Improving Biobehavioral Health in Younger Breast Cancer Survivors

Pathways to Wellness Trial Secondary Outcomes

Julienne E. Bower, PhD; Ann H. Partridge, MD; Antonio C. Wolff, MD; Steve W. Cole, PhD; Michael R. Irwin, MD; Elissa D. Thorner, MHS; Hadine Joffe, MD, MSc; Laura Petersen, MA; Catherine M. Crespi, PhD; Patricia A. Ganz, MD


J Natl Cancer Inst. 2023;115(1):83-92. 

In This Article

Abstract and Introduction


Background: The Pathways to Wellness trial tested the efficacy of 2 interventions for younger breast cancer survivors: mindful awareness practices (MAPs) and survivorship education (SE). This planned secondary analysis examines intervention effects on stress, positive psychological outcomes, and inflammation ( NCT03025139).

Methods: Women diagnosed with breast cancer at or before age 50 years who had completed treatment and had elevated depressive symptoms were randomly assigned to 6 weeks of MAPs, SE, or wait-list control (WLC). Assessments conducted at pre- and postintervention and at 3- and 6-month follow-up measured general stress perceptions, cancer-related intrusive thoughts and worry, positive affect, meaning and peace in life, altruism and empathy, and markers of inflammation. Analyses compared change in outcomes over time in each intervention group relative to WLC using linear mixed models.

Results: A total 247 women were randomly assigned to MAPs (n = 85), SE (n = 81), or WLC (n = 81). MAPs statistically significantly decreased intrusive thoughts and worry at postintervention and 3-month follow-up relative to WLC (P < .027) and statistically significantly increased positive affect and meaning and peace at postintervention, with positive affect persisting at 3-month follow-up (P < .027). SE statistically significantly decreased intrusive thoughts at 3-month follow-up and statistically significantly increased positive affect at 6-month follow-up relative to WLC (P < .01). Proinflammatory gene expression increased in WLC relative to MAPs (P = .016) but did not differ from SE. There were no intervention effects on other outcomes.

Conclusion: MAPs had beneficial effects on psychological and immune outcomes in younger breast cancer survivors and is a promising approach for enhancing biobehavioral health.


Breast cancer is the most common cancer in younger women (<50 years at time of diagnosis), who comprise approximately 19% of incident breast cancer cases.[1] The breast cancer experience is particularly stressful and disruptive for younger women not only because they are generally at higher risk of recurrence than older women,[2] often necessitating more aggressive therapy, but also because the disease is occurring at a time in life when they are focusing on completing their education, developing their careers, and/or raising a family.[3] Younger women perceive cancer as more threatening,[4] have higher levels of illness intrusiveness,[5] and report greater fear of recurrence[6] than older survivors. Younger breast cancer survivors (BCS) also report lower levels of positive psychological factors that may help buffer the negative impact of diagnosis and treatment, including a sense of peace and meaning in life.[5]

Interventions are needed for this vulnerable group that target biobehavioral factors contributing to poor quality of life and the potential for shorter survival. However, few interventions have been specifically designed for younger BCS beyond the acute phase of treatment.[7] In the broader literature, psychoeducation[8] and mindfulness meditation[9,10] have emerged as promising approaches for reducing distress and improving quality of life in cancer patients and survivors. These approaches may be particularly relevant for younger women, who often report unmet informational needs (targeted by education) as well as high levels of stress (targeted by mindfulness).[11,12]

The Pathways to Wellness (PTW) trial was designed to test the efficacy of both educational and mindfulness-based interventions developed specifically for younger BCS. As previously reported, both interventions led to reductions in depressive symptoms, the primary trial outcome; mindfulness also led to reductions in physical symptoms (fatigue, insomnia, vasomotor symptoms) relative to wait list control.[13] Here, we report on intervention effects on additional psychological and biological outcomes relevant for long-term health and well-being in BCS. These were predefined outcomes designed to assess cancer-specific and general measures of stress[14] as well as measures of well-being (positive affect, meaning and peace in life, altruism and empathy).[15] In addition, we examined intervention effects on inflammation, which is known to play a role in tumor growth and spread,[16–18] contribute to cancer-related physical symptoms,[19] and promote medical conditions that are prevalent in cancer survivors (eg, cardiovascular disease).[20] Inflammation is regulated by physiological stress systems,[21] and interventions that reduce stress signaling have the potential to influence inflammatory biology. Indeed, psychosocial and mind-body interventions have been shown to reduce markers of inflammation, particularly proinflammatory gene expression.[22,23]