Some cancer survivors have long, complex relationships with anxiety, depression, irritability and other psycho-emotional symptoms. Other patients report having pretty sturdy emotional lives, guided by a positive outlook and filled with examples of emotional agility and resilience.
There are so many causes for anxiety and depression related to having cancer and also completing care, including:
Inflammation: Conventional treatments like surgery, chemo & radiation, create biological mechanisms that lead to inflammation, which in turn through a number of biochemical pathways, may lead to depression symptoms.
With ongoing chronic stress, the sympathetic nervous system is stimulated and the parasympathetic nervous system is inhibited. The hypothalmus, pituitary, adrenal gland axis is activated which for many leads to long lasting depression and anxiety. It’s also important to note that some chemotherapeutic agents have depression as known side effect. Research points to the fact that depression impacts quality of life, increases physical symptoms and negatively impacts families. Depression in cancer patients lengthens hospital stays, dollars spent and risk of suicide.
A cancer diagnosis and certainly experiencing cancer care impacts the emotional realm for most every cancer patient. Even when treatment is completed concerns remain, for many, shifting to what if if comes back? Or is this how I have to live now? How will I deal with the rest of life? The more this idea is studied, the more we learn that an upbeat outlook and the capacity to use skills that help keep anxiety and depression at bay, matter. We now understand that mood impacts immune function which impacts disease progression and mortality. Research underscores the concept that depression & anxiety have a negative effect on quality of life of course, but also on actual survival.
There are pharmceuticals offered to patients suffering emotionally. One meta-analysis found no advantage among drugs given. Some SSRIs can worsen nausea & vomiting during the treatment time. And SSRIs have been shown to decrease the time to disease progression in ovarian cancer patients. Knowing these facts gives me pause when patients ask if I think they might consider drugs to treat emotional problems. I will lean into the non-pharmacuetical and naturopathic approaches, described below, before considering referral for medication.
So, what do I mean by the head game? It’s the capacity to handle a diagnosis and treatment and stress that piles on once treatment is completed and not get stuck in any one emotion such as anxiety, fear, depression, overwhelm, terror, anger. All those emotions are normal, part of life. Big time emotions are a common aspect of going through cancer treatment and afterwards, while also worrying about, in no particular order — your health, your livelihood, your relationships, your family, your very mortality! What are tools and skills and attitudes that help patients raise the threshold for feeling stress and help dissipate the stress they have?
For those who feel powerless and overwhelmed, I work with patients to create an island of personal power and space and ownership. When I making naturopathic recommendations related to overall care, when I have two ways to accomplish the same goals, I present patients with choices. As after-care begins, I continue to suggest bringing your own healthy food or snacks to hospitals or clinics when possible, declining hospital gowns when not essential, telling medical assistants you’ll meet the doctor fully dressed, little things like that, taking back some slivers of self-agency and power. Of course, I encourage every patient to bring a friend or family member to doctor visits to take notes, act as an ally and to offer general support.
And during follow-up visits, I tell patients, if you hear something, say something! Doctors need feedback too, and cancer survivors often feel somewhere between utter thankfulness for being alive, to paralyzing fear of recurrence and can forget their own voices. Be THAT patient everyone loves, remember names of staff, nurses, phlebotomists, administrative staff, bring small gifts, lean in if you can. Write thank you notes, be specific!
I also like to give patients permission and tools to halt unwanted comments, stories and advice by using strong words! “OH let me stop you there! I am not taking any advice but thanks so much for your concern.” Or one hand up, “NO cancer stories — I MEAN IT!” Or a pre-composed email ready to send: “I am confident with the team I have put together and the plan we have created but thanks for your concern and thoughts! Sincerely, xxx”). I will do roll playing in the office with patients so they get the hang of of it.
I like to help patients emphasize the idea that with their conventional care team and hopefully input from a licensed naturopathic doctor, we will create the best possible plan going forward. Then we’re going to grab onto the plan and commit to it. I borrow an expression from the world of scubadiving: We’re going to plan the dive & dive the plan and not second guess our decisions. We may need to modify approaches, but we are going to be confident in our plan, no regrets.
I almost do not care what kinds of skills or tools or practices a patient has to help with the head game. I just want to be sure to bring this up, to allow time during our office visit to talk about the feelings and to make space for this part of healing, too.
Here are some of the tools I recommend, teach and practice with patients or I refer to colleagues whose approaches I admire. No one is going to do all these things and naturally, there are many other avenues toward peace and healing; surely there is something for everyone. Here are some of my go-to practices, skills, past times that I encourage patients to consider:
Exercise, support groups, in person &/or online, gratitude practice, prayer, mantras, guided imagery/visualizations, mindfulness meditation, breathing techniques, exercises, yoga, tai chi/qigong, hobbies, making music, family & social support, humor, improvisation, talk therapy, tapping, EMDR, Somatic Experience, Massage, Reiki, Therapeutic Touch & the ongoing potential for the role of work. In 2018, The Society for Integrative Oncology (SIO) produced an evidence-based set of guidelines reflecting research on such approaches for breast cancer patients. Those guidelines were adopted by the American Society of Clinical Oncology (ASCO) membership. I remember to take time to understand my patient’s history with any of these or other approaches, to understand their openess to or energy for bringing in some new ideas. It’s good to practice ANYTHING in this vein, so that when you need it, the skill is there to dip into.
And let’s not forget escapism and things that just feel good. It doesn’t all have to be work or new or intentionally bettering oneself. Besides fatigue from biological causes it can be exhausting trying to do everything right! So let’s add to the list things like: movies/TV shows, podcasts, reading, a change of scenery, listening to music, socializing, snuggling and intimacy.
If a patient persists with depression or anxiety or irritability, I also employ specific naturopathic approaches related to diet and nutrition and botanical medicine prescribed individually for the way my patient experiences their emotional symptoms. Read here about how licensed naturopathic doctors address anxiety.
It’s important that cancer, wherever it is or was is addressed and that we tend to symptoms that may have arisen during the course of treatment, but I also want to put my patient’s heart and spirit front row & center and to remember that we are all more than the sum of our parts, that feelings matter and that an upbeat attitude and some degree of equanimity helps with quality of life and also with long term survivorship.
Additional pieces in this series:
- *You Finished Treatment, Now What? Part One: Exercise
- *You Finished Treatment, Now What? Part Two: Nutrition and Eating
- *You Finished Treatment, Now What? Part Three: Intermittent Fasting
- *You Finished Treatment, Now What? Part Four: The Head Game
- *You Finished Treatment, Now What? Part Five: Botanical Medicine
- *You Finished Treatment, Now What? Part Six: Off Label Use of Pharmaceuticals
- *You Finished Treatment, Now What? Part Seven: Nutritional Supplements