UNIVERSITY OF CALGARY

UNIVERSITY OF CALGARY
Online Mindfulness-Based Cancer Recovery Program for People Living with Cancer in
Alberta: A Randomized Wait-List Controlled Trial
by
Kristin Anne Zernicke
A DISSERTATION
SUBMITTED TO THE FACULTY OF GRADUATE STUDIES
IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE
DEGREE OF DOCTOR OF PHILOSOPHY
GRADUATE PROGRAM IN PSYCHOLOGY
CALGARY, ALBERTA
AUGUST, 2015
© Kristin Anne Zernicke 2015

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Abstract
Objective
Through a randomized treatment-as-usual (TAU) wait-list controlled trial, the current
studies examined the feasibility and impact of an online “real-time” synchronous
Mindfulness-Based Cancer Recovery (MBCR) group program for distressed people
diagnosed with cancer, who did not have access to in-person MBCR. Sub-analyses
combined both the immediate and TAU wait-list groups to evaluate potential medical and
physical demographic effects on participant mindfulness facets and symptom subscale
scores to determine which participants improved most after the online MBCR
intervention.
Methods
Sixty-two men and women exhibiting moderate-to-high distress were randomized to
either immediate online MBCR or to wait for the next available program. Intent-to-treat
mixed-model analyses for repeated measures were conducted. Subsequent, pre-post linear
mixed model analysis was conducted on all participants who completed MBCR, and
standardized change scores were calculated for subscales of mood and stress symptom
measures.
Results
Feasibility targets for recruitment and retention were achieved. Participants were satisfied
and would recommend online MBCR to other cancer survivors. Completion rates were
comparable to in-person MBCR. Improvements and moderate effect sizes were reported
in the online MBCR group relative to a TAU wait-list following MBCR for total scores
of mood disturbance, stress symptoms, spirituality, and mindfully acting with awareness.

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Significant main effects of time were observed for posttraumatic growth and remaining
mindfulness facets. Sub-analyses revealed younger participants had greater reductions in
stress symptoms, increases in spirituality, and non-reactivity to experience over time.
Over time, men experienced significantly greater posttraumatic growth than women.
Subscale analyses of mood disturbance and symptoms of stress revealed greatest relative
improvements in the subscales of Vigor, Fatigue, and Sympathetic Nervous System
Arousal.
Conclusions
Results provided evidence for the feasibility and efficacy of an online adaptation of
MBCR, facilitating reduction of mood disturbance and stress symptoms, and increasing
participant-reported spirituality and mindfully acting with awareness. Online MBCR also
reduced the negative physical impact of distress by improving energy levels and inducing
relaxation. Future study is warranted using larger active control RCT designs. Programs
utilizing similar technology could potentially improve access to other specialized
psychosocial programs.

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Preface
While conducting the eCALM Trial for this dissertation, the following two
manuscripts were published, and the third manuscript is in preparation for submission to
a peer-reviewed journal. For each of the manuscripts, the first author conducted the data
analysis, interpretation, and writing of the manuscripts. Overseeing, guiding, and
directing throughout this process were Dr. Campbell and Dr. Carlson. All authors
reviewed the published manuscripts. Chapters two and three contain the published
articles that are reproduced in their entirety and are included as chapters within this
dissertation with permission from the publishers. Chapter four includes the manuscript in
preparation for submission.
Zernicke, K., Campbell, T., Speca, M., McCabe-Ruff, K., Flowers, S., Dirkse, D.,
& Carlson, L. (2013). The eCALM Trial-eTherapy for Cancer AppLying Mindfulness:
Online mindfulness-based cancer recovery program for underserved individuals living
with cancer in Alberta: Protocol development for a randomized wait-list controlled
clinical trial. BMC Complementary and Alternative Medicine, 13(1), 34.
Zernicke, K., Campbell, T., Speca, M., McCabe-Ruff, K., Flowers, S., & Carlson,
L. A randomized wait-list controlled trial of feasibility and efficacy of an online
mindfulness-based cancer recovery program: The eTherapy for Cancer AppLying
Mindfulness Trial. Psychosomatic medicine, 76(4), 257-267.
Zernicke, K., Campbell, T., Speca, M., McCabe-Ruff, K., Flowers, S., Tamagawa,
R., & Carlson, L. Exploratory analyses of the associations between online mindfulness-
based cancer recovery participation and changes in mood, stress symptoms, mindfulness,
posttraumatic growth and spirituality. (In preparation for submission)

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Acknowledgements
To my supervisors, Dr. Tavis Campbell and Dr. Linda Carlson, thank you for
your insight, encouragement, and guidance throughout this adventure. To my committee
members, thank you for your valuable time and expert contributions to this research.
Thank you to Dr. Tak Fung, Dr. Rie Tamagawa, Dale Dirkse, Aldo Aquirre-Camacho,
Tobi Ceh, and Lihong Zhong for your invaluable support and dedication to this project.
Thank you to Jill Johnson and Codie Rouleau for reviewing manuscript drafts. Thank you
to the participants for making this research possible through their generous contribution
of both time and experience.
Thank you to the sources of funding for this research: Dr. Carlson’s Enbridge
Research Chair in Psychosocial Oncology (co-funded by the Canadian Cancer Society
Alberta/North West Territories Division and the Alberta Cancer Foundation); Canadian
Institute of Health Research – Frederick Banting & Charles Best Canada Graduate
Scholarship Doctoral Award; Psychosocial Oncology Research Training Fellowship;
Alberta Innovates – Health Solutions Full-Time Studentship; and Mind and Life
Francisco J. Varela Research Award. Sincere thanks to our facilitator Steve Flowers,
Kelley McCabe-Ruff and the eMindful support team, the Psychosocial Resources
Department at the Tom Baker Cancer Centre, and the Alberta Cancer Registry for their
support.
I am grateful for the unwavering love, support and encouragement from my
family and friends during this process. Thank you for believing in me.