Acceptance and Body Compassion Improve Quality of Life in Endometrial Cancer Patients

Acceptance and body compassion improve quality of life in endometrial cancer patients

Running Title: Acceptance and body compassion in endometrial cancer

1,*Stefanie L. Denu, PsyD 1Christine M. Dacey, PhD, ABPP 1,#Abbie O. Beacham, PhD 1Renee Zucchero, PhD

Author Affiliations: 1Xavier University, School of Psychology, Elet Hall, 1020 Dana Avenue, Cincinnati, OH, 45229

*Present Affiliation: University of Wisconsin-Madison, University Health Services, 333 East Campus Mall, Madison, WI, 53715

#Present Affiliation: University of Colorado School of Medicine, 13001 E. 17th Place, Aurora, CO 80045 ABSTRACT

Objective: This study explored the predictive role of body-related components, such as body compassion and body mass index, and components of the Acceptance and Commitment Therapy

(ACT) model, such as mindfulness and experiential avoidance, on the experience of pain and quality of life quality of life in endometrial cancer survivors.

Methods: Surveys were sent to members of a national online support group for endometrial cancer patients who had completed treatment. The study included 82 total participants.

Results: ACT components and body-related components, as a set, predicted pain interference and quality of life but not pain severity. Experiential avoidance was determined to be an independent predictor of quality of life. Negative affect, used as a covariate, independently predicted unique variance in pain severity, pain interference, and quality of life. Age was an independent predictor of pain interference and quality of life. Lastly, obese endometrial cancer survivors endorsing higher experiential avoidance, lower mindfulness, and lower body compassion compared to non-obese endometrial cancer survivors.

Conclusions: Body-related and ACT components, taken together, may be predictive of pain interference and quality of life, while experiential avoidance may contribute uniquely to quality of life, rendering it a key target of future intervention for endometrial cancer survivors post- treatment. BACKGROUND

The American Cancer Society recognizes endometrial cancer as the most common gynecologic cancer, with approximately 63,000 new cases diagnosed in 2018.1 Survival rates for endometrial cancer are generally good, with an average 81.1% five-year survival rate, reaching a peak of 94.9% among early-stage patients.2 With a growing success rate for early detection of endometrial cancer – rate of 66.9% diagnosed at the local stage − an increasing number of women are likely to be survivors at the five-year mark in the coming years.1 Consequently, survivors will be managing a number of risk factors that may continue to affect their quality of life (QOL) post-treatment, one of the most common being obesity, as obesity if a well known comorbidity.3,4 In general, overweight or obese women are two to four times more likely to be diagnosed with endometrial cancer compared to healthy-weight women.5 Increasing body mass index (BMI) is significantly associated with an increased risk of death in late-stage endometrial cancer, indicating that unmanaged obesity after diagnosis may increase the likelihood of a problematic host of future complications, particularly cardiovascular disease.6 Therefore, risks associated with obesity may impact QOL while endometrial cancer is ongoing as well as post treatment, especially if the obesity goes unmanaged.

Given that endometrial cancer is most frequently detected in its early stages and has a high survivorship rate, QOL concerns may persist long after diagnosis and treatment, particularly obesity-related complications.7,8 Morbidly obese women reported significantly worse physical functioning, less perceived social support, and more somatic complaints (e.g., pain, difficulty breathing, and diarrhea) compared to non-obese and obese women.9 Among both obese and non- obese women, loss of sexual desire, decreased self-esteem, greater dissatisfaction with intimate relationships, and perceived loss of femininity also contribute to negative emotional effects experienced in those recovering from endometrial cancer that may persist for 5 to 10 years after diagnosis.10 As such, it is important to explore both physical and emotional influences on QOL post-treatment in this population.

Acceptance and Commitment Therapy (ACT) is a third-wave behavioral approach that strives to increase an individual’s valued living while still experiencing the pain and discomfort of everyday private events, including unpleasant thoughts, feelings, and bodily sensations.11

Increasing psychological flexibility is the means through which ACT enacts change in individuals. Psychological flexibility is “the ability to contact the present moment more fully as a conscious human being, and to change or persist in behavior when doing so serves valued ends.”11 As such, ACT prompts individuals to recognize and be present with unpleasant experiences and cope effectively with psychological suffering without overreacting or avoiding such experiences. Recently, ACT has grown in popularity as an effective intervention for cancer survivors. However, little research has been conducted examining individual core processes of

ACT (i.e., Mindfulness and Experiential Avoidance) within the endometrial cancer population.12

The emerging conceptualization of body compassion is grounded in Neff’s13 components of self-compassion: 1) kindness toward oneself (versus judgment), 2) seeing one’s experiences as part of the common humanity (versus isolation), and 3) mindfulness (versus over-identification).

These three components of self-compassion were applied with a shift in emphasis from the overall or general “self” to the physical self. As such, body compassion can be viewed as the

“regarding of one’s own body, in appearance, competence and health, with mindfulness, kindness and awareness of common humanity.”14 In general, body compassion provides a conceptualization of body-related disturbances in the context of mindfulness and acceptance- based approaches, and as such, is fitting within an ACT framework. Given this is a newly formed construct, body compassion has not yet been explored in the literature with cancer patients,

Given the high levels of obesity occurring post-treatment, the endometrial cancer population is highly relevant for exploring body compassion as an ACT-related variable predicting pain and

QOL.

The purpose of the current study was to examine the predictive role of body compassion and BMI and components of the ACT model, including mindfulness and experiential avoidance, on pain and QOL in endometrial cancer survivors. METHODS

Participants

Approval from the Xavier University Institutional Review Board (IRB) was obtained prior to collecting data for this study. Participants were recruited from an endometrial cancer support group via What Next (https://www.whatnext.com) and Rare Patient Voice, LLC, the exclusive partner of What Next in conducting patient surveys with cancer patients. Participants were included in the study if they met the following criteria, 1) were at least 18 years or older, 2) had completed treatment (surgery, chemotherapy, radiation, and/or hormone therapy) for endometrial cancer (diagnosed at any stage 0-IV), and 3) were fluent in English. Women who had a previous cancer diagnosis (other than basal cell carcinoma) were excluded from present study analyses. Of the 848 endometrial cancer patients who are members of the support group,

325 had completed treatment. A total of 154 participants initially opened the link to the online survey, with 11 participants (7.1%) disagreeing to consent. Of the 143 participants who consented (92.9%), 61 (42%) were excluded from study analyses due to 47 completing less than

90% of the survey, 9 being currently in treatment, and 5 having a previous cancer diagnosis. A total of 82 participants were included in the primary analyses of the study, demonstrating statistical power of 0.78.

All 82 participants who met criteria for study inclusion also answered at least two of the three validity items correctly that were embedded within survey measures to detect random responding and responded accurately to the manipulation check to verify their ability to comprehend English proficiently and thus were included in the study analyses.

Participants in this study sample identified as female (100%), were predominantly

Caucasian (91.5%), and were mostly well educated with some college (29.3%), a Bachelor’s degree (30.5%), or a Master’s degree (25.6%). The participants were primarily middle-aged (M =

59.52, SD = 8.97) though ages ranged widely from 34 to 76. The majority of participants in this sample were employed (36.6%) or retired (43.9%). Most of the women endorsed having an intimate partner (78.0%) and English as their first language (97.6%). Participants were distributed across geographic areas of the United States, with the Midwest being the most prevalent region (31.7%). (See Table 1 for sample demographics).

All participants had completed their treatment, with approximately half of the women being diagnosed with Stage I endometrial cancer (54.9%), followed by Stage II (19.5%), Stage

IV (12.2%), Stage III (9.8%), and Stage 0 (3.7%). Most participants did not have a history of metastatic cancer (87.8%). The majority of participants in this sample endured a combination of treatments (62.2%) or a hysterectomy or other surgery (34.1%). Many participants had completed treatment years prior to the study (M = 4.05 years, SD = 2.57 years), though there was a wide range from 0 to 14 years. Over half of the sample reported not losing weight since treatment (59.8%), with most indicating that doctors had not informed them to lose weight

(81.7%).

General Demographic and Medical History Questionnaire

A General Demographic and Medical History Questionnaire constructed for the purposes of this study included items regarding age, race/ethnicity, geographic area, education, marital/partner status, work status, and primary language. Medical history items were related specifically to history of endometrial cancer-related illness, including age at diagnosis, stage of disease at diagnosis (i.e., 0-IV), treatment type (i.e., chemotherapy, radiation, hysterectomy, or combination of treatments), completion of treatment status, and time since treatment completion. Additional items were included for the purpose of calculating BMI, including height and current weight, weight at time of diagnosis, and the amount of weight lost since diagnosis and primary reason contributing to weight loss, if applicable. Given the association between obesity and increased risk of recurring cancer, participants were asked whether weight loss was intended as a formal component of their recovery recommended by their physician or other healthcare professional.

Brief Pain Inventory- Short Form (BPI-SF)

The BPI-SF is a nine-item self-report questionnaire used to evaluate the severity of pain and the impact of pain on daily functioning. The BPI-SF is primarily used as a state measure of pain characteristic of cancer patients as opposed to chronic, trait-like pain that is more commonly found in other medical conditions.15 The BPI was originally designed to assess pain related specifically to cancer, given previous research demonstrating that patients with cancer frequently experience incapacitating pain that is often poorly managed.

The BPI-SF gives two main scores: a pain severity score and a pain interference score.

Items 3 through 6 of the BPI-SF constitute the pain severity scale and are rated on an 11-point

Likert-type scale ranging from 0 (No pain) to 10 (Pain as bad as you can imagine), with higher scores indicating greater pain intensity. The mean score of the four items was used as the overall

Pain Severity score, with a possible range from 0 to 10. The specific content of the items asked respondents to rate pain at its worst, least, and average in the last week as well as pain “right now” when completing the measure.

The pain interference score measures the degree that pain limits functioning on an 11-point Likert-type scale. Only item 9 (comprised of the seven sub-items A through G) of the BPI-SF constitutes the pain interference scale. The mean of the seven items was used as the overall Pain Interference score, with a possible range from 0 (Does not interfere) to 10

(Completely interferes). The specific content of the items asked respondents to rate to what extent pain interfered with their (1) general activity, (2) mood, (3) walking ability, (4) work, (5) relations with other people, (6) sleep, and (7) enjoyment of life during the past week. Higher scores indicated greater interference with daily functioning.

The remaining items on the BPI-SF (items 1, 2, 7, and 8) were not used in the analyses due to their qualitative nature and inability to be included in a total score on the measure. The

BPI-SF has strong construct validity on its two-factor structure and high internal consistency, with alpha values of .92 for pain severity and .95 for pain interference in the current sample, which are comparable to Cleeland’s norms. For the purposes of this study, a validity item was embedded amongst the pain interference sub-items to detect random responses to the survey; however, this value was not comprised in the total score.

Functional Assessment of Cancer Therapy- Endometrial Cancer (FACT-En)

The FACT-En is a 43-item, general QOL instrument specifically designed for endometrial cancer patients to rate their QOL over the past seven days.16 This instrument has been validated for measuring four QOL domains (i.e., physical, social/family, emotional, and functional well-being indices). The total score for the FACT-En is based on the summed score of the 43 items including the physical (7 items), social/family (7 items), emotional (6 items), and functional (7 items) subscales, with an additional section of 16 items of endometrial cancer specific concerns. Negatively phrased items were reverse scored. Each item was scored on a 5- point Likert-type scale ranging from 0 (not at all) to 4 (very much), with higher total scores indicating better QOL, with a possible range from 0 to 172.

Although the FACT-En has been used in clinical and research applications, a formal validation study of the FACT-En has not been conducted.8 Therefore, its psychometric properties are compared to the FACT-G, with Cronbach’s alpha comparable between the current sample (r

= .95) and norms from a general cancer population (r = .89). Construct validity has been demonstrated adequately among the general cancer population in the FACT-G;17 therefore it is suggested that normative data can be similarly applied to the disease-specific versions of the measure, such as the FACT-En.

Five Facet Mindfulness Questionnaire-Short Form (FFMQ-SF)

The FFMQ-SF is a 24-item self-report measure that assesses an individual’s tendency to attend to his or her present experiences in a nonjudging manner (i.e., mindfulness).18 The FFMQ-

SF was developed from the original 39-item Five Facet Mindfulness Questionnaire (FFMQ) and was created as a shorter, 24-item version measuring five facets of mindfulness.19 Each of the five facets in the FFMQ-SF is first scored separately as individual subscales comprised of observing

(4 items), describing (5 items), acting with awareness (5 items), nonjudging (5 items), and nonreactivity (5 items). Participants are asked to rate how frequently they had each experience in the last month, as measured on a 5-point Likert-type scale ranging from 1 (Never or Rarely

True) to 5 (Very Often or Always True). Negatively phrased items were reverse scored. A high score for each subscale indicates a high degree of that facet of mindfulness. A total score for the purpose of this study was obtained by summing subscale scores with a possible range from 24 to 120. Cronbach’s alpha for the total FFMQ-SF in the present study sample was .89, consistent with previously reported alphas for the five facet scales ranging from .73 to .91.18

Acceptance and Action Questionnaire-II (AAQ-II)

The AAQ-II is a unidimensional measure comprised of 7 items assessing psychological inflexibility, or experiential avoidance.20 The self-report questionnaire requires participants to rate how true each statement is on a scale of 1 (Never True) to 7 (Always True), with higher scores indicating greater levels of experiential avoidance. The AAQ-II produces a total score ranging from 7 to 49 and is obtained by summing each individual item. The scale has high internal consistency with a Cronbach’s alpha of .93 from the present study, as compared to previously reported alpha of .84,20 as well as strong predictive validity of psychological distress.

For the purposes of this study, a validity item was embedded amongst the AAQ-II items to detect random responses to the survey; however, this value was not comprised in the total score.

Body Compassion Scale (BCS)

The BCS is a newly developed 23-item measure adapted from the Self-Compassion Scale to measure how individuals typically regard their body in terms of compassion, respect, and acceptance.13,14 Normative data have thus far been collected with undergraduate college students but not with cancer patients or individuals with chronic health conditions.14 Participants rate how often they believe or behave in the stated manner on each of the items on a 5-point Likert-type scale of 1 (Almost never) to 5 (Almost always). Negatively phrased items are reverse scored.

Higher scores indicate the greater presence of compassion and acceptance of the state of one’s body. Ratings on each individual item are summed to produce a total BCS score ranging from 23 to 115. In addition to the total score, the BCS is comprised of three subscales: Defusion,

Common Humanity, and Acceptance. However, for purposes of this study, the BCS total score was used as the measure of body compassion. The BCS has high internal consistency with a

Cronbach’s alpha of .97 from the present study, as compared to Altman and colleagues’ reported alpha of .92,14 as well as adequate validity, especially strong predictive validity of BMI. A validity item was embedded amongst the BCS items to detect random responses to the survey; however, this value was not comprised in the total score.

Positive and Negative Affect Schedule (PANAS)

The PANAS is a 20-item self-report measure made up of a two-factor model, positive affect and negative affect, which are independent, although moderately negatively correlated measures.21,22 The PANAS is comprised of 10 positive and 10 negative mood state adjectives

(e.g., “distressed”) that are rated on a scale of 1 (very slightly or not at all) to 5 (extremely). For the purposes of this study, only the Negative Affect (NA) scale was used as a covariate in the analyses. Therefore, all negative items were summed to create a total score for NA, with higher scores indicating greater negative affect, with a possible range from 10 to 50. The NA scale demonstrates adequate reliability and validity, with the current sample indicating Cronbach’s alpha of .90 as compared to .85 derived from the normative sample.21 RESULTS

Effects of ACT components and body-related components on pain and QOL in endometrial cancer survivors

Our study examined the relationship between body-related and ACT-related components and pain and QOL in a sample of endometrial cancer survivors. Demographic and medical characteristics of the 82 participants are demonstrated in Table 1. First we assessed correlations among the study variables and covariates. Negative affect was positively correlated with pain severity (r = .33, p = .001) and pain interference (r = .42, p < .001). Age was negatively correlated with pain interference (r = -.29, p = .004). With regard to QOL, negative affect was negatively correlated with QOL (r = -.62, p < .001) and age was positively correlated with QOL

(r = .44, p < .001; Table 2).

We next performed a series of three hierarchical multiple regressions to assess the extent to which one or a combination of variables, including body compassion, BMI, mindfulness, and experiential avoidance might predict pain severity, pain interference, and QOL. We controlled for age, negative affect, and time since treatment completion; time since treatment completion was included because it has been previously shown to be an important factor in pain and QOL for cancer survivors.23,24 In the first model assessing pain severity, negative affect was a statistically significant individual contributor to pain severity (β = .33, p = .003). Body compassion, BMI, mindfulness, and experiential avoidance did not contribute statistically significant variance unique to the model (Table 3). In the second model assessing total pain interference, age (β = -.24, p = .02) and negative affect (β = .40, p = .001) were significant predictors of pain interference. Additionally, the combination of body compassion, BMI, mindfulness, and experiential avoidance was found to significantly contribute to pain interference and accounted for an 11.8% increase in the variance, (p = .01, ΔR2 = .118; Table 4).

Although the combination of these four variables as a whole predicted added variance in pain interference, no individual predictors were found to contribute unique variance. In the third model, age (β = .37, p = .001) and negative affect (β = -.57, p = .001) were significant contributors to overall QOL. Additionally, the combination of body compassion, BMI, mindfulness, and experiential avoidance was found to significantly contribute to pain interference and accounted for an 11.9% increase in the variance, (p = .001, ΔR2 = .119).

Furthermore, experiential avoidance was found to be a unique predictor accounting for a statistically significant portion of the variance in QOL (β = -.29, p = .03; Table 5).

From these hierarchical regressions, we conclude that: ACT components and body- related components, as a set, predicted pain interference and QOL but not pain severity; experiential avoidance predicts QOL; negative affect predicts variance in pain severity, pain interference, and QOL; and age predicts pain interference and QOL.

Differences between survivors with and without pain

A smaller sample of 64 participants who endorsed at least some pain was compared to the

18 participants who indicated no presence of pain. Women with pain had statistically significant lower levels of QOL (p = .001), compared to women with no pain (Table 6). Further, Cohen’s effect size value (d = .84) suggested a high practical significance between groups. No significant differences were found between groups on scores of mindfulness, experiential avoidance, body compassion, and BMI.

The same set of hierarchical regression analyses conducted for the primary hypotheses was used with the smaller subset of 64 participants who indicated at least some pain to examine differences in results compared to the overall sample (N = 82). Even amongst the 64 participants who endorsed at least some pain, which included ratings of pain at their worst, least, average, and at time of survey administration, the presence of physical pain was still not well endorsed (M

= 2.79, SD = 1.75). Similarly, compared to the regression analysis of the full sample, Block 1 was statistically significant, accounting for 12.5% of the variance in pain severity (p = .05, R2

= .125; Table 10). Block 2 was not statistically significant nor did any of the predictors contribute statistically significant variance unique to the model, similar to the results found among the full sample.

Overall pain interference was still not well endorsed (M = 3.42, SD = 2.58) as compared to the full sample (M = 2.67, SD = 2.68), indicating that the presence of pain generally did not affect daily functioning to a highly distressing level. Similarly compared to the full sample,

Block 1 was statistically significant, accounting for 30.0% of the variance in pain interference,

F(3, 60) = 8.56, p < .001, R2 = .30. Using this model, age was a statistically significant individual contributor to pain interference (β = -.31, p = .007) as well as negative affect

(β = .39, p = .001). At Block 2, the predictive model was statistically significant and accounted for a 16% increase in the variance, (p = .005, ΔR2 = .160; Table 8). Although the combination of variables as a whole predicted added variance in pain interference, no individual predictors were found to contribute unique statistical variance.

With regard to QOL in the sample with pain, Block 1 was statistically significant, accounting for 56.3% of the variance, (p < .001, R2 = .563). Similarly compared to the full sample, age was a statistically significant individual contributor to QOL

(β = .39, p < .001) as well as negative affect (β = -.57, p < .001). Block 2 still predicted a significant increase in the variance of QOL, (p = .003, ΔR2 = .107; Table 9). However, experiential avoidance was no longer a unique predictor of the variance.

A series of three hierarchical regression analyses was conducted on the full sample (N =

82) to isolate experiential avoidance in Block 2 of the model due to 1) the findings from the primary analyses that generally the combination of predictors, not independently, contributed to statistical significance in the criterion (except experiential avoidance in QOL) and 2) the high correlation among predictors (Table 2). It was hypothesized that experiential avoidance would account for statistically significant added variance in pain interference and QOL but not pain severity, given that the combination of variables in Block 2 for pain severity had not predicted statistical significance. Body compassion and mindfulness were added in Block 3 of the model due to their high negative correlations with experiential avoidance (r = -.78, p < .001; r = -.72, p

< .001, respectively), to determine whether they would account for an increase in statistical variance above and beyond experiential avoidance. BMI was added in Block 4 given its lower correlations with the other predictors to determine whether it would predict unique variance above and beyond the variables likely measuring ACT-related constructs.

With the criterion variable of pain severity, only Block 1 was statistically significant, accounting for 12.2% of the variance, (p = .02, R2 = 122), with negative affect as an individual contributor to the variance (β = .33, p = .003) (Table 10). With the criterion variable of pain interference, experiential avoidance in Block 2 accounted for a significant portion of the variance above and beyond the effects of age, negative affect, and time since treatment completion.

Experiential avoidance accounted for an additional 7.4% increase in the variance, (p = .005, ΔR2

= .074. Body compassion and mindfulness did not predict variance in pain interference above and beyond the effects of experiential avoidance (Table 11). A similar pattern was found with experiential avoidance predicting statistically significant variance in QOL above and beyond the effects of the covariates, while body compassion and mindfulness did not predict significance above and beyond experiential avoidance (Table 12).

Impact of BMI on pain severity, pain interference, and QOL

Despite BMI not emerging as a unique predictor of pain severity, pain interference, or

QOL, over half of the total sample (54.9%) had a BMI of 30.0 or above, which classified them in the obese or morbidly obese range. Only 19.5% of the sample fell in the normal-weight BMI range (less than 25.0), with the remaining 25.6% in the overweight BMI category of 25.0 to 29.9

(Table 1). To explore whether BMI had an impact on the study variables, two groups were established, based on splitting the study sample between obese (N = 45; BMI ≥ 30.0) and non- obese (N = 37; BMI ≤ 29.9) women, with BMI based on height and current weight at time of survey (Table 13). A series of t-tests were calculated and the Bonferroni correction was used to control for increased alpha error when using multiple t-tests (Bonferroni correction: p = .005). In the sample, obese women had statistically significant lower levels of mindfulness (p = .003), and body compassion (p = .001), and statistically significant higher levels of experiential avoidance,

(p = .001), compared to non-obese women (Table 13). Further, Cohen’s effect size values for body compassion (d = .99) and experiential avoidance (d = .81) suggested very high practical significance while the effect size for mindfulness (d = .68) suggested a moderate to high practical significance. No significant differences were found between groups on scores of pain severity, pain interference, total QOL, and QOL subscales. CONCLUSIONS

Women who endorsed negative mood affect during the time taking the survey were more likely to endorse pain experienced over the past week. It may be that negative mood states are more predictive of the physical experience of pain as compared to variables that could be more trait-like (i.e., experiential avoidance, mindfulness, and body compassion). Unlike the findings with pain severity, the combination of mindfulness, experiential avoidance, body compassion, and BMI predicted a statistically significant portion of the variance in pain interference above and beyond the effects of the covariates. Taken together, these results suggest that ACT-related and body-related components may influence the functional aspects of pain but not the physical experience of pain itself. No known studies had examined the impact of acceptance-related variables (i.e., mindfulness and experiential avoidance) on pain interference in cancer post- treatment. The present findings shed light on the unique dimensions of pain affected in endometrial cancer survivors and suggest that functioning in daily life activities is possible even with pain post-treatment. However, due to the low average mean of pain severity in this sample, it is recommended that future research explore this finding with pain severity scores that are more widely distributed.

Although the combination of predictors was statistically significant in accounting for unique variance in pain interference, none of the individual predictors were statistically significant in the regression model for pain interference. It is important to note that all of the predictors had statistically significant correlations with pain interference, such that mindfulness and body compassion were negatively correlated while experiential avoidance and BMI were positively correlated. It is also important to note the intercorrelated nature of the predictors in these models, which may signify overlapping constructs in what they intend to measure. Similarly, negative affect was a significant individual predictor of pain interference.

Additionally, age was found as a significant covariate, such that increased age predicted lower interference of pain with daily activities. Given that there was no significant correlation or predictive quality found between age and pain severity, it can be assumed that physical pain remained relatively consistent across age while ratings of the extent to which pain negatively impacts functioning decreased with age. It may be that as survivors of endometrial cancer age, they learn to relate in more adaptive psychological ways to pain that do not necessarily rid them of pain but rather allow them to function more effectively despite its presence. Further research is suggested to explore this interpretation of the results with greater precision and accuracy.

Similar to the results found with pain interference, the combination of mindfulness, experiential avoidance, body compassion, and BMI predicted a statistically significant portion of the variance in QOL above and beyond the effects of the covariates. Negative affect was again a significant individual predictor of variance accounted for in the first step of the model, indicating that the presence of a negative mood state at the time of taking the survey predicted lower QOL over the past week. Age also predicted a significant portion of variance in QOL, with increased age predicting higher QOL. This is consistent with findings from a previous study demonstrating higher QOL among older cancer patients in treatment compared to younger patients,25 the main difference being that the present study only included patients who had completed treatment.

Further, experiential avoidance was the one predictor resulting in a statistically significant increase in variance added to the model. Previous research found a negative correlation between experiential avoidance and QOL in cancer post-treatment and that reductions in experiential avoidance predicted higher QOL following four sessions of ACT.12,26 While these correlative and predictive relationships between QOL and experiential avoidance found in the current study were consistent with previous literature, it may be unique to this research that experiential avoidance was not measured as an outcome variable of an intervention. As such, experiential avoidance in the current study intended to measure an individual’s general tendencies to suppress or escape from unwanted internal experiences. It may be that cancer survivors with less experiential avoidance demonstrate a greater willingness to contact and accept their present experience, which is predictive of overall QOL. Further, the results of the post hoc analyses isolating experiential avoidance from the other predictors in Block 2 of the regression models suggest that experiential avoidance may have a prominent role in predicting pain interference and QOL without the added influence of mindfulness, body compassion, and BMI. Factors underlying what influences experiential avoidance post-treatment are unclear at this time. These may be important to explore in future research, given the prevalence of secondary health complications, such as cardiovascular disease, that can occur following endometrial cancer as a result of unmanaged obesity.

The study of ACT variables (i.e., mindfulness and experiential avoidance) and their influence on physical and emotional facets of QOL among cancer survivors has become an area of interest in the clinical and research spheres, although there are few reports on endometrial cancer. Previous research has shown that mindfulness has a positive impact on QOL post- treatment,27,28 while experiential avoidance tends to impede QOL,12,26 with most studies exploring the impact of ACT-based treatment interventions over a period of time with recovering cancer patients. Preliminary evidence has also demonstrated links between mindfulness and improvement of pain symptoms in cancer,29 as well as experiential avoidance and decreased adjustment to pain.30 Although mindfulness and experiential avoidance have been shown to impact pain, evidence remains unclear of the dimensions of pain affected (i.e., physical or functional). Given the prevalence of pain among endometrial cancer survivors post-treatment and the complications that obesity can incur on pain levels, the current study sought to explore how mindfulness, experiential avoidance, and BMI predicted post-treatment pain and QOL in endometrial cancer.

The present study also included an additional variable (i.e., body compassion) that is new to the literature and had not been explored with cancer patients.14 Similar to the other ACT variables used in the study, body compassion conceptualizes body-related disturbances in the context of mindfulness and acceptance-based approaches and was relevant to the study given the high levels of obesity often occurring post-treatment for endometrial cancer.

The sample of the current study endorsed overall low mean scores of pain severity

(M = 2.17, SD = 1.93) and pain interference (M = 2.67, SD = 2.68), with 22% of participants endorsing no pain at all, indicating that the majority of women in this sample had only mild pain that did not seem to interfere significantly with daily functioning. These results are compared to normative data for the BPI-SF scale suggesting that mean pain severity scores of < 5 are considered to be non-clinically significant, with mean pain severity and interference scores characterized as mild when ranging between 0-4.31 The nature of the BPI-SF measure prompts participants to rate their pain levels over the last week; therefore, it is unclear whether pain ratings would have differed with a more extended frame of reference. There was no correlation found in this study between pain and time since treatment completion, a surprising finding that differs from previous studies demonstrating a steady decrease in pain over time.32,33 The average time since treatment completion (M = 4.05 years, SD = 2.57) of the present sample was notably higher than previous research measuring pain in this population,32,34 serving as a possible explanation for the minimal presence and influence of pain in the sample. In expanding the inclusion criteria of the study, both acute and chronic pain were likely represented due to data gathered from all stages of diagnosis (0-IV) and at any point after treatment completion.

However, there were no significant differences in pain severity reported between women diagnosed at early stages 0-II (N = 64) and later stages III-IV (N = 18) in the sample. As such, the BPI-SF may not have been the most useful measure to capture participants who experienced pain in their past given that it only assessed pain levels over the previous week. Most participants in the sample (93%) were at least six months beyond completion of their treatment. In early- stages (Stages 0-II), the acute pain that likely occurred as a result of a hysterectomy or other surgery may have reduced by the time participants took the survey. Therefore, it is possible that the nature of the pain found in the data may be more chronic and it is unclear whether it was a precursory symptom or direct result of endometrial cancer or its treatment. Future longitudinal research is recommended to measure pain severity and interference more consistently both during and after treatment to determine the influence of the predictors on a sample with greater pain distribution.

The conceptual relationship between mindfulness and experiential avoidance is much debated in the literature, revealing that a key similarity is the representation of constructs that influence the experience of emotions, with a notable difference being that they are on opposing ends of an acceptance-based theoretical spectrum.35 While mindfulness is thought to involve an attentive, accepting stance of the present moment and experiential avoidance encompasses non- acceptance toward mental events, the newly explored construct of body compassion bears similar resemblance of this acceptance-based framework.14 This was shown through the measurement of acceptance of the state of one’s body on the BCS, which likely requires a mindful awareness of one’s physical self. High correlations between body compassion, mindfulness, and experiential avoidance suggest how these constructs may collectively represent a willingness to attend to internal experiences with a kind and nonjudgmental stance. Finally, the significant intercorrelations between BMI and the other predictors found in this study may indicate a conceptual underpinning linking obesity with a lesser tendency to accept one’s physical and mental state. Further research is recommended to gain a deeper understanding about the common variance found among these measures.

Although the sample as a whole endorsed low average pain, we did note key differences between the participants reporting some pain versus no pain, such that the sample with pain indicated lower QOL compared to those with no pain. This is consistent with previous reports linking pain to QOL.29 Additional prior research suggested a high correlation between the average change of pain severity and QOL over a two-week pain management program for cancer pain, providing further evidence for the salient influence of pain on overall life satisfaction.36 As such, it is likely that pain management may be a key component of future interventions for cancer patients with pain following treatment. Given the predictive influence of acceptance- related components on pain interference found in this study, it is promising that mindfulness- and compassion-based interventions may be influential in determining the extent to which pain interferes with daily functioning even if the interventions do not significantly reduce pain intensity.

Results of the regression analyses utilizing the sample of 64 participants with at least some pain found that experiential avoidance was no longer a unique predictor of the variance in

QOL as it was with the overall sample of 82 participants including those with no pain. This suggests the possibility that the predictive influence of experiential avoidance on QOL may be partially dependent on the presence of pain. A recent study examined the effects of experiential avoidance on pain among individuals with arthritis-related disorders, finding that experiential avoidance may reflect a more benevolent coping reaction to escape from pain rather than a generalized negative response to highly aversive conditions.37 This raises the importance of considering the opposing bidirectional relationship used in the study (i.e., to what extent pain might predict experiential avoidance) and whether experiential avoidance may be occupying a different role among individuals with pain (i.e., way of coping in the moment to maintain one’s functionality in daily life rather than a generally negative way of responding to unpleasant thoughts and feelings).

The prevalence of obesity found post-treatment in the sample (54.9%) was consistent with previous findings indicating a high obesity rate (59%) after treatment completion (Smits et al., 2014). A relevant addition to the literature found in the present study are statistically significant differences between obese and non-obese groups within the sample, such that obese endometrial cancer survivors endorsed higher experiential avoidance, lower mindfulness, and lower body compassion compared to non-obese endometrial cancer survivors. There were no significant differences in pain severity, pain interference, or QOL between the two groups. Given that there were no significant differences between actual levels of reported pain between groups, it is possible that obese survivors relate to their pain differently utilizing more avoidant responses, which may negatively interfere with functioning as a consequence. These results suggest a potential relationship between obesity following treatment with acceptance-related variables, such that obese endometrial cancer survivors may tend to escape from internal suffering and be unkind toward their physical self more than non-obese survivors.

Study Limitations Our current study was not a longitudinal study that addressed pain and QOL at multiple points during and after treatment, making it difficult to draw causal conclusions. Given that a majority of women had completed treatment between 6 months to 4 years prior to taking the survey, the scope of this study does not enable conclusions to be made about the prevalence of pain and QOL immediately following treatment nor changes in these variables over time.

Further, this study relies on self-report data, which has inherent limitations in that participants may not accurately report their experiences. It is difficult to control for differences in attentiveness to endorsing symptoms based on the specific time frames of the various measures.

For example, participants were asked to rate their pain and QOL over the past week compared to the predictor measures that inquired about endorsement of attitudes or behaviors over a longer period of time. It is unclear to what extent participants’ responses accurately reflected these differing time frames and whether the combination of ACT and body-related variables predict pain and QOL in the long term.

Regarding the measures themselves, it was not readily apparent based on existing literature whether state-like or trait-like characteristics were being assessed, especially amongst the predictor variables used in the study. For example, although Boelen and Reijntjes conceptualized the AAQ-II as a trait measure of experiential avoidance,38 research supports that experiential avoidance can be amenable to change following ACT-based interventions.26 Due to the ambiguity of state versus trait measurement of the variables, it is unclear to what extent general tendencies to be mindful, avoidant, and compassionate were measured and whether any changes in these variables may have occurred at various time points before, during, and after treatment.

For the purposes of this study, only total scores of the measures were used to test the proposed hypotheses. Due to difficulties with obtaining a larger N, sample size rendered it difficult to examine subscale scores (i.e., of the FACT-En, FFMQ-SF, and the BCS), which may have added depth to understanding the results. Future research is recommended to gain perspective on specific QOL domains impacted as well as individual subscales of mindfulness and body compassion that may contribute unique variance to the predictive model.

Another limitation of this study is that, due to the recruitment of participants from a support group, inherent differences in predictor and criterion variables between these participants and those not part of the support group for endometrial cancer were not able to be controlled for or measured. Generalizability to the broader endometrial cancer population, particularly in regard to ethnicity and education level, may be difficult to ascertain due to the predominantly white, well-educated nature of the sample.

Clinical Implications

Overall, the findings from the present study suggest that both ACT components and body-related components are predictive of pain interference and QOL of endometrial cancer survivors. Experiential avoidance may be a unique construct of the ACT and compassion-related research, suggesting how the importance of an accepting and mindful attentiveness to potential post-treatment health concerns instead of an avoidant dismissal could beneficially impact long term QOL for endometrial cancer survivors. Differences in experiential avoidance, mindfulness, and body compassion found between obese and non-obese women in the sample may have clinical significance in terms of their impact on QOL and health behavior change. Body compassion could serve as a helpful component of intervention for endometrial cancer survivors, especially given the continued prevalence of obesity post-treatment with accompanying risk factors to health and QOL. ACKNOWLEDGEMENTS

This project was financially supported by the Frank and Catherine Miltz Mini Grant from Xavier

University. The authors thank What Next and Rare Patient Voice, LLC.

CONFLICT OF INTEREST

The authors declare that they have no conflicts of interest. REFERENCES

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Demographic Variable Study Sample Pain No Pain (N = 82) Sample Sample (N = 64) (N = 18) Age in years M (SD) 59.52 (8.97) 59.59 59.28 (7.84) (9.31) Gender N (%) Female 82 (100.0%) 64 18 (100.0%) (100.0%) Race/Ethnicity N (%) Caucasian / White 75 (91.5%) 59 (92.2%) 16 (88.9%) Hispanic / Latino 4 (4.9%) 3 (4.7%) 1 (5.6%) Asian / Pacific Islander 2 (2.4 %) 1 (1.6 %) 1 (5.6%) Multiracial 1 (1.2 %) 1 (1.6 %) 0 (0.0%) Educational Level N (%) High School / GED 10 (12.2%) 10 (15.6%) 0 (0.0%) Some College 24 (29.3%) 19 (29.7%) 5 (27.8%) Bachelor’s Degree 25 (30.5%) 20 (31.3%) 5 (27.8%) Master’s Degree 21 (25.6%) 14 (21.9%) 7 (38.9%) Doctoral Degree 2 (2.4%) 1 (1.6%) 1 (5.6%) Region (U.S.) N (%) Northeast 19 (23.2%) 15 (23.4%) 4 (22.2%) Southwest 13 (15.9%) 12 (18.8%) 1 (5.6%) West 12 (14.6%) 9 (14.1%) 3 (16.7%) Southeast 12 (14.6%) 8 (12.5%) 4 (22.2%) Midwest 26 (31.7%) 20 (31.3%) 6 (33.3%) Intimate Partner N (%) Yes 64 (78.0%) 50 (78.1%) 14 (77.8%) No 18 (22.0%) 14 (21.9%) 4 (22.2%) Work Status N (%) Employed Outside Home 26 (31.7%) 18 (28.1%) 8 (44.4%) Employed Inside Home 4 (4.9%) 2 (3.1%) 2 (11.1%) Unemployed 3 (3.7%) 2 (3.1%) 1 (5.6%) Unable To Work 13 (15.9%) 12 (18.8%) 1 (5.6%) Retired 36 (43.9%) 30 (46.9%) 6 (33.3%) 1st Language - English N (%) Yes 80 (97.6%) 64 16 (88.9%) No 2 (2.4%) (100.0%) 2 (11.1%) 0 (0.0%) Age at Diagnosis M (SD) 54.68 (10.29) 54.64 54.72 (10.94) (10.27) Completion of Treatment Status N (%) 82 (100.0%) 64 18 (100.0%) (100.0%) Time Since Tx Completion in years M (SD) 4.05 (2.57) 4.08 3.97 (2.70) (2.08) Stage at Diagnosis N (%) Stage 0 3 (3.7%) 3 (4.7%) 0 (0.0%) Stage I 45 (54.9%) 35 10 Stage II 16 (19.5%) (54.7%) (55.6%) Stage III 8 (9.8%) 14 2 (11.1%) Stage IV 10 (12.2%) (21.9%) 4 (22.2%) 4 (6.3%) 2 (11.1%) 8 (12.5%) Type of Treatment N (%) Chemotherapy 2 (2.4%) 2 (3.1%) 0 (0.0%) Radiation 1 (1.2%) 0 (0.0%) 1 (5.6%) Hysterectomy or other surgery 28 (34.1%) 24 4 (22.2%) Combination of Treatments 51 (62.2%) (37.5%) 13 38 (72.2%) (59.4%) Weight Loss Since Treatment Completion N (%) Yes 33 (40.2%) 25 8 (44.4%) No 49 (59.8%) (39.1%) 10 39 (55.6%) (60.9%) Recommended Weight Loss By Physician N (%) Yes 15 (18.3%) 12 3 (16.7%) No 67 (81.7%) (18.8%) 15 52 (83.3%) (81.3%) Current BMI N (%) Normal-Weight (< 25.0) 16 (19.5%) 12 4 (22.2%) Overweight (25.0 – 29.9) 21 (25.6%) (18.8%) 6 (33.3%) Obese (30.0 – 39.9) 23 (28.0%) 15 5 (27.8%) Morbidly Obese (≥ 40.0) 22 (26.8%) (23.4%) 3 (16.7%) 19 (29.7%) 18 (28.1%) Table 2. Correlation Matrix for Study Variables and Covariates for Sample.

Note: * p < .05. ** p < .01 (2-tailed) Note: FFMQ-SF = Five Facet Mindfulness Questionnaire – Short Form; AAQ-II = Acceptance and Action Questionnaire-II; BCS = Body Compassion Scale; BMI = Body Mass Index Table 3. Hierarchical Linear Regression of Pain Severity.

Step 1 Step 2 Variable β SE B t β SE B t Age -.08 .02 -.71 Time Since Tx .08 .00 .76 Completion Negative Affect .33 .03 3.07** AAQ-II .27 .05 1.34 FFMQ-SF -.07 .03 -.46 BCS .23 .02 1.27 BMI .12 .02 .98

ΔR2 .12 .05 F for ΔR2 3.61* 1.14

Step 1 Step 2 Variable β SE B t β SE B t Age -.24 .03 -2.39* Time Since Tx .15 .00 1.47 Completion Negative Affect .40 .04 4.03** AAQ-II .21 .06 1.18 FFMQ-SF -.19 .03 -1.38 BCS .09 .02 .58 BMI .20 .03 1.83

ΔR2 .25 .12 F for ΔR2 8.61** 6.12*

Step 1 Step 2 Variable β SE B t β SE B t Age .37 .25 4.65** Time Since Tx -.05 .02 -.57 Completion Negative Affect -.57 .35 -7.15** AAQ-II -.29 .45 -2.20* FFMQ-SF .14 .25 1.28 BCS .13 .15 1.07 BMI .13 .24 1.56

ΔR2 .52 .12 F for ΔR2 27.65* 18.35* * *

Pain Sample No Pain Sample t-values Effect size (N = 64) (N = 18) Measure M SD M SD t p Cohen’s d

FACT-En 121.78 29.18 142.33 18.96 -3.56 .001** .84

FFMQ-SF 80.09 10.91 86.56 14.11 -2.08 .04 .51

AAQ-II 20.06 8.56 17.17 7.97 1.29 .20 .35

BCS 73.70 22.56 76.78 25.62 -.50 .62 .13

BMI 34.04 9.94 31.63 9.14 .92 .36 .25 Note: **p < .01 (adjusted alpha from Bonferroni correction) FACT-En = Functional Assessment of Cancer Therapy – Endometrial Cancer; FFMQ-SF = Five Facet Mindfulness Questionnaire – Short Form; AAQ-II = Acceptance and Action Questionnaire-II; BCS = Body Compassion Scale; BMI = Body Mass Index Table 7. Hierarchical Linear Regression of Pain Severity.

Step 1 Step 2 Variable β SE B t β SE B t Age -.12 .02 -.93 Time Since Tx .07 .00 .57 Completion Negative Affect .31 .03 2.52* AAQ-II .33 .05 1.35 FFMQ-SF .08 .03 .45 BCS .10 .02 .47 BMI .09 .03 .64

ΔR2 .13 .04 F for ΔR2 2.85* .68

Step 1 Step 2 Variable β SE B t β SE B t Age -.31 .03 -2.78** Time Since Tx .14 .00 1.33 Completion Negative Affect .39 .04 3.50** AAQ-II .21 .06 1.10 FFMQ-SF -.16 .04 -1.05 BCS -.08 .02 -.46 BMI .19 .03 1.63

ΔR2 .30 .16 F for ΔR2 8.56** 4.16**

Step 1 Step 2 Variable β SE B t β SE B t Age .39 .27 4.43** Time Since Tx .03 .02 .40 Completion Negative Affect -.57 .04 -6.54** AAQ-II -.17 .52 -1.13 FFMQ-SF .18 .31 1.53 BCS .19 .18 1.36 BMI .16 .27 1.75

ΔR2 .56 .11 F for ΔR2 25.82** 16.28* *

Note: * p < .05. ** p < .01 Note: FFMQ-SF = Five Facet Mindfulness Questionnaire – Short Form; AAQ-II = Acceptance and Action Questionnaire-II; BCS = Body Compassion Scale; BMI = Body Mass Index Note: FFMQ-SF, AAQ-II, BCS, and BMI centered at their means Table 10. Hierarchical Linear Regression of Pain Severity (N = 82) with Experiential Avoidance in Step 2. Note: * p < .05. ** p < .01 Note: FFMQ-SF = Five Facet Mindfulness Questionnaire – Short Form; AAQ-II = Acceptance and Action Questionnaire-II; BCS = Body Compassion Scale; BMI = Body Mass Index Note: FFMQ-SF, AAQ-II, BCS, and BMI centered at their means Table 11. Hierarchical Linear Regression of Pain Interference (N = 82) with Experiential Avoidance in Step 2.

Non-Obese Obese t-values Effect size (N = 37) (N = 45) Measure M SD M SD t p Cohen’s d

BPI-SF (PS 1.89 1.77 2.41 2.05 1.20 .23 .27 subscale)

BPI-SF (PI 2.06 2.35 3.18 2.85 1.96 .05 .43 subscale)

FACT-En 132.03 29.06 121.58 27.42 -1.67 .10 .37 Physical 22.54 5.45 20.56 6.12 -1.54 .13 .34 Social/Family 20.14 6.27 17.20 6.57 -2.06 .04 .46 Emotional 17.70 4.87 16.89 4.98 -.74 .46 .16 Functional 20.30 7.39 17.04 6.89 -2.06 .04 .46

FFMQ-SF 85.76 12.22 78.02 10.54 -3.08 .003** .68

AAQ-II 15.95 7.26 22.29 8.40 3.62 .001** .81

BCS 85.49 16.31 65.24 24.06 -4.52 .001** .99

Note: **p < .005 (adjusted alpha from Bonferroni correction) BPI- SF = Brief Pain Inventory – Short Form; PS = Pain Severity; PI = Pain Interference; FACT- En = Functional Assessment of Cancer Therapy – Endometrial Cancer; FFMQ-SF = Five Facet Mindfulness Questionnaire – Short Form; AAQ-II = Acceptance and Action Questionnaire-II; BCS = Body Compassion Scale