A Phenomenological Qualitative Exploration of Mind-Body Therapy Use and Effectiveness Among Young,Middle,and Older Adult Cancer Survivors

Abstract

Background:

Having been diagnosed with and treated for cancer can have negative psychosocial repercussions that may differ across the lifespan. Mind-body therapies (MBTs), such as tai-chi/qigong (TCQ) or mindfulness-based cancer recovery (MBCR), have shown promise in decreasing negative psychosocial outcomes in cancer survivors, but few studies have explored potential differences in MBT use and effectiveness across age groups.

Methods:

A descriptive phenomenological qualitative design was used. Participants included young (18-39), middle (40-64), and older (65+) adult cancer survivors who were diagnosed with any type of cancer and had participated in Mindfulness-Based Cancer Recovery (MBCR) or Tai Chi/Qigong (TCQ) MBTs. Semi-structured qualitative interviews explored participants’ experiences in MBTs and these were analyzed using descriptive phenomenological analysis.

Results:

Among the interviews (n = 18), young (n = 6), middle-aged (n = 8), and older (n = 4) adults participated. 5 themes emerged: influences in joining the program, unique lifestyles, positive class experiences, use of media, and program impacts. Though all age groups benefitted from MBT participation, variations between age groups with respect to the benefits received and motivations for joining the program were observed.

Discussion:

MBTs had beneficial physical and mental health effects on survivors of all age groups. These benefits were particularly connected to the ongoing life stresses common to each age cohort, such as relief from work and family roles for young adults or support during retirement transition for older adults. Hence, access to MBT programs may be beneficial as part of the survivorship plan for patients and the recruitment strategies or content can be adapted by MBT providers to better target and support age-specific groups. More research is required with a larger sample.

Background

The incidence of cancer has risen worldwide, while mortality rates have declined due to rapid advancements in treatment. ¹ This has led to an increase in the cancer survivor population—those who were diagnosed with cancer but have finished their treatment course. This population face unique and understudied biological and psychosocial repercussions of cancer diagnosis and treatment. ¹ The physical intensity of cancer therapies and the mental duress of having a serious disease can result in a variety of negative psychosocial outcomes, such as stress and anxiety. ²

Psychosocial Challenges in Survivors of Cancer

The life-course approach stipulates that unique biological, social, and economic conditions across the life-course alter the cancer survivorship experience. ³ Adolescent and Young Adult (AYA) cancer survivors (15-39) have unique experiences in contrast to middle-aged adult (40-64) or older adult (65+) survivors. ⁴ Specifically, AYA cancer survivors typically live with the psychosocial repercussions of their cancer experience for a longer time than older survivors, ¹ with over 80% of young adult cancer survivors living for more than 5 years post-recovery, and many living for decades beyond the end of treatment. ¹ AYA cancer survivors experience issues related to infertility, family strain, and loss of work that are not as common among older survivors. ⁵

For middle-aged adults, some influences of cancer include changes in sexual practices, changing relationships with spouses, children, and parents, and their perceived self-image of appearing sick. ⁶ Balancing family roles with work responsibilities and the debilitating nature of their illness can be difficult for middle-aged adults. ⁶ Younger and middle-aged adults may also deal with the financial burdens of their household and disease together and face greater socioeconomic stress than older adults. ⁷ Navigating interactions with healthcare workers and accessing health supports may be more difficult for older adult survivors compared to younger survivors due to their lack of confidence in communicating health concerns or hesitation to begin treatment. ⁸ Despite this, while distress is seen in all age cohorts, younger and middle-aged adults typically experience more cancer-related distress than older adults, potentially due to the lowered level of preparedness for ill-health that younger or middle-aged adults may have. ⁹ Given the evidenced differences in psychosocial and supportive care needs between cancer survivors from different age cohorts, research comparing survivors from age groups across the cancer care continuum is needed to understand how to better support this growing population.

Mind-Body Therapies in Cancer Care

Mind-body therapies (MBTs) involve activation of both the mental and physical state of being to combat disease and promote health. As such, MBTs may be relevant for aiding cancer survivors in coping with the physical and psychosocial consequences of cancer. Mindfulness-based cancer recovery (MBCR) and Tai Chi are two MBTs that are of particular interest for cancer survivors due to the potential for reducing stress, anxiety, and other health outcomes.^10,11

Mindfulness is the practice of self-regulating attention and focusing on the current moment. ¹² Mindfulness is often taught in Western healthcare settings through the mindfulness-based stress reduction (MBSR) program of Kabat-Zin. ¹³ In this structured group program, participants practice mindfulness in a variety of contexts with particular attitudes, including formal practices such as body scan, sitting meditation, and gentle yoga. Cultivating attitudes of nonjudgment, acceptance, patience, self-compassion, non-striving, and others are encouraged. ¹³ The MBSR program was adapted by Carlson and Speca to be used in cancer contexts through the Mindfulness Based Cancer Recovery (MBCR) program. ¹⁴ MBCR is a 9-week program with weekly classes and daily homework consisting of mindfulness practices such as sensory body scans, sitting and standing meditation, and gentle moving meditation (Hatha Yoga). ¹⁴ Adaptations of MBSR are collectively commonly referred to as Mindfulness-Based Therapies (MBTs).

Current MBT studies are limited to either non-cancer participants from different age groups or cancer survivors not from different age groups, and typically samples are comprised of middle and older aged adults. Notably, research evaluating the effects of MBTs in individuals without cancer has shown varying efficacy for younger adults. For instance, a meta-analysis by Chi et al. ¹⁵ found that MBTs produced a moderate effect size for reducing depressive symptoms among clinically depressed AYAs, but after 12 to 24 week follow-ups the effect was no longer significant. MBTs have also shown efficacy in reducing anxiety symptoms amongst AYAs with a clinical diagnosis of social anxiety; however, the results varied based on perceptions about mindfulness programs, with greater benefits for those with higher expectancy for benefit. ¹⁶ Specifically, the MBTs were more impactful in reducing social anxiety outcomes for those who already had positive perceptions of mindfulness. ¹⁶ MBTs have been shown to improve sleep and mood, and to decrease stress in older adult cancer survivors. ¹⁷ Despite this, there remains a paucity of research investigating the effects of MBTs in younger and middle-aged adult cancer survivors. ¹⁷ While mindfulness research in oncology contexts has shown promise, further research is needed to understand the impact of MBTs on cancer survivors of different age groups.

Tai Chi and Qigong (TCQ) are another form of MBT consisting of ancient Chinese practices that focus on controlled movements and postures to regulate attention. ¹⁸ Research has previously operationalized TCQ in research contexts for different chronic health conditions such as COPD and chronic back pain, ¹⁹ but few studies have assessed the effects of TCQ in cancer survivors across different age groups. ¹⁸ TCQ interventions have helped reduce muscle pain in patients suffering from osteoarthritis ²⁰ and in cancer patients, a TCQ intervention group saw greater reductions in shoulder pain that was accrued from cancer treatment in comparison to a cancer control group. ²¹ Few TCQ studies have addressed psychosocial factors such as mood or post-traumatic growth, and AYA and middle-aged adult populations have generally been left out from TCQ research entirely. ²¹ In fact, the study of TCQ interventions in any young adult demographic, even those without cancer, is limited. ²¹ This lack of evidence limits the potential use of TCQ interventions in AYA and middle-aged adult cancer survivors.

Present Study

Current literature does not evaluate the impacts of MBTs on cancer survivors from distinct age groups. Considering the success of MBTs in other health-related areas, conducting research to address this gap could prove useful in improving the psychosocial well-being of cancer survivors of all ages. Therefore, the purpose of this study was to investigate the effects of two types of MBTs, MBCR and TCQ, on psychosocial outcomes in cancer survivors of different age groups. Specifically, the aims of this study were: (1) to qualitatively explore the personal experiences of MBT participants from young, middle, and older adult groups; and (2) to compare the experiences of MBTs across the groups.

Methods

Study Design

A descriptive phenomenological qualitative study design was used. ²² Participants were recruited from the MATCH (Mindfulness and Tai Chi for Cancer Health) study, a multisite randomized comparative effectiveness trial assessing the efficacy of MBCR and TCQ interventions in cancer survivors. ¹⁸ Both the MBCR and TCQ intervention groups were pooled together in a joined MBT group, which was what was assessed for the purpose of this study. MATCH participants were given demographic questionnaires. For the two aims, semi-structured interviews were conducted and analyzed using a descriptive phenomenological analysis. A qualitative analysis was employed in this study as qualitative exploration of the participants’ experiences in the MBTs provides rich data detailing lived experiences, which is useful in understanding cancer survivors’ perspectives.

Participants

In the MATCH study, participants were recruited from cancer registries in Calgary and Toronto and invited to participate through a mailed invitation letter. Participants for the MATCH study were included if they met the criteria of being 18 years of age or older, having been diagnosed with any stage of cancer and at least 4-months post primary treatment, and having experienced significant distress. MATCH study participants were required to have sufficient capacity to attend the classes and a satisfactory understanding of English to complete the demographic questionnaires. For the current qualitative study, participants were emailed or phoned for follow-up from the contact information in the MATCH data list. All the AYA MATCH study participants (n = 7) were contacted for interviews due to the smaller sample size, but purposive sampling was used for middle and older-aged adult participants to increase sample diversity. While data were collected from Calgary and Toronto cohorts, only Calgary participants were included for qualitative interviews due to logistical considerations. Ethics approval for the MATCH study was approved by the Health Research Ethics Board of Alberta Cancer Committee (HREBA.CC-16-0246) and a modification for this study was approved (HREBA.CC-16-0246_MOD15).

Sample Size

A sample of 18 MBT MATCH participants agreed to participate in the qualitative semi-structured interviews, divided into ages groups for AYA (n = 6), middle-aged adult (n = 8), and older adult participants (n = 4). Based on Noon (2018), this is considered to be an acceptable sample size for phenomenological analysis. ²³

Intervention

In the MATCH study, cancer survivors could either choose their preferred intervention, or choose to be randomly assigned to either MBCR or TCQ. The MBCR program followed the MBCR manual, including 9 weekly meetings and a 6-hour weekend retreat. ¹⁸ Practices included walking and sitting meditation and yoga to be done at home. MBCR programs have been previously used to assess their efficacy to treat a variety of symptoms in cancer patients. ²⁴ The TCQ program was an 11-week program rooted in the traditional Chinese practices of Tai Chi and qigong, with a variety of movement postures and cognitive practices. ¹⁸ The TCQ program has also been used to assess its efficacy in reducing psychosocial and biomedical symptoms in clinical cancer contexts in the past. ¹⁸ Both interventions involved a trained instructor leading weekly 2 hour sessions at a local cancer clinic space. For the sake of this study, both interventions were considered together as part of the broader MBT group.

Procedures

After responding to their letter of invitation, participants from the MATCH study who were screened for eligibility provided informed consent. MATCH study participants could self-select MBCR or TCQ if they had a preference or, if not, be randomized into either of the interventions. Participants in the MATCH study were also assigned to either immediate group participation, or a 4-month waitlist. These participants answered a battery of survey questions administered in-person or via an online survey, which collected data on demographic, clinical, and psychosocial outcome measures. MATCH study participants were also asked to provide biological samples (i.e., saliva, blood). All outcome measures were collected before beginning the MBT (baseline), at the end of the MBT (post-intervention), and then at 6 months follow-up. Participants, for the current qualitative study, were those who took part in the MATCH study between 2017 and 2020.

As part of this qualitative project, participants from both MBCR and TCQ groups were contacted for follow-up qualitative interviews in 2021, and participants were asked to digitally sign an informed consent form and were orally asked for consent prior to starting the interview. The interviews were audio recorded and sent to a secure third party for transcription.

Semi-Structured Interviews

For the qualitative interviews, an interview guide with 6 broad questions to understand participants’ experiences with the MBTs and their relation to life stage and cancer recovery was used. This was created based on current literature and informed by the quantitative findings, see Supplemental Appendix A. Questions covered topics relating to media, work or family roles, and cancer recovery as a journey. The first author conducted all the interviews.

Qualitative Phenomenological Analysis

Semi-structured interviews were conducted by phone. Interviews were electronically recorded and transcribed verbatim for analysis. To assess the two aims, a descriptive phenomenological method was used to analyze the interviews. ²² Descriptive phenomenology involved the primary researcher first opening the data and understanding the phenomenon (cancer survivor experiences in an MBT) while bracketing out personal beliefs. ²² The primary researcher coded the transcripts for units of meaning which were of importance to the phenomenon. Similar codes were put together to form themes. A second coder then went through the transcripts in the same process and developed themes. The themes were compared and discussed between both coders and revised until common themes emerged. Themes were then compared between the adult age groups. Using two coders helped to achieve credibility and trustworthiness, and codes were verified with the data by a third independent lab member.

Results

Sample Demographics

Interviews were conducted with 17 participants from all 3 age groups: AYA (n = 6), middle-aged adult (n = 8), and older adult (n = 3). The mean interview length was 35.8 (SD = 6.4) minutes. The majority of the interviewees were female (n = 11) and white (n = 15), see Table 1. Five main themes emerged from the analysis: influences in joining the program, unique lifestyles, positive class experiences, use of media, and program impacts (Figure 1).

Table 1.

Sample Demographics.

	AYA N (%)	Middle-aged adults N (%)	Older adults N(%)	Total N (%)
Age group	6 (33.3)	8 (44.4)	4 (22.2)	18 (100)
Participant sex
Female	3 (50)	6 (75)	3 (75)	12 (66.7)
Male	3 (50)	2 (25)	1 (25)	6 (33.3)
White	4 (66.7)	8 (100)	4 (100)	16 (88.8)
Ethnic background
Indigenous	1 (16.7)	0 (0)	0 (0)	1 (5.6)
Asian	1 (16.7)	0 (0)	0 (0)	1 (5.6)
Breast	1 (16.7)	3 (37.5)	2 (50)	6 (33.3)
Gl (colon)	0 (0)	0 (0)	1 (25)	1 (5.6)
Urinary (Kidney)	0 (0)	2 (25)	0 (0)	2 (11 .1)
Type of cancer
Pelvic (endometrial, ovarian, prostate, and testicular)	2 (33.3)	2 (25)	1 (25)	5 (27.8)
Skin	0 (0)	1 (12.5)	0 (0)	1 (5.6)
Hematological	2 (33.3)	0 (0)	0 (0)	2 (11 .1)
Head and neck (thyroid)	1 (16.7)	0 (0)	0 (0)	1 (5.6)
Radiation	1 (16.7)	2 (25)	1 (25)	4 (22.2)
Treatment received
Surgery	3 (50)	2 (25)	1 (25)	6 (33.3)
Chemotherapy	1 (16.7)	1 (12.5)	2 (50)	4 (22.2)
Unknown	1 (16.7)	3 (37.5)	o (0)	4 (22.2)

Figure 1.

Visual map of themes and sub-themes.

Influences in joining the program

This theme dealt with factors that participants felt influenced them to join. Across all three age groups, two sub-themes emerged, though there was variation within the subthemes in each age group. The first sub-theme was motivators; participants from all 3 age groups experienced a wide array of internal and external motivators. The second sub-theme was exposure, including any prior exposure to MBTs or if the participants were new to MBTs.

Motivators

AYAs and middle-aged adults both experienced internal motivation to join the MBTs, particularly with the promise of working on and creating a better version of themselves. For AYAs, internal motivation also encompassed how participants viewed their own nature, particularly of being open-minded.

It’s just how willing you are to look stupid and how, like, trying something and maybe not being good at it right away, and just trying again, and just being, like, that’s fine. (YA6)

Many participants mentioned that MBTs were something they were naturally attracted to. Middle-aged adults reported generally having more curiosity about MBTs and they felt they were generally more curious people.

AYAs, middle, and older adults experienced external motivators. For all groups, being actively invited into the program, through the means of a letter, made the participants feel valued and enticed them further to join the program, particularly in contrast to some other programs available. Both AYAs and middle-aged adults were influenced by their friends and family. Having peers and friends who attended yoga or other mindful practices made it more comfortable from AYA participants to also attend such classes. Namely, one AYA participant found that his mother’s connection to Tai Chi influenced him to join.

If someone, with my mom’s perspective, can find some benefit in it, then perhaps, there might be even more so there for someone like me, who is already kind of willing to, I don’t know, welcome it into my life in some way. (YA1)

For middle-aged adults, family motivation manifested in the form of participants’ feeling like they had to participate in this program because their school-age children emphasized how important it was to participate in scientific research and, importantly, to ensure they made a proper recovery for their young children.

I thought I had a moment where I thought I would have died. I was inspired to live an even longer life just for the sake of my kids. (MA1)

For older adults, the main external motivator for the program was the provision of information and marketing of the program by trusted individuals, or the premise that the program was being put on by those who were trusted. Either through posters seen in the cancer center, which they felt were trustworthy or because they had read in a newspaper how this program and the teacher were both trustworthy, older adults felt motivated to join the program.

I trusted the people. Tom Baker [Cancer Centre]. I trusted that they wouldn’t put up recruitment signs for things that were counterproductive. Like I said, you have to trust a lot. People know more than what you know. (OA2)

Prior Exposure

All AYAs (n = 6) and half of the middle-aged adults (n = 4) and older adults (n = 2) had knowledge of mind-body therapies. All these experiences were either neutral or positive. For participants who did have prior knowledge, they felt the prior knowledge supported them in the programs and importantly allowed them to build on the prior skill sets and knowledge they had surrounding mind-body practices.

I mean I’m always looking for opportunities to improve my skills and myself, and it seemed like a recipe to do it especially at the time. (YA3)

Where the participants received their prior information varied by age group, with many AYAs growing up around these practices, often by seeing friends or family undertake Tai Chi practices or yoga sessions. None of the AYAs, however, knew the specifics of the MBCR or Tai Chi programs used in the MATCH study, though they felt their prior knowledge had prepared them enough for the programs. Middle-aged adults had seen mindfulness and tai chi on TV or in books and their experiences were uniformly positive. Older adults had knowledge of mindfulness or Tai Chi programs through work settings or hearing from trusted others. In fact, older adults mentioned feeling more comfortable in joining the study and the program because they trusted those who had done MBT programs prior.

Certainly other people that had gone before me that meditated, said, yeah, it was helpful for them. So I guess I trusted that. (OA2)

A few young adult (n = 3) and middle-aged adult (n = 2) participants had actually taken mind-body courses before and had positive experiences in the classes, which motivated them to join the classes.

For the middle and older adult participants who did not have prior experiences with mind-body therapies, these participants mentioned having incorrect but not damaging expectations of what these therapies encapsulated. These participants who did not know of mindfulness or Tai Chi felt they learned a new skill that they could use elsewhere.

Unique lifestyles

Another key theme that emerged was that of the participants’ lifestyle. Their life experiences impacted the way participants experienced the mind-body therapies, but also the therapies influenced the choices they made in the way they lived their lives. There were four subthemes under the lifestyle theme: current life schedule, uniqueness due to cancer, health, and good program design.

Current Life Schedule

Participants joined the MBTs at different stages of their life, and this influenced their experiences in the therapies. For AYAs, two-thirds of participants (n = 4) were working while the others were either students or had taken time off to be with young children. All young adult participants mentioned the tightness and difficulty of their schedules due to their work, school, and family role demands, with many juggling multiple demands or roles. Particularly for those working, they felt that the MBT programs were beneficial and the timing worked for them as it just barely fit in their schedule. When it fit into their schedule, participants felt it was an excellent break from the hectic work environment they were in.

No, I was choosing the evenings, so it was easy to attend after work . . . after a long day of work, it just be like a nice break from it all. (YA5)

Despite this, the need for a flexible design that accommodated evenings was documented. Participants said that if the program was not flexible or available at multiple times with different options, they would have not been able to participate, or take as much out of the program. For instance, a new mother noted that the program came at the perfect time, as she had taken time off for her child, though she admitted that if the program had happened at any other time, it would not have been possible.

About half of the middle-aged adults (n = 4) were working, while others were either retired or in the process of retiring. For a few participants, retirement came earlier because of cancer-related effects. For working participants, while most felt they could fit the program in because the program was flexible, there was one participant who experienced some stress about working and fitting the program in with work. For that participant it felt like the program happened because it needed to, and that in hindsight it came at the perfect time, though it did not seem that way initially. There was a greater appreciation for the program afterward, since it was less stressful to not feel like there were competing demands for her time between the program and work.

For retiring participants, the mind-body programs felt as though it fit perfectly with the transition into winding down.

I was going into retirement and it was really a matter of winding down. So, I think the mindfulness program came at the right time for me. (MA1)

All older adults were retiring or retired, so they liked that they could attend the program easily without worrying about work, and especially enjoyed attending the daytime session. One participant felt they had to specifically make time for the program, and it was an added item in their schedule, but it felt worth it.

Uniqueness Due to Cancer

The lifestyles of participants were influenced by the unique circumstance cancer brought in their lives. The MBTs served as a distraction for all 3 age groups although they were being distracted from different things. For young adults, being a cancer survivor left them feeling alone or without the support and routines they had during cancer treatment. As well, there was a sense of falling behind the traditional trajectory of school or career development. The program helped them cope with this.

I was in my career. I was supposed to start my graduate studies and it had to defer for two years because of [cancer] and there’s lots of stressors. (YA3)

For middle-aged and older adults, it was a distraction from the physical repercussions of surgeries and treatments, but also the lack of understanding from others about the unique parts of their cancer journey. Coming into the survivor-only environment of the class allowed them to feel less alone as they were surrounded by other fellow survivors who understood the cancer journey better.

Health

The health subtheme encompassed where participants were in terms of health prior to entering the program. In young adults, nearly all participants had very strong physical health and mentioned conducting a range of low to high intensity physical activity. For middle-aged adults, there was a greater mix of activity, with some having more negative physical effects from their cancer or loss of function due to chemotherapy. This, in turn, often influenced the individual’s lifestyle.

Because of my cancer treatment, actually I’ve got neuropathy. I still have neuropathy, and I actually had to retire because I can’t use my hands to work any longer because I was on the computer quite a lot. (MA7)

The advent of mental health problems was another feature unique to middle-aged adults. For one participant, the cancer recovery left him with feelings of depression and suicidal ideation.

Good Program Design

The subtheme of good program design entailed the weekly routine the program followed, which AYAs and older adults felt brought about a sense of regularity and helped them form a habit or routine that they could maintain afterward. Having continuous follow-up allowed young adults to stay on top of the program when their lives were quite occupied with other family and career responsibilities. For older adults, the routine allowed participants to check in with others and hold each other accountable to stay in the class, particularly when it was physically challenging for them. As well, with older adults having lost loved ones to other illnesses or cancer specifically, being able to check-in with other members of the class felt reassuring. Both the element of having to come in-person week after week, as well as having homework or practices to conduct in-between helped maintain that routine.

It was matter of building the discipline to actually do the tai chi almost on a daily basis and after a while it becomes habit forming. (OA3)

Positive class experiences

Participants generally found the MBT classes to be a positive experience. In the experience theme, 3 subthemes emerged: good program design, a group experience, and personality effects on experience.

Good Program Design

The design of the program played an important role in the positive experience for all 3 adult groups, though there were some suggestions on how to improve the design provided by middle and older adults. All 3 adult groups enjoyed that the class was not physically intensive and that they could participate without overly exerting their body or could adapt the practices to be at a comfortable level. This made the program easy to follow and achievable. Having adaptability was particularly important for older adults who had undergone drastic bodily changes due to cancer. AYA and middle-aged adult participants also found the session instructor helpful, with middle-aged adults feeling a greater connection to the instructor, because she was in a similar life stage as them.

[The instructor] just has a sense of calm around her and she had two teenage kids at the time. She was busy working. She had had issues, not cancer, but she said that problems that she had had for years and I felt like she just had it all together even though she was dealing with the same thing that everybody else was. And she was a huge motivator because even after the class I just still felt it was uplifting for the rest of the day. (MA8)

A unique finding for middle-aged adults was that they particularly enjoyed that there was weekly homework that they felt kept them accountable. Older adults, uniquely, found the supplementary material helpful.

I still got the DVD and I still got it online if I want it. So it’s fresh in my mind because my wife and I do use that program that was offered on a regular basis when we do tai chi. (OA3)

In contrast, a middle-aged participant mentioned offering a summarized one-pager, or something easy to look at and remember for the future, in contrast to the less-accessible DVDs. Two middle-aged adults and an older adult also brought up some logistical concerns and suggestions for bettering the program. They noted the inconvenient nature of the location and how offering the class at the same center where they underwent cancer treatment was triggering and made the class less positive than it could have been.

Group Experience

The group nature of the mind-body therapies positively contributed to the participants’ experience for AYAs and older adults, though the reasons for doing so varied, and middle-aged adults had more mixed opinions on having a group setting. The group setting provided a sense of belonging and being part of community for the younger and middle-aged adults. Especially for younger adults, knowing other survivors within their immediate circle was rare, so this provided an opportunity to connect with other survivors. Being in a group of survivors with shared experience provided a connection that survivors felt they could not find elsewhere, and it helped alleviate some of the isolation felt.

I think that was the biggest thing. Previous to this study I felt that it was very much on my own and dealing with my own mental aspects of recovery from cancer to feeling part of a community and realizing that there’s a larger network of help out there that’s available for people. So it was definitely a plus. (MA4)

For older adults, the group was impactful as they enjoyed seeing other cancer survivors, as opposed to cancer patients in their social circles who may have passed away from the disease. Negatively, one middle-aged adult participant had mentioned not feeling like she belonged at first, but she mentioned feeling like the group was such a comfortable environment that she felt like she fit in later on.

Personality Effects on Experience

Participants felt as though their own personality affected the way they went through the program and what they were able to take out of it. For younger adults, having an open mind helped them get more out of the program, and many hypothesized that others would not enjoy the program as much if they were not as open-minded. For one middle and one older adult, their personality of being introverted presented a challenge in how they experienced the group component of the class.

That was a very stressful time because of the diagnosis and so on and so forth and the fact that I was with other people and I tend to be introverted. So it was a challenge for me to go. (OA2)

It was important to note, however, that both these participants mentioned receiving benefits from the program post-hoc, particularly in the years following the MBT. One participant noted that she continues to use practices and enjoyed the group component in hindsight.

Use of media

The media theme pertained to the use of mind-body therapy related material and content beyond the scope of the MBT course itself, either prior to, during, or after the intervention. The two major types of media, and consequently the sub themes, were social media and traditional media, which both influenced participants’ experiences through the program.

Social Media

Social media was more commonly used in AYAs and middle-aged adults with YouTube being the most common source of media, and Facebook and Instagram also being mentioned. Participants characterized these sources as social media because there was an opportunity for validation (likes/dislikes/upvoting) and commenting, not seen in traditional media sources. Social media had a positive impact for some young adult participants. For one participant, social media was something akin to her job, so she knew about MBTs already and could further incorporate MBTs into her social media job. However, during MBT sessions, participants noted that they tried to stay off social media and devices, citing social media as a distraction from the peace attained during the sessions. Additionally, one AYA participant found social media, in general, was “poisonous.”

Yes, I do think that all forms of media are not good for people, before, after, during any type of meditation practice where your brain should be focused on something. I think that is a very poisonous thing in this world. (YA6)

This mixed reaction also existed for middle-aged adults, where half of participants (n = 4) said they used social media. A few participants found social media propaganda-like, and instead used traditional media. Older adults generally stayed off social media, though one participant used YouTube.

Other Media

Other media sources included books or news/research articles. These were seen in middle-aged adults and more common in older adults. Middle-aged adults who felt they could not trust social media sources often turned to books to better understand MBTs. Older adults investigated sources such as journal articles. These other media sources were mostly positive and allowed participants to be more self-reliant in the MBTs.

I use self-help books and you go through their material to kind of help yourself. (MA1)

Program impacts

The impacts of the program were wide-ranging and varied between AYAs, middle-aged adults, and older adults. The main impacts were seen in 5 sub-themes: physical, mental, transformative, beneficial, and no impact.

Physical

For all 3 age groups, the MBTs helped participants regain a sense of body awareness and return to higher levels of physical functioning. For AYAs, this was apt considering they often were at high levels of physical functioning, including taking part in extreme sports, prior to their cancer diagnosis and journey. Physically, the programs helped participants deal with physicality they had lost because of surgery rather than natural aging effects on the body. Middle-aged adults similarly felt a sense of increased physical ability, particularly being motivated to return to doing exercise, which had stopped during their cancer treatment regimen.

I almost found the mindfulness and doing this—almost the yoga part, the stretching part got me more active again after doing the mindfulness, I got more physically active and then incorporated the stretching in my cardio sessions. (MA7)

For older adults, the regaining of body awareness often had to do with the mental elements of lost physicality they felt. Starting with something low-intensity and accommodating like Tai Chi allowed participants to regain the motivation and ability to conduct physical activity, which participants noted improved their health or at least perceptions of health.

I realized that it took time for me to recover. I had lost about 45 pounds. So a lot of that was muscle. So it took a lot of work to bounce back. Tai Chi helped with that. (OA3)

Mental

The program supported participants from all 3 age groups as they dealt with mental health related challenges, including—diagnosed or undiagnosed—depression, anxiety, or grief. The complex mental emotions that come with cancer diagnosis were better understood and participants felt supported through their use of mind-body therapies. Having a supportive environment and nature of the class increased mental well-being for participants. For AYAs and middle-aged adults, the mind-body therapies allowed them to become more present in their own lives and brought about a sense of calm and tranquility. This allowed the AYA and middle-aged adult participants to slow down from the otherwise fast pace of their lives due to balancing the roles of work, family, and cancer and reduce the stresses from these roles.

It was just really calming, really—it just felt at peace with everything, your health, and your life. And for some people that didn’t happen until they had gone to this class. (MA8)

The MBTs also allowed young and middle-aged adult participants to find greater emotional benefits, helping them to regulate their mood and generally be in a more joyful or happier mood. Managing the stress was also important for disallowing middle-aged adult participants’ mental state to transform into something worse.

It just helps me stay on top of potential stress kind of evolving into something that could be dangerous to me versus managing it on a daily basis. (MA1)

Transformative

For many participants, the program helped “transform” their life. Nearly all participants noted a life-changing or “completely altering” experience. For many AYAs (n = 3), middle-aged adults (n = 6), and older adults (n = 3), this involved continuing the practices of MBTs even after the classes themselves had ended, and often reaping benefits of the classes and programs afterward. Participants continued their practice because they felt the program had a profound impact on them and they wished to continue. One AYA participant went on to become a community connector and teacher of MBTs in their home community due to the impact they felt. Several AYA participants mentioned recommending the mind-body practices to people they knew, both those who had cancer and those who did not.

I consider the goals of those practices are beneficial to anybody and everybody, I think the world would be a better place practicing Tai Chi and Qigong. (YA1)

For middle-aged adult participants, it was particularly important that the future programs or classes they attended were from the instructor of the 9-week or 11-week session itself, as they felt this would maximize the benefits they gained from the session due to their connection with the instructor. Older adult participants either attended classes or enjoyed simply incorporating exercises into their day-to-day activities. For middle and older adults, the program also seemed to have a contagion effect, where the positive benefits from the class pushed participants to pursue other healthier behaviors in other domains of their lives including nutrition, sleep, and exercise, thereby promoting an overall healthier lifestyle.

We touched on overeating. That’s something you got to be mindful when you’re eating and you don’t fill your plate like 100% full. You take 70% and then walk away and you’ll probably be full 20 minutes later. We kind of touched on everything, sleep, nutrition. (MA8)

Beneficial

Participants from all age groups also noted that the program was beneficial to them in some way. Members of all 3 age groups felt the program helped them build new skills. For AYAs the therapies allowed them to learn skills in how to relax or calm the body. These were assets participants felt they could use for the future and particularly could apply into everyday life.

I could go to this place weekly, I would be able to learn something that is practical, and that I can implement into my regular life. (YA3)

Middle-aged adults learnt skills related to refamiliarizing the body with comfortable physical activity levels and becoming a more active listener. These benefits were felt directly when the program was occurring, but importantly some benefits were seen later on as the new skills were applicable in daily life. Particularly, these delayed benefits occurred for participants who felt as though they did not gain as much during the program itself.

I will tell you that since then I’ve actually appreciated the [mindfulness] practice more as time has gone on. (MA6)

For older adults, the program helped participants build skills in learning how to cope with loss of physical ability and mental hopelessness from their cancer. The fear of recurrence, which was high among older adults, was also lowered by the MBT programs, with participants noting they felt the resilience to reduce the anxiety by cancer recurrence thoughts.

You’re always thinking, well, I hear about people getting cancer again, it’s just a matter of time before I get it. And I think tai chi gave me some mental resilience to say, no, no, this isn’t going to happen again. (OA3)

No impact

There was an AYA and a middle-aged adult participant who felt as though the program had no direct impact on their cancer journey. These two participants cited their diagnosis and treatment journey as not being severe enough—both had a stage 1 breast cancer with surgery—to need the help mind-body therapies offered them, though they mentioned experiencing benefits, such as feeling a sense of peace and calm, in other parts of their lives.

Discussion

This study is the first to directly examine the effects of two specific MBTs on participants from different adult age groups. A descriptive qualitative analysis explored the experiences of participants from each of the age groups and compared them to one another.

Qualitative findings from the present study provide insight into the benefits of the MBT programs, physically and mentally, for participants from each of the age groups. While the benefits differ, qualitatively it is clear that the MBTs do benefit participants from each of the age groups and may leave lasting and transformative impacts on participants, positively changing their lives. We found that nearly all participants from all three age groups reported a positive experience in the program, with none having negative experiences. In particular, the calm and relaxed nature of the classes, the group setting, and the relatable approach used by the instructors provided something for each of the adult groups to connect to. However, the elements of the program design that were most positively received varied slightly from group to group.

These differences in benefits and the positive program experience may be explained in part due to the unique life stages and lifestyles for members of the different age groups. For instance, young adults dealt with new parenthood, work, and student roles that created added stress that the MBT programs helped to provide a break from. Particularly the feeling of going from being this young and healthy person who is on track with their peers in terms of school and work to suddenly feeling potential mortality and being behind on normal life milestones was seen for young adults. This finding is consistent with previous research showing that for younger adults, a cancer diagnosis can have repercussions on career development and the ability to play a part in the upbringing of their children. ²⁵ This influenced young adults to experience the greatest number of benefits of MBTs in their family and work life.

Middle-aged adults had both working parents and retiring people, and therein enjoyed the calming nature of the class but particularly connected with the session instructor who was in a similar life stage. The need to feel understood through their cancer or personal life circumstances has been seen in a study by Vivar with long-term breast cancer survivors, ²⁶ and in the current study it seems the MBT instructor allowed for that.

In contrast, for older adults, they often experienced drastic loss of physical function due to cancer and had an added stress they were not anticipating in their otherwise relaxed retirement phase. As both MBT programs were low-impact, older adults felt physically supported and able to obtain maximal benefits from participation. This is consistent with what a study by Adler suggested, about how the gentle nature of tai chi makes it more comfortable for older adults than high-intensity physical activity, ²⁷ and the results of this current study indicate this is increasingly true for older adult cancer survivors. As well, as Arastu et al. have shown, being of older age puts cancer patients at risk of financial toxicity, ²⁸ often exacerbated by being retired, and so the MBTs being free of cost also made them accessible and more beneficial to older adults.

The qualitative findings also elucidate some alterations to the MBTs provided in this study that may help to create more beneficial environments of practice. For example, we found that one important element to consider is the unique personalities of participants who may be eligible to participate in MBT studies. Two participants, who were self-designated introverts, experienced some stress from the group environment. Creating a non-group class or an individualized course of study as an alternative for introverted participants may allow such participants to derive the most benefits from the class. With the rise of virtual programming during the COVID-19 pandemic this may be an option to investigate. Studies have shown virtual non-cancer mindfulness participants have seen equal levels of sleep improvement ²⁹ and coping and well-being, ³⁰ in comparison to in-person delivery. Despite this, the self-identified introverted participants in our study mentioned experiencing delayed benefits in mental health and a newfound sense of satisfaction from the program after they had completed it, suggesting that even for introverted participants encouraging them to join group sessions may still be beneficial.

The “influences in joining” theme also provides insight into how recruitment for such MBT programs can occur. Participants seemed to be both internally and externally motivated, though external motivators, such as family or trusted experts, were more common in middle and older-aged adults, with younger adults being more motivated by internal factors, such as the desire for self-betterment. Complementing this finding, prior research has shown that one of the most important motivational factors for young adults practicing yoga was that they were driven by a desire to be more mindful and present. ³¹ Regardless, these factors can be considered in the development of recruitment material targeted to a specific group. As well, younger and middle-aged adults were more likely to have prior knowledge about MBTs than older adults. Hence, recruitment efforts can be designed to target potential participants’ existing knowledge on the subject or potentially offer classes above the foundational level. This is an important consideration for future MBT study and program design and implementation.

Notably, participants mentioned that the flexibility of the MBT programs seemed to perfectly fit into where they currently were in their life stage. For young adults, they were able to adjust the classes around their work or they had already taken time off for school or their children. There may be the option to offer programs on weekends or evenings, as suggested by working middle-aged adult participants, which may allow for better recruitment outcomes for future MBT programs.

The media theme also provides insight into how and when media can or should be used with the program. Participants agree that access to technology devices is distracting during class time and class environments should be kept device-free, though this is particularly important for younger adults. Younger and middle-aged adults thought that YouTube or mobile apps, such as Calm, could be a useful resource provided to participants to supplement the program, with older adults mentioning the CDs provided in the class or news or research article media as the most useful. This builds on past literature, which has shown that for children and adolescents technology can be helpful in allowing for mind-body therapy practice and adherence.^32,33 Supplementary media in the program, therefore, can be tailored to best support members of a specific age cohort.

The findings suggest that participants from all three age cohorts had positive and beneficial experiences through the MBTs, and these benefits often corresponded directly with ongoing life events, such as parenthood or retirement. Themes surrounding class experience, past exposure, and media use all provide insight into what elements of the MBT programs work most for members of each age cohort and how to adapt MBT programs to be accessible for certain or all age groups.

With evident positive experiences for participants, it is worth noting the limited resources needed to run such MBT programs for providers or healthcare settings. Notably, only a trained instructor and a room are needed, which make these programs accessible to participants and are what allowed a number of participants to continue their practice even after the study was completed. In several places across the country, trained MBT instructors are present within the community and may be valuable in leading such programs and local community or healthcare spaces may be utilized as the physical setting.

Limitations and Future Directions

A limitation of the qualitative methodology in the present study was that the interviews were conducted by phoning participants, which was done due to COVID-19 restrictions. Phone interviews lack the personal connection developed through in-person interviews, and potential facial expressions and gestures are missed. With changing COVID-19 restrictions, future research can conduct in-person or video conferencing interviews.

Another limitation was the smaller qualitative sample size. While n = 18 participants is adequate for phenomenological analysis, a larger sample could make for richer analysis. There was also a lack of diversity since over two-thirds of the sample was female and nearly all participants were white. These groups are already overstudied in psychosocial oncology research, and therefore a more diverse perspective is needed to enhance the generalizability of our findings. ³⁴ Future studies could selectively recruit for AYAs, men, and participants from diverse ethnic backgrounds, potentially choosing recruitment centers that are in diverse communities or conducting the studies in institutions that regularly serve more diverse patient populations.

Additionally, the heterogeneity of the age groupings made comparisons and generalizations difficult. While the three adult age categorizations are commonplace within literature,^9,35 there is overlap in the social and biological conditions participants in each of the 3 groups may experience. For example, retirement was a social process seen among both middle and older adult populations. Isolating the conditions affecting individuals in an age group category is difficult. Conversely, there also exists within-group variation, as individuals in the same age category may experience different social and biological circumstances, such as both working and retired members being present in the middle-aged adult category. However, in real-world conditions, age groupings do often have imprecise boundaries, so this study may be more reflective in that way. With larger samples, future research can assess subgroups within age cohorts, for example by gender, occupation, or income, to better evaluate which social and economic factors may specifically affect experiences in MBTs.

Lastly, this study focused on two MBTs, MBCR and TCQ, and participants from both were considered as MBT participants for this study. MBCR and TCQ differ considerably and a wealth of other MBTs that exist, each with possibly varying benefits or risks. A review by Deleemans et al. highlighted that TCQ has shown the strongest effects in fatigue and sleep, while mindfulness/meditation has shown its strongest effects on anxiety and depression. ³⁶ As such, focusing only on two types of MBTs may reduce the generalizability of these findings for other MBT programs, and warrants further research on other modalities of MBTs in age-stratified cancer care.

In the future, specific MBT interventions with adapted recruitment, class logistics, or supplementary media may be assessed in comparative research contexts to directly evaluate if these programs are preferentially beneficial to young, middle-aged, or older adult cancer survivors. A feasible way to do this may be creating technology supported or fully virtual class options for young adult survivors and assessing their efficacy. As well, future research can assess a broader range of MBTs, including more emerging fields such as psychedelic-assisted therapy or hypnosis, with these age cohorts on a broader range of psychosocial outcomes, such as sleep or depression.

Conclusion

This study presented findings on the experiences of young, middle, and older-aged adults participating in one of two MBT programs. The interview findings showed that the program benefited survivors from all age groups. This lends evidence to clinicians and patients about the potential benefits of incorporating MBTs in the psychosocial survivorship journey of adults in any of the age cohorts. Qualitative findings also showcase how the benefits obtained from MBT programs adapt for age cohorts based on life-stage specific events and can thus support survivors during otherwise challenging life events. Findings about influences in joining the program, program experiences, and media may be used as a resource for those providing MBT programs to better adapt recruitment and the content of the MBT to their target age demographic, creating a modified MBT program that may be more resonant with participants. Future research with larger and more diverse samples is needed to further explore the experiences of different age cohorts participating in MBTs. This can provide more insight into how MBT programs can be successfully adapted to provide psychosocial benefits to survivors of different age groups.