We will often see patients who, having completed their first battle with breast cancer and having been pronounced “cancer free,” will tell us that their greatest concern is recurrence. This concern of recurrence will of course present a lot of stress on the cancer survivor. Our cancer patients know that stress can and needs to be managed to help prevent disease recurrence, progression, and to help build a stronger immune system. We will start this article with a brief description of stress management techniques that some may find successful and then we will explore research which demonstrates the importance of stress management in breast cancer survivors.
Psychological Aspects to Consider in Breast Cancer Diagnosis and Treatment
A research paper from March 2021 (1) outlined in its title the: “Psychological Aspects to Consider in Breast Cancer Diagnosis and Treatment.” The paper was published in the journal Current oncology reports. The learning points of this paper are highlighted:
“Anxiety is one of the most common psychological symptoms in breast cancer patients, with rates ranging from 10 to 30%.”
“The patient can experience anxiety symptoms because of the anticipation of negative outcomes, and the uncertainty about the future; anxiety can spring from the concern over recurrence and the worry of treatment side effects both during and after treatments. Recent findings suggest that anxiety is even more prevalent than depression, in contrast what has been presented in the past.”
Distress is a broad construct, covering a wide continuum of emotions related to symptoms of depression, anxiety, and adjustment disorder. Even though prognostic prospects are relatively good, a breast cancer diagnosis is threatening and confronts women with numerous additional stressors, such as treatment and its side effects. breast cancer patients’ distress levels may rise at different stages throughout the disease trajectory. For example, some patients experience clinical distress at the time of diagnosis, yet during the active phases of treatment . . . breast cancer patients report higher distress expressing concerns about fatigue, family and friends, weight, fears, worries, and pain.
From an oncological point of view, having a mastectomy, chemotherapy or radiation, and chemotherapy compared to radiation therapy alone, were strong clinical predictors of durable distress.”
Cognitive-behavioral changes and techniques
In the research, we will discuss below, we will see phrases such as, “cognitive function.” The term cognitive simple means “how we think.” In stress management, we or the patient seeks to change how the thought process works, from creating stress and anxiety to creating relaxation. We know, easier said than done, but it is achievable.
Cognitive-behavioral stress management is a broad umbrella term that encompasses the following general relaxation – stress management techniques:
Deep or relaxing breathing
Deep breathing is a well researched and documented method of stress management. It can also help you make better behavioral decisions. A May 2019 study (2) examined the effects of two breathing patterns on Heart Rate Variable and on stress and decision-making performance.
Heart rate variable is not heart rate. Think of it as the opposite. Heart rate variable is the variation in time, measured in milliseconds, between you heart beats. Heart rate variables change in response to stress. Increasing heart rate variable is a good thing, decreasing heart rate variable is a bad thing. Increasing heart rate variable is seen as a major factor in stress management as scientists have shown that increasing heart rate variable helps you recover from stress and physical and emotional exertion. It can help you make better behavioral decisions.
In the current research, the investigators were able to show just that, how effective breathing patterns reliably increase heart rate variable and improved decision-making. Deep breathing is important in physically altering stress by way of the heart rate variable.
One of the breathing techniques that these researchers examined was exhalation longer than inhalation. Breathing out longer than breathing in.
Some of you may recognize this as the 4–7–8 breathing technique.
You breathe in slowly for 4 seconds, you hold that breathe for 7 seconds, you slowly exhale for 8 seconds. You would repeat this relaxing cycle.
This can be a very effective stress management technique for many.
Muscle tension and relaxation
Muscle tension and relaxation techniques are sometimes used to manage cancer pain more naturally. They have also been shown to be effective in reducing stress and anxiety. You can start at your head, clenching the muscles of your face for a few seconds, then gently unclenching them. Breathing is important. You breathe in during the clench, you exhale in the relax phase. Then you would go down your body, to you neck, your shoulders, arms, forearms and hands, then to the upper back, etc. Giving yourself a few seconds between each muscle group and practicing good breathing techniques.
A study published in the International journal of clinical and experimental medicine (3) suggested: “Relaxation training during chemotherapy can reduce anxiety and other adverse events in postoperative breast cancer patients. This should be considered a valuable complementary approach in improving patient care.”
In this next section we will look at more research to help you understand why it is important to follow through on these techniques.
Stress may increase risk for breast cancer recurrence and mortality.
Recently, doctors at the University of Miami published their research on the significance of stress management for breast cancer patients.(4)
Stress among postsurgical breast cancer patients can affect biological processes that regulate the endocrine and immune systems and these influences can have long-term effects on disease outcomes.
Chronically elevated cortisol (stress hormone) suppress the naturally occurring anti-inflammatories in the body (glucocorticoid receptors), as a result pro-inflammatory signals are released into the blood by small proteins – cytokines.
Cytokines and their inflammatory messages can congregate near tumor cells.
These cytokines may contribute to disease progression by promoting metastasis.
Therefore stress-associated neuroendocrine changes may contribute to disease course in post-surgical breast cancer patients and increase risk for breast cancer recurrence and mortality.
“statistically significant results”
In March 2019, in the medical journal Supportive Cancer Care (5), researchers evaluated the effectiveness of mindfulness-based stress reduction in breast cancer patients. They did this by reviewing previously published research and making an accumulation of those findings. They looked at 14 research studies, documenting 1505 women with breast cancer.
These researchers found: “statistically significant results” for: physiological function, cognitive function,fatigue, emotional wellbeing, anxiety, depression, stress, distress. and mindfulness. Although the effects on pain, sleep quality, and global Quality of Life were in the expected (positive direction) direction, they were not statistically significant based on insufficient evidence. . . mindfulness-based stress reduction is worthy of being recommended to breast cancer patients as a complementary treatment or adjunctive therapy.”
The positive aspects of stress management in breast cancer patients
Earlier research explored the positive aspects of stress management in breast cancer patients shedding another view on how stress management may prevent recurrence of breast cancer.(6)
The researchers noted that after treatment completion, breast cancer survivors frequently experience residual symptoms of pain, fatigue, high levels of psychological stress, anxiety, depression, fear of recurrence, and metastasis.
“Post-treatment stress, in particular, can adversely affect health-related quality of life, which, in turn, induces onset or recurrence of chronic diseases. Effective interventions that target these psychological symptoms and their physiological consequences are needed”
One of the worst periods of stress, the researchers wrote, was when women completed main treatments (such as chemotherapy and radiotherapy) and they progress to and have to face the stage of “watchful waiting”, a stressful period when the physician seems to be “doing nothing”.
Therefore, survivors continue to report remaining physical symptoms of pain, fatigue, and sleep dysfunction, high levels of psychological stress, anxiety, depression, fear of recurrence and metastasis, and impaired quality of life. This the researchers report may even contribute to the recurrence or progression of the disease.
Women given the opportunity to learn stress management techniques during treatment may benefit well into survivorship.
In agreement with the research presented is a recent study shows that providing women with skills to manage stress early in their breast cancer treatment can improve their mood and quality of life many years later. Published online in CANCER, a peer-reviewed journal of the American Cancer Society, the findings suggest that women given the opportunity to learn stress management techniques during treatment may benefit well into survivorship.
In this study patients who learned relaxation techniques and new coping skills in a supportive group over 10 weeks experienced improved quality of life and less depressive symptoms during the first year of treatment.
In their latest report, the researchers found that the women who received the stress management intervention had persistently less depressive symptoms and better quality of life up to 15 years later.
1 Dinapoli L, Colloca G, Di Capua B, Valentini V. Psychological Aspects to Consider in Breast Cancer Diagnosis and Treatment. Current Oncology Reports. 2021 Mar;23(3):1-7.
2 De Couck M, Caers R, Musch L, Fliegauf J, Giangreco A, Gidron Y. How breathing can help you make better decisions: Two studies on the effects of breathing patterns on heart rate variability and decision-making in business cases. International Journal of Psychophysiology. 2019 May 1;139:1-9.
3 Song QH, Xu RM, Zhang QH, Ma M, Zhao XP. Relaxation training during chemotherapy for breast cancer improves mental health and lessens adverse events. International journal of clinical and experimental medicine. 2013;6(10):979.
4 Amiel CR, Fisher HM, Carver CS, Antoni MH. The importance of stress management among postresection breast cancer patients. Future Oncol. 2016 Dec;12(24):2771-2774. Epub 2016 Oct 19.
5 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. Supportive Care in Cancer. 2019 Mar 1;27(3):771-81.
6 Huang J, Shi L. The effectiveness of mindfulness-based stress reduction (MBSR) for survivors of breast cancer: study protocol for a randomized controlled trial. Trials. 2016;17:209. doi:10.1186/s13063-016-1335-z. 51316