In this blog, you will learn: (1) about the experience of anxiety, depression and stress among cancer patients and survivors; (2) how cancer patients describe those emotions in response to diagnosis, treatment, or long-term care; (3) how these emotions affect likelihood of recovery or recurrence; (4) how we know, scientifically, that mind and emotion impact cancer outcomes; (5) what animal and human clinical trials tell us about emotional impact on biology and cancer progression and (6) how cancer patients and survivors have engaged their mind and emotions to improve the likelihood of best outcomes after a diagnosis of cancer.
If you have been diagnosed with cancer, it is natural to experience a ‘bucketful’ of emotional responses. You may experience shock, fear, anxiety, panic, or a combination of these emotions. As the news sinks in, and you go through the rigors of treatment, questions may arise. “How did this happen?” “Why me?” At some point in time, most cancer patients and survivors will experience at least mild symptoms of depression; many will experience a deeper sense of sadness and symptoms of moderate to severe depression. Almost all cancer patients and survivors will experience mild, moderate or severe stress, anxiety and fear in response to diagnosis and treatment. These responses may last for only a few days or weeks, or they may become a longer-term conditioned response that impacts everyday life. If these responses become ‘conditioned’ and are experienced on a long-term basis, (e.g., for months or years, not just weeks) it will be important to develop skills to mitigate these conditioned emotional responses.
I’ve Finished Treatment, So Why Don’t I Feel Better?
Often, the greatest risk of depression comes after completing cancer treatment. We know from the research that Post-Traumatic Stress Disorder (PTSD) and its related depression most often occurs six to eight weeks after cancer treatment has ended. Why is this so? Cancer survivors will tell you that when in treatment, their medical providers and others, including themselves, are very busy saving their life, and watching their medical status closely. So, even in this fearful time of turmoil, there is the comfort of knowing that much is being done to produce the best medical outcome. Once the treatments have ended, the survivor enters a different stage of recovery. In the post-treatment stage, there is time to think more deeply about the ‘big’ questions. Why did this happen? Was it something I did? What should I do now? There is also the concern of recurrence. The term “waiting for the other shoe to drop” is used often among cancer survivors who have recently completed their treatment. They are no longer being medically ‘watched’ on a daily or weekly basis, and they become fearful of what may be occurring in their body. So, it is important to recognize that depression can occur at the time of diagnosis, during treatment, and even well after treatment has ended.
What If I Can’t Be ‘Cured?’
If cancer treatment lasts for years, as with metastatic disease, the risk of depression is even greater because ‘treatment weariness’ may set in. Even in Stage IV patients, cancer can often be treated and managed long-term, much like a chronic disease, and patients can experience decades of productive, high quality life. However, in those survivors who cannot be cured, the treatment journey can wear on their emotional and physical resources. It is very important that stage IV patients develop ‘smart’ strategies for mood state management and not ‘give up.’ Research has clearly demonstrated that lower levels of depression can extend survival time and even help significantly slow metastatic disease. We will cover this research in more detail in the next blog.
The patients I see often describe depression in terms of its ‘heaviness.’ One patient told me he felt as if a great weight had been deposited on his chest the day he heard the diagnosis of cancer—and that the weight did not lift during treatment, or even after treatment ended. Some patients experience the ‘heaviness’ in the pit of their stomach instead of in the chest. Other cancer patients and survivors describe depression as being drained of all physical energy—as an inability to find the motivation or strength to perform even the simple day-to-day tasks. Some describe depression as feeling helpless or hopeless. Often, individuals will describe depression as a “black hole” they have fallen into that blocks their ability to feel any sense of pleasure in the activities and events that once gave them pleasure. They describe their sense of smell, taste, touch, hearing and sight as ‘blunted’. Sometimes, depression is experienced as a sense of numbness—an inability to feel at all.
Is Depression Normal?
I explain to the patients I see that depression is a normal life event that all of us will experience at some point. In fact, most of us will have, in our lifetime, seven or more moderate depressive events lasting from a few days to several weeks. It is part of the human experience to face loss and the depression that accompanies loss. Storm victims lose their homes and possessions. Others experience the loss of divorce, or of their chosen career.
When someone receives a diagnosis or cancer, they may experience the loss of the ‘personal life story’ as they believed it to be. Now, their days may be filled with doctor’s appointments and treatments; with financial challenges; and with physical limitations during treatment or after treatment ends.
So many cancer survivors that I treat tell me the ‘story’ that represented their life has been dramatically changed and that their ‘personal story’ will never be the same again. Many describe the process as becoming ‘storyless.’ In other words, their interpretation of who they are, and what they believed their life would be like has been dramatically altered. It is true that after any serious life trauma, our life story is altered. What is important to understand is that although the story will be changed, there is every potential for the ‘story plot’ to become more than it was before. The transformation of the life story that occurs in persons facing life-threatening events is called ‘benefit finding’ and we will explore this in the next blog. Benefit finding is the key to moving forward after cancer in ways that makes life even more meaningful than it was before the diagnosis.
Short-term stress, as occurs with anxiety, fear, upset or depression, may actually ‘boost’ immune function for a short period of time. Our bodies evolved to respond to short-term stress as a threat to our lives. So, when we experience short-term stressors like anxiety or depression, our immune systems and our ability to heal ourselves may go into a state of ‘alert’ where all of our physical reserves are hijacked to help us flee or fight (like when our caveman ancestors had to run from an enemy or fight the enemy) and to heal (such as healing a wound inflicted by the enemy). Even our natural killer (NK) cells that fight, among other things, cancer, can become more vigilant when we experience short-term stresses. But this is only helpful for stress that lasts a matter of hours or at most a few days. Our bodies were not created to be able to withstand long-term activation by stress. So, if significant depression or anxiety lasts for more than a few weeks, the immune system may become impaired and fail to perform as it should. We can, literally, ‘burn-out’ our bodies’ natural defenses.
This is often experienced in the body as what we call “inflammatory responses.” In fact, inflammatory responses in the body are a major ‘driver’ of cancer progression. Inflammation also is a driver of almost all chronic disease states (cardiovascular disease, diabetes, arthritis, asthma), not just cancer. So, if depression, anxiety, fear and other stressful emotions are significant and last more than three weeks, it is important to put into place strategies and practices to help reduce the impact of these feelings on your body and mood state.
The good news is that all of us have the capacity to assess and modify our emotional responses. We can ‘direct’ and even rewrite the ‘storyline’ in the perceptions, interpretations and themes that play in our pre-conscious minds all day long. You will learn, in the next blog, what is occurring in the pre-conscious state, how to assess it, and what practices you can put in place to become more of a ‘director’ of your life play, and less of just a transfixed audience member.
How Do We Know That Mind and Emotion Affect Our Bodies? The Science
Research on how the mind and emotions affect the body began in the 1900’s, with the work of innovative scientists such as Cannon and Seyle. These two trail blazers asked the basic questions: What are the negative psychological and physiological effects of stress on the body? What are the biochemical pathways for those effects? They, and the researchers that followed them, discovered two very important pathways that explain how anxiety, depression and other stressful emotions impact our physical health. Those two pathways drive both the production of cortisol, often called the stress hormone, and adrenaline (also called noradrenaline). Adrenaline is the chemical you think of when you talk about having an ‘adrenaline rush’ and is linked with what are called “Type A” personalities. Cortisol is especially important because it has a rhythm, and how healthy that rhythm is predicts the likelihood of, among other things, full recovery from cancer or recurrence of cancer.
Later, other researchers began to ask an equally important question. If stress affects our mind and body in negative ways, can we consciously take control of that process and reverse it? Can we actually engage our mental processes and our emotions in ways to improve psychological and medical outcomes? Fortunately, the answer is ‘yes.’
Of course, some clinical questions cannot be initially answered with human patients because answering the questions would require invasive procedures or even ‘sacrificing’ the subject of study. So, in those circumstances, the lowly mouse, whose immune system often responds like ours, becomes the object of study. Using the mouse model, MD Anderson Cancer Center in Houston, Texas, demonstrated some of the most definitive scientific ‘links’ between stress and cancer documented to date. In very elegant studies, mice were randomized into two groups: Those that were to be ‘stressed’ for two hours, every day for thirty days, and those mice that were not to be ‘stressed.’ The ‘stress’ was delivered by putting the mice in a tube-like container that prevented them from being able to move at all. This was done at the same time of day, each day. The animals that were being ‘stressed’ were not harmed (e.g., not squeezed or physically damaged), but they did display the hallmark signs of anxiety (poor appetite and mouse-style anxiety behaviors).
Four days after the ‘treatment’ protocol was begun (the mice ‘treated’ with forced restraint was called the ‘treatment’ group), all of the animals (those being stress and those not being stressed) were injected with breast cancer cells. Then, the mice were scanned every day, for twenty-eight days.
The outcomes showed that the tumors in both stressed and unstressed mice grew at about the same rate. However, in the mice that were being stressed, the tumors spread beyond the original tumor site, into other parts of the body (a process called metastasis) at a rate 38 times greater than the animals not being stressed. This is important, because if death results from cancer, it is typically not caused by the original tumor, which can be surgically removed, but from metastatic disease. The researchers also measured indicators of metastasis, like catecholamine levels, which were 2.5 to 3.5 times higher in the stressed mice. The researchers concluded that the sympathetic nervous system, when an animal is highly stressed, turned on a ‘metastatic switch’ in response to breast cancer. This research and other studies led researchers to evaluate, in less invasive ways, similar possible effects on human patients.
What Do The Human Studies Tell Us?
Human studies have enlightened us in two very different, and equally important ways.
- First, they have identified mind-body medicine intervention approaches that can improve quality of life and health outcomes on a number of different fronts.
- Second, and most stunning is they have traced the exact biochemical, hormonal and physiological pathways impacted by our thoughts, perceptions and mind-body work.
For decades, scientists like Michael Antoni, Susan Lutgendorf and others have produced elegant studies tracing how our minds, emotions, and mind-body practices alter the very microenvironment of the body. For you scientists out there, take a look at the Antoni 2006 article entitled “The influence of bio-behavioral factors on tumor biology” published in Nature Reviews Cancer; or for a more current review, read “Psychosocial intervention effects on adaptation, disease course and biobehavioral processes in cancer”, in Brain, Behavior and Immunity (2012) by Antoni.
So, What Can I Do To Give Myself The Best Chance Of Full Recovery Or Extended Life?
Knowing what occurs between the mind and body that supports recovery or fuels disease would be of little value if we couldn’t use that information to improve our health outcomes. Learn more on how our minds and emotions affect our biology, and what we can do about it. In the blog “Can We Engage our Mind and Emotions to Change our Biology? Yes we Can!” I will challenge the reader to learn, assess, and engage biology changing strategies. The reader will learn how to become a ‘mini-expert’ in their own mind-body processes. You can learn how to ‘conduct,’ in subtle ways, the biological symphony that affects the rhythms within the body. We are, after all, as you will see, biological “rhythm machines.”
Finally, I will challenge the reader to embark on a healing journey. This journey will be based on crafting a life ‘story’ and accompanying ‘themes,’ enriched by what is experienced after diagnosis, and what can be put into place in response to this life challenging event.
- Institute of Medicine and National Research Council (2006). From Cancer Patient to Cancer Survivor: Lost in Transition. Committee on Cancer Survivorship: Improving Care and Quality of Life. (M. Hewitt, S, Greenfield & E. Stovall, Eds.) Retrieved September 12th, 2006 from http://www.nap.edu/catalog/11468.html.
- Institute of Medicine and National Research Council (2004). Meeting Psychosocial Needs of Women with Breast Cancer. (M Hewitt, R Herdman & J Holland, Eds.) Retrieved September 12, 2006 from http://www.nap.edu/catalog/10909/html.
- Antoni MH, Lutgendorf SK, Blomberg B et al. (2012). Cognitive-behavioral stress management reverses anxiety-related leukocyte transcriptional dynamics. Biological Psychiatry, 71, 366-372.
- Antoni, MH. (2012) (in press). Psychosocial intervention effects on adaptation, disease course and biobehavioral processes in cancer. Brain, Behavior, and Immunity.
- Antoni MH, Lutgendorf SK, Cole SW et al. (2006). The influence of bio-behavioral factors on tumor biology: pathways and mechanisms. Nature Reviews Cancer, 6, 240-248.
- Cohen L, Cole SW, Sood AK, et al. (2012). Depressive symptoms and cortisol rhythmicity predict survival in patients with renal cell carcinoma: Role of inflammatory signaling. 7, 8, 1-8. Open Access.
- Satin SR, Linden W, Phillips MJ. (2009). Depression as a predictor of disease progression and mortality in cancer patients: A Meta-Analysis. Cancer, 115, 5349-5361.
- Sloan EK, Priceman SJ, Cox BF et al. (2010). The sympathetic nervous system induces a metastatic switch in primary breast cancer. Cancer Research, 0 (18), 7042-7052.