Laurie M. Fisher

When Tracy Maxwell finished treatment for stage 2C ovarian cancer in 2006, she thought her stress level had subsided. Then she had two auto accidents in a month. “I had one fender bender the day I got my driver’s license at 16, and then never had an accident until I finished treatment,” says the 39-year-old Denver resident. “I think it was a wake-up call.”

Dealing with post-treatment stress means recognizing the potentially complex relationship between physical and psychological stress, understanding how it might affect your immune system, and, ultimately, your health, while absorbing the new information that stress can impact cancer survival. 

According to the National Cancer Institute, psychological stress combines an individual’s emotional and physiological reactions when confronting a situation where the demands may exceed the person’s ability to cope. Simply put, the body is constantly bombarded by “stressors” of its external environment. It responds by releasing stress hormones, such as epinephrine (adrenaline) and cortisol (hydrocortisone) to help the body react to the stressful situation with speed and strength, while at the same time increasing blood pressure, heart rate, and blood sugar levels.

While small amounts of stress are seen as beneficial, studies indicate that chronic high levels of stress could be harmful and increase the risk of obesity, heart disease, and depression, among other illnesses. Stress beyond an individual’s ability to cope may also lead to unhealthy coping behaviors, some of which may affect cancer risk, such as overeating, smoking, or abusing drugs or alcohol. And newer studies indicate stress creates a cascade effect that promotes an inflammatory response in the body, which leads to a friendly environment for cancer. 

Michael Burke, MD, clinical director of psychiatric oncology at the Emory Winship Cancer Institute in Atlanta, explains how stress builds, beginning with the initial alarm stage, in which the body responds with stress hormones for a fight-or-flight response. Alarm is followed by a resistance phase, when the body attempts to cope with the demands of an ongoing stressor. Finally there is an exhaustion phase, when the body has been unable to adapt to the stressor. 

Burke explains that it is during the exhaustion phase that negative biological and psychological effects occur—such as Maxwell’s two car accidents, the &shy;inability to get along with family and friends, or unhealthy coping behaviors, such as overeating or drinking heavily.

According to the National Cancer Institute, studies conducted over the past 30 years examining the relationship between psychological factors, including stress, and the risk of developing cancer have produced conflicting results, with no direct cause-and-effect relationship  proven. Still, some studies have indicated an indirect relationship between stress and certain types of virus-related tumors. Evidence from both animal and human studies suggests that chronic stress weakens a person’s immune system, which in turn may affect the incidence of virus-associated cancers, such as Kaposi sarcoma and some lymphomas. 

Researchers in the interdisciplinary field of psychoneuroimmunology study the interaction between psychological processes and the nervous and immune systems of the human body, and how these interactions affect health. One area of research explores whether cancer and stress are connected in disease progression. Michael Irwin, MD, director of The Cousins Center for Psychoneuroimmunology UCLA Semel Institute for Neuroscience and Human Behavior, says that while data connecting stress to relapse in human cancer are weak, there are a number of animal studies linking stress to the growth of specific tumors. 

 in 2006, mice injected with human ovarian cancer cells showed disease progression when exposed to stress, compared with injected mice not exposed to stress. The study identified a biological mechanism caused by behavioral stress that can promote malignant cell growth, which suggests that blocking this mechanism could have therapeutic implications for managing ovarian cancer. 

In addition, results from studies conducted through the Stress and Immunity Breast Cancer Project at Ohio State University, reported in the December 2008 issue of the journal Cancer, indicate psychological interventions to reduce stress improved survival for the breast cancer patients being studied. 

OSU researcher Barbara L. Andersen, PhD, professor of psychology, reported the results of a long-term trial of 227 breast cancer patients who were randomized to either participate in psychological interventions to manage stress after breast cancer treatment or to only be assessed and receive no interventions. The intervention consisted of small-group sessions conducted by psychologists who taught participants strategies to reduce stress and improve quality of life. Specific strategies included progressive muscle relaxation (a series of exercises in which participants tense and release specific muscle groups for stress reduction), problem-solving for common difficulties such as fatigue, identifying supportive family members or friends who were capable of providing assistance, using assertive communication to get their psychological and medical needs met, strategies to increase daily activity such as walking, improving dietary habits, and finding ways to cope with treatment side effects and maintaining adherence to medical treatment and follow-up. 

Women in the study were followed from seven to 13 years, and analyses confirmed that patients randomized to the intervention arm had reduced risk of breast cancer recurrence, death from breast cancer, and death from all causes compared with patients in the assessment-only arm. 

“Basically, what the results show is that by reducing stress and depressive symptoms, it yields better immune function and a better psychological profile,” Andersen explains.

While the exact biological cause and effect remains unclear, Andersen explains that stress can trigger important effects involving the autonomic, endocrine, and immune systems, one result of which may be the release of pro-inflammatory cytokines, which are linked to a suppressed immune system. 

With inflammatory processes appearing to promote tumor growth in both clinical studies and mouse models, Andersen hypothesizes that psychological interventions that reduce stress could interrupt the inflammatory process and thereby reduce recurrence. (Read more about the link between inflammation and cancer in “The Internal Flame” from the Fall 2009 issue, available at 

With this latest data, survivors would hope that these interventions would become an integrated part of standard cancer care plans. However, Andersen says the hurdle to offering this type of stress-reducing support to all survivors is a matter of cost.  

“We are going to do a cost analysis with these data so we will learn exactly what the cost is to society. Keeping people alive and productive members of society, rather than not, would seem a huge benefit, but we will have to show the numbers in black and white. A key issue is what our health care system can financially support for mental health care by psychologists and psychiatrists,” she explains.

Emory Winship Cancer Institute’s Burke likens learning to deal with post-cancer stress to how an oak weathers a storm versus a palm tree. In a hurricane, the rigid oak may snap, but the palm bends with the squall. Learn to adapt, like the palm, to changing conditions to help you continuously manage stress, he says. He recommends reintroducing daily routines, having fun again, being productive at work, volunteering, and being involved with family and friends. But most important, he says, give yourself a break and accept help from your support system. 

Irwin adds that mind-body interventions that help patients sleep, as well as relax, such as yoga, tai chi, and mindful meditation, are very effective psychologically and physiologically. He also emphasizes the importance of maintaining positive social contact with friends and family. “Socially isolated people do worse; their mortality rates are significantly higher,” he explains. 

After treatment, Maxwell decided to change careers, leaving her high-stress CEO position at a speaker’s agency to become the executive director of a nonprofit aimed at preventing college hazing, a mission she believes in strongly. In her spare time, she focuses on what she truly enjoys, which includes leading white-water canoe trips on western Colorado waterways. Maxwell says these changes have reduced her stress and improved her quality of life.

Like Maxwell, Marcia Donziger’s post-treatment stress led her to make major life modifications. After a year that involved being diagnosed with ovarian cancer while trying to conceive a child, learning her husband was sterile, and the end of her marriage, Donziger found distraction the best stress reliever. When she completed her ovarian cancer treatment at age 28 in 1997, she wanted to distance herself from cancer. 

“I was tired of thinking about it every day,” she says, so she changed her career and environment, relocating from Chicago to California to be near a supportive family. “It was a great move. I didn’t have to drive by the hospitals; there were no reminders anymore.”

When Donziger reached the five-year survival mark, she says she knew her stress level was down when she could breathe and talk about having had cancer without getting anxious. Ten years after diagnosis, she launched 

, a nonprofit that provides a free online communication tool for cancer patients and their families. “I thought that I could do something to make big differences in the lives of cancer patients,” she says. Now Donziger receives thank you e-mails on how she has relieved the stress of other cancer survivors. 

Looking back at her cancer experience, Donziger says counseling helped her get through tough times. She also discovered yoga, good nutrition, exercising, and adequate sleep helped her manage stress levels. Today her stress comes from a different source—4-year-old twins that she and her second husband had through a surrogate and egg donor. However, it’s a challenge she is happy to pursue, considering the other stresses she has conquered.

Have you suffered from post-treatment stress? If so, what helped? Share your experience on our message board at 

Maxwell realized that, like many survivors, she anticipated her cancer-related stress would magically disappear when treatment ended. “Everybody thinks your life is going to get back to normal the next week after treatment ends, and it doesn’t. When you are doing something to battle the disease, it gives you comfort; when you are not, your stresses and worries come back into the picture.”

In a hurricane, the rigid oak may snap, but the palm bends with the squall. Learn to adapt, like the palm, to changing conditions to help you continuously manage stress.

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What effect does stress have on the healing process for survivors?

All Stressed Out

The depth and duration of stress may lead to depression, which occurs at a rate approximately three to five times greater in cancer patients than the general population, says Michael Irwin, MD, director of The Cousins Center for Psycho&shy;neuroimmunology UCLA Semel Institute for Neuroscience and Human Behavior. “Unfortunately, depression remains largely underdiagnosed and undertreated in cancer patients, and chronic depression might impact disease progression,” he says.

Michael Burke, MD, clinical director of psychiatric oncology at the Emory Winship Cancer Institute in Atlanta, says there is a difference between a depressed mood, which is transient, and the syndrome of depression, when patients report a sadness or lack of interest as well as significant changes in four or more brain-regulated functions, such as mood, cognition, sleep, appetite, self-image, psychological thought patterns, energy, concentration, memory, decision-making, interest, motivation, and self-protection.  

“Few would ignore cardiac symptoms if they were in the middle of cancer treatment. Why ignore brain symptoms like depression that can be effectively treated so the person can feel better during a difficult time?” Burke says.

Barbara L. Andersen, PhD, a professor of psychology at Ohio State University in Columbus, conducted a separate analysis of women with breast cancer who showed major depression as part of a larger study to determine if psychological interventions impacted survival. What was discovered, she says, was that reducing stress and depressive symptoms resulted in a better immune profile, meaning how well the immune system is functioning, and psychological profile. “The reduction in symptoms at four months and then measuring inflammation at eight and 12 months showed that when we reduced the depressive symptoms early, then later on, inflammation was less.”

Aside from depression, Burke says 3 to 10 percent of adult cancer patients have post-traumatic stress disorder (PTSD), an anxiety disorder that develops in reaction to physical injury or severe mental or emotional distress, such as military combat, violent assault, natural disaster, or other life-threatening events.

"Cancer is a perfect storm when it comes to how it affects the brain."

PTSD in cancer survivors may be expressed by reliving the cancer experience in nightmares or flashbacks, continuously thinking about it, avoiding places, events, and people connected to the cancer experience, and/or being continuously overexcited, fearful, irritable, and unable to sleep. To be diagnosed as PTSD, these symptoms must last for at least one month and cause significant problems in the patient’s personal relationships, employment, or other important areas of daily life. Patients who have these symptoms for less than one month may develop PTSD later. 

Burke says cancer patients with PTSD may avoid going to health appointments, ignore appropriate self-exams, or refuse to talk about or even say the word “cancer”—reactions that can lead to poor health behaviors, such as alcohol and drug use to numb the person’s emotions, lack of self-care, and emotional distancing.

Burke focuses on four components of therapy for these patients. First, he helps patients work on grieving the losses of cancer, which may be temporary or permanent. “They need to grieve that loss so they can deal with their new normal to redefine themselves,” he says. Next, he encourages survivors to define themselves not by what they can’t do, but by what they can do. Third, the survivors need to normalize the cancer experience by learning to accept that they might not feel great, even if they have survived cancer. Fourth, they must process what has occurred.

“Cancer is a perfect storm when it comes to how it affects the brain,” Burke explains. “The brain has been affected by chemotherapy, radiation, surgeries, cancer itself, and other inflammatory processes. The brain regulates so many functions, including thought, cognition, motivation, energy, and sleep. When there is a brain dysfunction, such as depression or PTSD, it needs to be treated, so that even the sickest patient with cancer can improve their quality of life.”

The depth and duration of stress may lead to depression.

Stress, Depression & PTSD

Here are 10 science-based stress reducers to help manage post-treatment stress, provided by Barbara L. Andersen, PhD, of Ohio State University’s Department of Psychology and the OSU Comprehensive Cancer Center-James Cancer Hospital and Solove Research Institute.

Understand stress and your responses to it.

 Recognize cancer stressors and try to identify the physical changes it may produce for you, such as headaches, heart pounding, and abnormal breathing. Emotional tolls may manifest as fatigue, difficulty making decisions, or anxiety.

 Progressive muscle relaxation lowers tension and reduces wear and tear on the body. Relaxation can help control cancer therapy symptoms, such as nausea and fatigue. Practice at least three times per week for 20-minute sessions. Learn to relax through other methods, including meditation, yoga, massage, and/or deep breathing.  

 Define and target your problem. Generate and implement solutions and evaluate the result. 

 Share your reactions to the cancer crisis and adapt coping techniques. Accept the spontaneous offers of help from friends and family. Seek out help through online support and cancer message boards. 

 Express your thoughts, feelings, and needs for help to your health care providers, support groups, friends, and family.  

 Eat less fat and more fiber. Fuel up with fruits, vegetables, and proteins. If appetite loss is a problem, eat smaller meals and eat more frequently. 

 Aim for seven to nine hours of sleep to encourage health and well-being.  Even with adequate sleep, however, individuals can experience cancer-related fatigue. 

 Increase your activity level. Gentle exercise, such as walking or swimming, can help relieve tense muscles and improves mood. Consult with your physician to affirm your readiness for exercise. Start with a small achievable goal, such as 10 minutes a day, and slowly increase as endurance improves. Exercising with a friend often can help to maintain your own interest and motivation.

Learn to manage physical and mental health symptoms.

 Call your doctor, when necessary, or come to your appointments with questions. Comply with follow-up visits and medical advice. Seek professional psychological help if needed.

 Treat yourself to something you enjoy. Easy-to-do, simple pleasures are often the best, such as reading a good book, listening to music, going to a movie, taking a walk, or talking with a trusted friend. 

Ten science-based stress reducers to help manage post-treatment stress.

Laurie M. Fisher

All Stressed Out

Stress, Depression & PTSD

Stress Reducers

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