Stress and Cancer: Cause and Effect
Anne Coscarelli, Ph.D.
“…cancer is a traumatic life event that begins at the time of diagnosis, continues through treatment and often extends into survivorship.”
Is there anyone who has been diagnosed with cancer who has not felt a quiver in their stomach or a moment of worry and concern about the future? Do most people feel upset by the diagnosis, panicked, anxious, worried, sad, depressed, angry, overwhelmed or stressed?
After working as a psychologist in this area for 24 years, I can attest from my clinical experience and research that when a cancer diagnosis is made, the patient and his or her family experience a host of feelings such as anxiety, sadness, depression, loss and stress. These reactions are common; however, there are a range of experiences and intensities that vary from one individual to another and a myriad of ways of responding to stressful events.
There is consistent data to suggest that cancer is a traumatic life event that begins at the time of diagnosis, continues through treatment and often extends into survivorship. After they complete their initial treatment, many patients frequently continue to experience stress emanating from the possibility of a recurrence. This stress can be heightened by any health problems or symptoms, and can even be associated with any visit to the doctor, including blood tests or scans.
How individuals cope with the stress of cancer varies. Many researchers have looked at different patient populations throughout the world to try and understand what mechanisms help patients mediate the negative feelings and stress that they experience. Beyond research studies, individual patients and family members often have their own ideas about what keeps them going, what helps make them feel better and what helps to mitigate their stress. In 1984, J. Singer gave what I believe is still a valid definition of coping: “Coping can be defined as cognitive, behavioral, or social strategies that patients and families use to bring about relief in relation to a perceived threat or a demand and to restore equilibrium.” This broad definition allows room for a variety of internal and external strategies that can create balance and reduce the stresses brought about by cancer. I am often awe struck by the strength and ability of the human spirit to find ways to adapt to significant and life altering changes and to maintain some sense of wholeness and integrity despite the traumas of a cancer diagnosis.
Coping can take many forms. After three decades of research on this topic, we have learned that patients who have multiple coping strategies, and are somewhat flexible in the use of these strategies, tend to fare better. We have also learned that while some strategies may be more effective than others, we cannot categorize a strategy as effective or ineffective without considering the nature of the stressor and how the strategy is applied. A strategy that may be inappropriate and dangerous in one situation might be extremely helpful in another situation. For example, psychologists once regarded “denial” as a maladaptive coping strategy. However, over time the thinking about this has changed. A patient might use denial, or a form of it known as “selective attention,” to reduce his or her focus on cancer statistics, but not deny the fact that he or she has the disease. Further, using some denial of the potential outcomes can help a patient actively engage in pleasurable activities because cancer is not foremost in his or her thoughts. On the other hand, if a patient denies the cancer or the seriousness of the cancer and, therefore, does not obtain adequate treatment, this would be a maladaptive strategy and would have deleterious effects on both quality of life and survival. Situations where denial keeps families from having important conversations can also be detrimental. Researchers have discussed and studied different coping styles, including the fighting spirit, helplessness, hopelessness, denial, avoidance, stoic acceptance and fatalism, anxious coping and preoccupation, depressive coping, active or problem-focused coping, emotional expression, and suppression of emotion. For any individual each of these styles might have a role at times and may be effective at some times while ineffective at other times. Learning effective coping strategies, developing new strategies and applying them in appropriate situations gives patients and family members beneficial ways to cope with the stress of cancer. Research has shown that expressing emotion, using problem-focused strategies and learning self-control techniques (which incorporate mind-body approaches) can reduce anxiety and help patients feel better and more satisfied.
As we delve into the huge area of stress and coping it is clear to me that there is some pervasive thinking that shapes decisions, coping and the experience of living with cancer. I believe this pervasive thinking is sometimes built around a little bit of research and a lot more myth. I also believe that these myths have psychological undercurrents that can have negative effects on patients’ and family members’ well being.
At the heart of these myths is the need and desire for control. The diagnosis, treatment and its sequelae can feel like a club that hits patients and family members over the head with the thought, “You are not in control.” The disease itself is a function of cell growth that also is out of control. So, the process of coping and living with cancer is often about learning to live with an event that challenges one’s sense of control. People try to cope by attempting to take back control or refusing to relinquish any of it. In their struggle to regain a sense of control, people often adopt certain beliefs about their diagnosis and their life. These myths or beliefs, however, are not always benign, and I think it may be important to articulate them with the hope of reorienting our sense of control in ways that do not have the potential for negative psychological consequences.
What are the myths or beliefs that are set into motion when the stressful event, cancer, becomes real?
Myth #1: How a person copes with cancer will determine survival.
One of the most powerful and pervasive myths that people hold is the notion that a patient must be positive in their approach to cancer. Many people believe that positive thinking is an important component for survival. Jimmie Holland, MD, a psychiatrist who began some of the early work in psychosocial oncology has appropriately termed this, “The Tyranny of Positive Thinking.” There is no data to suggest that positive thinking increases the likelihood of survival. There is also no data to suggest that having negative feelings will hasten the disease process.
While there has been a body of research that has attempted to associate a particular style of coping with survival (e.g., fighting spirit and hopeless/helpless) these studies have not shown a consistent pattern of benefit for either of these styles on the end-point of survival or recurrence. Studies investigating other coping styles have also been weak. In fact, the studies showing any positive results have been extremely flawed, utilizing small numbers of patients. In a recent systematic review of the research (2002), M. Petticrew concluded, “There is little consistent evidence that psychological coping styles play an important part in survival from or recurrence of cancer. People with cancer should not feel pressured into adopting particular coping styles to improve survival or reduce the risk of recurrence.”
Myth #2: Stressful events prior to cancer caused the cancer.
In the course of counseling patients and assisting them over the years, I have noticed that people often believe an event that happened in the one or two years prior to cancer was the primary causative factor of the disease because of the stress that it created. There are numerous books asking patients to use hindsight to identify the stresses in their lives and, in particular, to examine the stresses prior to their diagnosis. Needless to say, it is easy for patients to identify stressful events, as stress is a common life experience. However, there are many people without a diagnosis of cancer who are also able to list extensive stresses that have occurred in their lives in previous years. Along with the strongly held belief that stressful events can cause cancer is the notion that a stressful life leads to cancer. For some there may be some immediate comfort in these thoughts because controlling stress becomes a tangible and doable intervention and can help one to cope with the overwhelming fears associated with cancer and recurrence.
Stress as a causative factor in cancer is a complex area to research. It is one of the most strongly held beliefs, often with little understanding of the research. I have no doubt that like everything we think we know today in medicine and psychology, research will change our thinking in some way over time. Having good quality research is an important first step. Quality research usually has large subject samples, unbiased selection of subjects, and does not rely upon memory, which adds bias to the results. Data usually needs to be collected prior to the cancer diagnosis and examined over time. Confounding variables, other possible explanations for the cancer, need to be documented and controlled, and comparison groups need to be included that are similar to the studied group. These are very difficult studies to conduct in human populations. Many of the models studied are examined in the laboratory. In these studies mice are injected with tumor cells and then exposed to stress. The impact of the stress is then examined by comparing tumor growth to mice not exposed to extreme stress. While these early studies may begin to help understand this relationship, the research is a long way from making the conclusion that stress has a significant causal relationship in the development of cancer or recurrence for humans. It becomes a leap of faith and it is one that is promoted by many individuals and complementary and alternative medicine practices, as well as within traditional medicine environments.
Of the studies in humans, there are some looking at stressful life events in patients diagnosed with cancer. They tend to use patients with breast cancer and to be retrospective, which means that they have patients look back in time and recall what happened to them. This methodology is fraught with problems. One of the better studies in this area was done by D. Protheroe in 1999 and actually included 332 breast cancer patients. His conclusion, “These findings do not support the hypothesis that severe life events or difficulties are associated with the onset of breast cancer.” Further a study conducted in Finland by K. Lillberg (2001) which looked prospectively at 10,519 women concluded, “We found no evidence of an association between self-perceived daily stress and breast cancer risk.” A review article looking at life events, coping style and personality factors concluded that, “The evidence for a relationship between psychosocial factors and breast cancer is weak.” It is important to note again that much of this research has been done with breast cancer patients, not with other cancers and does not support the belief that cancer is caused by stress.
One of the most compelling studies that I have read was a nationwide study in Denmark that was able to look at the development of cancers following what most people would agree is the worst stress imaginable, the death of a child. The researchers were able to evaluate the development of cancer in 21,062 parents who were exposed to this stressful event and to evaluate whether there was an increased risk of developing cancer, especially particular types of cancer. They did not find an increased development of breast cancer with this stressful event. Further, their data did not find any elevated risk for immune- or viral-related malignancies. In other words, the results of this study do not support the common belief that reduced functioning in immune and endocrine systems influences the development of malignant disease. They found no increased risks in fathers and only a slightly higher overall risk in mothers. There was a small increased risk of developing smoking related cancers in mothers, but they concluded that stress-induced adverse life styles (e.g., smoking) might account for this finding. It should be noted that this study does not suffer from the methodological problems that haunt most of the studies in this area, such as small sample size, lack of follow-up, recall or selection bias or absence of an adequate control group. Finally, the data were collected as part of the national registry, making it uncontaminated from a variety of other sources.
There will continue to be studies in this area and it will be an important area to watch. I know that science is ever changing, but I think it is important to make certain that our beliefs about stress and cancer do not get too far out in front of the science. I am constantly reminded that as a society we believed that hormone replacement therapy for women must be great (it made sense), but as science caught up with belief, a new truth and new belief system has evolved.
Why do I think it is so important to talk about stress and cancer? Well, the two beliefs--or myths--described above lead to another very powerful myth that can create many difficulties and needless anxiety for patients and families. If there is a way to reduce this stress by providing information, then it is an important topic for patients and families living with cancer.
Myth #3: If I stop being stressed and live right, I can make the cancer go away or stay away.
This belief does not seem harmful on the surface. In fact there is some research in people with AIDS that suggests that beliefs may be related to survival. Beliefs are powerful. However, I am more concerned about the impact of these beliefs if cancer recurs. When or if cancer recurs, do we have to assume that the person did not do the right things, think the right thoughts, feel the right emotions or make the right choices? Do we blame the patient for his or her failings? When cancer returns, do we assume that the person failed to reduce the stress?
All of these beliefs have at their core the intent to find responsibility for the cancer in a way that gives back some control to the patient. However, there are some negative consequences to this thinking that becomes a powerful side effect of these belief systems. These beliefs can also blame the individual for causing their cancer, causing the recurrence or failing to survive. Personally, I think having cancer is a big enough stressor and no one needs to do anything that adds to that burden. Blame increases the psychological burden. In addition, it assumes a level of control that may not exist, and can create additional stress. For some patients the effect may be profound, while for others it is more subtle. The sense of blame may not even come from within the person with cancer, but from the surrounding support system. I worry about the impact of this blame. It comes with judgment and self-criticism. It can create a feeling of shame when a patient is not “keeping up the fight.” At a more unconscious level, accepting one’s cancer may be perceived or experienced as defeat, as their failure. Failure in our society is a powerful construct and there are a host of emotions and stressors associated with it.
Shapiro and Shapiro made the following remarks that are worth pondering as we move to a constructive approach to stress and cancer, “We see in all this a peculiarly Western characteristic which involves an overwhelming desire to be in control—of our jobs, our lives, our diseases, our deaths, our universe. Somewhere in all this push for self-responsibility we see a basic contradiction. No matter how purely we eat and drink, no matter how carefully we guard the air we breathe, no matter how much we become involved with our doctors and they with us, the mortality rate will still be 100%.”(cited in Astin, JA et al., 1999)
Inevitably, we must seek an alternative approach that might be a more helpful way to live with cancer. Here are some beliefs that are empowering.
Belief # 1: As an informed consumer, I can exercise control over what to include in my cancer journey.
Patients and family members do have some control over what elements and whom they want to involve in their treatment, their fight, or their acceptance. Information is a powerful component in helping to make these decisions. Information can come from many sources, but it is important to seek sources in which you have confidence and believe to be reliable. Choosing health care professionals with whom you can build trust and who will listen to and respect personal values may be an important part of this decision process. Choosing people who are knowledgeable about your particular cancer and its treatment can be the single best decision from the outset. Being informed about treatments, traditional Western medicine and integrative medicine can help to identify the best individual choices, taking into consideration the costs and benefits.
Making good choices regarding lifestyle changes such as diet, exercise and work may be within your control. These choices can be based on enhancing quality of life and not focused on issues of whether they will or will not cure your cancer. They may have indirect benefits such as a healthy diet leading to less co-morbid illness (diabetes, cardiac disease, other cancers) and a reduction in complications through survivorship. A healthy diet may help you to be stronger and have more energy, which will improve your overall well being. These are choices that you can make that provide some control without the burdens previously discussed.
Keep in mind that you have the right to choose and ignore suggestions. Many patients report pressure from friends and family to try certain approaches or potential cures. The pressure to try each and every approach, regardless of the data behind it, can be a powerful stressor and can lead to a sense of burden. Patients should use their own information and judgment to set limits; you do not need to try every option suggested. Some options may increase stress, take time and money from other choices, and deplete your energy in the pursuit of them. Be wary of these suggestions, especially when the data do not support their efficacy. Choose wisely about what will improve your chance of survival and focus on your quality of life.
Belief # 2: Cancers and their treatments create stress and there are a variety of techniques that can be helpful in coping with them.
Many helpful techniques come from psychology and can be integrated into a healthy life style. They include techniques such as relaxation exercises, guided imagery, meditation, and self-hypnosis. Included in these techniques are cognitive behavioral strategies that can shift the way an individual thinks about events and thus alters the feelings associated with it. These self-control strategies can make a difference in anxiety, depression, quality of life and sense of well being, and can be applied to specific types of stressors, such as anxiety about treatment or upcoming scans. Further, the integration of eastern philosophies that are founded on concepts such as balance can also relieve stress. Some of these techniques include Tai Chi, acupuncture and QiGong. Rather than practicing these as influencing the development of cancer, view them as enhancers to your quality of life and reducing the stress associated with cancer. Also note that none of these approaches seek to stifle the expression of emotion and feelings, nor do they dictate an attitude that you need to have in order to successfully manage cancer. If by chance the professionals that you see seem to have this subtle bias, look for someone else who is committed to your overall quality of life.
Belief # 3: Seek positive outcomes or changes embedded within the cancer experience.
We have noted that cancer is a stressful event that often causes trauma. As a result, many people are forever altered by the experience. Despite the negative stressors, losses and changes experienced by both patients and family members, it is also an opportunity for personal change and growth. Many people report positive effects and researchers are beginning to document these effects. These benefits can come in the form of new perceptions about life or a new understanding of priorities and can lead to meaningful changes in the way that life is lived. It is common to hear patients report on how they have developed a greater appreciation for their lives and the people in them. For example, a quote from a patient on this topic: “I am at a better place now and I like myself more now than ever before. Everything good has become acutely better and more appreciated. Everything trivial is not paid attention to. The focus of my life is now on what’s good and important.”
I must reiterate that these reflections may be momentary and these positive experiences are rarely maintained on a daily basis through all of the struggles of cancer. Rather, one can hope to find moments of appreciation and reminders of growth. The preciousness is not sustained in the everyday mood, but rather in the choices one makes in behaviors. Look for meaning and ways to find these positive changes even if they seem small relative to the losses. Some of the experiences that others have noted include a deepening of a relationship, friends who stepped up to the plate, and the personal strength to tolerate tremendous stress. These searches, reflections and realizations can lead to feelings of self-esteem and self-worth, which have positive benefits to one’s psychological well being. Rabbi Ed Feinstein presented a lecture at Insights Into Cancer on May 11, 2004. It is not summarized in our newsletters because it is best heard in his own words. As a cancer survivor himself, and with his own reflections and spiritual wisdom, he offers hope and opportunities for new perspectives. His lecture can be found as streaming video on our website or borrowed on tape from our library.
Belief # 4: Do not assume control of things outside your control, nor accept the suggestions from others that you should.
Making good treatment plans with a well-informed team, including activities that help you feel better―physically and psychologically―are the most important decisions that you can make. When you have made them, stick with them and do not be pulled off course. Please allow yourself the freedom to develop friendly and firm ways to say “thanks for the information,” and know that you do not have to act on it. There are limits to our control and acknowledging that can be a great stress reducer. Failing to recognize our limitations can lead to a frenzy of worry, inappropriate responsibility and heightened stress. Instead, seek strategies that can help you accept and live with the knowledge that control is sometimes elusive. While there is much debate about the serenity prayer, who wrote it and what were the actual words, there are specific concepts that seem to appear in all of the versions, whether from pagan worshippers to holy priests, to those involved in 12-step programs. I offer these as reminders…the power to accept with ease and grace what I cannot change, energy and courage to change the things I can, the ability to know the difference and the strength to continue my path…
Needless to say, the Resource Center is here to assist patients and family members to live as fully as possible within the limits imposed by cancers and their treatments. Through many of our services, patients and family members are able to live more fully, find enjoyments, reduce stress, survive through treatments and improve their overall quality of life. We can teach you skills to reduce the stress of cancer and help you navigate your journey of individual choices and understandings. We recognize you as the whole person you are―mind, body, and spirit. We welcome you to the Center to find what you need and offer a place to help you hold the weight of this diagnosis and its treatment.
Anne Coscarelli, Ph.D.
Wallis Annenberg Director’s Initiative in Psychosocial Oncology
© Anne Coscarelli, Ph.D. All rights reserved.
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