Hello.

I'm Dr. Barbara Andersen, professor of

psychology at Ohio State University
and a member of
the Cancer Control Program at
the Ohio State University Comprehensive
Cancer Center, James Cancer Hospital, and
Solove Research Institute.
Previous videos in this module
presented the various methods and
technologies used to diagnose cancer.
I am now going to tell you about
some of the behavioral effects,
including stress and emotional distress,
changes in behaviors, and
immune responses that may come
along with a cancer diagnosis.
In the United States, at least one
in four cancer patients experience
stress at a clinical level and clinical
levels of anxiety after their diagnosis.
If it's left untreated, this stress
can lead to poor mental health,
quality of life, and
even additional physical symptoms.
Research that I and
others have done over the last decade,
however, shows that psychological
interventions can help patients cope
with the stress of cancer and
improve their quality of life.
So in this video,
I'll cover three major areas.
A patient's reaction to a cancer
diagnosis, and the model that we've used
to capture this complicated phenomenon,
ways to help patients cope with
the stress of diagnosis and treatment,
and how healthcare professionals
can provide psychosocial care to
the newly diagnosed cancer patient.
So being diagnosed with
cancer can be life changing.
For many it's a frightening and
stressful experience.
The challenges may begin with
the words you have cancer.
Others can come during treatment, and
still others may arise as time passes.
We now know that stress influences
our mind, our body, and our behavior.
For example, stress can worsen physical
symptoms such as pain or fatigue.
Psychological changes can
include feelings of tension or
anxiety, more worries,
or having a sad mood.
Behavioral changes can include eating
an unhealthy diet, failing to exercise,

or having low motivation for

one's daily activities.
There's also evidence, though,
that stress levels can weaken
immune responses and
influence treatment outcomes.
Here's an example of how stress might
lower immune responses in cancer patients,
which can effect the immune system's
ability to fight the cancer.
The data shown in this scatter plat
suggests that a negative relationship
exists between patients' stress levels and
the death or
lysis of cancer fighting immune cells
called natural killer cells or NK cells.
On the x-axis,
you can see the level of cancer stress
going from low to high,
with higher numbers meaning more stress.
The y-axis shows the level
of NK cell killing,
or lysis,
where high numbers mean more killing.
So we obtained this data
by using blood samples
obtained from breast cancer patients.
They had been diagnosed,
had their surgery, and
were awaiting the start of chemotherapy.
The data show that for
these patients with higher stress,
their natural killer cell killing was low.
Conversely, those individuals with low
stress had higher levels of NK cell lysis.
This was a very robust relationship, and
we observed this same effect with other
NK assays and with T-cell assays.
So, experiencing a cancer diagnosis and
undergoing treatment can produce
a cascade of negative effects.
This is common for many, but
certain individuals are at higher risk for
continuing persistent stress.
They include the unemployed or
those having limited financial
resources, the poor,
people with limited education,
people who are alone, people with
a psychiatric history of anxiety or
depression for example, and
people with advanced or recurrent cancer.
Fortunately, there are ways to
help patients reduce stress and
improve their quality of
life after diagnosis.
I'll describe three
common coping strategies,
all ones with empirical support
not only for cancer patients and

patients with other kinds of illnesses,

but they're strategies we could all use.
They are relaxation,
social support, and exercise.
So, how does a person
who's stressed just relax?
[LAUGH] We recommend a particular
way to help your body relax,
and that's called progressive muscle
relaxation, or PMR for short.
PMR is regularly used in the treatment
of anxiety disorders, but
it is an effective complimentary
treatment for many physical disorders.
Cancer patients have used it to control
nausea, vomiting, reduce pain and
other symptoms.
The aim of relaxation is to
lower your body's tension, and
lower the wear and tear of stress.
When your body's physically relaxed, it
becomes easier to control your thoughts,
change your emotions, and reduce symptoms
of stress, such as difficulty sleeping.
And the physiologic effects
of relaxation are clear.
It decreases heart rate, and
blood pressure, and breathing rate.
It lowers muscle tension.
It alters mood, and improves your ability
to concentrate on what's important.
And subjectively, one feels calmer and
relaxed, as if you've had a brief nap.
For those interested in trying PMR,
you can listen to an audio
track online at our website.
Another aid in coping well is coping
with the aid of social support.
Close relationships ease stress by
providing guidance, advice, and support.
Support from friends, family, and
other persons can convey feelings and
thoughts that we're valued and cared for.
It provides a sense of satisfaction
with life and an all-round,
better physical and mental health.
With something as significant
as a cancer diagnosis,
social support can be a tremendous
resource for breaking through the stress.
Without support,
stress can linger and worsen, so
during this time of need, patients
need help from family and friends.
The help can come in the form
of helping with tasks,
such as transportation to an appointment,
caring for one's children while away,
or taking care of the heavy
work around the home.

Social support can also be emotional.

Someone to talk to, someone to help
you problem solve a difficulty, or
simply having someone to sit with you or
give you a hug.
Not everyone has a close friend or
family member, however.
Even so, it's important to not be
alone when going through cancer.
During difficult times, patients can
be encouraged to seek out new support
relationships or
bring more distant ones closer in.
Counseling with a mental health
professional, or the clergy, or
a specialized support group for
cancer patients can also help.
Despite the commonality of cancer,
social support can be difficult for
people in communities where there's
a stigma to being diagnosed with cancer.
Stigma can prevent early detection,
delay individuals in seeking a diagnosis,
and prevent patients from asking for
support, or those individuals who
otherwise might offer support don't.
If that's the case in your community,
think about ways you might cross
the stigma barriers and reach out to help.
A third stress reliever
is perhaps the easiest.
That is physical activity.
Just get out of the chair and move.
Receiving and recovering from
cancer treatment can take months.
It can take a toll on patients' diet and
activity patterns.
Curbing these effects is critical
to help patients recover and
to improve their quality of life.
Many people might have had a regular
routine of exercise, walking,
riding a bike, running,
before their cancer diagnosis.
With the doctor's permission,
we encourage many people,
even those patients in treatment,
to maintain some level of activity,
even if for only 15 minutes a day.
Research has found that regular
physical activity lowers stress,
improves mood and cognition, along with
having great cardiovascular benefits.
In fact, we can think of
cancer as a teachable moment,
an opportunity to encourage patients
to make healthy lifestyle choices.
So let's summarize.
It's important to identify and address
the stresses of the cancer diagnosis.

The psychological, behavioral, and

biologic effects of stress can linger and
worsen symptoms and lengthen recovery.
Patients, though,
can be helped to reduce stress
by using strategies such as
those I talked about here.
Progressive muscle relaxation,
social support, and
encouraging physical activity and
healthy eating.
Now I'll turn to what health
care professionals can do
to help meet the psychological
needs of the newly diagnosed.
First, be aware of the current national
and international guidelines for
the screening and treatment of mental
health concerns among cancer patients.
The guidelines published by the American
Society for Clinical Oncology, for
example, recommend evaluating
all cancer patients
at the time of their diagnosis and
periodically thereafter.
An easy way to screen patients for
symptoms of depression is to
use the Patient Healthcare Questionnaire,
or the PHQ-9.
For symptoms of anxiety,
use the Generalized Anxiety Disorder
Questionnaire, or the GAD-7.
Both are shown here.
What's great about these measures, is
they're very widely used in primary care
and they've been translated
to over 75 languages,
probably more tomorrow,
including Chinese, Spanish, French,
German, Italian, Russian, Portuguese,
and Arabic, to mention just a few.
Patients with no or
mild symptoms can be refered
to readily available resources
at their institution or
in the community, such as those that
might be provided at your hospital.
Those with moderate symptoms
are recommended for low intensity
interventions, such as group-based
treatments, such as cognitive behavioral
therapy, bio-behavioral interventions, or
structured physical activity programs.
Those with moderate to severe or
severe symptoms are recommended for
more intense therapies,
usually delivered individually or
face to face therapies such as
cognitive behavior therapy.
Guidelines have also been

developed by organizations such as

the Breast Health Global Initiative
to assist
healthcare professionals in low and
middle income countries, and
in regions with limited resources
to provide supportive care.
Their recommendations have four tiers,
starting at a basic level
of resource allocation and
incrementally adding services as resources
become available in the country.
At the basic level, these recommendations
include educating health professionals
about the psychosocial considerations like
the ones we are talking about here today.
Community education is also important for
reducing stigma and burden.
Then, educating patients about treatment
related toxicities and side effects,
such as fatigue, problems with cognition,
infertility, sexuality and others.
And lastly, educating patients and
families about the topics such as those
presented here, stress, relaxation,
social support, and offering peer
support by trained volunteers.
In the United States, national groups,
such as the American College of Surgeons
Commission on Cancer, have mandated
that by 2016 all cancer clinics must
provide psycho-social screening and
services to cancer patients and
also document the efficacy of doing so.
Here at Ohio State, we're participating in
an effort to provide the best empirically
supported treatment to patients in
this country and around the world.
So, how can we do that?
Well, we train mental health
professionals to provide those services.
Several times a year we conduct From
Cancer to Health training institutes for
mental health professionals
in the delivery
of evidence based
bio-behavioral interventions.
They were developed here.
The intervention that we use is based on
the conceptual model that incorporates
psychological, social, behavioral,
and biologic effects of stress.
The intervention uses cognitive and
behavioral techniques to
reverse the negative emotional,
behavioral, and physical responses to
cancer that we've just talked about.
The key components we teach professionals
are how to conceptualize and
use stress reduction strategies,

assertive communication and

problem-solving, how to help patients
garner social support from their friends
and family, health behavior change
focused on eating a healthy diet,
engaging in physical activity, and
reducing negative health behaviors,
such as smoking, or heavy alcohol abuse.
And very importantly, strategies to help
patients maintain their positive changes.
So the key to providing effective
psycho-social support to patients is to
use evidence based methods.
This is the central tenet of
modern health care delivery.
If you are a mental health professional
who works with cancer patients and
would like to learn more about our
intervention or our training institutes,
please visit our website or
follow us on Twitter.
Thanks so much.