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Mind-Body Approaches

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Mind-body approaches include several techniques. Some have a goal of relaxing both mind and body. Some focus on clarifying the mind, improving focus, enhancing decision-making capacity, managing stress or resolving conflict. Many of these techniques are associated with reduced levels of pain, fatigue, stress, anxiety, nausea and vomiting, depression, sleep disruption or other symptoms common in cancer and cancer treatments.

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Clinical Practice Guidelines

2009 evidence-based clinical practice guidelines for integrative oncology included “incorporation as part of a multidisciplinary approach for reducing anxiety, mood disturbance, and chronic pain and for improving quality of life in cancer patients. Evidence shows the benefit of support groups, supportive/expressive therapy, cognitive-behavioral therapy, and cognitive-behavioral stress management.”¹

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Managing Side Effects and Promoting Wellness

Managing or relieving side effects or symptoms, reducing treatment toxicity, supporting quality of life or promoting general well-being

Studying the effectiveness of these therapies is difficult because of the challenges in creating controls and placebo conditions. However, mounting evidence shows benefits for cancer patients from several of these therapies, as described below. These therapies are most likely beneficial across a wide range of cancers, even though research to date may focus on only a few cancer types. Because many of these therapies generally involve very little risk and may improve quality of life, many practitioners are comfortable recommending them for patients.

• Fewer depressive symptoms in stroke survivors and their caregivers with psychosocial interventions in ameta-analysis of RCTs⁸

Specific Therapies

Art Therapy

Art therapy is an expressive therapy that uses the creative process of making art to improve physical, mental and emotional well-being.⁹

Biofeedback

Patients using biofeedback are connected to electrical sensors or other instruments that report information about body status back to the patient. Information may include heart rate, blood pressure, breathing, muscle contraction, brain waves, sweat glands or skin temperature. The goal is for the patient to learn responses and actions that move these markers in the desired direction. While in the past, patients had to visit clinics, hospitals or physical therapists to access instruments, wearable devices are now available.

• Better immune parameters among women with stage 1 breast cancer with an intervention of relaxation, guided imagery, and biofeedback training compared to no intervention in a small RCT¹⁰  
• A weak trend toward less anxiety among women with stage 1 breast cancer with an intervention of relaxation, guided imagery, and biofeedback training compared to no intervention in a small RCT¹¹

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Breathing

Breathing is one of the simplest, most basic and yet powerful tools to manage a state of stress. Adjusting your breathing can be done anywhere and at any time. Deep diaphragmatic breathing is belly or abdominal breathing in which the belly, rather than the chest, expands when inhaling. This type of breathing resets the autonomic nervous system and has the following effects:¹⁴

• Decrease oxygen consumption, heart and breath rate
• Increase theta wave state and parasympathetic activity
• Generally feeling alert and invigorated

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Cognitive-Behavioral Stress Management

This psychotherapy approach combines meditation with a variety of cognitive-behavioral strategies, such as problem solving and interpersonal communication. The goal is to recognize and alter responses to negative thoughts.¹⁹

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Cognitive-Behavioral Therapy (CBT)

CBT, a type of psychotherapy, aims to help patients change behavior by changing thoughts and feelings. Used to treat mental, emotional, personality and behavioral disorders such as insomnia and depression, CBT has also been used to treat anticipatory nausea and vomiting.

Recommended with good evidence as part of a multidisciplinary approach to reduce anxiety, mood disturbance, chronic pain, and improve quality of life in Society of Integrative Oncology 2009 clinical practice guidelinesDeng GE, Frenkel M et al. Evidence-based clinical practice guidelines for integrative oncology: complementary therapies and botanicals. Journal of the Society for Integrative Oncology. Summer 2009;7(3):85-120.

A study investigated a single half-day group intervention for ovarian cancer survivors. The intervention included sexual health education and rehabilitation training, relaxation and cognitive-behavioral therapy skills to address sexual symptoms, followed by a single tailored booster telephone call four weeks after the group. The intervention led to significantly improved overall sexual functioning and psychological distress that were maintained at a six-month follow-up.²⁶

A 2017 study found that cognitive-behavioral therapy plus hypnosis reduced emotional distress in women with breast cancer undergoing radiotherapy.²⁷

Lower likelihood of developing an anxiety or depressive disorder among newly diagnosed cancer patients at high risk of these disorders, compared with those who received usual care; no effect was found with people without high risk in a mid-sized RCT²⁸

Better body weight, adiposity, leptin, insulin resistance, and C-reactive protein among overweight/obese women at high risk of breast cancer with an individually tailored, cognitive-behavioral therapy program that assists women in identifying strategies to improve their nutrition and physical activity habits with the goal of reduced body weight and obesity compared to controls in a small RCT²⁹

• Substantially less cancer-related fatigue during cancer treatment with cognitive–behavioral therapy combined with physical activity, and moderately less fatigue after treatment either with or without physical activity compared to usual care in a meta-analysis of RCTs³⁰
• Less cancer-related fatigue with cognitive–behavioral therapy in a meta-analysis of RCTs³¹
• Weak trends toward better quality of life and lower stress levels among breast cancer survivors with CBT in a meta-analysis of six RCTs³²
• Slightly lower scores of hot flashes at the end of treatment but not during follow-up among people with breast cancer with CBT compared to controls in a meta-analysis of RCTs³³
• No significant effect on sleep disturbance among people with lung cancer with acupuncture compared to controls, but only during active interventions and not persisting after completing acupuncture in a meta-analysis of RCT³⁴
• Lower ratings of anxiety and less emotional distress among women newly treated for stage 0–3 breast cancer with a 10-week group cognitive behavior stress management intervention that included anxiety reduction (relaxation training), cognitive restructuring, and coping skills training compared to controls in a mid-sized RCT³⁵
• Less cancer-specific anxiety and physiological adaptation among women with stage 1–3 breast cancer with a 10-week group-based cognitive behavioral stress management intervention compared to a 1-day psychoeducational training (controls) in a mid-sized RCT³⁶
• No effect on survival among women with metastatic breast cancer with 35 two-hour weekly sessions of supportive plus cognitive behavioral therapy compared to a home-study cognitive behavioral package in a small RCT³⁷  
• Similar effects on 5 of 12 symptoms of depression among people with clinical depression with CBT compared to antidepressant medications, but less effective with other 7 symptoms in a meta-analysis of 14 RCTs³⁸
• Less severe depression among people with clinical depression with faith-adapted CBT compared to CBT or usual care in a meta-analysis of 6 RCTs of low quality³⁹

Cognitive-Behavioral Therapy for Insomnia (CBT‐I)

Cognitive-behavioral therapy for insomnia (CBT‐I) is effective in improving insomnia:

• A 2017 review concluded CBT-I is effective.⁴⁰
• CBT-I led to improvements in attention and subjective cognitive function in cancer survivors with insomnia.⁴¹
• CBT-I for eight weeks was effective in treating moderate to severe insomnia and more effective than acupuncture for those with mild symptoms of insomnia. Both therapies also improved quality of life. Although both treatments produced meaningful and durable improvements, CBT-I was more effective and should be the first line of therapy.⁴²  
• Better sleep efficienty with medium effect sizes among people with cancer with CBT-I compared to controls in a meta-analysis of eight RCTs⁴³
• Better self-reported sleep outcomes among people with cancer with CBT-I compared to controls in a review of both RCTs and uncontrolled studies⁴⁴
• CBT-I has also shown success with adolescent and young adult (AYA) cancer survivors. Participants in small study reported a significant lessening in insomnia severity, daytime sleepiness and fatigue, and an overall improvement in quality of life eight and 16 weeks after beginning the online program.⁴⁵
• Better sleep quality among people with sleep disturbances with CBT-I compared to controls in a meta-analysis of a subset of 22 intervention studies⁴⁶

Cognitive Bias Modification (CBM)

CBM interventions are designed to directly modify attention and interpretation biases via repeated practice on cognitive tasks.⁴⁷

• Lower self-reported levels of worry, anxiety, depression, and other symptoms of generalized anxiety disorder (GAD)  with internet-delivered interpretation training (cognitive bias modification) in a mid-sized RCT⁴⁸

Dignity Therapy

Dignity therapy is psychotherapy to relieve psychological and existential distress in patients at the end of life. Preliminary evidence shows

• Benefits in anxiety, depression, and dignity-related distress among people with advanced cancer in a meta-analysis of RCTs⁴⁹
• Better dignity-related distress, but only a weak trend toward lower anxiety and depression among among people with cancer in palliative care in a meta-analysis of RCTs and other experimental studies⁵⁰

Guided Imagery

“Guided imagery involves using the imagination to create a specific sensory experience to achieve a clinical goal, such as promoting overall well-being or treating specific symptoms. The National Comprehensive Cancer Network recommends both imagery and hypnosis as effective treatments for anticipatory nausea and vomiting. A review of more than 100 imagery studies found that compared with no treatment, imagery was more helpful for treating depression, anxiety, discomfort, and quality of life, with effects similar to other mind-body interventions such as hypnosis and relaxation alone.⁵¹ See Guided Imagery.

Hypnotherapy

Also referred to as hypnosis or hypnotic suggestion, this therapy is usually done with the help of a therapist using verbal repetition and mental images to create a trance-like state. Hypnosis has been promoted to reduce pain, nausea and vomiting, hot flashes, fatigue and anxiety. A 2019 article in the Washington Post reported that "some US hospitals are offering hypnosis to patients to lessen preoperative anxiety, to manage postoperative pain and even to substitute for general anesthesia for partial mastectomies in breast cancer."⁵²

• A 2017 review of all studies of hypnosis for cancer patients concluded that "hypnosis is a viable means of reducing pain and anxiety without side effects, while allowing patients to play an active role in their comfort and well-being.”⁵³ A review in 2018 found limited evidence of improvements in depression, anxiety and quality of life, but not in pain.⁵⁴ However, study design to date may be inadequate to fully assess the impacts. A rigorous review in 2017 found "no studies met the inclusion criteria" for rigorous testing of hypnosis with cancer patients at the end of life.⁵⁵
• Less cancer-related procedural pain among children with cancer compared to standard care or attention control in a meta-analysis of controlled trials⁵⁶
• Self-hypnosis combined with self-care was linked to improvements in fatigue, sleep, emotional distress and cognitive functioning among people with cancer in a small RCT.⁵⁷
• Less anxiety (more relaxed) and less use of pain medication among people undergoing coronary artery bypass surgery with self-hypnosis compared to no intervention in a small RCT⁵⁸ or anodyne imagery⁵⁹
• No difference in quality of life, anti-emetic use, re-hospitalization rates, treatment delays, and infection rates among women with ovarian cancer undergoing chemotherapy with an intervention combining healing touch, hypnosis, and massage compared to no intervention in a small RCT⁶⁰
• Moderately lower scores of hot flashes at the end of treatment among people with breast cancer with hypnosis compared to controls in a meta-analysis of RCTs⁶¹
• Shorter hospital stays among people with head and neck cancer undergoing surgery with a hypnosis intervention compared to usual care in a small controlled trial⁶²
• Less depression and markers of better immune functionamong people being treated for stage 1 or 2 breast cancer with an eight-week hypnotic-guided imagery intervention compared to baseline, but the effects did not continue once the intervention ended in an uncontrolled study⁶³

Studies specific to breast cancer have found benefit. A 2017 study found that cognitive-behavioral therapy plus hypnosis reduced emotional distress in women with breast cancer undergoing radiotherapy.⁶⁴ A 2018 non-randomized study of women undergoing breast surgery found shorter hospital stays; less anxiety; less weakness (asthenia) during follow-up chemotherapy; less radiodermatitis; and reduced incidence of hot flashes, joint and muscle pain and asthenia while on endocrine therapy in the group receiving hypnosis sedation compared to those receiving general anesthesia.⁶⁵ A systematic review in 2020 concluded that hypnosis is effective in addressing cancer-related pain in breast cancer patients.⁶⁶

• Combined benefit: less pain, fatigue, and anxiety among women with breast cancer undergoing initial surgery with a self-care toolkit of audio-files of guided mind-body techniques (breathing, progressive muscle relaxation, meditation, guided imagery, and self-hypnosis) and acupressure antinausea wristbands compared to usual care in a mid-sized RCT⁶⁷

Evidence not specific to people with cancer:

• Lower anxiety in a meta-analysis of RCTs⁶⁸
• Lower anxiety scores among people with chronic obstructive pulmonary disease in a small RCT⁶⁹
• No impact on anxiety among adult burn patients with hypnosis in a meta-analysis of RCTs⁷⁰
• Use during invasive medical procedures:
  • Lower anxiety scores among men undergoing rigid cystoscopy with hypnosis in addition to routine local anesthesia in a small RCT⁷¹
  • Less use of pain medication with invasive medical procedures, but no significant change in anxiety or pain intensity⁷²
  • Anxiety was higher before a medical procedure, but lower after the procedure, with hypnosis compared to no hypnosis in a mid-sized RCT.⁷³

Hypnotherapy is generally considered safe when administered by a trained professional, but some mental health conditions preclude its use. Patients can learn this skill and therefore, after instruction, perform a type of hypnosis on themselves. See more on the CAM-Cancer website: Hypnotherapy.

Meditation and Mindfulness-based Clinical Interventions

All forms of meditation have the aim of reducing stress, mood disturbances and fatigue, as well as improving quality of life. Meditation generally strives to focus attention, regulate breathing, and raise awareness of thoughts and feelings to achieve inner calm, physical relaxation, psychological balance and improved vitality and coping. Participants practice approaching thoughts and feelings without judgment.

Some meditation practices include movement or energy, including these:

• Qigong
• Tai chi
• Walking meditation
• Yoga

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Expressive Arts Therapy, including Music Therapy

Music therapy may include playing instruments, vocal and instrumental improvisation, singing, composing, music-guided imagery and listening to music, led by a therapist. The goal is usually to address physical, emotional, cognitive and social needs. Music interventions may affect anxiety, depression, fatigue, pain and quality of life in cancer patients, with small impacts on heart rate, breathing rate and blood pressure.

Evidence of art therapy's effects:

• A 2018 review found that music therapy was associated with a decline in pain in patients with terminal illness and possibly with reduced anxiety in cancer patients.¹¹²
• A 2020 review and meta-analysis regarding studies of people with cancer concluded: "During curative treatment, results were most promising with regard to anxiety, depression, and pain medication intake, while in palliative settings, improvements with regard to quality of life, spiritual well-being, pain, and stress were reported."¹¹³
• Benefits with music therapy for anxiety, plus low-quality studies showing benefits for depression, pain, fatigue, quality of life, but no effect on mood or distress; small reductions in heart rate, respiratory rate and blood pressure but not on oxygen saturation levels or physical functioning¹¹⁴
• A 2020 systematic review concluded that music therapy is effective in addressing cancer-related pain in breast cancer patients.¹¹⁵
• Significantly better quality of life and lower scores for anxiety, depression, pain, and fatigue among people with breast and gynecologic cancers with use of arts therapies based on music, painting, or dance in a meta-analysis of 19 RCTs¹¹⁶ The analysis found no benefits for sleep disturbance, anger, vigor, tension, confusion, or stress.
• Lower scores for anxiety depression, and pain among people with cancer in a meta-analysis of RCTs,¹¹⁷ but no evidence of significant effect of five-element music therapy among people with cancer in a separate meta-analysis or RCTs¹¹⁸
• Lower anxiety among critically ill people¹¹⁹ and adult burn patients with music therapy in  meta-analyses of RCTs¹²⁰
• Better quality of life among people with breast cancer with expressive writing in a meta-analysis of RCTs¹²¹
• Less cancer-related fatigue after a session of music therapy among hospitalized adults with cancer and moderate to severe cancer-related fatigue receiving active music therapy such as singing or selecting songs compared to passive listening in a mid-sized observational study¹²²
• No effect on anxiety, depression, stress among people with cancer with dance/movement therapy in a meta-analysis of two small controlled trials¹²³  
• Large improvement in quality of life among breast cancer survivors treated within the prior five years with a 12-week dance and movement program compared to no intervention in a small RCT¹²⁴
• Less anxiety related to surgery with music therapy¹²⁵
• More responsiveness to music therapy and finding of benefit among people receiving outpatient chemotherapy treatment with supportive music and imagery compared to preferred music listening in an RCT¹²⁶

Listening to Music

• Less anxiety with listening to music during invasive medical procedures in meta-analyses of RCTs¹²⁷
• Benefits with listening to music (medical music) on anxiety and depression, but no impact on quality of life or on mood or distress¹²⁸
• Less anxiety and pain, and improvements in sleep, level or arousal, and duration of mechanical ventilation among critically ill adults in a review of RCTs¹²⁹
• Lower distress among people receiving outpatient chemotherapy treatment with preferred music listening compared to supportive music and imagery in an RCT¹³⁰
• No effect on anxiety among people undergoing excisional surgery for basal and squamous cell carcinoma with relaxing music compared to guided imagery or controls (assumed usual care) in a mid-sized RCT¹³¹  
• Lower anxiety among surgeons performing excisional surgery for basal and squamous cell carcinoma with relaxing music compared to controls (assumed usual care) in a mid-sized RCT¹³²  
• Less pain at discharge from the post anesthesia care unit to home among people receiving gynecologic laparoscopic surgery with music audiotapes compared to standard care in a small RCT¹³³

Music therapy is considered safe. See more on the CAM-Cancer website: Music therapy.

Progressive Muscle Relaxation and General Relaxation

This therapy involves successively tensing and relaxing major skeletal muscle groups to reduce feelings of tension, to lower perceived stress, and to induce relaxation.

• Some evidence indicates that patients participating in PMR training have experienced reduced anxiety, pain and symptoms of depression, as well as improvements in sleep parameters and overall quality of life. A review in 2017 categorized relaxation techniques ”as having preliminary positive evidence” for pain management.¹³⁴
• Better sleep quality and scores on anxiety among people with COVID-19 with progressive muscle relaxation in a small RCT¹³⁵¹³⁶
• Combined benefit: less pain, fatigue, and anxiety among women with breast cancer undergoing initial surgery with a self-care toolkit of audio-files of guided mind-body techniques (breathing, progressive muscle relaxation, meditation, guided imagery, and self-hypnosis) and acupressure antinausea wristbands compared to usual care in a mid-sized RCT¹³⁷ Sep/Oct;24(9-10):916-925.
• Less depression among people receiving chemotherapy with an intervention of guided imagery and progressive muscle relaxation compared to no intervention in a mid-sized RCT¹³⁸  
• Moderately less psychological distress among recently diagnosed with localized cancer with an intervention of progressive muscle relaxation with guided imagery compared to controls in a mid-sized RCT¹³⁹
• Less distress, anxiety, and depression among hospice patients with terminal cancer with interactive guided imagery and progressive muscle relaxation compared to baseline, and an apparently larger benefit than with usual care in a mid-sized randomized trial¹⁴⁰  
• A weak trend toward less anxiety (low to moderate effect size) among children hospitalized with a malignancy with an intervention of progressive muscle relaxation and guided imagery compared to no intervention in a small RCT¹⁴¹
• Less tension, anxiety, and sadness among parents of children hospitalized with a malignancy with an intervention of progressive muscle relaxation and guided imagery compared to no intervention in a small RCT¹⁴²
• Less anxiety and depression among people with breast cancer new to chemotherapy with an intervention of progressive muscle relaxation training and guided imagery compared to controls in a small RCT¹⁴³  
• Substantially less fatigue (fatigue decreased with the intervention and increased without it) among people receiving chemotherapy with an intervention of guided imagery and progressive muscle relaxation compared to no intervention in a mid-sized RCT¹⁴⁴  
• Less nausea, vomiting, and retching among people receiving chemotherapy with an intervention of guided imagery and progressive muscle relaxation compared to no intervention in a mid-sized RCT¹⁴⁵  
• Less anticipatory and chemotherapy-induced nausea and vomiting in the three days following chemotherapy among people with breast cancer new to chemotherapy with an intervention of progressive muscle relaxation training and guided imagery compared to controls in a small RCT¹⁴⁶
• Less pain intensity among hospice patients with terminal cancer with interactive guided imagery and progressive muscle relaxation compared to baseline, and an apparently larger benefit than with usual care in a mid-sized randomized trial¹⁴⁷  
• Substantially less pain (pain decreased with the intervention and increased without it) among people receiving chemotherapy with an intervention of guided imagery and progressive muscle relaxation compared to no intervention in a mid-sized RCT¹⁴⁸
• Lower pain intensity, less pain-related distress, and more perceived control over pain among hospitalized patients with cancer pain with either progressive muscle relaxation or analgesic imagery compared to controls, mostly among people with greater imaging ability, more positive outcome expectancy, and fewer concurrent symptoms, in a small controlled trial¹⁴⁹
• Substantially better health-related quality of life (quality increased with the intervention and decreased without it) among people receiving chemotherapy with an intervention of guided imagery and progressive muscle relaxation compared to no intervention in a mid-sized RCT¹⁵⁰

PMR is generally considered safe. See more on the CAM-Cancer website: Progressive Muscle Relaxation.

General relaxation techniques:

• No changes in proliferation among people with breast cancer undergoing radiotherapy with an intervention of relaxation and visualization therapy compared to radiotherapy alone in a small RCT¹⁵¹
• No effect on clinical or pathological response to chemotherapy three weeks after completion among women with newly diagnosed large or locally advanced breast cancer receiving six cycles of chemotherapy with standard care plus relaxation training and imagery compared to standard care in a small RCT¹⁵²
• Lower anxiety scores among burn patients with relaxation techniques¹⁵³
• Less aromatase inhibitor-associated joint pain (arthralgia) among postmenopausal female breast cancer survivors (but not those with metastatic cancer) with relaxation techniques in a meta-analysis of intervention studies¹⁵⁴
• Lower ratings of anxiety and less emotional distress among women newly treated for stage 0–3 breast cancer with a 10-week group cognitive behavior stress management intervention that included anxiety reduction (relaxation training), cognitive restructuring, and coping skills training compared to controls in a mid-sized RCT¹⁵⁵
• No effect on pulmonary function or duration of postoperative ileus among elderly people after conventional resection of colorectal carcinoma with relaxation compared to guided imagery or controls (no intervention) in a small RCT¹⁵⁶
• No effect on reported fatigue among elderly people after conventional resection of colorectal carcinoma with relaxation compared to guided imagery or controls (no intervention) in a small RCT¹⁵⁷
• No effect on analgesic consumption or subjective pain intensity at rest or while coughing among elderly people after conventional resection of colorectal carcinoma with relaxation compared to guided imagery or controls (no intervention) in a small RCT¹⁵⁸
• Lower stress, anxiety, and depression scores, but no changes in stress hormones among people with breast cancer undergoing radiotherapy with an intervention of relaxation and visualization therapy compared to radiotherapy alone in a small RCT¹⁵⁹
• Less anxiety and depression among people with gynecologic and breast cancer undergoing brachytherapy during hospitalization with an intervention of relaxation and guided imagery compared to controls in a small RCT¹⁶⁰
• Better mood scores among women with newly diagnosed large or locally advanced breast cancer receiving six cycles of chemotherapy with standard care plus relaxation training and imagery compared to standard care in a small RCT¹⁶¹  
• Less nausea and nausea combined with fatigue seven days after transplantation among people with breast cancer undergoing autologous bone marrow/peripheral blood stem cell transplantation with an intervention of preparatory information, cognitive restructuring, and relaxation with guided imagery compared to controls in a mid-sized RCT¹⁶²
• Less body discomfort among people with gynecologic and breast cancer undergoing brachytherapy during hospitalization with an intervention of relaxation and guided imagery compared to controls in a small RCT¹⁶³
• No effect on analgesic consumption or subjective pain intensity at rest or while coughing among elderly people after conventional resection of colorectal carcinoma with guided imagery compared to relaxation or controls (no intervention) in a small RCT¹⁶⁴
• Lower oral mucositis pain levels among people with cancer receiving bone marrow transplants with an intervention of relaxation and imagery, whether with or without an intervention of cognitive-behavioral coping skills, compared to usual care in a small RCT¹⁶⁵
• Better quality of life, health, functioning, and psychological/spiritual well-being among people with stage 2–4 breast cancer scheduled to receive high dose chemotherapy and autologous hematopoietic stem cell transplantation with a comprehensive coping strategy program of educational information, cognitive restructuring, coping skills enhancement, and relaxation with guided imagery compared to no program in a mid-sized RCT¹⁶⁶
• Better perceived quality of life among women in treatment after mastectomy with an intervention of relaxation, mental images, and spirituality added to brief psychotherapy (average of six sessions) compared to brief psychotherapy alone in a small RCT¹⁶⁷
• No effect on pulmonary function or duration of postoperative ileus among elderly people after conventional resection of colorectal carcinoma with guided imagery compared to relaxation or controls (no intervention) in a small RCT¹⁶⁸
• Better quality of sleep scores among people receiving surgery for anorectal diseases with a guided imagery tape with a relaxation technique of music and relaxing text before, during and after surgery compared to standard care in a small RCT¹⁶⁹
• Better immune parameters among women receiving chemotherapy followed by surgery, radiotherapy, and hormone therapy for large or locally advanced breast cancers, with relaxation training and guided imagery, especially among those who rated their imagery vividness highly in a small RCT¹⁷⁰
• Better immune parameters among women with stage 1 breast cancer with an intervention of relaxation, guided imagery, and biofeedback training compared to no intervention in a small RCT¹⁷¹
• A weak trend toward less anxiety among women with stage 1 breast cancer with an intervention of relaxation, guided imagery, and biofeedback training compared to no intervention in a small RCT¹⁷²
• A weak trend toward less negative affect among people with cancer receiving chemotherapy with relaxation training with guided relaxation imagery compared to standard care in a small RCT¹⁷³
• A weak trend toward less vomiting among people with cancer receiving chemotherapy with relaxation training with guided relaxation imagery, compared to standard care in a small RCT¹⁷⁴
• Less nausea, but no effect on frequency of vomiting, among people with cancer who had developed negative conditioned responses to their chemotherapy with progressive muscle relaxation training and guided relaxation imagery instructions immediately before and during their chemotherapy treatments compared to controls in an RCT¹⁷⁵

Psychedelic Therapies

Psychedelic therapies are used to “produce a nonordinary state of consciousness for religious or spiritual purposes.”¹⁷⁶ They may also be used to reduce anxiety and promote wellness.

Also known as entheogenic therapies, psychedelic substances or psychotropic substances, these are typically of two origins:

1. Entheogenic substances naturally produced by organisms, such as psilocybin produced by hundreds of varieties of mushrooms
2. Synthesized substances such as MDMA (ecstasy)

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Psychoeducation, Paced Respiration, and Relaxation (PEPRR)

• Lower depression scores with PEPRR compared to treatment as usual among caregivers for people undergoing hematopoietic stem cell transplant when the caregivers had poor sleep at baseline, but no impact of PEPRR on anxiety¹⁷⁷

Simonton Method

The Simonton method of counseling for cancer patients combines cognitive-behavioral elements, relaxation exercises, guided imagery and meditation. This method aims to prolong survival time and improve quality of life. See more on the CAM-Cancer website: Simonton Method and the Simonton Cancer Center website.

Support Groups

Support groups provide a safe place for patients to share feelings and challenges, helping many people cope with the emotional aspects of cancer. Groups also allow people to learn from others facing similar situations.¹⁷⁸

In his book Life Over Cancer, Keith Block suggests that support groups are most helpful during or after treatment rather than right after diagnosis. Benefits of a structured support group may include these:¹⁷⁹

• Confidential expression of concerns, fears and anger
• Development of new or strengthened coping skills
• Enhanced communication and a closer connection to those who matter most in your life
• Warding off isolation and disconnection
• Opportunities for relaxation, cognitive reframing and self-hypnosis training
• Meditation guidance
• Opportunities to laugh with people who can readily appreciate the difficulties of finding special moments of joy

Recommended with good evidence as part of a multidisciplinary approach to reduce anxiety, mood disturbance, chronic pain, and improve quality of life in Society of Integrative Oncology 2009 clinical practice guidelinesDeng GE, Frenkel M et al. Evidence-based clinical practice guidelines for integrative oncology: complementary therapies and botanicals. Journal of the Society for Integrative Oncology. Summer 2009;7(3):85-120.¹⁸⁰

See Sharing Love & Support and Healing Circles: Share Your Experience for further information.

Other Psychosocial and Behavioral Interventions

Sleep Training Education Program: Both STEP‐1 (a single sleep education session) and STEP‐2 (a three‐session, group cognitive behavioral treatment) improved Insomnia Severity Index (ISI) scores, with substantial remission of insomnia among cancer survivors in a small study.¹⁸¹ This therapy can be administered by non sleep-specialists, making it accessible to more patients.

A 2017 review found these benefits among breast cancer survivors:¹⁸²

• Acceptance and Commitment Therapy (ACT), using acceptance and mindfulness strategies and promoting commitment to behavior change, increasing psychological flexibility and adaptability. Studies show preliminary evidence for reduced anxiety and symptoms of depression.
  • A 2021 review found benefit among people with a psychological condition or symptoms (such as depression), but not otherwise, with internet-based ACT.¹⁸³  
  • A 2021 meta-analysis of RCTs of generally poor quality found ACT was associated with better outcomes after treatment completion and at 1-3 months and at 3-6 months of follow-up for depression, anxiety, quality of life, psychological distress, and stress. Outcomes were still significant after 6 months of follow-up for depression, anxiety, quality of life, and stress. ACT was associated with psychological flexibility and was not associated with a reduction in fear at treatment completion. However, psychological flexibility (1-3 months) decreased and fear (1-6 months) decreased, and the longer-term effect was still significant.¹⁸⁴
  • Fewer depressive symptoms among metastatic breast cancer with symptoms interfering with functioning with six telephone sessions of education/support compared to baseline, and comparable to six telephone sessions of acceptance and commitment therapy in a small RCT¹⁸⁵
  • A trend toward greater decreases in fatigue and sleep disturbance among people with metastatic breast cancer with symptoms interfering with functioning with six telephone sessions of acceptance and commitment therapy compared to six telephone sessions of education/support in a small RCT¹⁸⁶
• Behavioral lifestyle interventions, focusing on increasing health behaviors, primarily physical activity. Benefits include improvements in fatigue, symptoms of depression, body image and health-related quality of life.
• Couples-focused interventions, psychological interventions for breast cancer survivors and their partners. These interventions may impact quality of life, distress, relationship functioning and physical symptoms.
• Meaning-Centered Psychotherapy (MCP), targeting psychological, existential and spiritual distress of advanced survivors. Benefits include improvements in quality of life, symptoms of depression and hopelessness.
• Supportive-Expressive Therapy (SET), promoting peer social support and expression of emotions and existential concerns and focuses on facing and grieving losses. Benefits include improvements in symptoms of depression, hopelessness and helplessness, trauma symptoms, and social functioning. Recommended with good evidence as part of a multidisciplinary approach to reduce anxiety, mood disturbance, chronic pain, and improve quality of life in Society of Integrative Oncology 2009 clinical practice guidelinesDeng GE, Frenkel M et al. Evidence-based clinical practice guidelines for integrative oncology: complementary therapies and botanicals. Journal of the Society for Integrative Oncology. Summer 2009;7(3):85-120.
• Less pain intensity and suffering, but no effect on frequency of pain episodes or amount of constant pain among women with metastatic breast cancer with group therapy with hypnosis (supportive-expressive group therapy) plus education compared to an education alone in a mid-sized RCT¹⁸⁷
• A weak trend toward lower oral mucositis pain levels among people with cancer receiving bone marrow transplants with therapist support compared to usual care in a small RCT¹⁸⁸
• Better knowledge of the disease and its treatment, fewer anticipatory side effects, less negative affect, and improved general coping among people with cancer receiving chemotherapy with a general coping preparation package (PREP), whether with or without relaxation training with guided relaxation imagery, compared to standard care in a small RCT¹⁸⁹

A study found benefit of a single exercise counseling session during which symptoms were reviewed and current functional status, as well as current and previous exercise habits and capabilities were assessed. Individualized exercise recommendations were developed, including short- and long-term exercise goals and plans for follow-up sessions. At the close of the session, global distress scores had improved. At a follow-up session, improvements were noted in fatigue and in global health, mental health, and physical health scores.¹⁹⁰

Laughter therapy uses humor to help relieve pain and stress and improve a person’s sense of well-being. It can decrease stress hormone levels, alter dopamine and serotonin activity (related to mood and depression) and improve quality of life as shown in small randomized controlled trials not specific to cancer:

• Lower loneliness scores with laughter therapy among older adults¹⁹¹
• Improved pain and sleep quality¹⁹² and lower levels of stress hormones¹⁹³ with laughter yoga
• Lower anxiety levels in a meta-analysis of RCTs¹⁹⁴
• Decreased depression and anxiety, and improved sleep quality among adults in a meta-analysis of RCTs¹⁹⁵
• Less anxiety during medical procedures and improved psychological adjustment among children and adolescents in the presence of hospital clowns¹⁹⁶  
• Substantially less anxiety among children preparing for surgery, and a small-to-medium effect on reducing parents' state anxiety in two meta-analysis of RCTs¹⁹⁷ and intervention studies¹⁹⁸

Dyadic intervention: Interventions "offered to cancer patients and their family caregivers together as the unit of care" were linked to benefits by three months among people with cancer in these areas:

• Total quality of life
• Total spiritual aspect of quality of life
• Emotional, social, and mental aspects of quality of life
• Depression
• Anxiety
• Relatedness
• Marital functioning

By six months, dyadic was linked to better patient social aspect and depression in a meta-analysis of RCTs.¹⁹⁹

Unspecified psychological interventions (as a group):

• Less anxiety among people with cancer, especially those with higher psychological distress at baseline, and with evidence-based interventions in a meta-analysis of clnical trials²⁰⁰  
• Psychological interventions show positive, statistically significant benefits for anxiety and problem-solving skills, and, to a lesser extent, for posttraumatic stress among family members of children with cancer. No statistically significant differences were found for mood, acute stress, coping skills, social support, or quality of life in a meta-analysis of various types of experimental trials.²⁰¹

Integrative Programs, Protocols and Medical Systems

• Programs and protocols
  • Alschuler & Gazella complementary approaches²⁰²
  • Block program²⁰³
  • Cohen & Jefferies Mix of Six anticancer practices²⁰⁴
  • Lemole, Mehta & McKee protocols²⁰⁵
  • McKinney protocols²⁰⁶
  • Ornish Lifestyle Medicine
• Traditional systems
  • Ayurveda
  • Traditional Chinese medicine

BCCT has not conducted an independent review of mind-body therapies research. This summary draws from several sources:

• CAM-Cancer Summaries
• Mayo Clinic
  • Healthy Lifestyle: Stress management
  • Biofeedback
  • Meditation: A simple, fast way to reduce stress
• Memorial Sloan Kettering Cancer Center’s About Mind-Body Therapies
• National Cancer Institute Topics in Integrative, Alternative, and Complementary Therapies (PDQ®)–Health Professional Version
• Greater Good in Action
• Other sources as noted

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More Information

Courses, Guides & Apps

• Insight Timer: Guided Meditations free app for meditations
• Greater Good in Action: Walking Meditation
• Smith Center for Healing and the Arts: Progressive muscle relaxation instructions by Shanti Norris
• Linda E. Carlson and Michael Speca:
  • Mindfulness-Based Cancer Recovery
  • Mindfulness‐Based Cancer Recovery: A Step‐By‐Step MBSR Approach to Help You Cope With Treatment and Reclaim Your Life
• UMass Memorial Medical Center's Center for Mindfulness: MBSR 8-week Online Live (summer 2020)

Books and Websites

• Mayo Clinic:
  • Biofeedback
  • Healthy Lifestyle: Stress management
  • Hypnosis
  • Meditation: A simple, fast way to reduce stress
• Memorial Sloan Kettering Cancer Center: About Mind-Body Therapies
• National Cancer Institute Topics in Integrative, Alternative, and Complementary Therapies (PDQ®)–Health Professional Version
• Alschuler LN, Gazella KA. The Definitive Guide to Cancer, 3rd Edition: An Integrative Approach to Prevention, Treatment, and Healing. Berkeley, California: Celestial Arts. 2010.
• Alschuler LN, Gazella KA. The Definitive Guide to Thriving after Cancer. Berkeley, California: Ten Speed Press. 2013.
• Lemole G, Mehta P, McKee D. After Cancer Care: The Definitive Self-Care Guide to Getting and Staying Well for Patients with Cancer. New York, New York: Rodale, Inc. 2015.
• Ornish Lifestyle Medicine Program for Prostate Cancer
• Rossman M, Shrock D. Chapter 13: Mind-body Medicine in Integrative Cancer Care. In Abrams DI, Weil AT. Integrative Oncology. 2nd Edition. New York, NY: Oxford University Press. 2014.

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• Ralph Moss: Moss Report Podcast
• Dr. Cynthia Li: Brave New Medicine
• Gurdev Parmar and Tina Kaczor: Textbook of Naturopathic Oncology
• Integrative Oncology Talk
• University of Arizona Andrew Weil Center for Integrative Medicine: Integrative Pain Management Series
• University of Arizona Andrew Weil Center for Integrative Medicine: Introduction to Integrative Oncology (2019-2021)
• Dawn Lemanne and Victoria Maizes: Advising Women Undergoing Treatment for Breast Cancer
• Translational Behavioral Medicine: Frontiers in Mindfulness and other Complementary & Integrative Approaches in Behavioral Medicine
• Dr. Ralph Moss: Dealing with the Trauma of Cancer: Dr. Moss interviews Dr. James S. Gordon
• Lee Majewski: Coping with Cancer: A Journey to a New Life
• Andrew Weil Center for Integrative Medicine: CanHEAL
• Block KI, Block PB, Gyllenhaal C: Integrative Treatment for Colorectal Cancer
• Integrative Cancer Review
• Martin L. Rossman, MD: Fighting Cancer from Within
• Julie Lusk: 30 Scripts for Relaxation, Imagery and Inner Healing–Volume 1
• Julie Lusk: 30 Scripts for Relaxation, Imagery and Inner Healing–Volume 2
• Mala Cunningham, PhD: Before and After Surgery
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• National Cancer Institute: Cancer Pain Control: Support for People with Cancer
• September 2018 Issue of the Journal of Alternative and Complementary Medicine
• Wayne Jonas, MD: Your Healing Journey: A Patient’s Guide to Integrative Breast Cancer Care
• The New School at Commonweal: Dwight McKee, MD: 40 Years Practicing Integrative Cancer Medicine, Part 2
• Foundation for a Mindful Society: Mindful
• Donald I. Abrams, MD, and Andrew T. Weil, MD: Integrative Oncology, 2nd Edition
• Ted Schettler, MD, MPH: The Ecology of Breast Cancer: The Promise of Prevention and the Hope for Healing
• Lise Alschuler, ND, FABNO, and Karolyn Gazella: The Definitive Guide to Cancer, 3rd Edition
• Keith I. Block, MD: Life over Cancer: The Block Center Program for Integrative Cancer Treatment
• Memorial Sloan Kettering Cancer Center: Integrative Medicine Education & Training Programs
• Lorenzo Cohen and Alison Jefferies: Anticancer Living: Transform Your Life and Health with the Mix of Six
• O. Carl Simonton, MD, and Reid Henson with Brenda Hampton: The Healing Journey
• Carole O'Toole and Carolyn B. Hendricks: Healing outside the Margins: The Survivor's Guide to Integrative Cancer Care
• National Comprehensive Cancer Network Patient and Caregiver Resources
• Belleruth Naparstek: Belleruth Naparstek
• Memorial Sloan Kettering Cancer Center: About Herbs, Botanicals and Other Products
• Cancer Research UK
• CAM-Cancer Collaboration: CAM-Cancer
• Fang Fu, Huaijuan Zhao, Feng Tong, and Iris Chi: A Systematic Review of Psychosocial Interventions to Cancer Caregivers
• Michael Lerner: Choices In Healing: Integrating the Best of Conventional and Complementary Approaches to Cancer
• Belleruth Naparstek: A Guided Meditation to Help with Concentration, Focus & Learning
• O. Carl Simonton, MD, James Creighton, PhD, and Stephanie Matthews Simonton: Getting Well Again
• David Zuniga, PhD: Guided Meditation for Cancer Patients and Caregivers HD
• Martin L. Rossman, MD: Fighting Cancer
• Jeanne Achterberg: Imagery in Healing: Shamanism and Modern Medicine
• American Academy of Anti-Aging Medicine and Metabolic Medical Institute: Integrative Cancer Therapy Fellowship Modules
• Jeanne Achterberg: Jeanne Achterberg (1942-2012): Imagery in Healing -- Part One Complete: Thinking Allowed
• Jeremy R. Geffen, MD, FACP: Jeremy Geffen, MD—The Seven Levels of Healing
• healthjourneys: Meditations
• National Cancer Institute: Office of Cancer Complementary and Alternative Medicine
• Jeanne Achterberg and Barbara Dossey: Rituals of Healing
• Sexuality during and after Cancer
• Martin L. Rossman, MD: The Healing Mind
• Ting Bao, MD: The Role of Integrative Therapy in Cancer Care
• Julie Lusk, MEd: Wholesome Resources