The rapid spread of the novel coronavirus disease (COVID-19) has dramatically disrupted societal life within a very short time. Patients with cancer in particular can be affected by delays in routine medical care in addition to experiencing heightened anxiety and stress associated with the threat of the viral disease itself.

Shelly Latte-Naor, MD

Jun J. Mao, MD, MSCE

In a published survey of 1,210 individuals from 194 cities in China, 58.3% reported a psychological impact of the outbreak: 28.8% reported anxiety, 16.5% reported depressive symptoms, and 8.1% reported stress. All of these symptoms were rated as moderate to severe,¹ and they can be a significant detriment to quality of life, negatively impacting physical activity² and disrupting sleep.³

Patients with cancer especially are more vulnerable to further exacerbation of psychological symptoms because of their preexisting anxiety and stress stemming from symptom burden, treatment concerns, fear of cancer progression or recurrence, and higher susceptibility to infections. Social distancing efforts aimed at controlling the spread of COVID-19 can cause delays in diagnosis and initiation of cancer treatment, disrupt ongoing treatment and supportive care, and hinder optimal patient-physician interactions via regular face-to-face appointments. All of these unfamiliar situations can worsen stress and anxiety in patients with cancer and their caregivers. As we are only beginning to grasp the ramifications of this outbreak, there is an urgent need to address the enormous psychological burden it is inflicting.

“As oncology health-care providers delivering treatment in the context of COVID-19, it is vital that we attend to the overall health and psychological well-being of patients with cancer.”

— Shelly Latte-Naor, MD, and Jun J. Mao, MD, MSCE

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Mind-Body Therapies

Mind-body therapies are well supported by a number of studies that demonstrate their effectiveness in alleviating anxiety and stress. They are recommended by the Society for Integrative Oncology⁴ and ASCO⁵ as safe, nonpharmacologic options to address psychological distress and to improve quality of life.

The Integrative Medicine Service at Memorial Sloan Kettering Cancer Center (MSK) offers these therapies online, which can be particularly useful in coping with anxiety and stress in this time of unprecedented difficulty. They include modalities such as tai chi, meditation, and exercise and are available to anyone with a computer, tablet, or mobile device and an Internet connection. Practicing these techniques throughout the day under professional guidance can have calming and relaxing effects, and can contribute to overall psychological well-being and resilience.

Meditation

Meditation has been shown to help calm the mind and improve vitality, coping, and overall well-being, particularly in patients with cancer.^6-8 This video series has easy-to-follow guided meditation practices to help manage pain, relieve anxiety and stress, and promote sleep.

Exercise

Exercise can improve mood, boost the immune system, and prevent and reverse physical side effects such as fatigue.⁹ The videos below demonstrate simple exercises, highlighting the importance of exercise during and after cancer treatment. For those with balance issues, some of the exercises can be performed while sitting, requiring little to no equipment (https://www.mskcc.org/videos/exercise and https://www.youtube.com/user/mskcc [Click on the Playlists tab, and then “Exercise with MSK”]).

Tai Chi

Tai chi helps reduce stress and improve sleep,¹⁰ which can help maintain a healthy immune system response.¹¹ It has also been documented to improve balance, muscle strength, flexibility, stamina, and mental outlook. This video series guides through a tai chi practice.

The Integrative Medicine Department at MSK also provides additional online resources to help patients cope with anxiety and stress. Please follow us on Twitter at @MSK Integrative and #CalmCovid19.

As oncology health-care providers delivering treatment in the context of COVID-19, it is vital that we attend to the overall health and psychological well-being of patients with cancer.

Dr. Latte-Naor is Director of Mind-Body Medicine and Assistant Attending Physician of the Integrative Medicine Service at Memorial Sloan Kettering Cancer Center, New York. Dr. Mao is the Laurance S. Rockefeller Chair in Integrative Medicine and Chief of the Integrative Medicine Service at Memorial Sloan Kettering Cancer Center, New York.

DISCLOSURE: Dr. Latte-Naor reported no conflicts of interest. Dr. Mao has received institutional research funding from Tibet Cheezheng Tibetan Medicine Co. Ltd. and Zhongke Health International LLC.

REFERENCES

1. Wang C, Pan R, Wan X, et al: Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China. Int J Environ Res Public Health 17:E1729, 2020.

2. Stults-Kolehmainen MA, Sinha R: The effects of stress on physical activity and exercise. Sports Med 44:81-121, 2014.

3. Hall MH, Casement MD, Troxel WM, et al: Chronic stress is prospectively associated with sleep in midlife women: The SWAN Sleep Study. Sleep 38:1645-1654, 2015.

4. Greenlee H, Balneaves LG, Carlson LE, et al: Clinical practice guidelines on the use of integrative therapies as supportive care in patients treated for breast cancer. J Natl Cancer Inst Monogr 2014:346-358, 2014.

5. Lyman GH, Greenlee H, Bohlke K, et al: Integrative therapies during and after breast cancer treatment: ASCO endorsement of the SIO clinical practice guideline. J Clin Oncol 36:2647-2655, 2018.

6. Lengacher CA, Reich RR, Paterson CL, et al: Examination of broad symptom improvement resulting from mindfulness-based stress reduction in breast cancer survivors: A randomized controlled trial. J Clin Oncol 34:2827-2834, 2016.

7. Speca M, Carlson LE, Goodey E, et al: A randomized, wait-list controlled clinical trial: The effect of a mindfulness meditation-based stress reduction program on mood and symptoms of stress in cancer outpatients. Psychosom Med 62:613-622, 2000.

8. Haller H, Winkler MM, Klose P, et al: Mindfulness-based interventions for women with breast cancer: An updated systematic review and meta-analysis. Acta Oncol 56:1665-1676, 2017.

9. Juvet LK, Thune I, Elvsaas IKØ, et al: The effect of exercise on fatigue and physical functioning in breast cancer patients during and after treatment and at 6 months follow-up: A meta-analysis. Breast 33:166-177, 2017.

10. Irwin MR, Olmstead R, Carrillo C, et al: Tai Chi Chih compared with cognitive behavioral therapy for the treatment of insomnia in survivors of breast cancer: A randomized, partially blinded, noninferiority trial. J Clin Oncol 35:2656-2665, 2017.

11. Irwin MR, Olmstead R, Breen EC, et al: Tai Chi, cellular inflammation, and transcriptome dynamics in breast cancer survivors with insomnia: A randomized controlled trial. J Natl Cancer Inst Monogr 2014:295-301, 2014.