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The Sixth Vital Sign

Barbara J. Walker, Ph.D.
Integrative Health and Performance Psychologist
Associate Professor, Department of Psychiatry and Behavioral Neuroscience, UC-COM
Diplomate, American College of Lifestyle Medicine

Receiving a diagnosis of cancer is disruptive and frightening.  Patients and their family members likely find themselves feeling overwhelmed and initially powerless, with few skills to cope.  Being treated for cancer is a complex, multifactorial process, and may lead to many psychosocial challenges and changes.   Even when patient’s outcome is optimal, the journey to recovery can change them psychologically and behaviorally (Lang-Rollin & Berberich, 2018).   

About 50% of cancer patients have clinically significant emotional distress and/or unrecognized or  untreated psychosocial conditions as a consequence of cancer at some point during the cancer trajectory (Grassi, 2020).  These problems are associated with the patient’s reduction in quality of life, impairment in social relationships, longer rehabilitation time, poor adherence to treatment and abnormal illness behavior.  Symptoms may range from physical pain, fatigue, and loss of autonomy, to anxiety, depression, and strain on personal relationships and have a deep impact on quality of life.   (Lang-Rollin & Berberich, 2018).   It is also suggested that at least 40% of cancer survivors have diverse, often sub-clinical or focal psychosocial and lifestyle needs, such as post-traumatic stress symptoms, or distress related to life changes such as persisting symptoms, altered body image, existential distress, social isolation or lack of support (Recklitis & Syrjala, 2017).   Fear recurrence (also fear of progression) represents a distinct, yet normal, entity in cancer treatment (Galica et al., 2021).

The way we equip patients and family members to cope with cancer might affect not only patient’s quality of life but also survival.   Being aware of reactions and responses throughout treatment (of patients, caregivers, and staff working with patients), and providing the tools and resources to integrate various ways to cope with their illness will help boost their resilience and create a sense of ease to the stressors throughout this journey.  

Importance of Assessment and Intervention

Not all patients need or want intervention, or even know that they may need it at various times during their treatment.  It’s a careful balance, however, because we want to make sure that we refer to the right person, for the right type of support, at the right time, knowing that this process may not always be perfect.  It is important for all those interacting with patients to take a pause to pay attention to any potential needs for patients.  It would be helpful for patient’s to be screened routinely to assess their degree of distress throughout different stages of the disease, as this is now considered a sixth vital sign (such as the Stress Thermometer; Ownby, 2019).  A comprehensive review of different short screening tools has been published (Grassi et al., 2015).  In addition to screening, it would also be helpful for patients to be given psychoeducation materials as well the range of psycho-oncological services available to them for support.   

Psycho-Oncological Interventions

Psycho-oncology has risen as a relatively new interdisciplinary field with the aim of addressing these issues and providing support for patients confronting numerous challenges through the different stages of the disease. The demand for psychosocial interventions to treat and support patients with cancer and survivors has dramatically increased over the last few decades.  The de-stigmatization of cancer and of mental concerns, changes in the relationship between health care provider and patient, a change in focus from increasing survival and life expectancy to improving quality of life and development of palliative care (Lang-Rollin & Berberich, 2018).

There is growing evidence supporting the benefits of psycho-oncology for patients with cancer.  The psycho-oncological therapeutic approach has become a crucial tool in the care of cancer patients, improving not only physical and psychiatric symptoms, but also quality of life.

Cancer may also disrupt a patient’s feeling of purpose and poses a challenge to the premorbid coherent self and world concept, resulting in existential or spiritual distress.  There is now growing attention on the important role of the sense of meaning in improving psychological well-being and reducing psychological distress among cancer patients (LeMay, et al, 2008).  We know that patients who experience more meaning in life have higher psychological well-being, more successful adjustment, better quality of life, and less psychological distress after the cancer diagnosis than patients who experience little life meaning (Winger, Adams, & Mosher, 2016).

Integrating mind-body techniques, which includes a variety of practices, and can be defined as techniques to help modify biological, physiological, or psychosocial processes as well as improve quality of life. Identifying evidence-based stress reduction interventions that are low cost and easy to use, and that can be self-administered is essential.   One intervention that meets this criteria is diaphragmatic breathing.  Our very existence relies on us breathing all day, every day, but the quality of our breath makes a difference physiologically and psychologically.  Diaphragmatic breathing has been identified as a benefit to both physical and mental health (Ma et al., 2017).  Diaphragmatic breathing involves breathing deeply and expanding the lungs into the diaphragm rather than using the abdomen or ribcage alone (Hopper, 2019).  Diaphragmatic breathing techniques focus on the breath and slowing the breath rate by using a process such as counting the breaths while expanding the abdomen and inhaling deeply through the nose, pausing, followed by contracting the abdomen and exhaling slowly and completely through the mouth. This type of deep breathing technique includes developing a pattern of inhalation and exhalation to decrease respiratory rate. Deep breathing assists in blood flow, lowering the pulse rate and blood pressure by improving vagal activity and reducing the sympathetic reaction (Hopper, et al, 2019).  Diaphragmatic breathing needs no equipment or specific setting, and it can be easily taught and learned. Further, diaphragmatic breathing can be self-administered when a person identifies a stress trigger, making it a readily available treatment for the management of stress (Hopper, 2019).

Mindfulness and/or Mindfulness Meditation is another area that has been found helpful for patients managing stress and finding ease in their journey.   Mindfulness has been around for over 2500 years and has been studied rigorously within the last few decades.  Mindfulness is the basic human ability to be fully present, aware of where we are and what we’re doing, and not overly reactive or overwhelmed by what’s going on around us.  There are many studies that have shown that with regular practice, mindfulness can lower states of physical arousal, decrease heart rate, make changes in brain wave patterns, lower stress and reverse the stress response, calm breathing and allow our bodies to use oxygen more efficiently, reduce cortisol levels, reduce blood pressure, improve onset and quality of sleep, and reduce chronic pain.    Psychologically, with a regular mindfulness practice, studies have shown increased self-awareness, improved emotional well-being, better stress management skills, improved mood, improvement in working memory, and decreases in subjective anxiety and depression.   There are multiple mindfulness based programs that can be found in person, online, or through apps.   Supported through Integrative Medicine, I offer a 15- minute online guided meditation for anyone who would like to join called Mindful Mondays at 8:30am (link below).

Cognitive-behavioral techniques (CBT) are yet another tool to help patients cope with their diagnosis and treatment, emphasizing the significance of how our thinking affects the way we feel.  CBT is targeted to change the perceptions of how and what patients think, recognizing that how a person thinks has a tremendous effect on his or her emotions and behavior. The patient works with a CBT practitioner to develop skills to recognize, counteract, and manage problematic thoughts and beliefs (Daniels, 2015).  These techniques aim to improve coping and acceptance of pain, self-efficacy, reframing of catastrophic thoughts, modulation of activities, and shifting the focus on attention. 

All the areas within psycho-oncology cannot be fully covered within this article, but I’d like to highlight one of the evidence-based programs that we offer through Survivorship - available at no cost to patients from a very generous donor through Integrative Medicine that encompasses several of the areas within psycho-oncology.  Within this 4-session series, we cover areas of meaning and mindfulness, and strategies for managing stress, resilience, and self-compassion.  The program includes experiential practice of breath and mindfulness meditation, relaxation techniques, and take-home activities and resources to help patients increase their coping with the intention of improving their quality of life throughout this journey.  Above all, it is offered as a group so that there is an established community to share and learn from one another. (Please see link below to refer a patient or to join group).     

The final area that I’d like to leave you with is the concept of Hope.  Hope can assist patients through the trajectory of illness spanning diagnosis, treatment, and follow-up.    Hope is what keeps patients getting up in the morning, coming to, and following through with treatment recommendations.  The concept of hope is measurable and can be enhanced via therapeutic intervention.  Hope has been defined as the belief that the future will be better than the present, along with the belief that you have the power to make it so (Lopez, 2013); it is a perceived capacity to produce clear goals along with routes to reach those goals and the motivation to use those routes (Lopez, Pedrotti & Snyder, 2019).   

There are various models of hope that exist in published medical and social sciences literature.  Hope Theory, conceptualized by Snyder, has received the most attention amongst social science researchers.   He defines hope as a positive motivational state that is based on an inter-actively derived sense of successful agency (willpower and goal-directed energy) and pathways (waypower and planning to meet goals) (Snyder, 2000).   Snyder portrayed hope as a goal-oriented cognitive construct with affective and behavioral implications.  A condition for the presence of hope is to have something for which to hope – a goal or goals.  Within this framework hope has two inter-related components:  pathways thinking and agency thinking.  A pathway is a strategy for achieving goals.  Agency thinking consists of thoughts that people have regarding their ability to begin and continue movement on selected pathways toward those goals.  Hope and accomplishment of goals reciprocally affect one another.  Hope predicts progress towards goal attainment.  However, the degree of progress then affects the subsequent levels of hope for an individual.  For example, if a person perceives they are advancing towards a goal, their tendency to engage in pathways and agency thinking readjusts to reflect this goal success.  Conversely, when people sense they are not making sufficient progress, their tendency to engage in pathways and agency thinking is reduced.  This process leads to upward and downward spirals of hope, both of which can be relevant in oncological settings in which patient motivation and adherence to medical regimens are necessary to meet treatment goals (Corn, et al, 2020).   Even though it is intangible, I observe Hope or lack of hope in patient’s eyes, words, and actions daily, and they likely see and feel it from us.  We need to make sure we are not only providing hope through our comprehensive treatments, but in our words and actions - not blind hope, but helping them compartmentalize the process of treatment into manageable steps and goals, so they can hold hope and maintain an upward spiral, no matter how small. 

There is strong evidence that assisting patients with mind-body psychological tools and techniques can help ease emotional distress, depression, anxiety, uncertainty, and hopelessness, and give patients an opportunity to have hope, ease their disposition, and improve their quality of life, and may even lead to post-traumatic growth.  Psycho-oncology is a discipline that helps cancer patients mobilize all of their resources to live well with cancer.  We know that it is not simply mind over matter, but mind matters (Spiegel, 2012).   I look forward to continuing to work alongside all of you to help patients live their best life. 

You are welcome to reach out, refer your patients to either program, or inquire about additional psycho-oncological services that we offer. 

Mindful Mondays (15 minute guided meditation 8:30am):

Mindfulness Meditation for Cancer 4 week series (Tuesdays at 9am):


Corn, B.W., Feldman, B.R., & Wexler, I. (2020).  The Science of Hope.  The Lancet Oncology, 09/2020, Volume 21, Issue 9.

Galica, J. , Maheu, C. , Brennenstuhl, S. , Townsley, C. & Metcalfe, K. (2021). Examining Predictors of Fear of Cancer Recurrence Using Leventhal’s Commonsense Model. Cancer Nursing, 44 (1), 3-12. doi: 10.1097/NCC.0000000000000760.

Grassi, L., Caruso, R., Sabato, S., Massarenti, S., Nanni, M. G., & The UniFe Psychiatry Working Group Coauthors (2015). Psychosocial screening and assessment in oncology and palliative care settings. Frontiers in psychology5, 1485.

Grassi L. (2020). Psychiatric and psychosocial implications in cancer care: the agenda of psycho-oncology. Epidemiology and psychiatric sciences29, e89.

Hopper, S., Murray, S., Ferrara, L. & Singleton, J. (2019). Effectiveness of diaphragmatic breathing for reducing physiological and psychological stress in adults: a quantitative systematic review. JBI Database of Systematic Reviews and Implementation Reports, 17 (9), 1855-1876. doi: 10.11124/JBISRIR-2017-003848.

Lang-Rollin, I., & Berberich, G. (2018). Psycho-oncology. Dialogues in clinical neuroscience20(1), 13–22.

LeMay, K., & Wilson, K. G. (2008). Treatment of existential distress in life threatening illness: a review of manualized interventions. Clinical psychology review28(3), 472–493.

Lopez, S. J. (2013). MAKING HOPE HAPPEN: Create the Future You Want for Yourself and Others. N.York: Atria Books.

Lopez, SJ, Pedrotti, JT, & Snyder, CR (2019). Positive Psychology:  The Scientific and Practical Explorations of Human Strengths. (4th edition).  Thousand Oaks, CA:  Sage Publications.    ISBN-13: 978-1506357355

Ma, X., Yue, Z. Q., Gong, Z. Q., Zhang, H., Duan, N. Y., Shi, Y. T., Wei, G. X., & Li, Y. F. (2017). The Effect of Diaphragmatic Breathing on Attention, Negative Affect and Stress in Healthy Adults. Frontiers in psychology8, 874.

Ownby K. K. (2019). Use of the Distress Thermometer in Clinical Practice. Journal of the advanced practitioner in oncology10(2), 175–179.

Recklitis, C. J., & Syrjala, K. L. (2017). Provision of integrated psychosocial services for cancer survivors post-treatment. The Lancet. Oncology18(1), e39–e50.

Snyder, C. R. (Ed.). (2000). Handbook of hope: Theory, measures, and applications. Academic Press.

Daniels S. (2015). Cognitive Behavior Therapy for Patients With Cancer. Journal of the advanced practitioner in oncology6(1), 54–56.

Spiegel D. (2012). Mind matters in cancer survival. Psycho-oncology21(6), 588–593.

Winger, J. G., Adams, R. N., & Mosher, C. E. (2016). Relations of meaning in life and sense of coherence to distress in cancer patients: a meta-analysis. Psycho-oncology25(1), 2–10.

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