Yin and Yang of Psychological Health in the Cancer Experience: Does Positive Psychology Have a Role?

Introduction

Positive psychological health is crucial to optimal clinical outcomes across the cancer care continuum, from prevention and risk reduction to palliative care and survivorship.^1,2 Yet, the positive psychological factors that affect morbidity and mortality^3,4 have not been extensively studied in diverse oncologic populations compared with other medical populations^4-8—although they could be extremely influential in a cancer population facing a life-threatening diagnosis.^9,10 Positive psychological well-being (PPWB), a broad construct defined as “the positive cognitions, feelings, and strategies individuals use to evaluate their life favorably and function well,”⁴ includes indicators such as positive affect, gratitude, optimism, happiness, and life purpose.¹¹ Although PPWB coexists with symptoms of distress, it is not simply the opposite of distress. For example, optimism and depression are only modestly inversely correlated.¹² 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.^4-8 Hence, the primary focus of alleviating symptoms of distress and psychiatric disorders to achieve optimal psychological health in oncology populations ignores an essential aspect of well-being: overcoming adversity and accentuating life-affirming perspectives that may enhance the positive aspects of well-being. Importantly, 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 that can lead to poor clinical outcomes and disease setbacks).¹³

The Positive Psychological Aspects of Well-Being in the Oncology Population

The positive aspects of psychological health are especially relevant for patients with cancer and their caregivers because PPWB factors can buffer against distress.¹⁴ Although significant distress accompanies a cancer diagnosis and treatment, the entire cancer care experience can also result in significant positive experiences such as strengthening connections with loved ones.^15,16 Numerous studies have reported resilience and post-traumatic growth among patients with cancer and their caregivers.^17-21 The experience of cancer can also allow individuals to reflect on their lives and re-evaluate their choices, resulting in more meaning and satisfaction in life.²² 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 cancer treatment.²³ The existential threat of a cancer diagnosis and treatment can provide one of the first opportunities for most individuals to consider their own mortality seriously, perhaps resulting in a memento mori philosophy in which acknowledging the inevitability of death makes each day more gratifying.²⁴ Thus, including positive psychological health in the routine psychological evaluation (currently mostly focused on distress screening) for all patients with cancer may be especially relevant and invaluable for patients to achieve holistic well-being during and after treatment²⁵ and empower patients not just to survive but also to thrive regardless of early-stage or advanced cancer.²⁶ As Gilda Radner famously said, “cancer changes your life, often for the better. You learn what's important, you learn to prioritize, and you learn not to waste your time. You tell people you love them. If it wasn't for the downside, having cancer would be the best thing, and everyone would want it. That's true. If it wasn't for the downside.”²⁷

Just like distress, positive psychological factors could contribute to clinical outcomes in the cancer population via biologic and behavioral pathways.^28,29 Empirical data, however, on biologic links between positive psychological health and clinical outcomes in serious illness populations are less robust and consistent, especially in the cancer population.^30,31 A few studies in cardiac populations linked positive psychological factors with beneficial effects on inflammation³²—an important component of tumorigenesis and the focus of cancer therapeutics.^33,34 In a cross-sectional study of 950 individuals, Oreskovic and Goodman³⁴ showed that dispositional optimism was associated with less inflammatory markers (interleukin-6: B = –0.03, P = .02) after adjusting for sociodemographic factors. Also, Ikeda et al³⁵ reported that higher overall optimism scores were associated with lower levels of interleukin-6 and soluble intercellular adhesion molecules in 746 participants in the Normative Aging Study. Since inflammation plays an important role in the evolution of several cancers, the potential benefit of positive psychological factors in decreasing inflammation could be pertinent for patients with cancer. Hence, studies that specifically examine the association between positive psychological factors and inflammation in the oncology population could further advance the science of PPWB in medical populations.

The evidence is more extensive for healthy lifestyle behaviors (eg, physical activity, smoking cessation, and medication adherence) as a probable link between positive psychological factors and clinical outcomes in medical populations.^36,37 Indeed, individuals who report more positive psychological factors are likely more cognitively flexible, more adept at problem solving to manage stressors, and more likely to use diverse positive coping strategies in overcoming barriers to important healthy lifestyle behaviors.³⁸ For example, several studies have shown that positive psychological factors are associated with an increased likelihood of engaging in physical activity after controlling for sociodemographic, disease, and psychological factors.³⁷

Since healthy behaviors such as avoiding smoking or smoking cessation are protective against several cancers,³⁹ positive psychological factors could directly reduce the risk of cancer incidence via better health behaviors.⁴⁰ 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.⁴¹ Thus, if PPWB can reduce the barriers preventing cancer survivors from engaging in healthier behaviors that protect against chronic health conditions, its long-term impact on the oncology population could be substantial.

From Distress Screening to Psychological Well-Being Assessment

Increasing evidence that screening programs may help detect distress in patients with cancer has fueled the drive for distress screening for all oncology patients.⁴² We agree that it is essential that oncology clinicians assess the psychological and mental health of their patients at multiple points in their care cycle to ensure that psychological factors are not causing undue burden and suffering.⁴³ Current guidelines for distress screening at cancer centers recommend the use of valid distress screening instruments such as a distress thermometer.^44-47 However, this campaign is rather narrow and negatively focused and divides the population into distressed and not distressed. We 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. Although some PPWB factors are considered trait constructs, many are closely associated with state constructs whose reassessment at key clinical junctures (eg, time of diagnosis and treatment change) could engage patients' innate strengths and resilience factors that influence their illness, treatment, and recovery experiences. Unlike distress and negative psychological factors that should be addressed expeditiously, the ultimate goal of having 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. Conversely, state constructs (eg, positive affect) can fluctuate and change over time and might be more amenable to improvement with increased awareness of their influence in patients' lives. Indeed, assessing the full spectrum of psychological functioning multiple times during the care cycle acknowledges the breadth of responses to cancer and sets the aspirational goal of not only preventing or reducing distress but also cultivating resilience and other PPWB constructs in the lived experience of patients managing a cancer diagnosis, treatment, and recovery. A potential barrier to incorporating PPWB discussions in psychological health assessments is time constraints faced by oncology clinicians. However, PPWB discussions could easily be integrated into routine patient-reported outcome monitoring or current routine psychological health assessments completed by social workers with minimal extra training—prior positive psychological interventions in other medical populations were successfully delivered by social workers.^48-51 Also, with effective use of digital health technologies for patient-reported outcome monitoring and the fact that most validated PPWB assessments (eg, the gratitude questionnaire⁵²) are relatively short in length (ie, ≤ 10 questions), PPWB assessments could effectively be completed by patients remotely and reviewed systematically during routine social work visits without adding undue time burden to standard psychological health assessments. It is also possible that physicians would welcome an opportunity to discuss positive ways that patients are handling their diagnoses and treatment instead of solely focusing on distress and monitoring for complications.

We acknowledge that just as distress screening creates a conundrum where patients who screen positive may not readily have access to much-needed psychosocial services, PPWB discussions may pose similar concerns in that clinicians may not know what to do with their findings. However, unlike assessing for distress, anecdotally, several specific questions (Table 1) about PPWB may be informative and can stimulate conversation about overall psychological well-being throughout the cancer care experience, inform treatment planning and prognostic awareness conversations, and be therapeutic without the need for involvement of mental health clinicians. Several studies in medical populations other than cancer^4,51,66 show that PPWB can be increased by interventions and is not merely a reflection of a person's health status.^8,38 Indeed, positive psychology interventions, which use deliberate and systematic activities (eg, gratitude letter) to foster PPWB and mitigate distress,⁸ can be delivered by clinicians with different training backgrounds. This includes those outside of specialty mental health care, allowing easier accessibility compared with other psychological treatments in cancer care settings.^38,67 With growing evidence for the efficacy of positive psychology interventions for cancer populations, Rosenberg et al⁶⁷ have shown that a positive psychology intervention focused on cultivating resilience in young adults with cancer delivered by trained bachelor-level nonclinical coaches is feasible and is associated with sustained improvements in psychological outcomes up to two years postintervention. A similar intervention for patients with more advanced disease was also feasible.²⁶ Hence, positive psychological interventions could be customized for patients depending on their values, life circumstances, disease stage, and prognosis. For example, future-oriented PPWB constructs such as life purpose could be emphasized in patients with early-stage disease. By contrast, more reflective constructs like meaning in daily life could be emphasized in patients with advanced disease. Hence, interventions that focus on increasing a patient's life satisfaction, social support, life purpose, coping, and positive affect, in relation to their overall life circumstances and health, could be especially important for the cancer population during active cancer treatment and in their future lives.^4,67

TABLE 1.

Validated Instruments and Clinical Questions to Explore Positive Psychological Well-Being in the Oncology Population

Recommendations

Overall, we advocate that enhancing PPWB during the entire cancer care cycle should go hand-in-hand with minimizing 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 patient with cancer wants to maintain an optimistic spirit, satisfaction with their life, and gratitude, as we have observed in patients with other medical conditions.⁴ Robust interventions to harness PPWB in both the short- and long-term are overdue in the cancer population. Suggestions for an investigation into PPWB in heterogeneous cancer populations are as follows: first, research that describes the trajectory of positive psychological health factors among patients with different cancers is essential to developing effective supportive oncology interventions and helps us identify relevant time points for intervention. Second, theory development, conceptual clarity, and research that describes the interaction between PPWB and distress in patients with cancer are needed—many questions remain about whether PPWB and distress are orthogonal versus parallel constructs. Third, although optimism is the most studied positive psychological factor among patients with medical illnesses, including cancer, studies examining other PPWB factors (eg, gratitude, perseverance, acceptance, and satisfaction) are needed. Fourth, further studies should evaluate PPWB intervention strategies (alone or integrated with other supportive care interventions) for improving health and quality of life. Fifth, more research is needed to describe which PPWB constructs yield the most benefit, are associated with better health and quality of life, and when they could or should be enhanced. Sixth, studies designed to dissect the biologic and behavioral mechanisms by which positive psychological factors affect clinical outcomes in cancer are also needed to further aid in intervention development. Ultimately, fostering PPWB in patients, regardless of their circumstances, could enhance patients' overall psychological health throughout their treatment and lived experience with cancer.

AUTHOR CONTRIBUTIONS

Administrative support: Hermioni L. Amonoo

Provision of study materials or patients: Hermioni L. Amonoo

Manuscript writing: All authors

Final approval of manuscript: All authors

Accountable for all aspects of the work: All authors

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

Yin and Yang of Psychological Health in the Cancer Experience: Does Positive Psychology Have a Role?

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