The Critical Importance of Stress Reduction in Cancer Care

In a paper published in the high-impact Annual Review of Psychology, researchers at Sylvester Comprehensive Cancer Center at the University of Miami Miller School of Medicine shared decades of data from NCI-funded studies showing how stress reduction approaches, such as cognitive behavioral therapy (CBT) and relaxation training, can improve outcomes for cancer patients.

Headshot of Dr. Michael Antoni
Michael Antoni, Ph.D.

“From the moment they’re diagnosed and well into survivorship, cancer patients face many emotional challenges, including anxiety, depression and distress,” said Michael Antoni, Ph.D., a lead investigator in Sylvester’s Cancer Control Research Program, professor of psychology, and first author on the paper. “Some work has suggested that chronic distress can affect neuroendocrine signaling, producing stress hormones that could promote poorer cancer outcomes.”

Stress-activated hormones, such as cortisol and norepinephrine, have been shown to impair the body’s immune response to cancer, increase inflammatory signaling and potentially hasten metastasis.

Patricia Moreno, Ph.D.

The Cancer Control Research Program study team, which included Patricia Moreno, Ph.D., Sylvester’s lead of evidence-based survivorship supportive care and assistant professor in the Department of Public Health Sciences, and Frank Penedo, Ph.D., associate director, Cancer Survivorship and Translational Behavioral Sciences, and director of Cancer Survivorship and Supportive Care, also showed that psychological interventions reduce stress and promote emotional well-being, which may ultimately prolong survival.

“People who receive these interventions have increased antiviral immunity signaling and decreased inflammatory signaling,” said Dr. Antoni. “It’s complicated, because chemotherapy, surgery, and radiation all increase inflammation on their own; however, people who received stress management showed smaller increases in inflammation than those not receiving a stress management intervention.”

Stress Management Enhances Breast Cancer Survival

Much of the stress management research conducted at Sylvester has focused on breast and prostate cancer patients, and the long-term results have been encouraging. Using the state of Florida’s tumor registry, researchers have shown that stress management enhances survival in breast cancer patients.

Many of these findings involve CBT, which focuses on actively changing thoughts and behavior, along with common relaxation techniques, such as deep breathing or meditation.

Headshot of Dr. Frank Penedo
Frank Penedo, Ph.D.

“We teach patients to discern between controllable and uncontrollable stressors,” said Dr. Moreno. “For controllable stressors, CBT techniques help them become aware of how they respond to the stressors and develop adaptive coping strategies. For uncontrollable stressors, relaxation techniques and social support help them manage their emotional responses.”

Sylvester clinicians are working to better integrate stress management into routine care. Currently, patients are referred based on their symptoms and care needs through My Wellness Check. This is part of a national trend to make these approaches more accessible.

“It’s been well documented that these techniques promote adjustment for breast and other cancer patients,” said Dr. Penedo. “They are now being incorporated into large, comprehensive NCI-funded trials.”

Long-Term and Telehealth Studies of Stress Management in Cancer

Early stress management studies were mostly conducted with face-to-face groups. Though effective, in-person approaches can limit patient access — some people don’t have the time or resources to visit the clinic every week for two or three months.

“We’ve tested a five-week version that would be more convenient, and it did show efficacy, changing psychological and immunologic outcomes,” said Dr. Antoni. “We are now conducting the eight-to-16-year follow-up to determine if the shorter intervention also lengthens survival and improves quality of life well into survivorship.”

The next step is telehealth. The group is currently studying whether group Zoom interventions could also deliver improved outcomes.

“Telehealth may be the best way to integrate these approaches into oncology care without patients having to schedule extra time, travel, etc.,” said Dr. Antoni. “We’re going to be titrating the interventions into smaller doses and studying different ways to deliver them to see if that still moves the dial.”

The team would also like to reach underserved populations who may not have access to emotional care. They are also exploring patients’ greater living environments. Working with Sylvester breast cancer surgeons, such as Neha Goel, M.D., assistant professor of surgery, they are asking: Do specific neighborhoods increase stress levels and make the cancer journey even more difficult?

“We plan to combine CBT and other techniques to help those who are most in need,” said Dr. Antoni. “We want to be a model for major metropolitan centers in the United States on how to make these interventions effective for the largest, most diverse groups of patients.”

Tags: Annual Review of Psychology, Cancer Control Research Program, cancer survivorship, Cancer Survivorship Program, Department of Psychology, Department of Public Health Sciences, Dr. Frank J. Penedo, Dr. Michael Antoni, Dr. Neha Goel, Dr. Patricia Moreno, My Wellness Check, Sylvester Comprehensive Cancer Center