Managing Stress
Key Points
- Our stress response is a physical phenomenon that can have far-reaching impacts on our bodies, including anxiety, insomnia, immune-system suppression, heart malfunctions, muscle tension and extra wear on organs.
- A cancer diagnosis is often a stressor, as are repercussions from both cancer and treatments.
- Managing our responses to stressful situations and stimuli is possible and can benefit health.
- Several complementary approaches promote healthy responses to stress, including natural products, mind-body approaches, eating well, sleeping well and social support.
- Pharmaceuticals may help manage a stress response if complementary approaches are not sufficient.
- Some stress responses may need professional intervention.
- Some foods and habits can exacerbate stress and can be avoided.
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The Oxford English Dictionary defines stress as “a state of mental or emotional strain or tension resulting from adverse or demanding circumstances.” Those adverse or demanding circumstances, called “stressors”, can disrupt your internal balance and call on your body to activate a stress response. This response is automatic and calls on every bodily system to bring the body back into balance.
A certain amount of stress is normal—in fact, we couldn’t survive without the stress response. However, a sustained stress response can be damaging. "Chronic stress results in glucocorticoid receptor resistance (GCR) that, in turn, results in failure to down-regulate inflammatory response." Sustained stress leads to inflammation, a known driver of cancer.
Remember that stress is not only the challenging situation—it’s also your response to the situation. Even if you cannot change the stressors in your life, you may still be able to manage your response. On this page, we explore many tools that can help you manage your stress. However, seek outside or professional help if needed. Responses such as post-traumatic stress disorder (PTSD) may be beyond self-help.
Your Body’s Stress Response
The physical stress response is driven by a complex cascade of nerve activation and hormones:
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- First, the hypothalamus activates the sympathetic nervous system (the "fight or flight" response).
- The adrenal glands pump the hormone epinephrine—also known as adrenaline—into the bloodstream, causing these physiological changes and others:
- Rapid heartbeat and breathing
- Rise in blood pressure
- Release of glucose and fats into the bloodstream
- Release of cortisol to keep the sympathetic nervous system engaged
- When the stressor or threat lasts only a short time, the parasympathetic nervous system (the "rest and digest" function) calms the body and returns it to a pre-threat state.
- An extended “alert status” state can manifest as chest pain, heart palpitations, headaches, dysphagia (difficulty swallowing), intestinal cramping, anxiety, panic, immobility, frustration, muscle tension and inflammation.
The Stress Response and Cancer
Common Stressors in People with Cancer
Stress is our response to challenging situations in our lives. What is stressful for one person may not be for another. However, some events and environments are stressful for many cancer patients, survivors and caregivers:
- The cancer diagnosis, all by itself, can be a stressor
- Financial burdens from treatments, travel and caregiving
- Uncertainty regarding your job, medical insurance, housing, child care and other logistics
- Changes in roles of family members
- Disruptions to schedules for work and family
- Disruptions to eating, sleeping, recreation and other daily routines
- Pain, anxiety, fatigue, grief, nausea and vomiting, and other symptoms
- Feelings of isolation
- Changes in physical appearance
- Worry regarding suffering, dying and loved ones
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How Stress Interacts with Cancer
When stressors and threats are frequent or constant, cortisol remains at high levels most of the time. When the stress response continues for a prolonged period, the constant bodily imbalance that it causes can be physically damaging. Over time, this delays restorative repair and pushes the body into pre-disease states. Stress hormones have been found to fuel cancer growth and spread.
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Organs and tissues begin to function differently in response to the continual outpouring of stress hormones and chemicals. A prolonged stress response may compromise health and result in symptoms such as anxiety, depression and insomnia. The immune system is also affected—immune cells become preoccupied with triggering alarm reactions instead of doing their normal duties. With the body’s attention now focused on dealing with stressors, the job of finding and killing cancer cells is neglected.
Eventually, if the chronic stress response goes unmitigated, a state of cortisol depletion and adrenal exhaustion ensues. This state may require a different medical approach than high cortisol levels do.
Communicating Your Distress
Distress tools are available for both patients/caregivers and clinicians to use to assess your level of distress:
See our Communicate Your Distress page for more information.
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In sum, constant stress is not compatible with healing and good health. Stress deteriorates health and resilience, and health outcomes can include mental illness, chronic disease and premature death. Stress can deliver a double whammy with cancer, both promoting cancer growth and diverting your body’s natural defenses against it.
If you think that stress is adversely affecting your current or future health, consider making managing stress a high priority in your integrative cancer care plan.
Can Stress Cause Cancer?
People sometimes ask, “Did stress cause my cancer?” No one has a simple answer to this question. We do not have good evidence that stress causes cancer. Those of us with years spent caring for people with cancer believe that stress can affect the cancer itself as well as a person’s experience of having cancer. We know that the chemicals released in the stress response can speed up tumor growth. These stress-response chemicals can also promote conditions such as insulin resistance, which changes the tumor microenvironment in favor of the cancer.
Read more Chronically high levels of stress hormones can also aggravate the mental anguish that many people with cancer experience, which then increases anxiety and depression. Then the dog begins to chase its tail, so to speak, as emotional distress raises cortisol levels, and high cortisol levels increase distress. This all impairs your attention and memory, interfering with your ability to reason through problems and decisions.
Psychiatrist David Servan-Schreiber explains: “It usually takes anywhere from five to forty years for the ‘seed” of cancer in the form of a cellular anomaly to become a detectable cancerous tumor . . . No psychological factor by itself has ever been identified as being capable of creating that cancer seed . . . However, certain reactions to psychological stress can profoundly influence the soil in which the seed develops. . . The factors contributing to cancer are so numerous and varied that no one should ever blame themselves or feel guilty for developing this disease . . . However, anyone who has been diagnosed with cancer has the opportunity to learn to live differently, with the likely benefit of aiding in recovery.”
In sum, although stress may not cause cancer, unmanaged stress can increase the chance of the cancer progressing as well as decrease your quality of life.
Knowing whether your cancer has been caused or exacerbated by stress might be interesting but will not help you address your stress now. Rather than try to chase an answer, BCCT recommends that you focus on what you can do now and move forward. |
PTSD and Cancer
In addition to the stress from dealing with cancer, for some people with cancer and/or their caregivers, the experience can be traumatic and/or bring up past unresolved traumas. For these people, long-term problems may develop or resurface, such as adjustment difficulties, anxiety or depression. In addition to normal stress reactions, traumatic stress-like reactions may be seen in some people with cancer or their caregivers such as these:
- Intrusive upsetting thoughts
- Reacting to reminders such as follow-up scans
- Avoidance
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The Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV, a clinician’s reference guide to diagnosis) expanded PTSD criteria to include diagnosis and treatment of a life-threatening illness as a stressor that could elicit PTSD. These criteria were further revised in the DSM-5. Some situations and factors may increase the risk for a traumatic reaction to cancer, such as prior trauma history, pre-existing psychiatric conditions or poor social support.
Psychiatrist David Servan-Schreiber, author of Anticancer: A New Way of Life, describes the impact of past traumas being reactivated by cancer:
“They may take over the individual’s entire mental and physical functioning . . . Inwardly, the emotional wound also affects deep vital processes. Just as a lesion on the skin activates repair mechanisms, a psychological wound sets off mechanisms of the stress response: release of cortisol, adrenaline, and inflammatory factors, as well as a slowdown in the immune system . . . these physiological stress mechanisms can contribute to the growth and spread of cancer . . . unhealed traumas lead the person back to a false sense of helplessness . . . it is not a true reflection of the present. Allowing a person to realize this illusion is the key to therapy.”
A 2017 study in Malaysia found that more than one in five cancer patients reported symptoms of PTSD in clinical evaluations six months after diagnosis. After four years, about six percent of patients had PTSD.
BCCT and many others in the field recommend that a cancer team conduct a careful psychosocial assessment for all their patients with cancer (and their caregivers) including precancer diagnosis trauma and psychiatric history, plus concurrent conditions such as adjustment disorder. Either overlooking or incorrectly labeling a patient as having PTSD can be detrimental to their wellness and response to therapy. The care team should then routinely assess their patients for distress and refer them for help, if needed.
If you, as a person with cancer or a caregiver of a person with cancer, know that you have a risk factor for PTSD, and/or are experiencing distress or symptoms of PTSD, consider notifying your cancer care team as soon as possible.
Managing PTSD in People with Cancer
“PTSD should be approached with caution and be informed by existing evidence-based approaches for traumatic stress.” Certain proven psychotherapy techniques for PTSD also seem to be useful in cancer-related PTSD. Systematic reviews have found that the following techniques are helpful for one or some of the symptoms of PTSD:
- Cognitive Behavioral Therapy
- Eye movement desensitisation and reprocessing (EMDR)
- Supportive Expressive Therapy (SET), which promotes peer social support and expression of emotions and existential concerns and focuses on facing and grieving losses
- Cognitive behavioral stress management
- Couples based coping intervention
- Mindfulness-based approaches
- Promising approaches requiring further study:
- Narrative therapy
- Dyadic disclosure-promoting interventions
The authors of one review advise caution in using PTSD medications for people with cancer-related PTSD, as very little research has been done in this area. However, beta blockers may reduce intrusive ideation (a thought pattern used as a coping strategy) in newly diagnosed cancer patients. The authors discuss medications that might be used for cancer-related anxiety and sleep disruption, as well as the indications for using psychoactive medications and psychotherapy.
The late Dr. David Servan-Schreiber describes how he helped cancer patients heal the helplessness associated with trauma. He asked them to list the ten most painful events of their lives. These events, he viewed as “screws fastening down a large metal plate crushing their desire to live.” He helped people to “unscrew” these events one by one and found that patients were often awakened to a very different way of living. “Once relieved of the weight they had been carrying around, they were able to look at everything differently. Although relieving patients of the pain of trauma is not a treatment for cancer, it often enables natural defenses to recover their strength, which can aid in the fight against the disease.”
Natural Substances for Managing Stress
According to naturopathic oncologist Lise Alschuler, evidence shows several herbs and nutrients have antistress properties. These substances seem to work by either helping the body recover from stressful situations or supporting the body’s organs and tissues that are affected in the stress response:
Integrative oncologist Keith Block, MD, also includes natural substances in his integrative plan for balancing stress hormones and creating healthier biorhythms. Block distinguishes among three patterns of stress adaptation:
- Hyperadapted or high-stress pattern with prolonged elevated cortisol
- Inverted stress pattern, in which the timing of cortisol and melatonin are reversed.
- Non-adapted pattern, in which cortisol levels are either consistently high or depleted, melatonin levels are low, and both hormones have no circadian rhythm
Block’s approach with natural supplements varies with the pattern. This plan includes natural substances such as these:
Products for Calming or Reducing Stress
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Details of specific uses, dosing and cautions are available in books by Alschuler & Gazella and by Block (see below).
Mind-Body Approaches
The Relaxing Breath
Shanti Norris, a yoga teacher who works with people with cancer, explains: “One cannot feel anxious as long as one is breathing slowly and deeply.” Her instructions for managing stress with “The Relaxing Breath”:
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- Sit in a comfortable position or lie on your back on the floor. Take a moment to get comfortable. Feel your body. Take a deep breath or two.
- Now take a breath by inhaling into the nose and exhaling out the mouth. The exhalation is like an audible sigh: AAAHHH! Do this three or four times. In through the nose and out through the mouth. AAHH. This is the most relaxing breath.
- Continue for one to two minutes.
- Let the breath come back to normal.
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Many mind-body approaches, such as meditation, progressive muscle relaxation, tai chi and music therapy help with regulating breathing and heart rate, bringing on a calm state. These are discussed in more detail on these pages:
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Breathing is one of the simplest, most basic and yet powerful tools to manage a state of stress. Adjusting your breathing can be done anywhere and at any time. Deep diaphragmatic breathing—belly or abdominal breathing in which the belly, rather than the chest, expands when inhaling—resets the autonomic nervous system and has the following effects:
- Decrease oxygen consumption, heart and breath rate
- Increase theta wave state and parasympathetic activity
- Generally feeling alert and invigorated
Usually, deep abdominal breathing will begin to induce a calm state rather quickly. Regular practice several times a day can be an effective tool in managing your stress response.
Dr. David Servan-Schreiber describes practices involving reciting mantras, such as saying the rosary or other mantra-based meditations. These practices have the capacity to affect the body rhythms—breathing, heart rate, blood pressure and blood flow to the brain. While reciting the mantra, the person's breathing automatically harmonizes or becomes coherent with the rhythms of other automatic physiological functions. This state is called “resonance” or “coherence” and increases variations in biological rhythms. The resonant or coherent state provides these benefits:
- Better immune system function
- Reduced inflammation
- Better regulation of blood sugar
“These are, precisely, three of the principal factors that act against the development of cancer.”
Examples of simple mantra meditation instructions:
More information about meditation and other relaxation approaches is available on our Mind-Body Approaches page.
Even if you cannot change the stressors in your life, you may still be able to manage your response.
Theta Brain State
Theta brain state “is a state where tasks become so automatic that you can mentally disengage from them. The formation of thoughts and ideas that can take place during the theta state is often free flow and occurs without censorship or guilt. It is typically a very positive mental state.”
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Healthy Dozen Food Families
From Life Over Cancer:
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- Carotenoids: foods containing carotenoids usually have bright red, yellow and orange hues, such as carrots, pumpkins and other winter squash, tomatoes and tangerines, but also some green vegetables.
- Cruciferous vegetables: broccoli, cabbage, cauliflower, collards, kale and Brussels sprouts
- Alliums: garlic, onions, shallots, scallions and leeks
- Roots and rhizomes: ginger, turmeric, cassava, horseradish, turnips, radishes and parsnips
- Leafy greens: spinach, kale, lettuce, chard, beet greens, bok choi, mustard greens, collard greens, arugula and dandelion leaves
- Fruits: especially berries and other fruits with deep colors
- Sprouted seeds and cereal grasses: sprouts of broccoli, alfalfa, cabbage, cauliflower or kale seeds; sunflower seed greens; wheat, barley or oat grass juice
- Medicinal mushrooms: Maitake, shiitake and reishi are a few examples, and readily available in food form. See our Medicinal Mushrooms page [link] for more information.
- Probiotics and prebiotics: probiotics are live bacteria and yeasts including lactobacillus, bifidobacterium and Saccharomyces boulardii; these are often found in the cultures of dairy products, including yogurt and kefir. Prebiotics are fibrous foods that act as food for probiotics: garlic, leeks, onions, dandelion greens, asparagus, wheat bran, bananas and Jerusalem artichokes.
- Essential fatty acids: linoleic and alpha-linolenic acids, including omega-6 fats and omega-3 fats derived from linoleic acid. See our Omega-3 Fatty Acids page [linked] for more information.
- Sea vegetables and algae: kombu/kelp, arame, spirulina and nori algaes, sea lettuce
- Vitamins, minerals and other cofactors: Dr. Block recommends getting these from your diet, but if supplements are used, a basic vitamin and mineral supplement specifically designed for cancer patients is recommended. Some vitamins in high doses may fuel cancer growth, such as Vitamin B12 during prostate cancer. Specific recommendations and doses are listed in his book.
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Eating Well to Reduce Stress
Foods can support or undermine a healthy stress response and biorhythms.
Eating Well: Strategies
Dietary strategies for supporting a healthy stress response and biorhythms:
- Reduce use of caffeine and other stimulants.
- Avoid excessive alcohol consumption: alcohol as a nightcap or to relax can instead disrupt melatonin production as well as cause repeated awakening from sleep.
- If you eat a late-night snack, keep it light and let it consist of protein and/or whole grains. Avoid eating during the hour before bedtime.
- Include complex carbohydrates in your diet: whole grains, beans, and whole fruits and vegetables.
- Work with your doctor or dietitian/nutritionist to improve your ratio of omega-6 to omega-3 fatty acids.
- If diet, fitness and mind-body approaches do not completely manage stress chemistry and biorhythms, consider using a combined stress hormone support supplement in addition to a program of taking a cancer-specific multivitamin and fish oil supplements and also eating what Block calls the “healthy dozen food families” listed in a side box above.
Pharmaceuticals for Managing Stress
A good integrative cancer care plan will include mind-body therapies, eating well, moving more, and possibly natural products to manage stress. Sometimes, however, these therapies may not be enough. If natural treatments alone are inadequate, then even more symptoms of stress can arise, causing needless emotional suffering.
As Dr. Keith Block points out, patients commonly resist medical treatments for stress or depression, fearing treatments indicate they are psychologically unstable. However, because managing stress is key to many aspects of wellness, consider working with your physician to see if medications—such as antidepressants, tranquilizers and even stimulants—can help you.
Evidence suggests that propranolol, a prescription drug for heart disease, may have anticancer effects, possibly in part due to its effects on stress hormones which can fuel cancer growth and spread.
For more information about the effects of propranolol and other beta-blockers on the stress response, see Propranolol page.
Sleep and Managing Stress
Getting good sleep and rest is a key practice in creating a body that doesn’t encourage cancer. Poor sleep and stress can become a self-reinforcing cycle: unmanaged stress can disrupt biorhythms, including sleep. When sleep quality is poor, the stress response hormone cortisol rises at night when it should instead be lower. Because a chronic rise in blood cortisol can speed tumor growth and cause any number of increased health problems for people with cancer, consistently good sleep and rest are tools to combat stress. Effectively managing stress will improve the quality of sleep. For more information on sleep and rest, see our Sleeping Well page.
Social Support
The loss of love causes intense feelings of helplessness in many people, perhaps by tapping into psychological wounds received in childhood through experiences of rejection and criticism.”
David Servan-Schreiber
Stress Inventory: Creating a Stress Score
The Holmes-Rahe Stress Inventory assigns a score to the top stressors in people’s lives to allow people to assess their risk of developing a stress-induced breakdown. Of the 25 biggest stressors, 14 relate to changes in relationships and social support. The Holmes-Rahe Inventory makes a profound statement about the importance of relationships in influencing one’s health.
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Mediating the stress response with social support is an important part of an integrative cancer care plan. “The effect of social support on life expectancy appears to be as strong as the effects of obesity, cigarette smoking, hypertension, or level of physical activity.”
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Both in the lab and in community settings, positive social support seems to enhance resilience to stress. It may also protect against psychological problems related to trauma and reduce the functional problems related to post-traumatic stress disorder (PTSD).
Studies have looked at the impact on women with breast cancer who faced the disease with positive coping mechanisms and women with ovarian cancer who felt loved and supported and who kept up their morale. These women had much more active natural killer cells than those who felt helpless, depressed, alone and/or emotionally distraught.
If you or someone you love is living with cancer, tapping into love and support may help in managing stress and countering the ill effects of stressful circumstances. See our Sharing Love and Support page [linked] for ideas for finding support.
Stress Offenders
Medical acupuncturist Janet Spitzer, MD, and Keith Block, MD, inform us about foods and natural substances that can promote a stress response.
Foods and Natural Products
Anything that is a stimulant increases heart rate, anxiety and the stress response:
- Caffeine in coffee, tea or chocolate
- Ephedra
- Other stimulants, including ginseng and bitter orange
- Alcohol
- Spicy foods
In addition, some eating patterns can promote stress:
- Low-carb, high-fat diet
- Low-carb, high-protein diet
- High ratio of omega-6s to omega 3s
Eating Habits That Are Stress Offenders
Dr. Keith Block lists eating habits that can promote a stress response:
- Timing of snacks and drinks (eating within one hour of bedtime; eating a heavy evening meal or snack)
- Overeating
Reducing stress offenders is an important step in managing stress.
Be sure to determine if any stress management therapies involve potentially harmful interactions with your cancer treatment.
Cautions
Several of the therapies mentioned on this page come with cautions about interactions with other therapies or with medical conditions. For example, ashwagandha may increase testosterone, so use is not recommended by people with prostate cancer. Use is also contraindicated in patients with hemochromatosis. Please review cautions listed on therapy summaries or outside linked pages and consult your integrative physician before use.
Integrative Plans, Protocols and Medical Systems
- Protocols and programs
- Abrams & Weil integrative medicine approaches
- Alschuler & Gazella complementary approaches
- Cohen & Jefferies Mix of Six anticancer practices Anticancer Living. New York: Viking. 2018.
- Block program
- Geffen Seven Levels of Healing
- Lemole, Mehta and McKee protocols
- McKinney’s guidelines for stress management
- Ornish Lifestyle Medicine
- Servan-Schreiber anticancer way of life
- Traditional systems
Janet Spitzer, MD, April 16, 2018: “According to the Chinese 5 Element Theory, it would be helpful to ‘cool’ or at least not overheat the Fire element (heart, pericardium). Salty flavor would help cool the heat, while sour and excessive bitter flavors would tend to aggravate the heart. Alcohol also powerfully ‘heats’ the Heart-fire element.
I generally aim more at supporting/nourishing the adrenals when someone has chronic stress (ashwaganda, holy basil, Siberian ginseng, etc.) and decreasing oxidative stress with antioxidants (vitamin C, vitamin E) and decreasing inflammation (fish oil, turmeric/curcumin) and nutrients that help soothe the nervous system and support biochemical pathways (like magnesium, CoQ-10, Ribose, etc.).”
Written by Laura Pole, RN, MSN, OCNS, and Nancy Hepp, MS; most recent update on December 11, 2018.
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- Alschuler LN, Gazella KA. The Definitive Guide to Cancer, 3rd Edition: An Integrative Approach to Prevention, Treatment, and Healing. Berkeley, California: Celestial Arts. 2010. p. 191.
- Block KI. Life Over Cancer. New York: Bantam Dell. 2009. pp. 408-428.
- Block KI. Life Over Cancer. New York: Bantam Dell. 2009. p. 424.
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- Watkins JL, Thaker PH et al. Clinical impact of selective and nonselective beta blockers on survival in patients with ovarian cancer. Cancer. 2015 Oct 1;121(19):3444-51; Merville S. Betting on Beta Blockers. The University of Texas MD Anderson Cancer Center. Summer 2014. Viewed October 31, 2017.
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- American Institute of Stress. The Holmes-Rahe Stress Inventory. Viewed April 23, 2018.
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View All References
More Information
- Alschuler LN, Gazella KA. The Definitive Guide to Thriving after Cancer. Berkeley, California: Ten Speed Press. 2013.
- American Psychological Association: Stress
- Collaborative on Health and the Environment page on the stress response: Psychosocial Environment
- McKinney N. Naturopathic Oncology, 3rd Edition. Victoria, BC, Canada: Liaison Press. 2016.
- National Institute of Mental Health: 5 Things You Should Know About Stress
- National Center for Complementary and Integrative Health:
- Servan-Schreiber D. Anticancer: A New Way of Life. New York: Penguin Group. 2008.
- WebMD: What Are Probiotics?
- Prebiotin.com: Foods Containing Prebiotics
- Physicians Committee for Responsible Medicine: Essential Fatty Acids
- Edibly Educated: Why and How to Include Sea Vegetables and Algae in Your Diet
- Fortmann SP, Burda BU et al., editors. Vitamin, mineral, and multivitamin supplements for the primary prevention of cardiovascular disease and cancer: a systematic evidence review for the US Preventive Services Task Force [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2013 Nov. Report No.: 14-05199-EF-1.
- Podcasts and Video: I-Thrive Radio broadcasts; this show is broadcast live on W4CS—The Cancer Support Network part of Talk 4 Radio on the Talk 4 Media Network.
- Stress Management Techniques: Nancy Gahles, DC, discusses a technique that she uses to help her patients manage stress more effectively. Listeners will learn about the three areas she focuses on and why this technique can be so effective.
- Post Traumatic Growth after Cancer: Cancer survivor expert Dr. Shani Fox talks about "post-traumatic growth" after cancer and describes why it's important to understand that cancer can be a traumatic event. She provides concrete strategies about how listeners can heal from trauma. Also see Dr. Fox's assessment tool: Are You Thriving After Cancer?
- NCCN Distress Thermometer and Problem List for Patients
- Michael Lerner: Choices In Healing: Integrating the Best of Conventional and Complementary Approaches to Cancer
- Hillingdon Oncology & Palliative Care Team : Coping with Stress: The Distress Thermometer
- Martin L. Rossman, MD: The Healing Mind
- Julie Lusk, MEd: Wholesome Resources
- O. Carl Simonton, MD, James Creighton, PhD, and Stephanie Matthews Simonton: Getting Well Again
- Joan Borysenko, PhD: Minding the Body, Mending the Mind
- Martin L. Rossman, MD: Fighting Cancer
- Morgan Freeman and Lori McCreary: The C-Word
- Lorenzo Cohen and Alison Jefferies: Anticancer Living: Transform Your Life and Health with the Mix of Six
- Keith I. Block, MD: Life over Cancer: The Block Center Program for Integrative Cancer Treatment
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