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.