Effects of a Second-generation Mindfulness-based Intervention on Quality of Life, Pain Management, and Psycho-spiritual Wellbeing in Cancer Patients: A Randomised Controlled Trial

Spiritual wellbeing has been shown to contribute to quality of life in cancer patients, with the National Institute for Health and Care Excellence (NICE) implementing spiritual wellbeing support as part of their person-centred care initiative (NICE, 2004). A cancer scare and diagnosis can lead to individuals contemplating their mortality and life perspective, regardless of whether they receive a palliative prognosis, they are invariably reminded of human vulnerabilities to disease, death and suffering. During contemplation, many patients begin questioning what their life is about and whether they have spent their time 'wisely' (Vehling \& Phillipp, 2018).

Mindfulness is a meditative technique that derives from Buddhist practice and refers to an individual remaining 'present' attentionally, with the notion that they can embrace life as it is in that moment (Sapthiang et al., 2023). The effectiveness of mindfulness-based interventions (MBIs) in enhancing the wellbeing of individuals diagnosed with cancer, particularly in reducing anxiety and depression levels, and improving overall quality of life, has been documented in studies (Chayadi et al., 2020; Shennan et al., 2011). Moreover, research conducted by the current PhD candidate (Wells et al., 2020) has further confirmed these benefits by demonstrating significant reductions in anxiety and depression scores among cancer patients who underwent an 8-week Mindfulness-Based Cognitive Therapy (MBCT) intervention. However, the rapidness with which MBIs have been adopted and rolled out amongst clinical settings and populations have raised concerns as to whether these interventions encompass the 'true' meaning of the concept of mindfulness. For example, researchers have suggested that First-Generation MBIs (FG-MBIs), such as Mindfulness-Based Cognitive Therapy (MBCT) and Mindfulness-Based Stress Reduction (MBSR), have been tailored towards Western perspectives and thus overlook important Buddhist wisdom concepts. Examples of such wisdom principles include emptiness and impermanence, which have been shown to enhance effective mindful practice and increase personal spirituality (Shonin et al., 2014).

This critique of FG-MBIs led to the investigation of second-generation MBIs (SG-MBIs), including Meditation Awareness Training (MAT). MAT is based on the idea that mindfulness is a psychospiritual intervention rather than a purely psychological one, in contrast to most FG-MBIs (Van Gordon et al., 2015). MAT includes meditative teachings and practices based on Buddhist wisdom principles such as emptiness, impermanence, and non-duality, which can cultivate deeper insights into reality and the self (Van Gordon, 2017). Empirical studies have demonstrated the efficacy of MAT in treating clinical populations, including those with pain disorders, schizophrenia, depression, anxiety, stress disorders, and addictions (Van Gordon, 2017). However, while SG-MBIs like MAT show promise for mindfulness research, findings related to clinical applications are still at an early stage, particularly for those diagnosed with cancer. Individuals with cancer often confront questions about their mortality and future suffering, leading to existential-related concerns (Puchalski, 2012). Although SG-MBIs may not provide immediate answers to these concerns, they could guide individuals to reframe negative experiences/thoughts by learning spiritual concepts such as emptiness, non-duality, and impermanence. MAT's focus on spiritual well-being makes it a promising candidate for those with cancer experiencing psychological distress and existential contemplative thoughts.

Participants in the study will be randomly assigned to one of two groups:

Intervention Group: Participants in this group will receive Meditation Awareness Training (MAT).

Control Group: Participants in this group will continue with their usual treatment without any additional intervention. Importantly, once the RCT is complete, participants in the control group will be offered the opportunity to receive MAT, ensuring everyone has access to the potential benefits of the intervention.

Participants will be assessed at four different time points:

Baseline: Before the intervention begins. Week 4: Midway through the intervention. Week 9: At the end of the intervention. Six-month Follow-up: To see if the effects last over time. What We Are Measuring

The researchers are interested in several aspects of well-being, including:

Psychological Well-being: How participants feel emotionally and mentally. Pain Severity: How much pain participants are experiencing. Quality of Life: Overall satisfaction with life and daily functioning. Spiritual Well-being: Sense of peace and purpose. Trait Mindfulness: The ability to be present and aware in the moment.

To measure these, the study will use four questionnaires:

Five Facet Mindfulness Questionnaire: Assesses mindfulness traits. FACIT-Sp: Measures spiritual well-being. McGill Pain Questionnaire Short-form: Evaluates pain levels. DASS (Depression Anxiety Stress Scales): Assesses emotional states like depression, anxiety, and stress.Additionally, researchers will look at whether changes in depression, anxiety, and stress are not only statistically significant but also meaningful in a real-world, clinical sense.

Beyond the numbers, researchers will also gather qualitative data to capture participants' personal experiences and perspectives. This might include interviews or open-ended survey questions, providing a richer understanding of how MAT affects their lives.

Researchers will also collect demographic information such as age, sex, ethnicity, educational background, and details about cancer type and stage.