How to Ease Stress

Welcome to The Breastcancer.org Podcast, the podcast that brings you the latest information on breast cancer research, treatments, side effects, and survivorship issues through expert interviews, as well as personal stories from people affected by breast cancer. Here’s your host, Breastcancer.org senior editor Jamie DePolo.

Jamie DePolo: Hello, thanks for listening.

That being diagnosed with breast cancer is stressful is an understatement. It may be difficult to accept the diagnosis. You may feel overwhelmed by making so many decisions at once. Which doctors should you see? Which treatments should you have? Where should you have treatment? You may have concerns about how you’re going to keep up with your responsibilities at home and at work.

Our guest today is Dr. Pamela Ginsberg, a retired psychologist who specializes in women’s health and the psychological issues that come with a cancer diagnosis.

Dr. Ginsberg will be a keynote speaker at the 2024 Living Beyond Breast Cancer Conference on Metastatic Breast Cancer, April 19 to 21. At the conference, she’ll be discussing the psychological effects of metastatic breast cancer. During this podcast, she’s going to talk about tools anyone who’s been diagnosed with any type of breast cancer — as well as caregivers — can use to manage stress and anxiety.

Dr. Ginsberg, welcome to the podcast.

Pamela Ginsberg: Thank you so much. Thanks for having me.

Jamie DePolo: So, I talked about some of the stressors in the introduction, but in your practice, what seem to be the most stress inducing aspects of a breast cancer diagnosis? Are there things that stand out to you?

Pamela Ginsberg: I mean if there is a word that is kind of the overarching theme that causes stress, I think the word is “uncertainty.” I think that, you know, what people experience from the point of diagnosis throughout their course of treatment and then also even into survivorship is uncertainty every step of the way, and we don’t like being uncertain about our lives. We don’t like when everything is kind of thrown into chaos in a sense of not knowing what tomorrow is going to bring. And I think that most people who have a breast cancer diagnosis feel a tremendous sense of uncertainty from the start.

If you think about what has to happen, as you mentioned, from the beginning. There are so many questions. There are so many fears. There are so many worries and there’s a language that you may not know anything about yet and so much to learn.

And so, from the very beginning, at the moment of diagnosis, this wave of uncertainty happens and it really kind of comes and goes like waves. You’ll get some of those initial questions answered and you and your physicians and your medical team kind of create this course of treatment and you start getting through it and then the next wave comes because either some question comes up or the next course of treatment starts and the last one ends. It’s a very, very uncertain time, and so that kind of uncertainty really increases our level of anxiety, our overall sense of unwellness.

Jamie DePolo: Yeah. That makes a lot of sense. You know, too, I’m sure any side effects also add to that uncertainty. Am I going to have them? Am I not going to have them? If I do have them, what do I do with those kinds of things?

Pamela Ginsberg: So, again, every step of the way, and then when you do have them, what do I do about them? Do I try this medication? Do I try that medication? Can I just meditate them away?

And people who are going through this experience are getting a lot of information. They’re getting feedback from people who may have had this experience before, or just their friends and family are saying have you tried this? Have you tried that? Their medical team is saying why don’t you try this or why don’t you try that. It’s just a lot to process.

Jamie DePolo: Yes. Now are the stress-inducing aspects, are they different for caregivers in your experience?

Pamela Ginsberg: I think there are some things that are the same and there are some things that are different. I just have to say about the caregivers and the friends and family of somebody with a breast cancer diagnosis, the caregivers are the unsung heroes, I think. They have their own path of worries and difficult experiences, some of which are the same as the patient’s, some of which are uniquely different and unique to the caregiver role. The caregiver is really asked to also change the way that they are living their lives for a period of time and yet it’s not their illness.

And so, they have all of the worry, all of the uncertainty. They have to learn the language. They have to understand the process as well, and then they are also asked to change kind of how they’re spending their time or what this means for their work situation or what it means for caring for children or caring for elderly parents or whatever the case may be. So, some of the things are very similar and some of the things are unique to the caregiving role.

Jamie DePolo: That makes sense, too, and I’m thinking, not in all cases but generally, it’s the woman who’s diagnosed with breast cancer, and in many relationships, many hetero relationships, it’s the woman who does a lot of the take care of the house, take care of the kids. And so, that whole role reversal, if the man now has to take care of the house and the kids and cook that can be very stressful too.

Pamela Ginsberg: It can be very stressful and you know I think that when the caregiver is being completely honest there can be some resentment associated with that, because it’s a lot to take on. But I think that the caregiver may not feel at ease with talking about feeling resentful because their spouse is also dealing with their own set of difficulties. It can be a very, very fraught time for couples and if the couple is already experiencing any kind of relational difficulty or stress, it really can increase that tension between those two people. And we don’t talk a whole lot about that, and certainly a person’s medical team is not addressing this. Caregivers’ needs are rarely addressed by the medical team. And so, the caregiver role is a very difficult one for so many of these reasons.

Jamie DePolo: Okay. Now I’ve read some statistics that seem to suggest about one in four people diagnosed with breast cancer experiences depression. And I know depression is actually a clinical diagnosis where stress I don’t think is. I could be wrong there. So, how does someone -- if you’re feeling all this, you’re probably having all these feelings -- how do you tell the difference between stress and anxiety, which you can maybe meditate away or talk to somebody about, and actual depression where you may need medicine?

Pamela Ginsberg: Yeah. These are tricky ones. So, just in general, the rate of clinical depression among the general population is somewhere between like 8 or 9 percent. In the cancer population, not just breast cancer but just in the general cancer population, it really ramps up to about 20 to 25 percent. So, what’s important about that number is that it’s important to recognize that the majority of people who are dealing with cancer do not have clinical depression. Seventy-five to 80 percent of people do not experience clinical depression.

They may have sadness. They may have tearfulness. They may have sleep problems but it may not arrive to the level of clinical depression in the majority of people who are managing a cancer diagnosis, but for that population, that 20 to 25 percent who are having clinical depression, what we’re looking for with clinical depression are intense sadness, hopelessness, suicidal thoughts, lots of thoughts of death, problems with eating, problems with concentration, and this is global. This is not just when you’re in a doctor’s office or just when you’re sitting in the chemotherapy chair. It’s global and it affects you all the time basically. So, we’re looking for that sense of really not functioning well, where that sadness, that sense of depletion, is interfering with a person’s life.

Most treatment teams will ask about levels of distress and how a person is doing. They may not ask often, but they will ask occasionally and it’s really important for patients to be honest about that and forthcoming with how they’re feeling because it really does matter because we can do something about it. And even when it’s stress and anxiety, you know, those can become extremely debilitating as well.

And so, when I said meditate something away, I don’t mean to be flip about that. We are talking about mental illness and we’re talking about somebody who may have had a depressive disorder before their cancer diagnosis and it’s triggered it again, or an anxiety disorder that’s been retriggered, or post-traumatic stress disorder that’s been retriggered. These are very serious diagnoses and they do need to be addressed because they really cause suffering for the patient that can be addressed and can be treated.

Jamie DePolo: Okay. Okay. Thank you. Now that was the perfect lead in, we’ll get to what I’m sure everybody wants to know. So, what are some strategies you can give folks to manage stress and anxiety? And I’ll kind of ask also, you know, do certain strategies work for everyone or is it sometimes more personality driven, so you have to kind of try a few things and see what works best for you? What would you recommend?

Pamela Ginsberg: So, I do think that they are personality driven or preference driven, maybe, is a better way of saying that. I think that not everything will work for everybody, clearly. So, what I always like to do is kind of give my patients and the people that I’m speaking to lots of different options. I call it the toolbelt or the toolbox. I want to give people a lot of different strategies so that they can kind of toy around with trying things, maybe some things that they’ve never done before, and see what actually helps them. I think we don’t really know what’s going to help us until we start doing it.

You know, I’ve had patients say to me, I hate yoga. I’m never doing yoga. I’m like well, try. Give it 10 minutes a day and see what happens for a week and they love it, you know. So, you just never know what’s going to work for you.

But the question of what do we do about it. What are some of the strategies? It would take hours for me to really go through all the strategies, but I like to break it down into three basic categories of strategies and I’m going to talk a little about each one of these categories.

So, the three categories are behavioral, cognitive, and emotional.

So, behavioral strategies are things that we do, that we do with our behavior. So, exercise is my top strategy in the behavioral category, and I know that a lot of people will say, I can’t exercise. I’m too tired. I’m not feeling well. The most minimal movement is helpful for a person in terms of managing stress and that might seem like, how does that manage stress? But the more we move our bodies and the more we allow our bodies to move and do what our bodies know how to do, the better we’re going to handle our treatment side effects.

So, exercising is a behavioral strategy. It’s one of the best ones. Movement therapies like yoga or tai chi or dance, wonderful behavioral strategy for the same reason. Spending time with people you love and people who you enjoy is a behavioral strategy. Doing things, engaging in your hobbies that you love.

The cognitive strategies, cognitive is about your thinking, your thoughts. And so, it’s really important to identify what’s called catastrophic thinking, which is like worst case scenario thinking which is very common with a cancer diagnosis.

We start thinking about what the worst-case scenario will be. How will this progress? How sick will I get? Am I going to die from this? Those are all catastrophic thoughts. It’s really important to recognize that that’s what those are. Those catastrophic thoughts set off this whole cascade in our bodies of panic and anxiety and stress. And so, when we can identify what our personal catastrophic thoughts are, it’s very helpful. And I always ask people, write down what you think your catastrophic thoughts are, so that when they pop up in your head you can kind of recognize them quickly and begin to have some strategies where you learn to create thoughts around the catastrophic thoughts. Thoughts that are a little bit more neutral or thoughts that are a little bit more optimistic to help balance out some of the catastrophic thinking.

Journaling is a great cognitive strategy and journaling is a way of helping you identify the catastrophic thoughts and some of the more neutral or optimistic thoughts that might help balance things for you. Also journaling, it activates a different part of our brain, actually, when we write things down versus when we just think about them. And so, it just helps us process information a little bit better. So, journaling is a really great tool.

The other thing that I ask people to do in terms of cognitive strategies is to prepare themselves for certain situations. So, we know that certain situations are triggers for us, and so when we’re going to our doctor’s appointment, when we’re heading into the infusion room, when we’re going for a scan, when we’re, I don’t know, even just getting a blood draw, when we have to talk to somebody, when we run into somebody in the supermarket who might know something about what’s going on with us, these trigger moments are very stress inducing for people. People worry about how they’re going to handle it.

So, I encourage people to create a strategy or even a script that they can say to themselves or say to somebody else so that they have a way of managing situations that they know are anxiety provoking. Sometimes those things, we don’t always know. They come out of left field sometimes but the ones that we know about we can prepare for and so I encourage people to do that.

And then finally, the emotional strategies are things like, this is how we manage the worry, the stress, the anxiety, the fears that come up, the sadness, the hopelessness. These are all emotions and normal emotions that we experience. So, some of the emotional strategies are things like breathing exercises, which I’m a big fan of. I talk about them a lot with my patients. I teach them. I encourage all of your listeners to just Google some breathing exercises. You can find them very easily online and all kinds of different sites that help to calm the nervous system down.

Things like meditation, talking through your emotional experiences with a trusted friend or a trusted other in your life, using support groups, using psychotherapy. Prayer is another meditative practice that can help with some of the difficult emotional experiences that people are having. One of the things that’s important for me to say is that these emotional experiences are mostly normal responses. So, as I said earlier, most people do not have a psychological disorder that is a diagnosed disorder during this experience, but they do have intense emotional experiences that are very uncomfortable. And so, it’s really important to normalize that so that we don’t think that there’s something wrong with us when we have these intense experiences because they can be frightening.

Jamie DePolo: Oh sure. Sure. I was going to mention I saw a presentation on this study last December in fact. It was at San Antonio. It was the San Antonia Breast Cancer conference, and it was on exercise in people with metastatic breast cancer exercising and one of the things they found was that it actually helped with fatigue and feeling tired. And I spoke to the researcher and she told me several of the participants said, you know I’m really tired. I don’t think I can do this but I’m going to go. And what they found was they felt better afterwards. So, I would just toss that out as you said exercise was one of your top recommendations. That even if you feel tired and don’t think you can do anything even if you just do something, I’m almost positive that you’ll feel better.

Pamela Ginsberg: Yes. That really bears itself out in research that the best strategies for combating fatigue is exercise, which seems just the opposite of what it should be, but because it actually releases endorphins, because it manages serotonin, because it releases dopamine. Exercise does a lot of good things for us.

This is one of my favorite little factoids. Cortisol is the stress hormone. It’s released by our adrenal glands and when cortisol is released in our system it’s the thing that makes us feel like we want to jump out of our skin, it makes us very agitated when we have a lot of cortisol in our system. And there’s only a few ways that cortisol leaves our system and one of the ways is through sweat. And so, when we exercise we are literally sweating out that stress hormone.

And so, it’s one of the reasons why exercise helps to calm us down. Exercise is good for us for so many reasons. I have done whole presentations just on the benefits, the psychological benefits of exercise. Not just the physical benefits because that’s not my area, but there are so many psychological benefits to exercise. It doesn’t mean you have to go, you know, train for a marathon. Just move your body. And like I said, dancing, walking, the simplest things can really help us.

Jamie DePolo: Yeah. That’s very interesting about sweating out cortisol. I did not know that, so I’m going to add that factoid to my arsenal as well.

Pamela Ginsberg: Well, let me finish that thought. Cortisol only leaves our system a few ways. One is through sweat. One is through urination. So, just increasing your water intake helps us to get rid of cortisol in our system. And that’s a simple one. I love the simple ones. I like when our strategies are simple. So, everybody can drink more water and water is good for us, again, for so many reasons. And one of the other ways that it leaves our system is through our tears. There is cortisol in our tears and it’s the reason why we feel better when we have a good cry.

And so, so many people will stop themselves from crying. They see it as a sign of weakness. That’s kind of a cultural thing for us, but I say go for it. Just have the ugly cry. Just bawl it out either by yourself or with a trusted other in your life and just let it go, because it releases toxins in our body. Think about how you feel after a good cry. You feel better and that’s one of the reasons.

Jamie DePolo: Oh, that’s fascinating. I did not know either of those things either. So, I’m adding all of that to my repertoire. I thank you. That’s fascinating.

Now I’m wondering, does it make sense for people…they’re just diagnosed and I’m not saying that everybody won’t feel stressed, but maybe some people feel just a little bit stressed. Should they start sort of using these anxiety and stress control strategies even if they don’t feel particularly stressed yet? I guess that’s a long way of asking is it possible to kind of de-stress before you’re stressed or prevent yourself from becoming stressed, if that makes sense?

Pamela Ginsberg: I mean, I always feel that we should all be using stress management strategies. I see it as kind of psychological hygiene, like just good psychological habits or emotional habits. You know, people who are regular meditators just have that in the toolbox. It’s a great thing to have in the toolbox. People who know those breathing exercises, it’s a great thing to have in the toolbox. So, even if you’re not experiencing really high levels of worry, throughout the course of a cancer diagnosis trajectory, there are going to be more moments where you are going to have high levels of anxiety or higher levels of worry. It’s just inevitable. We’re not robots. And so, we can use those strategies, you know, even just during those moments where we’re having a rough time because those moments are going to happen.

But these are good emotional habits for everybody, for patients, for caregivers, for providers, for everybody. It’s just helpful to know some of these strategies and again to play around with them a little bit and know the two or three or five that work for you. Know the ones that are your primary strategies. 

I know for me, and we’re going back to exercise again, but for me without exercise I am just not doing as well. I just don’t do as well when I’m not exercising regularly. I feel myself being just a little bit less alert. I feel my mental clarity is not as good. I’m certainly more snappy with people. I don’t have the patience that I normally would have. You know, my sleep is affected. My appetite is affected. So, know the ones for you that are helpful and try to practice them as much as you can.

Nobody needs to be perfect here. There’s just no such thing, but anything that we can do to help ourselves is helpful.

Jamie DePolo: Absolutely. Absolutely. So true. And then you’ve talked a lot about the benefits of managing stress and anxiety, but I’m wondering are there physical effects? I’ve seen some research that seems to suggest that it can help to improve outcomes if you have like a good mental space. What’s your opinion on that?

Pamela Ginsberg: This is a little controversial because there’s no really clear studies on, you know, that if you manage your stress, you will have a better outcome. It’s not kind of a one-to-one relationship like that. But it’s more of an indirect relationship. So, when people are good stress managers and they can decrease their overall level of anxiety or stress, they give their body kind of a better fighting chance. So, when we are good stress managers, it means that our immune system can work better. It means that our cardiovascular system works better. When we are good stress managers we get better sleep and our cells heal themselves and restore themselves during sleep.

And so, they’re kind of an indirect relationship but whatever we can control to give ourselves a fighting chance, we should. You know, take control where you can, and again, none of that is perfect, but it just gives your body more space to fight the disease and to process the toxins through radiation, through surgery, through chemotherapy. Anything that we can do to strengthen our body is going to be useful and helpful for us, and stress is a really important part of that whole picture. So, we haven’t found a study where we can directly say, you know, if you decrease your level of stress or decrease your depression, you will have better cancer outcomes. We don’t really have that, but we certainly know that it helps our body to manage the disease process.

Jamie DePolo: Okay. That makes sense. It’s almost like, I talked to another exercise researcher and she was saying if you start exercising before you start treatment, it’s like you’re training for treatment, and this is almost like managing stress helps with that training for outcomes. Like just putting yourself in the best possible position to have a good outcome.

Pamela Ginsberg: That’s right. You know, physical exercise and emotional exercise are just going to help our brains and our bodies manage the experience. You know, we’re stronger going into the experience when we’re good stress managers and we’ll be stronger through the experience if we continue to use those strategies throughout the entire trajectory. And even into survivorship. You know one of the things we haven’t talked about is survivorship, you know the fear of recurrence is some of the most problematic parts of survivorship emotionally speaking, and again the more strategies we have to manage the fear of recurrence phenomenon that happens in survivorship and the depression or anxiety that happens in survivorship, that surprises people, the more strategies we build in the toolbelt the more we are ready to manage those difficult situations as well.

Jamie DePolo: That makes sense. Doctor Ginsberg, thank you so much. This has been incredibly informative and helpful and I hope everyone starts using some of the tools that you’ve mentioned here. Thank you.

Pamela Ginsberg: You’ve very welcome.

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