Positive psychological factors that affect morbidity and mortality have not been extensively studied in diverse oncologic populations, although they could be extremely influential in patients facing a life-threatening diagnosis.
In an article published in the Journal of Clinical Psychology, entitled Yin and yang of psychological health in the cancer experience: does positive psychology have a role? a team of collaborators writes that the positive aspects of psychological health are especially relevant for patients with cancer and their caregivers.
The specialist authors include psychiatrists and oncologists from various institutes: Dana Farber Cancer Institute, Boston; Harvard Medical School; Brigham & Women’s Hospital Psychiatric Department; Mass General Cancer Centre; and Fred Hutchinson Cancer Research Center, University of Washington.
They said because positive psychological well-being (PPWB), defined as “the positive cognitions, feelings, and strategies individuals use to evaluate their life favourably and function well”, includes indicators like positive affect, gratitude, optimism, happiness, and life purpose. These PPWB factors can buffer against distress, and although they coexist with symptoms of distress, PPWB is “not simply the opposite of distress”.
Optimism and depression are only modestly inversely correlated, said the authors. Many studies in medical populations have found that the beneficial effects of positive psychological health on clinical outcomes are independent of the adverse effects of negative psychological conditions, like depression on clinical outcomes.
So the primary focus of alleviating symptoms of distress and psychiatric disorders to achieve optimal psychological health in cancer patients “ignores an essential aspect of well-being: overcoming adversity and accentuating life-affirming perspectives that may enhance the positive aspects of well-being”.
Importantly, said the authors, supporting PPWB should not be confused with the tyranny of positive thinking (ie, where patients feel pressured to think positively and may believe that failure to think positively is a character flaw leading to poor clinical outcomes and disease setbacks).
They added that although significant distress accompanies a cancer diagnosis and treatment, the whole cancer care experience can also result in significant positive experiences, such as strengthening connections with loved ones. Numerous studies have reported resilience and post-traumatic growth among patients with cancer and their caregivers. The experience of cancer can also allow people to reflect on their lives and re-evaluate their choices, resulting in more meaning and satisfaction in life.
Furthermore, robust evidence supports that patients undergoing cancer treatment lean into their spirituality and re-engage in activities that enhance meaning and overall quality of life during and after treatment.
The existential threat of a cancer diagnosis and treatment can provide one of the first opportunities for most people to consider their own mortality seriously: acknowledging the inevitability of death makes each day more gratifying.
Thus, including positive psychological health in the routine psychological evaluation (currently mostly focused on distress screening) for cancer patients may be especially relevant and invaluable for them to achieve holistic well-being during and after treatment, and empower them not just to survive but also to thrive, regardless of early-stage or advanced cancer.
Just like distress, positive psychological factors could contribute to clinical outcomes via biologic and behavioural pathways, said the team. Empirical data, however, on biologic links between positive psychological health and clinical outcomes in serious illness patients, are less robust and consistent, especially in the cancer population.
Since healthy behaviours like avoiding smoking or smoking cessation are protective against several cancers, positive psychological factors could directly reduce the risk of cancer incidence via better health behaviours. Furthermore, known risk factors for malignancy such as tobacco use and physical inactivity are also established risk factors for chronic diseases (eg, cardiovascular disease and diabetes) among cancer survivors.
Thus, if PPWB can reduce the barriers preventing cancer survivors from engaging in healthier behaviours that protect against chronic health conditions, its long-term impact on cancer patients could be substantial.
The authors recommend oncology clinicians assess the psychological and mental health of their patients at multiple points to ensure that psychological factors are not causing undue suffering.
Current guidelines for distress screening at cancer centres advise using valid distress screening instruments such as a distress thermometer. However, the authors advocate changing from distress screening to psychological well-being assessment, with future aspirations of incorporating assessments for both negative and positive aspects of well-being. Hence, a discussion of PPWB could help patients and clinicians uncover potential gaps in resilience factors that undermine their overall well-being in the cancer care experience.
The ultimate goal of PPWB discussions should not only be to identify those who need intervention but also to uncover patients’ inherent traits that inform how they engage with treatment and decision making.
Overall, the authors say that enhancing PPWB during the entire cancer care cycle should go hand-in-hand with minimising the negative psychological outcomes associated with the cancer care experience, regardless of disease stage and prognosis.
Despite the challenges of managing cancer and its treatment, the average cancer patient wants to maintain an optimistic spirit, satisfaction with their life, and gratitude, they wrote.
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