1. Introduction
ancer is a serious problem of the healthcare system in Iran and the world; it is the second leading cause of death in developed countries and the third leading cause of death in Iran [1]. Chronic diseases, including cancer, persist for a long time and affect the individual’s ability to function normally. Besides, they and are a major cause of death and disability. They require long-term pharmacotherapy, and often their hallmark is the development of physical disability.
Additionally, there is no definitive cure for this disease; the affected subjects may encounter numerous issues, such as unemployment, poor quality of life, cognitive impairment, and mental health problems, especially depression and anxiety [2]. Normally, the body’s cells are destroyed after performing their function towards the relevant organ. The present study aimed to compare the effects of Cognitive-Behavioral Group Therapy (CBGT) and Mindfulness-Based Cognitive Therapy (MBCT) on multifaceted pain symptoms in patients with breast cancer.
2. Materials and Methods
This was a quasi-experimental study with pretest-posttest and a control group design. The statistical population of this study included all women with breast cancer referring to the Cancer Research Center of Shahid Beheshti University of Iran between May and February 2016. The sample was selected per coordination with physicians and by observing the inclusion and exclusion criteria of the study. The study samples were selected by non-random and convenience sampling methods. Accordingly, among women with breast cancer referring to the Cancer Research Center of the Shahid Beheshti University of Iran, 60 subjects were selected and randomly divided into 3 groups of 10, including two experimental groups (CBGT & MBCT) and a control group. No intervention was performed in the control group. The West Haven-Yale Multidimensional Pain Inventory (WHYMPI/MPI; Kerns, Turk, and Rudy, 1985) was applied to evaluate multiple pain indices. The repeated-measures Analysis of Variance (ANOVA) was used in SPSS to analyze the obtained data at the significance level of 0.05.
3. Results
The mean age of the study participants equaled 27-61 years. Most research participants (83.3%) were married and 13.3% were single. Furthermore, 63.3% had a diploma education, followed by postgraduate education (13.3%), BA degree (13.3%), and MA degree (6.7%). Moreover, 1 subject had a PhD. The collected results suggested that CBGT and MBCT were effective on pain experience (P<0.001); however, there was no significant difference between the experimental groups concerning their effectiveness on pain experience.
The obtained data indicated that the ANOVA results of pain experience were significant for the effect of time (P<0.001) and group effect (P<0.001) and the effect size of a group intervention for pain experience was equal to 0.17. Thus, there was a significant difference between the experimental and control groups in different research stages, highlighting the effect of the intervention on pain. Furthermore, the scores of pain experienced in the CBGT and MBCT groups were lower in the posttest, compared to the pretest step (P<0.001). The present research results indicated that pain experience scores in the follow-up stage were significantly different from those of the pretest stage (P<0.001); however, no significant difference was observed between the posttest and follow-up stages. The collected results signified that the effectiveness of CBGT and MBCT in the follow-up phase was sustained for both variables of the pain experience.
4. Discussion and Conclusion
Based on the present study findings, CBGT and MBCT affected the management and pain intensity of the explored patients with breast cancer. Accordingly, CBGT considers chronic pain as a complex and multidimensional mental phenomenon in which patients experience pain uniquely. In this theoretical framework, in addition to the patient’s assessment of pain, the health clinician should be aware of the impact of various activities of daily living activities [23]. Furthermore, according to another study, mindfulness-based stress reduction methods in the experimental group, affected improving pain intensity in patients with chronic pain, compared to the control group. Moreover, in explaining this finding, the absence of the catastrophic pain-initiating mind tends to process its messages instead of the knowledge-based processes of the present moment, causing it to perceive pain more than before, resulting in the severity of the risk. Satisfy it more. It seems that the state without judgment and evaluation exists in the present, which can reduce the intensity of pain perception from the beginning of habitual patterns in the face of different experiences [17, 24]. In general, pain management indicates reducing the severity and duration of pain and physical disability as a result of reducing psychological conditions, such as depression, anxiety, stress, and all mental health disorders and empowering and improving self-efficacy to encourage the subject to increase the quality of life and change. Lifestyle, motivation for self-care, and enjoyable activities increase, subsequently [24]. Cognitive-Behavioral methods and the MBCT approach include or overlap with various other therapies. Comparing the results of these two methods makes it easier for patients with chronic pain.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Research Ethics Committee of Karaj Branch, Islamic Azad University (Code: IR.IAU.K.REC.1397.037). All ethical principles are considered in this article. The participants were informed about the purpose of the research and its implementation stages. They were also assured about the confidentiality of their information and were free to leave the study whenever they wished, and if desired, the research results would be available to them.

Fnding
The paper was extracted from the PhD. dissertation of the first author at the Department of Psychology, Karaj Branch, Islamic Azad University, Karaj.

Authors' contributions
All authors observed standard writing criteria based on the recommendations of the International Committee of Medical Journal Publishers (ICMJE), and all contributed equally to the drafting of the article.

Conflicts of interest
The authors declared no conflicts of interest.

Acknowledgements
The authors express their gratitude to the esteemed management and staff of the Cancer Research Center of Shahid Beheshti University and all the participants in this study for their cooperation.



References

1. Laird BJA, Fallon MT. Palliative care in the elderly breast cancer patient. Clin Oncol. 2009; 21(2):131-9. [DOI:10.1016/j.clon.2008.11.009]
2. Joly F, Giffard B, Rigal O, De Ruiter MB, Small BJ, Dubois M, et al. Impact of cancer and its treatments on cognitive function: Advances in research from the paris international cognition and cancer task force symposium and update since 2012. J Pain Symptom Manag. 2015; 4(3):830-41. [DOI:10.1016/j.jpainsymman.2015.06.019]
3. Pirnia B, Pirnia K. Comparison of two mindfulness-based cognitive therapies and acupuncture on the pain and depression index in a case with lobular carcinoma: A single case experimental study. Int J Cancer Manag. 2018; 11(6):22-40. [DOI:10.5812/ijcm.65641]
4. Maindet C, Burnod A, Minello C, George B, Allano G, Lemaire A. Strategies of complementary and integrative therapies in cancer-related pain-attaining exhaustive cancer pain management. Support Care Cancer. 2019; 27(8):3119-32. [DOI:10.1007/s00520-019-04829-7]
5. Johannsen M, O’Connor M, O’Toole MS, Jensen AB, Zachariae R. Mindfulness-based cognitive therapy and persistent pain in women treated for primary breast cancer. Clin J Pain. 2018; 34(1):59-67. [DOI:10.1097/AJP.0000000000000510]
6. Sinha UK, Kumar D. Mindfulness-based cognitive behaviour therapy with emotionally disturbed adolescents affected by HIV/AIDS. J Indian Assoc Child Adolesc Ment Heal. 2010; 6(1):19-30. http://www.jiacam.org/ojs/index.php/JIACAM/article/view/207
7. Liu R. Cognitive behavioral therapy for highly stressed breast cancer survivors. J Pain Manag. 2012; 5(1):33-52. https://www.proquest.com/openview/afe97122bfdcfceaa35120b220309006/1?pq-origsite=gscholar&cbl=2034829
8. Johannsen M, O’Toole MS, O’Connor M, Jensen AB, Zachariae R. Clinical and psychological moderators of the effect of mindfulness-based cognitive therapy on persistent pain in women treated for primary breast cancer-explorative analyses from a randomized controlled trial. Acta Oncol (Madr). 2017; 56(2):321-8. [DOI:10.1080/0284186X.2016.1268713]
9. Chang KL, Fillingim R, Hurley RW, Schmidt S. Chronic pain management: nonpharmacological therapies for chronic pain. FP Essent. 2015; 432:21-6. [PMID]
10. Sandler CX, Goldstein D, Horsfield S, Bennett BK, Friedlander M, Bastick PA, et al. Randomized evaluation of cognitive-behavioral therapy and graded exercise therapy for post-cancer fatigue. J Pain Symptom Manage. 2017; 54(1):74-84. [DOI:10.1016/j.jpainsymman.2017.03.015]
11. Rahmani S, Talepasand S. The effect of group mindfulness-based stress reduction program and conscious yoga on the fatigue severity and global and specific life quality in women with breast cancer. Med J Islam Repub Iran. 2015; 29:175. [PMCID] [PMID]
12. Ghasemi F, Karimi M. The effectiveness of Mindfulness-Based Cognitive Therapy on the quality of life in women with breast cancer. Nurse Physician Within War. 2018; 6(20):51-9. http://eprints.ajaums.ac.ir/3934/
13. Akbari M, Nafisi N, Jamshidifar Z. [Effectiveness of mindfulness training in decreasing the perceived stress among the patients suffering from breast cancer (Persian)]. JTBCP. 2013; 7(27):7-16. https://jtbcp.riau.ac.ir/article_10_292a04ac611ae832d778233b3fd3a82d.pdf
14. Sanaei H, Mousavi S, Moradi A, Parhoon H, Sanaei S. The effectiveness of mindfulness-based stress reduction on self-efficacy, perceived stress and life orientation of women with breast cancer. JTBCP. 2017; 12(44):57-66. https://www.sid.ir/en/journal/ViewPaper.aspx?ID=553580
15. Dowd H, Hogan MJ, McGuire BE, Davis MC, Sarma KM, Fish RA, et al. Comparison of an online mindfulness-based cognitive therapy intervention with online pain management psychoeducation: A randomized controlled study. Clin J Pain. 2015; 31(6):517-27. [DOI:10.1097/AJP.0000000000000201]
16. Menning S, de Ruiter MB, Kieffer JM, Agelink van Rentergem J, Veltman DJ, Fruijtier A, et al. Cognitive Impairment in a subset of breast cancer patients after systemic therapy-results from a longitudinal study. J Pain Symptom Manage. 2016; 52(4):560-9. [DOI:10.1016/j.jpainsymman.2016.04.012]
17. Reich RR, Lengacher CA, Alinat CB, Kip KE, Paterson C, Ramesar S, et al. Mindfulness-based stress reduction in post-treatment breast cancer patients: Immediate and sustained effects across multiple symptom clusters. J Pain Symptom Manage. 2017; 53(1):85-95. [DOI:10.1016/j.jpainsymman.2016.08.005]
18. Johannsen M, O’Connor M, O’Toole MS, Jensen AB, Højris I, Zachariae R. Efficacy of mindfulness-based cognitive therapy on late post-treatment pain in women treated for primary breast cancer: A randomized controlled trial. J Clin Oncol. 2016; 34(28):3390-9. [DOI:10.1200/JCO.2015.65.0770]
19. Von Ah D, Tallman EF. Perceived cognitive function in breast cancer survivors: Evaluating relationships with objective cognitive performance and other symptoms using the functional assessment of cancer therapy - cognitive function instrument. J Pain Symptom Manage. 2015; 49(4):697-706. [DOI:10.1016/j.jpainsymman.2014.08.012]
20. Stewart RE, Chambless DL. Cognitive-behavioral therapy for adult anxiety disorders in clinical practice: A meta-analysis of effectiveness studies. J Consult Clin Psychol. 2009;77(4):595-610. [DOI:10.1037/a0016032]
21. Kabat-Zinn J. Mindfulness-based interventions in context: Past, present, and future. Clin Psychol: Sci Pract. 2003; 10(2):144-56. [DOI:10.1093/clipsy.bpg016]
22. Zhang Q, Zhao H, Zheng Y. Effectiveness of Mindfulness-Based Stress Reduction (MBSR) on symptom variables and health-related quality of life in breast cancer patients—a systematic review and meta-analysis. Support Care Cancer. 2019; 27(3):771-81. [DOI:10.1007/s00520-018-4570-x]
23. Leydon GM, Eyles C, Lewith GT. A mixed methods feasibility study of mindfulness meditation for fatigue in women with metastatic breast cancer. Eur J Integr Med. 2012;4(4):15-24. [DOI:10.1016/j.eujim.2012.05.003]
24. Johns SA, Brown LF, Beck-Coon K, Talib TL, Monahan PO, Giesler RB, et al. Randomized controlled pilot trial of mindfulness-based stress reduction compared to psychoeducational support for persistently fatigued breast and colorectal cancer survivors. Support Care Cancer. 2016; 24(10):4085-96. [DOI:10.1007/s00520-016-3220-4]