TO THE EDITOR
Cancer is more than a physical ailment—it takes a significant emotional toll on patients. Urinary system cancers including bladder, kidney, and urethral cancers, contribute to this burden, with over a million new cases reported globally in 2022[1]. Beyond the physical burden, these tumors are often accompanied by psychological challenges, such as depression, which can further diminish patients' quality of life. Epirubicin (EPI) is widely used in the treatment of urinary system tumors[2], but often accompanied by side effects and psychological challenges such as depression and anxiety, which hinder patients' recovery. This highlights the gap in traditional cancer care, which focuses primarily on the physical aspects of disease management. mindfulness-based interventions (MBIs) have recently emerged as promising strategies to address psychological distress[3].
Among various complementary approaches, MBIs, such as mindfulness-based stress reduction and mindfulness-based cognitive therapy, have shown promise in managing health-related stress[4]. Mindfulness has gained significant attention as a complementary therapy for cancer patients due to its noninvasive nature and potential to alleviate symptoms and treatment side effects[5]. This method is designed to help individuals achieve a state of present-moment awareness, which is applicable through both formal and informal practices. Formal techniques typically include structured activities such as breathing exercises, sitting meditation, and walking meditation, all of which encourage focused attention and relaxation. Moreover, informal mindfulness practices integrate the principles of mindfulness into daily activities, such as mindful eating, walking, or listening, thereby fostering a continuous state of awareness throughout the day[6].
Psychosocial care in cancer patients not only improves quality of life but also reduces the overall financial burden on the healthcare system—an essential goal in health management across both developed and developing countries[7]. The integration of such care aligns with the broader shift toward patient-centered oncology. Therefore, studies on the clinical value of combining commonly used approaches with MBIs for cancer patients makes an important contribution to advancing cancer care.
THE INTERPLAY OF PSYCHOLOGICAL HEALTH, CHEMOTHERAPY, AND MINDFULNESS IN CANCER CARE
Evidence indicates that a patient’s psychological state can directly influence immune function and impact cancer prognosis. For example, depression and inflammation independently worsen survival outcomes in metastatic lung cancer, while managing depression not only enhances quality of life but also improves treatment adherence, potentially increasing overall survival outcomes[8]. Moreover, chronic stress and depression impair immune function by disrupting the hypothalamic-pituitary-adrenal and sympathetic-adrenal-medullary axes, weakening immune surveillance and increasing the body’s susceptibility to cancer progression, which reduces its ability to control tumor growth[9]. However, psychosocial interventions, such as cognitive behavioral therapy (CBT), have been shown to improve immune function by lowering harmful immune responses, including proinflammatory markers, while enhancing beneficial immune activity, such as increased immune cell function. Notably, these positive effects persist for at least six months following treatment[10]. Therefore, early psychological intervention is essential to mitigate the negative effects of stress and depression, strengthen immune function, and improve overall cancer outcomes.
EPI, an anthracycline antibiotic, is widely utilized across various cancer treatments due to its antitumor efficacy and favorable safety profile[11]. In cases of non-muscle invasive bladder cancer (NMIBC), EPI remains commonly used in many regions due to its therapeutic efficacy and limited alternative approved treatments[12]. Previous studies on EPI in NMIBC have utilized various methodologies to assess its efficacy and safety. These include prospective trials, retrospective studies, and comparisons of EPI with other treatments like Bacillus Calmette-Guerin (BCG), Mitomycin C (MMC), Gemcitabine (GEM), and hyperthermic intravesical chemotherapy[12]. Outcomes analyzed in these studies typically focus on recurrence and progression rates, with some also assessing adverse events related to the treatment. Moreover, the methodologies vary in terms of sample size, follow-up duration, and statistical approaches, providing diverse insights into EPI's effectiveness and safety profile[12]. However, it is important to consider the psychological impact of EPI treatment, as some patients may experience worsening depression[13]. EPI has shown comparable efficacy to MMC and GEM. However, it is not approved for intravesical use in countries like the United States[14]. In a 5 year follow up in bladder cancer patients treated with intravesical EPI for NMIBC, 7% of the patients had to discontinue EPI treatment due to side effects. For the majority of patients side effects were generally well-tolerated, with mild hematuria, tiredness, fever, nausea, and occasional abdominal pain[15]. The European Association of Urology recommends EPI for patients who cannot tolerate BCG or during BCG shortages[2]. Single Intravesical Instillation of drugs such as postoperative MMC, EPI, or GEM have been found to be effective in reducing disease recurrences for low-risk bladder tumors[16].
In the context of optimizing chemotherapy outcomes, combining pharmacological treatments like EPI with supportive interventions such as MBIs offers a comprehensive approach to cancer care. Mindfulness involves purposefully focusing attention on the present moment with a non-judgmental attitude[17]. These interventions typically include structured programs that combine meditation, breathing exercises, and cognitive-behavioral techniques. Meditation practices help cultivate present-moment awareness, while breathing exercises promote relaxation and stress reduction. Cognitive-behavioral methods aim to reframe negative thoughts and build coping skills, ultimately enhancing emotional resilience and improving quality of life during cancer treatment[6]. while MBIs help individuals stay present, detach from negative thoughts or emotions, and enhance emotional well-being[18]; these practices also foster internal motivation for health optimization, aiding in both illness prevention and recovery[19]. In the context of urinary system tumors, mindfulness practices can help patients develop coping strategies to manage the distressing symptoms associated with chemotherapy or surgery, while promoting emotional well-being by reducing stress and improving mood. These interventions can also enhance self-awareness, helping patients manage the psychological burden of living with a cancer diagnosis, thereby improving their overall quality of life and treatment adherence[20]. MBIs have shown to effectively alleviate depression, anxiety, and cancer-related fatigue among tumor patients[21]. A review of 29 randomized controlled trials with 3476 participants, highlights that MBIs significantly reduced anxiety, depression, fatigue, and stress, while improving quality of life, mindfulness, and posttraumatic growth among cancer patients and survivors. Mindfulness-based art therapy showed the strongest effects, suggesting that these interventions are effective across diverse cancer types and can be valuable in managing cancer-related psychological and emotional challenges[3].
THE VALUE OF COMBINING CHEMOTHERAOY WITH MINDFULNESS FOR URINARY SYSTEM CANCERS
Cancer treatment is traditionally centered on physical intervention such as surgery, radiation, and chemotherapy. However, increasing evidence demonstrates that MBIs improve cancer prognosis by alleviating stress, anxiety, depression, and fatigue. They enhance both psychological and biological outcomes, such as cortisol regulation, blood pressure, and telomere length, with lasting benefits that support overall well-being and quality of life for survivors[22,23]. For example, bladder cancer patients undergoing intravesical EPI for NMIBC often experience depression and anxiety, impairing immune function and adherence to treatment protocols[24]. Moreover, integrating EPI chemotherapy with MBIs may not only enhance clinical efficacy but also improve patient well-being and treatment adherence. The study by Liu et al[25] reveals that EPI, when coupled with mindfulness practices, not only improved immune markers such as CD4+/CD8+ ratios but also resulted in lower levels of tumor markers (NMP22, BTA, and UBC).
THE FUTURE OF COMPREHENSIVE CANCER TREATMENT
Psychological interventions in cancer patients represent important steps in providing comprehensive cancer care[26]. However, these findings also need further innovation in how mindfulness interventions are designed and delivered. Several factors could potentially be studied to discover different benefits of these interventions[27]. Online access of patients to health providers for mindfulness practice could expand the accessibility of these interventions. Personalized treatment plans can further optimize outcomes, ensuring that interventions address both psychological and physiological care.
Large-scale, multi-center studies involving bigger patient populations are crucial to confirm how well these interventions work across different groups. While existing research shows that mindfulness can reduce anxiety and fatigue in the short term[26], we still need a clearer picture of its long-term benefits. Understanding how these improvements affect not just the immediate experience but also survival rates and quality of life over time will offer insights for more effective cancer care[28]. Comparing MBIs with other psychological therapies, like CBT, is another key step. While both CBT and mindfulness target different aspects of mental well-being, they complement each other in unique ways. CBT focuses on promoting better stress management and reducing stress-related disorders by helping individuals overcome avoidant and safety-seeking behaviors that inhibit the correction of inaccurate beliefs[29]. While mindfulness promotes acceptance and awareness of the moment[6]. Understanding how utilizing each method compare in terms of long-term benefits, survival rates, and quality of life could potentially enhance clinical decision-making.
CONCLUSION
While chemotherapy, such as EPI, remains essential for managing urinary system tumors, its side effects and associated emotional burdens can limit treatment adherence and hinder patient recovery. MBIs have shown significant promise in improving psychological well-being, reducing stress, and even influencing immune function, thereby complementing the physical benefits of chemotherapy. The combination of EPI chemotherapy with mindfulness for urinary system cancers offers a promising model for comprehensive cancer care. By addressing both physical and emotional challenges, this approach not only improves patient outcomes but also reflects the shift toward patient-centered care. Future research should continue to explore these integrative interventions that optimize both medical outcomes and quality of life.
Provenance and peer review: Invited article; Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Psychiatry
Country of origin: United States
Peer-review report’s classification
Scientific Quality: Grade A, Grade B, Grade C
Novelty: Grade B, Grade B, Grade B
Creativity or Innovation: Grade B, Grade B, Grade B
Scientific Significance: Grade B, Grade B, Grade B
P-Reviewer: Irfan S; Li ZM; Rodrigues de Bastos D S-Editor: Luo ML L-Editor: A P-Editor: Wang WB
