Managing Stress

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A certain amount of stress is normal. However, a sustained stress response can be damaging. Sustained stress leads to inflammation, a known driver of cancer. Hence, it is important to manage stress.

Managing Stress

The Oxford English Dictionary defines stress as “a state of mental or emotional strain or tension resulting from adverse or demanding circumstances.”1 Those adverse or demanding circumstances, called “stressors”, can disrupt your internal balance and call on your body to activate a stress response. This response is automatic and calls on every bodily system to bring the body back into balance.

A certain amount of stress is normal—in fact, we couldn’t survive without the stress response. However, a sustained stress response can be damaging. "Chronic stress results in glucocorticoid receptor resistance (GCR) that, in turn, results in failure to down-regulate inflammatory response."2 Sustained stress leads to inflammation, a known driver of cancer.

Remember that stress is not only the challenging situation—it’s also your response to the situation. Even if you cannot change the stressors in your life, you may still be able to manage your response. On this page, we explore many tools that can help you manage your stress. However, seek outside or professional help if needed. Responses such as posttraumatic stress disorder (PTSD) may be beyond self-help.

Your Body’s Stress Response

The physical stress response is driven by a complex cascade of nerve activation and hormones:4

 

  1. First, the hypothalamus activates the sympathetic nervous system (the "fight or flight" response).
  2. The adrenal glands pump the hormone epinephrine—also known as adrenaline—into the bloodstream, causing these physiological changes and others:
    • Rapid heartbeat and breathing
    • Rise in blood pressure
    • Release of glucose and fats into the bloodstream
    • Release of cortisol to keep the sympathetic nervous system engaged
  3. When the stressor or threat lasts only a short time, the parasympathetic nervous system (the "rest and digest" function) calms the body and returns it to a pre-threat state.
  4. An extended “alert status” state can manifest as chest pain, heart palpitations, headaches, dysphagia (difficulty swallowing), intestinal cramping, anxiety, panic, immobility, frustration, muscle tension and inflammation.

 

The Stress Response and Cancer

How Stress Interacts with Cancer

When stressors and threats are frequent or constant, cortisol remains at high levels most of the time. When the stress response continues for a prolonged period, the constant bodily imbalance that it causes can be physically damaging. Over time, this delays restorative repair and pushes the body into pre-disease states.5 Stress hormones have been found to fuel cancer growth and spread in animals.6

Organs and tissues begin to function differently in response to the continual outpouring of stress hormones and chemicals. A prolonged stress response may compromise health and result in symptoms such as anxiety, depression and insomnia. The immune system is also affected—immune cells become preoccupied with triggering alarm reactions instead of doing their normal duties. With the body’s attention now focused on dealing with stressors, the job of finding and killing cancer cells is neglected.7

Eventually, if the chronic stress response goes unmitigated, a state of cortisol depletion and adrenal exhaustion ensues. This state may require a different medical approach than high cortisol levels do.8

Communicating Your Distress

Distress tools are available for both patients/caregivers and clinicians to use to assess your level of distress:

See our Communicate Your Distress page for more information.

In sum, constant stress is not compatible with healing and good health. Stress deteriorates health and resilience, and health outcomes can include mental illness, chronic disease and premature death.9 Stress can deliver a double whammy with cancer, both promoting cancer growth and diverting your body’s natural defenses against it.

If you think that stress is adversely affecting your current or future health, consider making managing stress a high priority in your integrative cancer care plan.

PTSD and Cancer12

In addition to the stress from dealing with cancer, for some people with cancer and/or their caregivers, the experience can be traumatic and/or bring up past unresolved traumas. For these people, long-term problems may develop or resurface, such as adjustment difficulties, anxiety or depression. In addition to normal stress reactions, traumatic stress-like reactions may be seen in some people with cancer or their caregivers such as these:

  • Intrusive upsetting thoughts
  • Reacting to reminders such as follow-up scans
  • Avoidance

The Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV, a clinician’s reference guide to diagnosis) expanded PTSD criteria to include diagnosis and treatment of a life-threatening illness as a stressor that could elicit PTSD. These criteria were further revised in the DSM-5.13 Some situations and factors may increase the risk for a traumatic reaction to cancer, such as prior trauma history, pre-existing psychiatric conditions or poor social support.

Psychiatrist David Servan-Schreiber, author of Anticancer: A New Way of Life, describes the impact of past traumas being reactivated by cancer:

“They may take over the individual’s entire mental and physical functioning . . . Inwardly, the emotional wound also affects deep vital processes. Just as a lesion on the skin activates repair mechanisms, a psychological wound sets off mechanisms of the stress response: release of cortisol, adrenaline, and inflammatory factors, as well as a slowdown in the immune system . . . these physiological stress mechanisms can contribute to the growth and spread of cancer . . . unhealed traumas lead the person back to a false sense of helplessness . . . it is not a true reflection of the present. Allowing a person to realize this illusion is the key to therapy.”14

A 2017 study in Malaysia found that more than one in five cancer patients reported symptoms of PTSD in clinical evaluations six months after diagnosis. After four years, about six percent of patients had PTSD.15

BCCT and many others in the field recommend that a cancer team conduct a careful psychosocial assessment for all their patients with cancer (and their caregivers) including precancer diagnosis trauma and psychiatric history, plus concurrent conditions such as adjustment disorder. Either overlooking or incorrectly labeling a patient as having PTSD can be detrimental to their wellness and response to therapy. The care team should then routinely assess their patients for distress and refer them for help, if needed.

If you, as a person with cancer or a caregiver of a person with cancer, know that you have a risk factor for PTSD, and/or are experiencing distress or symptoms of PTSD, consider notifying your cancer care team as soon as possible.

Managing PTSD in People with Cancer

“PTSD should be approached with caution and be informed by existing evidence-based approaches for traumatic stress.”16 Certain proven psychotherapy techniques for PTSD also seem to be useful in cancer-related PTSD. Systematic reviews have found that the following techniques are helpful for one or some of the symptoms of PTSD:17

  • Cognitive Behavioral Therapy
  • Eye movement desensitisation and reprocessing (EMDR)
  • Supportive Expressive Therapy (SET), which promotes peer social support and expression of emotions and existential concerns and focuses on facing and grieving losses
  • Cognitive behavioral stress management
  • Couples based coping intervention
  • Mindfulness-based approaches
  • Promising approaches requiring further study:
    • Narrative therapy
    • Dyadic disclosure-promoting interventions

The authors of one review advise caution in using PTSD medications for people with cancer-related PTSD, as very little research has been done in this area. However, beta blockers may reduce intrusive ideation (a thought pattern used as a coping strategy) in newly diagnosed cancer patients. The authors discuss medications that might be used for cancer-related anxiety and sleep disruption, as well as the indications for using psychoactive medications and psychotherapy.18

The late Dr. David Servan-Schreiber describes how he helped cancer patients heal the helplessness associated with trauma. He asked them to list the ten most painful events of their lives. These events, he viewed as “screws fastening down a large metal plate crushing their desire to live.” He helped people to “unscrew” these events one by one and found that patients were often awakened to a very different way of living. “Once relieved of the weight they had been carrying around, they were able to look at everything differently. Although relieving patients of the pain of trauma is not a treatment for cancer, it often enables natural defenses to recover their strength, which can aid in the fight against the disease.”19

Integrative Approaches for Managing Stress

Research shows that quality of life is improved with use of stress management interventions. "A recent review found that after a breast cancer diagnosis, a formal mindfulness practice was associated with improvements in mood, anxiety, and physical symptoms."20

Guidelines from the American Society of Clinical Oncology21 and the Society for Integrative Oncology22 support these practices for managing stress:

Natural Substances for Managing Stress

According to naturopathic oncologist Lise Alschuler, evidence shows several herbs and nutrients have antistress properties. These substances seem to work by either helping the body recover from stressful situations or supporting the body’s organs and tissues that are affected in the stress response:23

Integrative oncologist Keith Block, MD, also includes natural substances in his integrative plan for balancing stress hormones and creating healthier biorhythms. Block distinguishes among three patterns of stress adaptation:

  1. Hyperadapted or high-stress pattern with prolonged elevated cortisol
  2. Inverted stress pattern, in which the timing of cortisol and melatonin are reversed.
  3. Non-adapted pattern, in which cortisol levels are either consistently high or depleted, melatonin levels are low, and both hormones have no circadian rhythm

Block’s approach with natural supplements varies with the pattern.24 This plan includes natural substances such as these:25

Products for Calming or Reducing Stress

 

A combined stress hormone support supplement in addition to a program of taking a cancer-specific multivitamin and fish oil supplements and also eating what Block calls the “healthy dozen food families” listed at right.

Details of specific uses, dosing and cautions are available in books by Alschuler Gazella and by Block (see below).

Some natural products can impact anxiety and stress levels. A 2017 review found that essential fatty acids (linoleic acid and alpha-linolenic acid) reduced perceived stress and salivary cortisol levels, with effects dependent on hormone status and whether depression was also evident. Vitamin B6, sometimes combined with magnesium, reduced anxiety in some women for conditions other than cancer. High-dose sustained-release vitamin C reduced anxiety and blood pressure in response to stress.26

 

Mind-Body Approaches

Many mind-body approaches, such as meditation, progressive muscle relaxation, tai chi and music therapy help with regulating breathing and heart rate, bringing on a calm state. These are discussed in more detail on these pages:

Breathing is one of the simplest, most basic and yet powerful tools to manage a state of stress. Adjusting your breathing can be done anywhere and at any time. Deep diaphragmatic breathing—belly or abdominal breathing in which the belly, rather than the chest, expands when inhaling—resets the autonomic nervous system and has the following effects:27

  • Decrease oxygen consumption, heart and breath rate
  • Increase theta wave state and parasympathetic activity
  • Generally feeling alert and invigorated

Usually, deep abdominal breathing will begin to induce a calm state rather quickly. Regular practice several times a day can be an effective tool in managing your stress response.

Dr. David Servan-Schreiber describes practices involving reciting mantras, such as saying the rosary or other mantra-based meditations. These practices have the capacity to affect the body rhythms—breathing, heart rate, blood pressure and blood flow to the brain. While reciting the mantra, the person's breathing automatically harmonizes or becomes coherent with the rhythms of other automatic physiological functions. This state is called “resonance” or “coherence” and increases variations in biological rhythms. The resonant or coherent state provides these benefits:

  • Better immune system function
  • Reduced inflammation
  • Better regulation of blood sugar

“These are, precisely, three of the principal factors that act against the development of cancer.”28

Examples of simple mantra meditation instructions:

More information about meditation and other relaxation approaches is available on our Mind-Body Approaches summary.

Manipulative and Body-Based Methods

Some studies have found that massage may help to alleviate stress in cancer patients.

Eating Well to Reduce Stress

Foods can support or undermine a healthy stress response and biorhythms.

Eating Well: Strategies

Dietary strategies for supporting a healthy stress response and biorhythms:

  • Limit foods or the timing of eating that may interfere with sleep:
    • Reduce use of caffeine and other stimulants.
    • Avoid excessive alcohol consumption: alcohol as a nightcap or to relax can instead disrupt melatonin production as well as cause repeated awakening from sleep.32
    • Night eating syndrome (consuming a large part of the total daily caloric intake in the evening and nighttime hours and a reducing caloric intake in the morning) is linked to sleep disturbance.33
  • Include complex carbohydrates in your diet: whole grains, beans, and whole fruits and vegetables.
  • Work with your doctor or dietitian/nutritionist to improve your ratio of omega-6 to omega-3 fatty acids.

See Eating Well.

Pharmaceuticals for Managing Stress

A good integrative cancer care plan will include mind-body therapies, eating well, moving more, and possibly natural products to manage stress. Sometimes, however, these therapies may not be enough. If natural treatments alone are inadequate, then even more symptoms of stress can arise, causing needless emotional suffering.

As Dr. Keith Block points out, patients commonly resist medical treatments for stress or depression, fearing treatments indicate they are psychologically unstable. However, because managing stress is key to many aspects of wellness, consider working with your physician to see if medications—such as antidepressants, tranquilizers and even stimulants—can help you.

Evidence suggests that propranolol, a prescription drug for heart disease, may have anticancer effects, possibly in part due to its effects on stress hormones which can fuel cancer growth and spread.34

For more information about the effects of propranolol and other beta-blockers on the stress response, see Propranolol.

Sleep and Managing Stress

Getting good sleep and rest is a key practice in creating a body that doesn’t encourage cancer. Poor sleep and stress can become a self-reinforcing cycle: unmanaged stress can disrupt biorhythms, including sleep. Stress hormones interact interact with sleep, with some contributing  to nighttime wakefulness and others causing daytime sleepiness  and fatigue.35

When sleep quality is poor, the stress response hormone cortisol rises at night when it should instead be lower. Because a chronic rise in blood cortisol can speed tumor growth and cause any number of increased health problems for people with cancer, consistently good sleep and rest are tools to combat stress. Effectively managing stress will improve the quality of sleep.

See Sleeping Well.

Social Support

Mediating the stress response with social support is an important part of an integrative cancer care plan. “The effect of social support on life expectancy appears to be as strong as the effects of obesity, cigarette smoking, hypertension, or level of physical activity.”38

Both in the lab and in community settings, positive social support seems to enhance resilience to stress. It may also protect against psychological problems related to trauma and reduce the functional problems related to posttraumatic stress disorder (PTSD).39

Studies have looked at the impact on women with breast cancer who faced the disease with positive coping mechanisms and women with ovarian cancer who felt loved and supported and who kept up their morale. These women had much more active natural killer cells than those who felt helpless, depressed, alone and/or emotionally distraught.40

If you or someone you love is living with cancer, tapping into love and support may help in managing stress and countering the ill effects of stressful circumstances.

See Sharing Love and Support.

Stress Offenders

Medical acupuncturist Janet Spitzer, MD, and Keith Block, MD, inform us about foods and natural substances that can promote a stress response.41

Foods and Natural Products

Anything that is a stimulant increases heart rate, anxiety and the stress response:

  • Caffeine in coffee, tea or chocolate
  • Ephedra
  • Other stimulants, including ginseng and bitter orange
  • Alcohol
  • Spicy foods

 In addition, some eating patterns can promote stress:42

  • Low-carb, high-fat diet
  • Low-carb, high-protein diet
  • High ratio of omega-6s to omega 3s

Eating Habits That Are Stress Offenders

Dr. Keith Block lists eating habits that can promote a stress response:43

  • Timing of snacks and drinks (eating within one hour of bedtime; eating a heavy evening meal or snack)
  • Overeating

Reducing stress offenders is an important step in managing stress.

Cautions

Several of the therapies mentioned on this page come with cautions about interactions with other therapies or with medical conditions. For example, ashwagandha may increase testosterone, so use is not recommended by people with prostate cancer. Use is also contraindicated in patients with hemochromatosis.44 Please review cautions listed on therapy summaries or outside linked pages and consult your integrative physician before use.

Integrative Programs, Protocols and Medical Systems

References

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Credits

This article has been taken from Beyond Conventional Cancer Therapies.

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