MA, Cordova MJ, Studts JL, Miller TW. Posttraumatic stressdisorder after treatment for breast cancer: prevalence of diagnosis and use ofthe PTSD checklist-civilian version (PCL-C) as a screening instrument. J ConsultClin Psychol 1998;66(3):586e90.

5. GanzPA,KwanL, StantonAL, Krupnick JL, Rowland JH,MeyerowitzBE, et al.Qualityof lifeat theendofprimarytreatmentofbreast cancer:first results fromthemovingbeyond cancer randomized trial. J Natl Cancer Inst 2004;96(5):376e87.

6. Ganz PA, Kwan L, Stanton AL, Bower JE, Belin TR. Physical and psychosocialrecovery in the year after primary treatment of breast cancer. J Clin Oncol 2011.http://dx.doi.org/10.1200/JCO.2010.28.8043. Published ahead of Print onFebruary 7, 2011.

7. Fallowfield LJ, Cella D, Cuzick J, Francis S, Locker G, Howell A. Quality of life ofpostmenopausal women in the arimidex, tamoxifen, alone or in combination(ATAC) adjuvant breast cancer trial. J Clin Oncol 2004;22(21):4261e71.

8. Burgess C, Cornelius V, Love S, Graham J, Richards M, Ramirez A. Depressionand anxiety in women with early breast cancer: five year observational cohortstudy. Br Med J 2005;330:702e5.

9. Ganz PA, Desmond KA, Leedham B, Rowland JH, Meyerowitz BE, Belin TR.Quality of life in long-term, disease-free survivors of breast cancer: a follow-upstudy. J Natl Cancer Inst 2002;94(1):39e49.

10. HoffmanC,BakerB. Futurehavensdevelopment. London:BreastCancerHaven;2011.11. The Haven e Breast Cancer Support Centres: Thehaven org uk; 2011. Available

from: URL: www.thehaven.org.uk.12. The Haven e Breast Cancer Support Centres. The Haven at home. www thehaven

org uk. Available from: URL: http://www.thehaven.org.uk/how-we-can-help-you/where-we-do-it/haven-home; 2011.

13. Mackenzie MJ, Carlson LE, Munoz M, Speca M. A qualitative study of self-perceived effects of mindfulness-based stress reduction (MBSR) in a psycho-social setting. Stress Health 2007;23(1):59e69.

14. Dobkin PL. Mindfulness-based stress reduction: what processes are at work?Complement Ther Clin Pract 2008;14:8e16.

15. Kabat-Zinn J. Full catastrophe living: how to cope with stress, pain and illnessusing mindfulness meditation. New York: Delacorte; 1990.

16. Hoffman CJ, Hopkinson JB, Nicholls PG, Harrington JE, Thomas PW. Effective-ness of mindfulness-based stress reduction in mood, breast- and endocrine-related quality-of-life and wellbeing in stages 0 to III breast cancer:a randomized, controlled trial. J Clin Oncol 2012;30(12):1335e42.

17. Miles MB, Huberman AM. Qualitative data analysis: an expanded sourcebook.2nd ed. London: Sage Publications; 1994.

18. Kabat-Zinn J. Wherever you go there you are: mindfulness meditation in everydaylife. New York: Hyperion; 1994.

19. Kabat-Zinn J. Coming to our senses. London: Piatkus; 2005.20. Santorelli S. Heal Thy Self: lessons on mindfulness in medicine. New York: Bell

Tower; 2000.21. Bandura A. Self-efficacy: toward a unifying theory of behavioral change. Psy-

chol Rev 1977;84:191e215.22. Silverman D. Interpreting qualitative data: Methods for analyzing text, talk and

interaction. 3rd ed. London: Sage Publications; 2006.