Cancer Survivorship—Considering Mindsets

To the Editor

We commend Baker¹ for his call to action to “do better” in cancer survivorship care. Baker advocates for an increased focus on treatment-specific late effects; this work can promote precision in survivorship care by targeting prevention efforts and increasing medical surveillance for those with elevated biomedical risk.

Yet, better survivorship care must think outside the confines of the biomedical model alone. During survivorship, mindsets matter. While treatments such as anthracycline chemotherapy may confer toxic effects on the heart, certain unhelpful mindsets may be equally toxic to the lived experience of a patient. Mindsets—core associations about the nature and workings of things and processes in the world—help patients make sense of complex states of health, guide responses to physical symptoms, and motivate health behaviors. Studies of the placebo effect are revealing that our mindsets can even leverage endogenous opioid² and neuroimmune³ pathways, thereby directly changing physiology and shaping objective markers of health. During cancer treatment, mindsets about the meaning of illness (eg, whether it is a catastrophe, a manageable challenge, or an opportunity to make positive life changes) are important.⁴

After treatment ends, a patient’s mindset about the capability of their own body becomes central. Take Baker’s adolescent patient, cured of his sarcoma but now at increased risk of a heart attack and stroke due to his cardiotoxic treatment.¹ While minimizing biomedical risk, increasing his surveillance for and awareness of this risk may (unwittingly) reinforce his mindset that his body is incapable of recovery and of handling future illness. Holding the mindset that his body is “incapable” may lead him to give up on his body, reducing his engagement in adaptive physical activity and ultimately neglecting his routine surveillance and follow-up visits, thereby increasing his risk of unmanaged late effects. Alternatively, the same mindset that his body is incapable may result in him anxiously misinterpreting and seeking consultation for every new ache and pain (ie, health care overutilization). As we see in chronic pain⁵ and posttraumatic stress disorder, this state of anxious hypervigilance and excessive monitoring is associated with increased severity and salience of physical symptoms and worse quality of life.

Mindsets matter, both during and after cancer, and are shaped by survivorship care. A comprehensive, precise survivorship care approach must strive to support individuals with the information and surveillance they need while also leveraging adaptive mindsets about their body’s capability to heal and function after treatment ends.