SABCS 2020: Easing Depression in Young Breast Cancer Survivors

Jamie DePolo: Hello, thanks for listening. Dr. Patricia Ganz is a medical oncologist who is distinguished professor of medicine and also professor of health policy and management at UCLA. She also serves as director of the Center for Cancer Prevention and Control Research at the Jonsson Comprehensive Cancer Center. Dr. Ganz is a member of the Breastcancer.org Professional Advisory Board. 

At the 2020 San Antonio Breast Cancer Symposium, she presented results from a study looking at using mindfulness meditation and survivorship education classes to ease depression in younger women treated for breast cancer. She joins us today to talk about the study. Dr. Ganz, welcome to the podcast.

Dr. Patricia Ganz: Thank you, Jamie.

Jamie DePolo: So, first to start, can you tell us how you defined younger women for this study? What was the age range?

Dr. Patricia Ganz: Sure. To be eligible for this study women had to be 50 years of age or younger at the time of diagnosis. However, when we enrolled them in this study they had to be at least 6 months after the end of treatment, or up to 5 years after diagnosis, so the data in terms of time since diagnosis was 2.6 years on average. So, some women were early on, but other women were further out in terms of their survivorship journey.

Jamie DePolo: Okay. Now, the study mentions that the breast cancer experience is different for younger women than it is for older women, so could you tell us a little bit about those differences?

Dr. Patricia Ganz: Certainly. Again, those of us who have been looking at the impact of breast cancer and its treatments on women’s lives, we have noted in many, many studies that overall, older women — and again the average of breast cancer diagnosis is 61, so we’re talking about women in their 60s, 70s, and 80s — generally emotionally deal with, and cope with, the illness better than younger women. And this is true, if you just look at anxiety and depression in the general population, younger women have more anxiety and depression than older women, so that’s not so different. But if you think about what younger women have to, in fact, deal with that’s different from older women is many of them have children that are young, they’re working, some women do not have a partnered relationship, some women are in school, some women don’t have a well-defined career trajectory yet when they have been diagnosed with cancer.

So, there’s so many developmental life events, if you will, that are going on when you’re less than 50 years of age, which are pretty much settled for women in their 60s, 70s, and 80s. So, it’s many more demands on them. And in addition, as your audience will know, many of the treatments that we give for breast cancer will push women into menopause earlier. So, they may, in fact, be also dealing with premature menopause as part of the cancer experience. So, a lot of these things are just much more disruptive for younger women.

Jamie DePolo: Okay, thank you. So, it sounds — if I can put it in my own words — it sounds like younger women really have perhaps higher levels of depression, stress, and fatigue compared to older women who have been diagnosed with breast cancer.

Dr. Patricia Ganz: Yeah. I mean, again, I wouldn’t say that it’s universal, but in the research that I’ve done over many years looking at fatigue and cognitive changes, for example, I would routinely ask my 65-year-old, who I was giving adjuvant chemotherapy to, "How is it going? Are you having any difficulties?" And I’m thinking in my mind of somebody who was a social worker and now retired, and she didn’t have to get up to go to work every day and she really didn’t have any problems. But if you’d ask somebody who was in her early 40s and had to get kids off to school, and had to work as an attorney, and had difficulty concentrating after getting her treatments, and was now having hot flashes — it’s much more complicated for them.

Jamie DePolo: Okay. Okay, so I’ll qualify that by saying on average that it’s not universal.

Dr. Patricia Ganz: Yeah on average, yes.

Jamie DePolo: Okay. So, now moving on to the study. Could you give us a summary of the study and its results?

Dr. Patricia Ganz: Sure. Because we were aware of depressive symptoms being much more frequent in younger women and because this leads to a lot of morbidity in terms of being able to do all the things that are important to people in terms of work and taking care of their families and enjoying life, we focused on this as the main outcome in a randomized trial where we recruited women from Los Angeles at UCLA, Dana-Farber in Boston, and in Baltimore at Johns Hopkins — my colleagues there were Ann Partridge and Antonio Wolff. And we focused on recruiting women who had at least a minimal level of depressive symptoms. Because if we took all-comers, you know, most women are actually doing pretty well, but some are having more difficulties. And in order to actually see a signal of benefit, we had to identify women who at least had some level of depressive symptoms.

So, they had to meet those eligibility criteria of being 50 or younger at diagnosis, being within 5 years of having had their diagnosis and being finished with their treatment, and no other really serious chronic illnesses, and then that minimal threshold of some depressive symptoms to be eligible. And once they met that eligibility bar, they then had to be willing to be randomized to either our survivor education program, our mindfulness meditation program, or our wait-list control group. And in the wait-list control group, those women were monitored at the same intervals as the women who were the intervention, but got the intervention of their choice at the end of the 6-month follow-up period. So, the groups themselves were delivered over 6 weeks, 2 hours a week, by professionals who were trained in delivery to the specific intervention.

So, again, imagine these busy young women with kids who were in soccer or piano lessons or whatever, or they had to work in the evenings or weekends, they then had to commit to being available for 6 weeks — at least through the first class — to be able to enroll in the study. So, there were a lot of barriers to doing the research, but in the end we actually recruited 247 women who were randomized to the three conditions. And the interventions we delivered over a 6-week period of time. 

The women in the mindfulness group met with a mindfulness instructor in a class session where they were trained in techniques to help them address issues related to your mind wandering and not being present. I’m not going to go into the details of the intervention.

In the survivor education program, we had nurses who were given a curriculum — a slide presentation — that covered various topics from breast cancer 101, to quality of life after breast cancer, sexuality and intimacy, genetics, and so forth — again, given over a 6-week period of time in a seminar format where there could be more discussion among the women about those issues that would come up. So, it was a bit more of a psychoeducational intervention, whereas the mindfulness [group] were just trained in practices of mindfulness over that period of time. 

There were a couple of booster sessions that were offered through the mindfulness [group] and some newsletters that we sent to the women in the survivor education program.

And we measured how they were doing before we actually randomized them, immediately after their 6-week program, and then 3 months later, and then 6 months later to monitor how the intervention may have affected a variety of outcomes including depression as the main one.

Jamie DePolo: Okay. And before I ask you about the results — I don’t mean to interrupt — but I’m curious, why did you choose those two particular interventions?

Dr. Patricia Ganz: Oh, that’s an excellent question. So, when we do this kind of research often, we wind up doing your initial study with experts, which is actually what we did at UCLA — we have a wonderful mindfulness center at UCLA. And kind of the head teacher — who’s really famous and she’s quoted in the New York Times frequently, et cetera — she taught our classes for a pilot study that we did, actually, in 70 women where we randomized them to either getting the intervention or not and then followed them. And we had a very encouraging signal that the mindfulness was helpful to the group of younger women just like this.

In addition, other investigators had looked at psychoeducational interventions in younger women with breast cancer and had found it to be promising as well. So, we actually developed this lecture series to be able to be delivered. So, we thought both of these were credible, meaningful, potential ways of helping women deal with the distress associated with surviving breast cancer and its side effects and complications. When you have the experts teaching it, that’s really different than trying to disseminate it, if you will. So, what we did initially, if we can think of it as an efficacy study, where we really had the best teacher possible, and we got a signal.

And, in this particular trial with the three sites, we trained local mindfulness teachers. There were two in Boston, two in Baltimore, and two in LA who were trained by this very expert teacher, and we had a manual telling them what you needed to do with each session. So, this was kind of a train-the-trainer situation. So these were, obviously, well-trained mindfulness instructors, but they hadn’t been delivering this particular six-session program. 

Similarly, for the nurses who delivered the survivor education, we actually role-modeled the lectures. They had lecture notes, they could listen to these before giving each talk, and there was a slide set that was annotated. So, again, instead of having experts actually deliver these lectures, we had local nurses delivering the survivor education.

Jamie DePolo: Okay, thank you. And so, I believe — I’m going to ask you to explain the results — but it sounds like the results showed that both the mindfulness meditation classes and the survivorship classes both eased depression. Is that right?

Dr. Patricia Ganz: Yes, that’s correct. And they both had a very dramatic effect immediately posttreatment, which was actually sustained after 3 months for both of the intervention groups. And then at 6 months there was some attenuation of the benefit from the survivor education, but the mindfulness group still had improvement in depressive symptoms.

Jamie DePolo: That’s wonderful. And, if I looked at the study results correctly, I believe that mindfulness meditation also helped with fatigue and sleeping problems as well as hot flashes, but I don’t think that the survivorship education classes helped with those issues. Is that correct?

Dr. Patricia Ganz: That is correct. And so, you never know how these results are going to come out, but it looks like there are pretty profound biological effects from mindfulness— which again we know from other studies — which differentiate it from the effects of the survivor education, certainly, on these other symptoms.

Jamie DePolo: Okay. Yeah, that’s pretty fascinating to me. And I’m curious, too — I want to make sure I understand correctly — there were only the three groups: the mindfulness meditation, and the survivorship education classes, and then the group that was on the wait-list, so basically kind of the control group. Did you consider having a group that did both? And I know you said that these are younger women with a lot of demands on their time, so I’m also wondering if the time commitment for both types of classes would’ve been too much.

Dr. Patricia Ganz: I think what we learned from this — and I think it’s reflected in some debriefing that we did with the women when they finished the classes — is that for the survivor education, it would’ve been helpful to some of these women much earlier in their cancer survivorship experience. So, as I mentioned, they were about 2.5 years out, and a lot of the patients said, "This is really useful, but I could’ve really used this a couple of years ago." And so, rather than have them both be together, maybe there would be better times or touch points that would be appropriate.

I think the mindfulness could be used any time because I think the skills that are — it’s a skill-based intervention where women are learning how to manage things that occur on a daily basis for themselves. Whereas the education kind of about what to expect and how to alleviate hot flashes or mood changes, or things like that, which are part of the education intervention, could be helpful to women in the earlier posttreatment period. In terms of where we might go with this we might, in fact, look at some of those kinds of issues.

Jamie DePolo: Okay. And I believe — if I read the information correctly — I know at least the mindfulness meditation classes are available online. Are the survivorship classes also available online?

Dr. Patricia Ganz: No, they are not. The mindfulness classes are available because they have been available for a long time at UCLA on the [MARC website]. So, people listening to the podcast if they were interested can, in fact, sign up for those classes and do them online. We actually — because of COVID at the very end of our study — we had the wait-list control group that we still had to offer some classes to. And we wound up doing two sets of classes for a mixture of women from both LA, Boston, and Baltimore by taking the classes from one of the UCLA instructors doing it on Zoom. And so, that is one kind of class where you can, in fact, do it with an instructor and replicate it. But they also have prerecorded classes where people can actually study it, take it themselves, and do the practice. It does have some interaction with an instructor as well.

Jamie DePolo: Okay. Yeah, that was actually going to be my last question. If somebody were interested in doing this they could just go to the UCLA website and start there. You said it was the MARC center and sign up for classes that way?

Dr. Patricia Ganz: Yeah. And they have drop-in meditation, they have some free classes and things like that. I will send you the exact email link for you to be able to share. They do charge for it, but it’s important to know that we used their standard class. We did not really particularly tailor it to breast cancer.

And the only thing, I think, that’s very special about what we did — because when we did our pilot study several years ago I would stop in and give a little talk to the second class to kind of say, "Why would mindfulness be useful?" — we didn’t do this now, for this study — but it was really amazing to me to be in a room with 10 all young women, you know? And I think that is the thing that was very special about doing these groups, either for the education or for the mindfulness, is that they were with their peers, which who had had a similar experience. And even though there wasn’t a lot of chitchat and support going on in the mindfulness class, you were in a room with women who looked like you. And so, I think that’s what we thought was one of the important strengths, if you will, of doing something special for younger women.

Jamie DePolo: Definitely. Definitely. Thank you so much. This has been very helpful. And again I believe this adds more evidence showing that mindfulness meditation can really be beneficial to breast cancer survivors. I know most of the studies have been small, but it seems like the benefits are definitely there.

Dr. Patricia Ganz: Yes. And we also have collected biological specimens along with the study. In our previous studies we did show reductions in inflammation, which are often associated with some of the symptoms like the insomnia and the fatigue. And so, we hope that we’ll be able to demonstrate that part of the mechanism by which this is working also in this study. So, stay tuned — hopefully, we’ll have those results next year.

Jamie DePolo: Oh, that would be great and hopefully we’ll get to talk to you again. Dr. Ganz, thank you so much for telling us about these results. It’s been very helpful and informative.

Dr. Patricia Ganz: My pleasure.