| Original Full Text | UCSFUC San Francisco Previously Published WorksTitleMindfulness-Based Group Medical Visits: Strategies to Improve Equitable Access and Inclusion for Diverse Patients in Cancer TreatmentPermalinkhttps://escholarship.org/uc/item/28j5d7k3JournalGlobal Advances in Integrative Medicine and Health, 13(16)ISSN2164-957XAuthorsMishra, Kavita KLeung, Ivan CChao, Maria Tet al.Publication Date2024DOI10.1177/27536130241263486 Peer reviewedeScholarship.org Powered by the California Digital LibraryUniversity of CaliforniaAdvancing the Science of Integrative Health Equity - Original ArticleGlobal Advances in Integrative Medicine and HealthVolume 13: 1–13© The Author(s) 2024Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/27536130241263486journals.sagepub.com/home/gamMindfulness-Based Group Medical Visits:Strategies to Improve Equitable Accessand Inclusion for Diverse Patients inCancer TreatmentKavita K. Mishra1,2,3,4,*, Ivan C. Leung1,2,4,5,6,*, Maria T. Chao1,2,5,6,*,Ariana Thompson-Lastad1,2,7, Christine Pollak1,4, Anand Dhruva1,2,4,5,Wendy Hartogensis1,2, Michael Lister1,4, Stephanie W. Cheng1,2,4,5, andChloe E. Atreya1,2,4,5AbstractBackground: Mindfulness-based interventions (MBIs) are supported by clinical practice guidelines as effective non-pharmacologic interventions for common symptoms experienced by cancer patients, including anxiety, depression, and fa-tigue. However, the evidence predominately derives from White breast cancer survivors. Racial and ethnic minority patientshave less access to integrative oncology care and worse cancer outcomes. To address these gaps, we designed and piloted aseries of mindfulness-based group medical visits (MB-GMVs), embedded into comprehensive cancer care, for racially andethnically diverse patients in cancer treatment.Methods: As a quality improvement project, we launched a telehealth MB-GMV series for patients undergoing cancertreatment, delivered as four weekly 2-hour visits billable to insurance. Content was concordant with evidence-based guidelinesand established MBIs and adapted to improve cultural relevance and fit (eg, access-centered, trauma-informed, with inclusivecommunication practices). Program structure was adapted to address barriers to participation, with ≥50% slots per seriesreserved for racial and ethnic minority patients. Intake surveys incorporated a demographic questionnaire and symptomassessments. Evaluations were sent following the visits.Results: In our first ten cohorts (n = 78), 80% of referred patients enrolled. Participants were: 22% Asian, 14% Black, 17%Latino, 45% non-Latino White; 65% female; with a median age of 54 years (range 27-79); and 80% had metastatic cancer.Common baseline symptoms included lack of energy, difficulty sleeping, and worrying. Most patients (90%) attended ≥3 visits.On final evaluations, 87% patients rated the series as “excellent”; 81% “strongly agreed” that they liked the GMV format; and92% would “definitely” recommend the series to others. Qualitative themes included empowerment and connectedness.1University of California, San Francisco (UCSF), San Francisco, CA, USA2UCSF Osher Center for Integrative Health, San Francisco, CA, USA3UCSF Department of Radiation Oncology, San Francisco, CA, USA4UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA5UCSF Department of Medicine, San Francisco, CA, USA6Zuckerberg San Francisco General Hospital, San Francisco, CA, USA7UCSF Department of Family and Community Medicine, San Francisco, CA, USA*Authors contributed equallyCorresponding Authors:Chloe E. Atreya, Osher Center for Integrative Health, University of California, 1545Divisadero Street, 4th Floor, San Francisco (UCSF), San Francisco, CA, USA.Email: chloe.atreya@ucsf.eduIvan C. Leung, Osher Center for Integrative Health, University of California, 1545 Divisadero Street, 4th Floor, San Francisco (UCSF), San Francisco, CA, USA.Email: ivan.leung@ucsf.eduCreative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative CommonsAttribution-NonCommercial 4.0 License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use,reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE andOpen Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).Conclusion: Telehealth GMVs are a feasible, acceptable, and financially sustainable model for increasing access to MBIs.Diverse patients in active cancer treatment were able to participate and reported high levels of satisfaction with this series thatwas tailored to center health equity and inclusion.Keywordsmindfulness-based interventions, group medical visits, integrative oncology, health equity, meditation, mind-body practicesReceived January 22, 2024; Revised April 22, 2024. Accepted for publication June 2, 2024IntroductionPsychological distress has profoundly negative impacts onpatients undergoing cancer treatment, particularly for racial andethnic minority patients facing structural inequities that lead tounmet healthcare needs. Psychological symptoms, along withassociated fatigue and sleep disturbance, are frequentlyundertreated.1,2 Moreover, access to mental health services andtreatment for depression is lower among Black, Latino, andAsian American patients compared to non-Latino Whitepatients.3,4 Psychological distress, including symptoms ofanxiety and depression, is an independent predictor of increasedcancer-specific mortality in multiple cancer types, notablycervical, colorectal, pancreatic, and prostate cancer – which areall correlated with racial and ethnic disparities in survivaloutcomes.5-9 Psychological distress is also associatedwith lowerquality of life, social isolation, higher healthcare costs, and poortreatment adherence– underscoring the importance of managinganxiety and depression during cancer treatment.10-12Mindfulness-based interventions (MBIs) are recom-mended for symptoms of anxiety and depression in adultsundergoing cancer treatment by the Society for IntegrativeOncology-American Society of Clinical Oncology (SIO-ASCO).13 CommonMBIs in healthcare include mindfulness-based stress reduction (MBSR), mindfulness-based cancerrecovery (MBCR) and Center for Mind-Body Medicine(CMBM) training.14-17 Many MBIs were designed for andresearched among primarily White, racially homogenouspopulations, and critiqued for neglecting cultural and historicroots of meditation practices, lack of cultural sensitivity, andcultural appropriation.18,19 Implementing evidence-basedMBIs could ameliorate undertreated symptoms among ra-cial and ethnic minorities during cancer treatment, but keychallenges need to be addressed. MBIs need to be adapted forfeasibility and appropriateness during cancer treatment andfor cultural relevance and acceptability among racially andethnically diverse populations. Adapted MBIs need to beembedded as part of routine oncologic care to increase up-take, particularly for patients with limited economic resourcesand demanding treatment schedules. Patient-level barriersalso need to be considered to support equitable access toMBIs. This should include personalized mind-body medicine(MBM), described by Mishra et al. as appropriate and ef-fective application of MBM for patients of varying back-grounds, inclinations, and abilities.20Group medical visits (GMVs) are an established strategyto increase access to mindfulness and other non-pharmacologic approaches for symptom management, andprovide extended time for multimodal care by addressing thetime constraints of usual one-on-one visits. Documentedbenefits of GMVs with mindfulness and other integrativetherapies include improved health outcomes,21 increased self-efficacy,22 improved quality of life,23-25 and lower emergencyroom visits.26,27 GMVs may also reduce social isolation,28-30and social isolation has been correlated with increasedcancer-specific mortality.31,32 GMVs improve access byproviding coordinated care to multiple patients simulta-neously, reducing wait time for visits and increasing effi-ciency for clinicians. The ability to bill insurance forguideline-concordant care makes GMVs a financially sus-tainable model for clinicians without burdening patients without-of-pocket costs that are often high when accessing MBIsoutside of clinical settings. Our prior quality improvement(QI) pilot documented the feasibility of GMVs for increasingaccess to integrative oncology during cancer treatment.21Notably, patients indicated a preference for being separatedby phase of care (active treatment or survivorship) but not bydiagnosis (ie, cancer type). However, like with our BeingPresent studies of remote-delivered MBIs designed for asimilar cancer population,33,34 75% of patients in our priorGMV pilot identified as non-Latino White.The primary objectives of this QI project are to assessthe feasibility and acceptability of remote-delivered,mindfulness-based group medical visits (MB-GMVs) de-signed for racially and ethnically diverse patients in cancertreatment. We describe two equity-focused strategies: (1)content adaptations to improve cultural relevance and fitfor a multicultural population of patients in active treat-ment, and (2) adaptations to program structure to addressbarriers to GMV participation. Because the MB-GMVs areconducted as a clinical service, the goal of assessingfeasibility and acceptability is to improve the quality ofclinical care for all patients in cancer treatment.MethodsSetting and ContextWe conducted this QI pilot at the University of California SanFrancisco (UCSF) Helen Diller Family Comprehensive2 Global Advances in Integrative Medicine and HealthCancer Center (HDFCCC), an urban, quaternary healthcaresystem with multiple campuses. The UCSF HDFCCCcatchment area is composed of the 25 counties in NorthernCalifornia that surround the Greater San Francisco Bay Area.The racial and ethnic distribution of individuals in the UCSFHDFCCC catchment area is 40% Non-Latino White, 37%Latino, 17% Asian/Pacific Islander, 6% non-LatinoBlack, <1.0% Native American. Our interprofessional teamincludes expertise in oncology, mind-body medicine, clinicaloperations, and integrative health research. Authors KKMand CEA were core GMV facilitators; ML and SWC wereamong four guest clinicians who each co-facilitated oneseries. A QI approach was chosen with a goal to improve thequality of clinical care available to all patients in cancertreatment. Data, de-identified and gathered during clinicalactivities, met criteria for UCSF Institutional Review Board-exempt QI activities. We report project findings using es-tablished SQUIRE guidelines.35MB-GMV Structure“Mindfulness Practices to Promote Health During CancerTreatment” was designed as a 4-visit synchronous telehealthGMV series. Each weekly GMV was 2 hours (8 hours total).The GMVs were designed for counseling patients on MBIs;interactive time for participation, reflection, and questions;assessment of physical, mental, and social determinants ofhealth as appropriate; and coordination of care. During theshared appointments, clinicians spent individual time withparticipants: this occurred both in individual breakout roomsand in front of the group, as allowable in the GMV setting.36Shared decision-making and patient preferences were foun-dational to prescribing mindfulness strategies.Visits were facilitated by two clinicians (two physicians ora physician and a nurse or Advanced Practice Provider). Inevery series, at least one facilitator identified as Black, In-digenous, or Person of Color (BIPOC). The GMVs weresupported by clinic staff, including a Practice Coordinatorand Medical Assistants. In addition, a clinical research co-ordinator was present at each session to optimize workflows,observe, and take structured field notes. Providers billedinsurance for all patients present per institutional and nationalcoding and billing guidelines based on the appropriate levelof medical Evaluation and Management codes.Electronic medical record (EMR) note templates werecreated for efficient documentation and billing compliance.An After-Visit-Summary was provided in the EMR’s PatientPortal after each session with a recap of the session’s contentand a personalized “prescription” for mindfulness practice,including links to relevant resources. All visits were con-ducted via telehealth due to the COVID pandemic and toprioritize access, eliminating the need for transportation andallowing flexibility to accommodate complex cancer treat-ment schedules and variable health status.MB-GMV Content and Equity Focused Strategies forDiverse Patients in Active Cancer TreatmentContent was adapted from our earlier MBI, Being Present,designed for patients undergoing treatment for metastaticcancer.33,34 We used a “pro-health approach” and ad-dressed mental health as a component of overall health,based on prior findings that patients find this more ac-ceptable than directly addressing distress. Interactivegroup MBM exercises were based on those taught in theCMBM Professional Training Program, as well as tech-niques adapted from MBSR and MBCR.15-17 The primaryfocus of the MBI was on anxiety (stress/distress) withsecondary focus on related symptoms of depression, dif-ficulty with eating, fatigue, and sleep disturbance com-monly experienced during cancer treatment. Cancer-related health behaviors (nutrition and physical activity)were addressed through a mindfulness lens (mindful eatingand meditative movement practices) (Table 1).Manualization of workflows and content delivery (in-cluding time allotments for each activity), along with sharednote templates, enabled guest co-facilitator participation,minimizing training requirements while maintaining fidelity.The manual defines which elements were included in allcohorts and which were modifiable depending on participantneeds and facilitator preferences.37,38We tailored the MBI as a clinical service for patients inactive cancer treatment by using a 4-session format and byincluding content on common cancer and treatment-associated symptoms, as well as mindfulness practices asevidence-based cancer risk-reduction strategies (eg, in-creasing activity), which still apply after a cancer diagnosis.In addition to prescribing daily meditation practice, we fo-cused on micro-practices or “MBM snacks”39 (eg, briefbreathing techniques) for times of acute stress and mindfulawareness in activities of daily life for when patients wereshort on energy or time. Emphasis was placed on meditationqualities of open awareness and friendliness vs concentration.As in our Being Present studies,33,34 we referred to the “bodyscan” as “body awareness meditation” because patients withcancer associate “body scan” with radiographic imaging,which may induce “scanxiety” (scan-provoked anxiety).Chair yoga was taught because it can be done in a range ofsettings without dedicated props and can be easily modifiedfor physical limitations. For walking meditation, a seatedalternative was also demonstrated, and qigong could beexperienced as guided imagery. Prompts provided beforemovement exercises emphasized awareness, acceptance, andnon-striving as mindfulness practices. For facilitated inter-action, we focused on cultivating inner wisdom and self-efficacy: what the patient can do and experience now, ratherthan what they can no longer do or is out of their control.Facilitators were sensitive to social needs including food,housing, and income insecurities. Free resources for con-tinued mindfulness practice were provided.Mishra et al. 3To support inclusivity in racially and ethnically diversegroups, we reviewed Communication Agreements for Mul-ticultural Interactions at the beginning of each session.40Specific cultural origins of different meditative practicesand harms of cultural appropriation were discussed. Weaddressed spirituality and alignment with individuals’ diversereligious contexts when introducing meditative practices. Weincluded a range of practices and approaches from differentcultural roots and encouraged patients to adapt MBIs basedon their needs, sociocultural inclinations, spiritual/religiousbeliefs, and racial/ethnic backgrounds. For example, nature-based phrasing, a line from a Zen Buddhist meal chant, andsaying grace in Judeo-Christian traditions were all accesspoints into a mindful eating exercise. The facilitation teams,content, and resources shared reflected the diversity of thepopulations served. Because racially and ethnically diverseTable 1. Mindfulness-Based GMV: General Format and Focused Patient Care by Visit Week.Hour 1 Hour 2Agreements for Multicultural Interactions (EBMC and Visions Inc.)a Facilitator 1: Consultation in individual settingIndividual check-in responses and assessment Practice questions and challenges assessmentAttitudes of mindfulness Supports counseling, evaluation and managementEvidence-based guidance related to topic Tailored practice recommendation and coordination of careChallenges posed by cancer symptoms and treatment Facilitator 2: Consultation in group settingHow mind-body practices can help to follow guidelines Micro-practiceExperiential practices (interspersed) Creative expression exercise (CMBM) and individual responsesCounseling and prescriptions for home practice Counseling, evaluation and management with each participantBreak Closing meditation practice and coordination of careTopics by Week Experiential Activities by Week1. Mindfulness practices for Emotional regulationAgreements: Confidentiality, right to pass, mindful listening Mindful breathing meditationCheck-in: What brings you joy? Lovingkindness meditationAttitudes: Generosity, gratitude Micro-practice: 4-7-8 breath, box breathing, abdominal breathingEvidence base: NCCN, SIO-ASCO Creative expression: Drawing (challenges and supports)Prescriptions: Daily meditation, gratitude journal Naming practice, “mind-body snacks”d2. Mindful EatingAgreements: Try it on, refrain from blaming or shaming Body Awareness Meditation (body scan)Check-in: One thing you are grateful for? Mindfully Eating a RaisinAttitudes: Beginner’s mind, non-judging Micro-practices: Lemon Guided ImageryEvidence base: WCRF, NCI Compassion-based meditationPrescriptions: Slow it down, give thanks (Chozen Bays, MD)b Creative expression: Dialogue with a problem3. Meditative MovementAgreements: Move up/move back; intent and impact Breath and Body MeditationCheck-in: Something surprising, sparking curiosity or wonder? Walking meditationAttitudes: Acceptance, non-striving Chair yogaEvidence base: AICR, ODPHP, ACSM, meta analysisc Micro-practice: Acupressure (union valley point), autogenicsPrescriptions: Meditative movement with resources Creative expression: Shaking/dancing4. Mind-body practices for sleep and fatigueAgreements: Practice” both/and,” self-focus Progressive muscle relaxationCheck-in: One thing you’d like to let go of? TonglenAttitudes: Patience, trust, letting go QigongEvidence base: NCCN, NCI Micro-practice: Bhramari Pranayama (bee breathing)Prescriptions: Practices for sleep/fatigue (eg, yoga nidra) Creative expression: Learnings, intentions to carry forwardaEBMC: East Bay Meditation Center and Visions Inc.: https://eastbaymeditation.org/2022/03/agreements-for-multicultural-interactions/.bChozen Bays: https://www.shambhala.com/mindfuleating/.cMeta analysis: Tai Chi and Qigong for Cancer-related Symptoms and Quality of Life, Wayne et al, J Cancer.Surviv. 2018 Apr;12 (2):256-267.dPersonalized Mind-Body Medicine in Integrative Oncology, Mishra KK, The ASCO Post, May 10, 2023. https://ascopost.com/issues/may-10-2023/personalized-mind-body-medicine-in-integrative-oncology/Abbreviations: ACSM: American College of Sports Medicine (Moving Through Cancer), AICR: American Institutefor Cancer Research (Blueprint to Beat Cancer), CMBM: Center for Mind-Body Medicine, NCI: National Cancer Institute (Eating Hints Before, During and AfterCancer Treatment; Fatigue; Ways to Improve Sleep; Cancer Treatment-related Symptom Clusters), NCCN: National Comprehensive Cancer NetworkSupportive Care Guidelines (Distress, Cancer-related Fatigue, Pain and Anticipatory Nausea), ODPHP: US Department of Health and Human Services Office ofDisease Prevention and Health Promotion (Move Your Way), WCRF: World Cancer Research Fund (International Cancer Prevention Recommendations).4 Global Advances in Integrative Medicine and Healthgroups include patients for whom English is a second lan-guage, extra scheduling and technology support - includingclose captioning - was made available to reduce barriers toparticipation.As an ongoing QI initiative, additional adaptations weremade as the series evolved based on specific patient acces-sibility needs and feedback. For example, we offer trauma-informed meditation instructions.41 We acknowledge thattrauma is common: for individuals with a history of trauma,focusing on the breath may bring up fear or panic, rather thanthe feeling of calm typically associated with meditationpractice. We use invitational language and endorse agency,including by offering alternatives to anchoring on the breathas an object of meditation and to taking a stationary, seatedposture. Anticipating the possibility of hypervigilance, wesay: “you can close your eyes, or you might choose to leaveyour eyes slightly open” and give a verbal cue beforesounding the mindfulness bell. In individual consultations,we tailor recommendations and write referrals for additionalsupport, as appropriate.Providing practice options made the program more in-clusive overall. Alternative focal points in lieu of concen-trating on the breath were also helpful for patients withrespiratory difficulties. The invitation to move during med-itation was beneficial to patients experiencing pain and fa-tigue. Meditation with eyes open was preferred by a patientexperiencing post-traumatic stress symptoms, and a deafpatient who needed to see the American Sign Languageinterpreter. Information presented on PowerPoint slides wasalso shared verbally for patients with impaired vision or thosewho identify as auditory learners, and recapped in an AfterVisit Summary, which helped a patient with mild cognitiveimpairment from a brain tumor. Following enrollment of apatient with known food insecurity, financial toxicity wasadded to a list of challenges that can make healthful eatingdifficult for people undergoing treatment for cancer (recog-nizing also the preference to be referred to as people livingwith cancer rather than “cancer patients”).Patient SelectionAll patients were adult, English-speaking patients in activecancer treatment at the UCSF HDFCCC. Active cancertreatment is distinct from post-cancer treatment (ie, no furtherplanned cancer treatment, as the patient has transitioned tosurvivorship or palliative symptom support). Active cancertreatment includes patients receiving systemic therapy, ra-diation, and those on a break from treatment for metastaticdisease. Half of the slots in each cohort were reserved forpatients who self-identified as BIPOC.The GMVs were introduced to patients verbally or via amessage in the EMR from a known oncology or supportivecare provider, followed by a formal invitation in the EMR. If aresponse was not sent via the EMR, clinic staff called patientsto confirm interest and availability. Occasionally, patients’treatment schedules were adjusted or space was secured in theclinic or infusion center to facilitate participation.We report here on the first 10 series, conducted betweenOctober 2021 and December 2022. Each cohort had 7-8 patients (median 8), with 78 patients total. Each patient hadthe option to invite one caregiver to attend with them;16 caregivers participated.Data Collection and AnalysisData was collected via participant questionnaires adminis-tered using REDCap (Research Electronic Data Capture).42 Aclinical research coordinator emailed participants links forREDCap surveys at baseline, mid-series, end-of-series, and at3-month follow-up. Reminders were sent via REDCap up to5 times, 3 days apart, if surveys were not completed. Baselinesurveys included demographics, symptoms (MemorialSymptom Assessment Scale and National ComprehensiveCancer Network Distress Thermometer [NCCN DT]), priorexperience with mind-body practices, and reasons for par-ticipation. Evaluations sent during and at the end of the seriesrequested feedback on various aspects of the intervention,such as overall satisfaction and feedback on length andfrequency of sessions. The 3-month follow-up survey as-sessed for ongoing impact, including whether participantscontinued to use practices they learned during the MB-GMVs.Descriptive statistics were used to summarize demo-graphics, clinical characteristics, baseline symptoms, andevaluation responses, as well as feasibility (ie, ≥50% BIPOCenrollment) and acceptability variables (ie, attendance andsatisfaction). Frequency distributions and percentages wereused to summarize categorical measures. Means (standarddeviation, SD) and medians (range) were used to describesymmetric and skewed continuous measures.We included three sources of qualitative data: responses toquestionnaires, field notes, and facilitators’ written reflec-tions. Questionnaires included open-ended fields elicitingcomments on what patients found most and least helpfulabout MB-GMV sessions. During GMVs, a clinical researchcoordinator (IL) engaged in participant observation usingstructured field notes with prompts on participant interac-tions, telehealth dynamics, what happened during each ses-sion, and any problems that arose. Additionally, core GMVfacilitators documented reflections in memos written im-mediately after each session and guest facilitators completedexit evaluations. Team members reviewed participant re-sponses to open-ended evaluation questions, observationalfield notes, and memos to identify thematic patterns acrosscohorts.ResultsOf the 101 patients invited to participate, 81 (80%) enrolled(Figure 1). Among 20 patients who declined participation, 14Mishra et al. 5(70%) identified as male, and 11 (55%) identified as BIPOC.Reasons for declining primarily related to scheduling or lackof interest. One patient cited inability to access Zoom. Threepatients enrolled but cancelled before the first visit due tocancer-associated complications.Seventy-eight patients participated in ten cohorts ofGMVs (Table 2). Patients had a median age of 54 years (range27-79); 55% identified as BIPOC; 35% identified as male.Fifteen (20%) patients had less than an associate degree; 41%had an annual household income of < $100,000 and 55%were not employed during the GMVs. Sixty-two (80%)patients had metastatic cancer; 59 (76%) patients had gas-trointestinal (GI) malignancies, and over half (58%) wereundergoing treatment with cytotoxic chemotherapy. Themedian time since diagnosis was 20 months. Nineteen (24%)patients had not accessed other supportive care at the CancerCenter (nutrition, integrative medicine, symptom manage-ment, or psychotherapy). Common symptoms reported atbaseline included fatigue (69%), insomnia (46%), anxiety(46%), and pain (42%) (Table 3). Fifty-four (69%) patientsreported any emotional distress symptom (worrying and/orfeeling irritable, nervous, or sad). The mean NCCN DT scorereported at baseline was 4.8 (SD 2.2); NCCN DTscores >3 define a clinically elevated level of distress.43Common reasons for participating in MB-GMVs includedstress reduction (34%), learning new information or skills(28%), and a wish to be present or at peace (26%). Roughlyhalf of the participants reported prior experience withmeditation (59%), yoga (56%), and/or mindfulness (50%);9% reported no prior experience.Attendance and Acceptability of InterventionThe missed appointment rate was 11% (33 missed visits outof 312 scheduled), with 70 (90%) patients missing one visitor less. The main reasons for missed visits were scheduleconflicts or feeling unwell. Attendance was encouraged bycommunicating with patients and coordinating with infu-sion center and clinic staff to provide a private space andtelehealth equipment to join visits on treatment days.Patients were invited to modify as needed, includingturning their cameras off, lying down, and mostly listeningif they were feeling ill. Patients regularly joined during carrides to and from medical appointments and with che-motherapy running, citing that they considered the GMVsan integral part of their cancer treatment. Sixteen (20%)patients joined with a caregiver, the majority of whom werespouses/partners (other caregiver relationships: mother,daughter, sister, and friend); dogs and cats also madefrequent appearances.Of respondents who completed any evaluation (n = 59),75% rated the GMVs as “excellent” (based on final seriesrating, if available, or average of up to 4 session ratings iffinal rating was missing). Among 37 patients who com-pleted the end-of-series evaluation, 87% rated the overallseries as “excellent (Table 4). Patients reported liking theFigure 1. Mindfulness-Based Group Medical Visits Patient Flow Diagram. Summary of patient recruitment, attrition, attendance, and datacollected. EMR: electronic medical record; BIPOC: black, indigenous, and people of color. A program goal was to enroll ≥50% patients whoidentify as BIPOC.6 Global Advances in Integrative Medicine and HealthGMV format and most recommended that we continue withfour, weekly 2-hour visits; 92% indicated that they would“definitely” recommend the GMV series to others. Among24 patients who completed the 3-month follow-up survey,58% reported continuing at least one of the mind-bodypractices (Table 4).Patient Experiences with Equity-Focused MB-GMVsQualitative data highlighted three aspects of MB-GMVsadapted for diverse patients in active treatment: the valueof offering mind-body practices from a range of culturaltraditions; patient empowerment; and group interactions.Patients frequently commented on the diversity of the fellowparticipants and sense of comfort and safety in seeing otherswith diverse backgrounds in the group, as well as the diversityof practices, as critical aspects of their learning. One patient,who was reserved during the first two visits, opened up afterthe shaking and dancing meditation, which has African,Native American, and Asian roots. They revealed that theyloved dancing in their youth and the freedom to move as thebody was able without choreography or expectation. Another,who was new to qigong, discovered that it felt familiar,having seen elders practice similar movements while growingup in China.Several patients observed that experiencing effects of thepractices in their bodies and on their state of mind wasimpactful and surprising— redirecting their focus from whatthey cannot do, to opening new possibilities for what they cando. For example, one patient who had been a yoga practi-tioner stopped due to physical limitations after their diag-nosis. They commented that chair yoga was more accessiblefor their current physical condition and enabled them toresume their practice. Patients also expressed that it wasempowering to hear medical professionals affirm their ex-isting spiritual traditions and self-care habits could contributeto mindfulness practice and overall health. Participants withdiverse secular, spiritual and religious backgrounds (in-cluding but not limited to Buddhist, Catholic, Christian,Hindu, Jain, Jehovah’s Witness, Jewish, Muslim, Nature andSpirituality-based paths, Shinto, Sikh, and Taoist) shared afeeling of encouragement to adapt mind-body practices asTable 2. Demographic and Clinical Characteristics (N = 78 Except as Noted).Demographic Variable N (%) Clinical Variable N (%)Age, median (range) 54 (27-79) Self-reported health status (N = 75) Very good/good 44 (58.7)Race/ethnicityAsian 17 (21.8) Fair/poor 31 (41.3)Black 11 (14.1) Cancer type Colorectal 34 (43.6)Latino/Hispanic 13 (16.7) Other gastrointestinal 25 (32.0)Non-Latino white 35 (44.9) Ovary/other gynecologic 7 (9.0)Othera 2 (2.6) Breast 5 (6.4)GenderFemale 51 (65.4) Lung 3 (3.8)Male 27 (34.6) Prostate 2 (2.6)Sexual orientation (N = 75)Hetersexual/straight 68 (90.7) Brain 1 (1.3)Gay/lesbian 3 (4.0) Multiple myeloma 1 (1.3)Prefer not to answer 4 (5.3) Cancer stage IV (metastatic) 62 (79.5)Education (N = 75)High school graduate or less 15 (20.0) Cancer treatmentc Chemotherapy 45 (57.7)Associate’s or Bachelor’s degree 32 (42.7) Targeted/hormonal 21 (26.9)Master’s or doctoral degree 26 (34.7) Immunotherapy 9 (11.5)Prefer not to answer 2 (2.7) Off treatment 3 (3.8)Household income (N = 75)Below $100,000 31 (41.4) Months since diagnosis, median (range) 20 (1-318)$100,000 and over 26 (34.6)Prefer not to answer 18 (24.0)Employment status (N = 75)Yes, full time 21 (28.0)Yes, part time 13 (17.3)Not currently workingb 41 (54.7)aOther: Persian ethnicity and multiracial (Asian and White). One Black Patient (Primary identification) also self-reported Other and Latin heritage.bNot currently working: 17 retired, 10 on disability, 8 unable to work but not on disability, 6 other (eg, homemaker).cChemotherapy includes cytotoxic chemotherapy combined with another modality. Immunotherapy includes combinations with targeted or hormonal therapy.Mishra et al. 7appropriate and integrate them into their personal and familytraditions.Patients consistently shared that interacting with peerswas a strength of the GMV format. They describedlearning from other group members and feeling sup-ported, connected and less alone. Several patients notedprior negative experiences with support groups, and thatthe facilitated MB-GMVs were different because of themind-body focus. We noted that patients with limitedEnglish proficiency shared less in the group setting.However, all responded to group prompts, questions and/or individual reflections; and most spoke very openlyduring individual consultations and reported benefitsfrom participation despite language barriers. One patientwho was doing well physically during the series found itdifficult to see others who were sicker. For others, GMVscreated an opportunity to connect through their sharedexperiences of cancer treatment. At the end of each series,one patient per group volunteered to be the point-personfor continued interaction. Following the GMVs, twopatients synchronized their infusion appointments so thatthey could spend time together in person. One patientshared (quote used with permission): “I found solace inthe idea that my experience is both entirely unique andsomewhat predictable. Hearing from others who are alsoexperiencing the anxiety and stress of cancer, but fromdifferent backgrounds, and with different approaches tomindfulness was helpful and interesting.”Provider ExperiencesIn exit evaluations, GMV facilitators universally reportedgaining knowledge, practices and/or resources that were bothpersonally helpful and useful for providing care to futurepatients with cancer. Reflections captured in facilitatormemos indicated that the MB-GMVs were a rare opportunityin healthcare to meet patients as fellow learners and teachers.During the GMVs, unlike in a usual oncology visit, all teammembers responded to the check-in questions (eg, whatbrings you joy?) and shared personal experiences with mind-body practices. Facilitators noted increased fulfillment inleading racially and ethnically diverse groups, and workingwith patients who were new to mind-body practices. Onenurse reported that MB-GMV facilitation was practice-changing, leading him to “look at the familiar through adifferent lens.” Employing techniques learned in the series,this nurse reported pausing and breathing with a distressedpatient whom he was attempting to counsel over the phone,effectively deescalating a tense communication. A physicianguest facilitator noted that she began using the micro-practices frequently with patients during her outpatientclinic visits, finding them to be highly accessible and ef-fective. She also expressed feeling a sense of “rejuvenationand nourishment” while facilitating the GMVs, sharing howmeaningful it felt to be in a community with colleagues andpatients in this unique context. She reported that this expe-rience increased her job satisfaction and deepened herTable 3. Memorial Symptom Assessment Scale: Burden of Symptoms With >20% Prevalence (N = 78).SymptomOverall Prevalence Duringthe Past Week N (%)Frequencya Frequently -Almost Constantly (%)Severityb Moderate -Very Severe (%)Distress/BothercSomewhat - Very Much (%)Lack of energy 54 (69.2) 63.0 83.3 53.7Difficulty sleeping 36 (46.2) 66.7 86.1 69.4Worrying 36 (46.2) 61.1 83.3 63.9Pain 33 (42.3) 54.5 93.9 78.8Feeling sad 32 (41.0) 15.6 56.3 37.5Difficultyconcentrating30 (38.5) 46.7 73.3 53.3Feeling nervous 29 (37.2) 34.4 68.9 55.2Nausea 27 (34.6) 18.5 55.6 55.6Constipation 26 (33.3) NA 69.2 46.2Feeling irritable 25 (32.1) 32.0 72.0 68.0Numbness/tingling inhands/feet22 (28.2) 90.9 77.3 50.0Feeling drowsy 17 (21.8) 52.9 94.1 35.3Change in way foodtastes17 (21.8) NA 58.8 35.3Sexual interest/activityproblems16 (20.5) 75.0 87.5 56.3Lack of appetite 16 (20.5) 50.0 87.5 68.8Choices for,aSymptom frequency: rarely, occasionally, frequently, almost constantly,bSeverity: slight, moderate, severe, very severe,cDistress/bother: not at all, a little bit, somewhat, quite a bit, very much.118 Global Advances in Integrative Medicine and Healthconnection to her clinical work. In addition, facilitators notedpositive impacts on communication between clinicians, pa-tients, and family members, extending beyond the groupseries. Several facilitators remarked that their newly learnedor augmented mindfulness skills improved their day-to-daycommunication in their professional interactions andrelationships.Common challenges reported by the guest facilitators weredifficulty initiating discussions when reflections and ques-tions were sparse and guiding the conversation when a patientbecame emotional in the group setting. Holding this dis-comfort, a nurse observed, “helped me see that not all patientsare aware that the challenges they experience during treat-ment are shared with other patients. It also helped me un-derstand the emotional needs of patients and their fortitudeunder emotional distress.” Specific prompts and tips wereadded to the manual based on co-facilitator feedback. Afterguest facilitation, clinicians reported being able to describethe GMVs to patients with greater specificity, aidingrecruitment.DiscussionWith this QI pilot of equity-focused MB-GMVs for raciallyand ethnically diverse patients in active cancer treatment, wedemonstrated feasibility of ≥50% BIPOC enrollment in atelehealth program serving people with advanced cancer.Acceptability and appropriateness were evidenced by highattendance rates and favorable satisfaction ratings. Sustain-ability was achieved by billing insurance for guideline-concordant care. Qualitative observations are consistentwith prior literature indicating that GMVs decrease socialTable 4. Mindfulness-Based Group Medical Visit Evaluation and Follow-Up Survey Data.Question (N = 37 except as indicated) Response N (%)Overall series rating Excellent 32 (86.5)Good 5 (13.5)Facilitator ratings (N = 35)a Excellent 30 (85.7)Good 5 (14.3)Adequate time for questions (N = 35) Strongly agree 26 (74.3)Agree 7 (20)Neither agree nor disagree 2 (5.7)Liked the GMV format Strongly agree 30 (81.1)Agree 7 (18.9)Optimal number of GMV sessions Keep as 4 sessions 23 (62.2)1 session 02 sessions 1 (2.7)>4 sessions 13 (35.1)Optimal GMV session length Keep as 2 hours 29 (78.4)<2 hours 8 (21.6)>2 hours 0Optimal GMV frequency Keep as weekly 29 (78.4)Every other week 8 (21.6)Recommend GMV series to others Definitely 34 (91.9)Very possibly 3 (8.1)3-Month follow-up survey (N = 24)Still practicing Any mind-body modality 14 (58.3)Breath-focused meditation 11 (45.8)Walking meditation 10 (41.7)Mindful eating 9 (37.5)Mindfulness in other daily activities 8 (33.3)Loving-kindness meditation 6 (25)Other stationary meditation 6 (25)Yoga 5 (20.8)Mindfulness in health care settings 5 (20.8)Gratitude journal 5 (20.8)Qigong 4 (16.7)Writing or drawing inner reflection 3 (12.5)Other movement meditation 2 (8.3)Other: “gratutude in thought always” 1 (4.2)GMV, group medical visit.aRatings were the same for facilitator 1 and 2’s organization, explanations, knowledge, and attitude.Mishra et al. 9isolation, increase social support, and improve patient-provider relationships.30,44 Our findings indicate that MB-GMVs using inclusive strategies, embedded into standardoncologic care, are a promising approach to promote healthequity by addressing unmet mental health and other symptommanagement needs that disproportionately impact patientsfrom racial and ethnic minority groups.1,2 Below we discusskey learnings from this pilot project related to recruitment,retention and sustainability, as well as challenges andlimitations.Designing the MB-GMVs with half the slots reserved forBIPOC-identified patients was a pragmatic decision to bal-ance timely access to integrative oncology care with an in-tention to provide a safer space for addressing cancerdisparities. Our high recruitment rate (80%) depended onoutreach by trusted clinicians (MDs, RNs, NPs, acupunc-turists, and psychotherapists), who referred patients ingreatest need of supportive care resources. Barriers to par-ticipation, including scheduling conflicts, were proactivelyaddressed. This “high-touch” recruitment method may be lessefficient than self-referral, however, it supported participationby patients who did not directly request integrative oncologyservices.Our MB-GMVs had a remarkably high attendance rate(89%), especially taking into account that the majority ofpatients were in treatment for metastatic cancer. In contrast toour Being Present MBI which had a significantly lowerparticipation rate in a similar population,34 we posit thatscheduling the GMVs as part of comprehensive cancer care,led by cancer center clinicians, motivated attendance. Thiswas supported by documented reasons for participation andqualitative responses on study evaluations. Our interventionis adapted for a multicultural population, equity-focused andtrauma-informed. Directly addressing trauma in an MBI fordiverse patients is important, acknowledging the highprevalence of trauma in BIPOC communities, and a cancerdiagnosis itself can be experienced as a trauma. Feedbackreceived suggests that being intentional about creating in-clusive experiences allowed patients to engage and feelconnected to the group.Attendance was also supported by the GMV structure,including assistance provided by clinical and researchstaff. Although some patients expressed a preference forin-person groups and/or a higher number of shorter visits,four 2-hour visits on Zoom worked for most patients andhad several advantages. Video visits increased access forpatients in cancer treatment, hailing from a large geo-graphic area, many of whom were also balancing work,childcare, and other responsibilities. An unexpected bonusof the video visit format was caregiver and pet partici-pation, contributing to an atmosphere of friendliness andjoint learning to establish new habits within families/socialnetworks. With a 4-week MB-GMV series, it is easier topredict health status of patients with advanced cancercompared with a longer time span.Sustainability is an important component of access. Co-facilitation by two MDs from different disciplines (medicaloncology and radiation oncology or palliative care) allowedboth providers to bill insurance. RNs were permitted by ourcancer center to participate under “Education & Training”time, with float coverage provided. Clinical practice coor-dinators and medical assistants were supported by revenuegenerated by MD and/or NP facilitators. The clinical researchcoordinator was supported by grants and philanthropy. Onechallenge is that if multiple clinician-facilitators are from thesame discipline, they cannot each bill independently for thesame patient on the same day of service. Another challenge isthat non-clinician content experts, like yoga and qigong in-structors, are unable to bill insurance currently. Because ourobjective is to avoid passing costs onto patients, we are in-vesting in the creation of free, high-quality video practiceresources tailored to diverse patients in active cancer treat-ment. Finally, manualization of workflows and content hasbeen critical to sustaining an interprofessional GMV teamwith fixed and rotating members, while maintaining con-sistent quality.Prior literature reports benefits of mindfulness programsand GMVs for clinician wellbeing,44-46 through increasedresilience and job satisfaction and reduced burnout. Our studysimilarly found multiple kinds of health professionals (cli-nicians, clinical and research staff) reported positive impactsof the MB-GMVs. These included opportunities for mind-fulness practice throughout the workday, extended time withpatients, improved communication, team-based care, andinterdisciplinary collabration. Moreover, this GMV series hasenhanced the provider experience across our center. Itsunique content, structure, and emphasis on diversity andequity has inspired the creation of a number of other GMVs atour institution. Several clinicians have approached the studyteam to learn how to launch and sustain GMVs of their own.Engagement of multiple healthcare providers in the MB-GMVs has promoted coordination of clinical workflows,data collection, and cross-recruitment.Limitations of our QI pilot include that it was not designedto formally assess intervention effectiveness for reducingsymptoms and improving quality of life. The 3-month followup survey return rate was low (31%), consistent with what wepreviously observed in a metastatic cancer population. Ad-ditionally, recruitment of Latino patients was low comparedto Latino representation in our catchment area (17% vs 38%).This reflects similar underrepresentation of Latinos at UCSFHDFCCC and is related to another limitation: our MB-GMVswere only offered in English. As a next step we propose toconduct a pragmatic effectiveness trial in English and Spanishat UCSF and community-based clinics to determine the ef-fectiveness of MB-GMVs adapted for racially and ethnicallydiverse patients in active cancer treatment.Our conclusions from this MB-GMV pilot are as follows:First, MBIs need to be adapted for feasibility and appro-priateness during cancer treatment and for cultural relevance10 Global Advances in Integrative Medicine and Healthand acceptability among racially, ethnically, and linguisticallydiverse populations. Second, effectively translating evidence-based interventions into practice requires careful attention tointervention fidelity and adaptations to ensure fit and flexi-bility for diverse contexts and populations. Third, adaptedMBIs need to be embedded as part of routine oncologic careto increase uptake, particularly for patients with limitedeconomic resources and demanding treatment schedules.Factors affecting implementation, such as patient-level bar-riers and healthcare setting, also need to be considered tosupport equitable access to MBIs.Guideline-concordant symptom support should be avail-able to all patients undergoing cancer treatment. Culturally-adapted and trauma-informed MB-GMVs embedded intostandard oncologic care offer a promising approach to reducehealth and healthcare inequities among BIPOC patients.AcknowledgementsWe gratefully acknowledge contributions from Donald Abrams,Neha Goyal, Sandy Cuevas, Julie Kesterson, Anand Parikshak, andNicole Thompson to content development and workflows. Inte-grative Health Equity and Applied Research fellows Anand Par-ikshak and Tiffany Nereida Lopez participated in summarizing fieldnotes. Nurses Julie Kesterson and Elizabeth Stewart served as co-facilitators. Julia Wu entered references. We also thank the HelenDiller Family Comprehensive Cancer Center, UCSFGastrointestinalMedical Oncology and Osher Center for Integrative Health clinicaland administrative teams for championing these efforts, togetherwith patients and their families.Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respectto the research, authorship, and/or publication of this article.FundingThe author(s) disclosed receipt of the following financial support forthe research, authorship, and/or publication of this article: this workwas supported in part by the National Cancer Institute [adminis-trative supplement to award number P30CA082103], the HelenDiller Family Comprehensive Cancer Center, theMount Zion HealthFund, and other philanthropic support. Authors received additionalsupport from the National Institute on Minority Health and HealthDisparities [ATL, K01MD015766]. The funding sources had noinvolvement in the design and conduct of the quality improvementproject; the collection, management, analysis, or interpretation of thedata; or in the preparation, review, or approval of the article.Contents are solely the responsibility of the authors and do notnecessarily represent the official views of the funders.ORCID iDsIvan C. Leung https://orcid.org/0009-0004-3560-9593Maria T. Chao https://orcid.org/0000-0001-9846-7044Ariana Thompson-Lastad https://orcid.org/0000-0002-4880-1371Anand Dhruva https://orcid.org/0000-0001-5552-7131Stephanie W. Cheng https://orcid.org/0009-0001-2194-1796Chloe E. Atreya https://orcid.org/0000-0003-2954-1727References1. Carlson LE, Angen M, Cullum J, et al. High levels of untreateddistress and fatigue in cancer patients. Br J Cancer. 2004;90(12):2297-2304. doi:10.1038/sj.bjc.66018872. Carlson LE, Waller A, Groff SL, Giese-Davis J, Bultz BD. 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