Quieting the Mind, Healing the Body: Guided Imagery and Mindfulness Meditation among Cancer Patients

INTRODUCTION

The physical, psychological and social well-being of individuals are profoundly impacted by cancer, which continues to be a significant global health challenge. By 2040, the World Health Organization anticipates that there will be nearly 28.4 million new cancer cases annually, a nearly 50% increase from 2020.^[1] India bears a substantial proportion of this burden, with over 1.4 million new cancer cases reported annually and a steady rise in cancer-related morbidity and mortality across both urban and rural populations. Despite advances in oncological care, a large proportion of Indian patients present at advanced stages, resulting in heightened symptom burden and increased need for palliative care services. Numerous patients continue to endure persistent pain, fatigue, anxiety, depression and a reduced quality of life, despite technological advancements in radiotherapy, chemotherapy and surgical interventions.^[2] Palliative care is designed to alleviate suffering in all of its forms, including physical, emotional and spiritual, thereby enhancing the quality of life for patients and their families.^[3] However, in India, access to structured palliative care remains limited, with estimates suggesting that <4% of patients requiring palliative care actually receive it. This unmet need is particularly pronounced among patients with cancer, where psychosocial distress often remains under-recognised and under-managed within routine clinical care. Mind-body interventions have become increasingly popular due to their ability to alleviate distress and encourage adaptive coping in cancer patients as healthcare increasingly adopts a holistic model. Among these, guided imagery (GI) and mindfulness meditation (MM) are two well-established, non-pharmacological approaches that are consistent with the philosophy of palliative care.^[4]

GI is the deliberate application of positive mental imagery to activate the parasympathetic nervous system and induce relaxation. Research suggests that it reduces cortisol secretion, stabilises cardiovascular parameters and reduces anxiety and pain in individuals with chronic illnesses.^[5] MM, in contrast, cultivates non-judgemental present-moment awareness, contributing to improved emotional regulation, attenuation of hypothalamic–pituitary–adrenal (HPA) axis activity and decreased inflammatory and stress-related responses.^[6]

Despite growing evidence supporting individual mind– body interventions, limited studies have directly compared GI and MM using both psychological outcomes and objective physiological stress markers. This evidence gap is particularly evident in the Indian palliative care context, where low-cost, culturally acceptable and resource-efficient non-pharmacological interventions are urgently required to address the high unmet symptom burden among patients with cancer. This gap is particularly evident in palliative oncology settings within low- and middle-income countries, where resource-efficient, culturally adaptable, non-pharmacological interventions are critically needed. The present study addresses this gap by comparatively evaluating the effects of GI and MM on both subjective psychological parameters and objective bio-physiological indicators, including salivary amylase, among patients undergoing chemotherapy or radiotherapy. By integrating biochemical validation with psychological assessment in an Indian palliative care context, this study offers novel insights into the comparative effectiveness, feasibility and clinical relevance of these complementary mind–body therapies. Such non-pharmacological, nurse-led interventions are particularly relevant in oncology and palliative care settings, where addressing psychological distress alongside symptom management is a core component of holistic care.

MATERIALS AND METHODS

A quasi-experimental pretest–posttest control group design was implemented to assess the impact of GI and MM on selected bio-physiological and psychological parameters among cancer patients. This design was chosen due to logistical constraints within the clinical oncology setting and the need to maintain continuity of routine treatment schedules without disruption. The study was conducted in the oncology and palliative care units of a tertiary teaching hospital in South India from January 2023 to December 2024. The study population comprised adult patients aged 18 years and above who were diagnosed with stage II or III cancer and were undergoing chemotherapy or radiotherapy during the study period. Participants were recruited using purposive sampling based on eligibility criteria and clinical stability. Allocation to the three study groups – GI (n = 49), MM (n = 49) and control (n = 50) – was non-random and based on participant availability and treatment schedules. To minimise potential allocation bias, baseline homogeneity between groups was statistically assessed before intervention, and standardised intervention protocols were uniformly implemented across participants. Group assignment was carried out sequentially as eligible participants were enrolled. To minimise contamination, participants assigned to one intervention were not exposed to the other intervention.

To ascertain the parameters for sample size estimation, a pilot study involving thirty participants was conducted. With a 5% level of significance and 80% statistical power, a minimum sample size of 47 participants per group was required, assuming a standard deviation of 7.43 mmHg for systolic blood pressure (BP). Accounting for an anticipated attrition rate of 5%, the total sample size was set at 150. Baseline homogeneity among the groups was assessed using analysis of variance (ANOVA) and Chi-square tests, and the final analysed sample comprised 148 participants.

Inclusion criteria included adults aged ≥18 years with a confirmed diagnosis of stage II or III cancer, currently receiving chemotherapy or radiotherapy, who were physically and mentally stable to participate and willing to provide written informed consent. Patients with metastatic or terminal-stage cancer [Eastern cooperative oncology group ((ECOG)≥3], diagnosed psychiatric disorders or those participating in other structured mind–body or relaxation programmes were excluded.

The investigator underwent structured online training and certification in GI and MM through accredited programmes before intervention delivery. Both interventions were standardised using validated, audio-recorded scripts in the local language, which were reviewed and approved by experts in psychology, oncology and nursing to ensure content accuracy and cultural relevance.

Intervention sessions were conducted in a designated seminar room within the oncology unit to ensure a quiet, controlled and distraction-free environment. Sessions were delivered on an individual basis to promote focused engagement and personalised guidance, rather than in group format. Sessions were scheduled either during hospitalisation or during outpatient treatment visits, depending on the patient’s treatment schedule and clinical condition. Family members were not permitted to be present during intervention sessions to maintain privacy and minimise external influence.

Participants in the GI group engaged in structured ‘feeling-state’ GI aimed at inducing relaxation and positive emotional states. Each session lasted 15 min and included 10 min of guided visualisation, 2 min of deep breathing and 3 min of contemplative silence. Participants in the MM group practiced breath-awareness meditation, focusing on non-judgemental observation of respiration and bodily sensations. Each session lasted 15 min and was conducted twice daily for 4 weeks in a quiet, well-ventilated setting under supervision. The control group received routine oncology and palliative care, including medical management, nursing care and psychosocial support, without any structured relaxation intervention. Attendance and adherence were recorded daily to ensure intervention compliance.

Attrition and compliance: Throughout the intervention period, two participants (1.3%) withdrew: One from the GI group due to treatment-related fatigue and one from the MM group due to personal scheduling conflicts. As a result, 148 participants finalised the study. Missing data were addressed utilising the last observation carried forward technique, which was deemed appropriate given the minimal attrition rate (1.3%) to maintain statistical power and ensure dataset completeness.

Outcome measures encompassed both physiological and psychological parameters. Heart rate and respiratory rate were manually assessed over 1 min, while BP was obtained using a calibrated mercury sphygmomanometer, with two readings averaged. Salivary amylase, utilised as a biochemical stress indicator, was obtained through the passive drool technique at 6:00 a.m., specifically to minimise diurnal variation in salivary amylase levels. Participants were instructed to abstain from food, beverages and oral hygiene for a minimum of 30 min before collection. Samples (2–5 mL) were promptly placed on ice, centrifuged at 3000 rpm for 15 min and subsequently analysed through a colorimetric enzyme assay with absorbance assessed at 405 nm. Salivary amylase levels were analysed using a commercially available colorimetric enzyme assay kit, following the manufacturer’s instructions. Pain was evaluated utilising the numerical pain rating scale (0–10), whereas depression, anxiety and stress [DASS] were measured with the (DASS-21).

The instruments’ content validity was confirmed through expert evaluation by specialists in nursing, psychology and medicine. The pilot study evaluated reliability, with all tools exhibiting a Cronbach’s α >0.80, signifying excellent reliability. Outcome measures were recorded at four time points: Baseline (pretest) before initiation of the intervention and subsequently at the end of weeks 1, 2 and 4 following the intervention. All measurements were conducted by the principal investigator to ensure consistency and reduce observer variability.

Data were analysed utilising IBM Statistical Package for the Social Sciences statistics version 27.0. Descriptive statistics, including frequency, percentage, mean and standard deviation, summarised demographic and baseline characteristics. The Shapiro–Wilk test evaluated the normality of data distribution. Paired t-tests and repeated-measures ANOVA were employed for within-group comparisons of normally distributed data, whereas Wilcoxon signed-rank and Mann–Whitney U tests were utilised for non-parametric variables. Comparisons between groups were conducted using one-way ANOVA with Bonferroni post hoc analysis, while associations between demographic variables and study outcomes were evaluated using Chi-square statistics. The significance level was established at p < 0.05.

Ethical approval was secured from the institutional human ethics committee of Yenepoya (Deemed to be University), Mangaluru (Ref. No. YEC/2022/217). Informed written consent was acquired from all participants before the commencement of data collection. Confidentiality, anonymity and voluntary participation were guaranteed and participants were apprised of their right to withdraw at any moment without impacting their current treatment. The research complied with the ethical standards established in the Declaration of Helsinki (2013).

RESULTS

Data in Table 1 show that both GI (Group I) and MM (Group II) resulted in marked reductions in heart rate, respiratory rate, systolic and diastolic BP and salivary amylase levels from pre- to post-intervention. These improvements were significantly greater in both intervention groups compared to the control group (p < 0.001), while the magnitude of change was largely comparable between GI and MM.

Table 2 summarises changes in pain and DASS across the three study groups. One-way ANOVA revealed statistically significant differences in post-intervention psychological scores among the GI, MM and Control groups (all p < 0.001). Both GI and MM groups demonstrated significantly greater reductions in pain, depression, anxiety and stress scores compared to the control group (p < 0.001). Baseline pain scores differed significantly among groups (p < 0.05); therefore, post-test comparisons were adjusted accordingly. Inter-intervention group differences (GI vs. MM) for psychological outcomes are detailed in Table 3.

Repeated-measures ANOVA and Wilcoxon signed-rank tests confirmed the significance of intragroup differences as presented in Table 4. Within-group analyses demonstrated statistically significant pre- to post-intervention changes across all physiological and psychological parameters in both the GI and MM groups (p < 0.001). The control group also showed statistically significant changes; however, the magnitude of change was smaller compared to the intervention groups.

Table 3 demonstrates that both GI and MM resulted in greater improvements across most physiological and psychological outcomes compared to the control group, with large effect sizes for most parameters. Differences between the two intervention groups were generally small, except for pain, depression and anxiety, where MM showed greater improvement. Given the significant baseline difference in pain scores, pain-related intergroup comparisons should be interpreted cautiously.

DISCUSSION

The present study evaluated the effectiveness of GI and MM on bio-physiological and psychological parameters among cancer patients receiving chemotherapy or radiotherapy. Both interventions produced statistically significant improvements across all measured outcomes compared to the control group, supporting the role of structured mind–body interventions as effective adjunctive strategies in palliative and oncology care.

CONCLUSION

This study provides comparative evidence that both GI and MM produce meaningful improvements in physiological stability and psychological well-being among cancer patients. Beyond physiological stabilisation, these autonomic changes were accompanied by marked reductions in emotional distress, underscoring the holistic benefits of mind–body interventions. While earlier studies have examined the psychological benefits of GI and MM independently, the present study advances existing knowledge by directly comparing both interventions using identical outcome measures, equivalent intervention duration and the integration of subjective psychological scales with objective biochemical stress markers.

The comparable effectiveness of GI and MM reinforces the notion that both visualisation-based and awareness-based strategies can serve as effective therapeutic approaches to alleviate emotional distress and existential uncertainty in individuals living with cancer. These findings support the integration of GI and MM as feasible, low-cost adjuncts to routine oncology and palliative nursing care. Translating these findings into clinical practice, GI and MM emerge as feasible, safe and cost-effective adjuncts to routine oncology and palliative care, supporting their integration into holistic, patient-centred treatment models.