Low resilience in patients with cancer as a factor influencing anxiety, depression, and quality-of-life

Abstract

Low resilience levels in patients with cancer have been associated with anxiety, depression, and reduced quality-of-life (QoL), resilience serves as a crucial mediating variable in these pathways, constituting one of the most actively investigated research domains. Recent studies on the correlation between resilience, coping styles, and QoL have offered important insights into the potential psychological mechanisms through which resilience could affect emotional well-being and overall QoL in patients with cancer. These findings suggest that low resilience constitutes a significant risk factor for cancer prognosis. This study reviews the negative impact of low resilience on cancer prognosis and highlights resilience-enhancing interventions. Promoting resilience-focused interventions may represent a promising approach to ameliorate anxiety and depression, thus improving QoL and potentially improving clinical prognosis for patients with cancer.

Key Words: Cancer; Resilience; Coping styles; Quality-of-life; Anxiety; Depression; Prognosis

Core Tip: Resilience, coping styles, and social support in patients with cancer are closely related to their quality-of-life. Substantial evidence confirms the adverse effects of low resilience in patients with cancer. However, enhancing the resilience of the patients through effective intervention can help improve negative emotions such as anxiety and depression, increase sleep quality, and boost overall quality-of-life, thereby positively impacting their prognoses. Strategies to improve resilience include psychotherapy, active coping, strengthened social support and self-efficacy, exercise, and medical assistance.

TO THE EDITOR

The rising incidence of cancer has made it one of the most significant threats to human health and longevity. Strengthening risk factor management is essential to improving patient prognosis[1]. Recently, research on patient resilience has gained increasing attention. Resilience refers to the capacity to cope with and adapt to stress[2,3]. For example, patients with lung cancer often experience a decline in resilience as the disease progresses, accompanied by multi-system dysfunction, heightened anxiety and depression, and elevated mortality rates. Interventions targeting resilience in patients with lung cancer may contribute to better clinical outcomes[4]. However, the underlying association mechanisms linking resilience to quality-of-life (QoL) in patients with cancer remain incompletely understood.

A recent study by Qin et al[5] published a study recently. Their results demonstrated that resilience scores were positively correlated with active coping styles, negatively correlated with passive coping styles, positively associated with all QoL domains (physical, role, cognitive, emotional, and social functioning, as well as global health status), and inversely related to fatigue, insomnia, and financial distress[5]. This study elucidates the bidirectional regulatory mechanisms of resilience on QoL in patients with cancer.

These insights support the development of more effective interventions to address negative emotions in patients with cancer; help them enhance their resilience, improve their coping styles; and, through more personalized treatment and support, ultimately enhance their QoL and prognosis. However, What interventions can be formulated to enhance resilience? This paper highlights the pivotal role of psychological resilience as a modifiable factor influencing cancer prognosis. Drawing upon recent research evidence, we advocate for the urgent integration of resilience-targeted interventions into multidisciplinary cancer care.

THE ASSOCIATION BETWEEN LOW RESILIENCE AND THE QOL AND PROGNOSIS IN CANCER PATIENTS

Numerous factors affect the QoL and prognosis of patients with cancer. Some of these factors, which include anxiety, depressive moods, sleep disturbances, and pain, have particularly significant impacts[6]. For instance, patients with colorectal cancer often exhibit high levels of anxiety and depressive symptoms, which are closely associated with severe pain and fatigue[7]. Depression in patients with cancer shortens survival rates and increases treatment discontinuation, worsening therapeutic outcomes[8-10]. The literature indicates that the incidence of anxiety among patients with cancer is 6.5%-40.0%, and the incidence of depression is 11%-58.0%[6,11,12].

Why do some cancer patients not exhibit anxiety, depression, and sleep disturbances when facing such significant stressors? Studies have shown that resilience and coping styles can serve as key predictors of health outcomes in patients with breast cancer. Higher resilience is closely associated with lower levels of depression and anxiety, as well as better sleep quality[13]. Not only is resilience significantly correlated with the QoL of patients with cancer, but coping styles also indirectly affect QoL through resilience[14]. Among patients with cancer, stress, anxiety, and depression are significantly negatively correlated with resilience, emphasizing the importance of enhancing resilience to maintain patients’ mental health and QoL. Treating psychological symptoms such as anxiety, depression, and sleep disturbances in patients with cancer can also help enhance their QoL and prognoses[15].

A study involving 773 nasopharyngeal carcinoma patients used structural equation modeling to explore the association between resilience and symptoms of anxiety and depression. The findings suggest that resilience significantly influenced both short- and long-term depression and anxiety post-cancer diagnosis[16]. Furthermore, low resilience may induce the onset of negative emotions such as depression and anxiety in patients with cancer, thereby reducing QoL and adversely affecting prognoses. Enhancing resilience may thus become a protective factor in preventing the onset of depressive and anxious symptoms in patients with cancer and in improving their QoL and prognosis.

NON-PHARMACOLOGICAL INTERVENTION FOR LOW RESILIENCE IN PATIENTS WITH CANCER

Psychological interventions

A meta-analysis indicates that resilience interventions can improve the cognitive flexibility, self-efficacy, self-esteem, self-regulation abilities, and coping skills of patients with cancer, positively impacting their resilience, post-traumatic growth, QoL, and anxiety and depression symptoms[17]. Social support directly affects resilience and indirectly influences it by promoting self-efficacy and positive coping styles[18]. Self-efficacy enhances confidence in achieving good health by controlling behavior and emotions and is expected to be a mediating factor between positive coping and resilience before the first chemotherapy in patients with gastric cancer, indicating a close relationship and mutual influence between self-efficacy, resilience, and coping styles[19]. Owing to the close relationship and mutual influence of social support and self-efficacy on resilience, good social support and enhanced self-efficacy are crucial for the rehabilitation of patients with cancer.

Narrative intervention methods based on cancer survivors’ experiences can effectively enhance patients’ resilience, self-efficacy, and QoL after surgery[20]. The application of mindfulness-based cancer recovery and cognitive behavioral therapy for insomnia can reduce the severity of insomnia in patients with cancer[21]. Mindfulness-based cognitive therapy and internet-based individual mindfulness-based cognitive therapy interventions have shown promising results in improving resilience and mental health and in extending overall survival in patients with cancer[16,22]. Comprehensive psychological interventions such as cognitive behavioral therapy, music therapy, and group interventions have been demonstrated to significantly alleviate psychological distress in post-operative patients with breast cancer. These interventions alleviate negative emotions, enhance resilience, and elevate patients’ QoL and treatment compliance[23]. Another meta-analysis, pooling data from 29 randomized controlled trials, revealed that positive psychological interventions for cancer patients - including meaning therapy, dignity therapy, positive psychotherapy, mindfulness, life review, expressive writing interventions, acceptance and commitment therapy, attention and interpretation therapy, and compassion training—significantly improved patients' resilience, QoL, and self-efficacy, while reducing negative emotions such as depression, anxiety, and hopelessness[24]. Psychological interventions can serve as the primary intervention approach to enhance resilience in patients with cancer.

Exercise therapy interventions

Personalized aerobic exercise interventions, tailored to the physical condition of patients with cancer, can help improve their sleep and QoL[25]. Appropriate exercises, such as strength training, resistance training, walking, cycling, yoga, or tai chi, can enhance the overall QoL of patients with cancer; alleviate related fatigue; improve sleep; and alleviate depression, anxiety, and pain[26,27]. Exercise also has positive effects on issues related to breast cancer, body image/self-esteem, emotional health, sexuality, sleep, social functioning, anxiety, and pain. These effects have been confirmed across various follow-up periods after cancer treatment[28]. Resistance exercise alleviated cancer-related fatigue, improved mental status, enhanced QoL, and increased physical mobility in older patients[29]. A four-month walking intervention study in patients with cancer demonstrated significant improvements in muscle strength, physical activity, and sleep quality, along with reduced fatigue and decreased psychological distress. The enhancement of resilience and physical health status served as important mechanisms underlying the reduction in fatigue levels following the walking intervention[30]. These findings suggest that appropriate exercise is beneficial for improving resilience and its related factors in patients with cancer.

Repetitive transcranial magnetic stimulation intervention

Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive neuromodulation technique. By inhibiting nociceptive signal transmission in the spinal cord, modulating hemodynamic changes in brain regions, and promoting the release of endogenous opioids, it exerts analgesic effects while improving mood, cognitive function, and QoL[31]. Patients with advanced cancer pain receiving rTMS therapy demonstrated better pain relief, reduced opioid dosage, and improved emotional state and QoL[32]. In another study, accelerated rTMS (600 pulses/session, eight sessions/day, hourly intervals, lasting for five days) significantly alleviated depression and anxiety symptoms in patients with advanced cancer showing psychological distress[33]. rTMS is a safe and effective therapeutic approach for cancer patients with depression; it can alleviate anxiety and depressive symptoms, reduce pain, improve QoL, and mitigate stress responses, while also demonstrating resilience-boosting potential.

PHARMACOLOGICAL INTERVENTION FOR LOW RESILIENCE IN PATIENTS WITH CANCER

Antidepressant medication intervention

There is a negative correlation between resilience, anxiety, and depression[34]. High resilience has a certain protective effect against depression and sleep disorders in patients with prostate cancer, but severe depression and sleep disorders can impair the protective effect of resilience due to their mutual interactions[35]. Resilience has been shown to be inversely associated with insomnia severity scores[5]. Conversely, insomnia itself can diminish resilience[36]. Antidepressants alleviate depressive symptoms and improve sleep quality, as evidenced by the effectiveness of low-dose mirtazapine, trazodone, and mianserin[37,38]. Antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs), demonstrate potential therapeutic benefits for cancer patients with comorbid depression[39,40]. Furthermore, fluoxetine and escitalopram (SSRIs drugs) demonstrate anti-hepatocellular carcinoma potential by activating caspase-3/8/9, releasing cytochrome C, and inhibiting the extracellular signal-regulated kinase/nuclear factor kappa B pathway and anti-apoptotic proteins, while reducing vascular endothelial growth factor and matrix metalloproteinase-9 expression. Collectively, these mechanisms suppress tumor invasion and angiogenesis. and reverse the Warburg effect. Similarly, SNRIs (e.g., venlafaxine) promote apoptosis via caspase-3/7 activation and enhance antitumor efficacy when combined with sorafenib[41]. While these studies offer initial evidence for the potential antitumor effects of SSRIs/SNRIs, substantial further investigation is needed.

However, in the treatment of cancer, appropriate use of antidepressants, anti-anxiety medications, and psychotherapy is necessary to reduce the severity of depression, anxiety, and sleep disorders, which may benefit the patient’s prognosis[39]. Compared with the control group, cancer patients with comorbid depression in one study showed significantly improved overall QoL scores after six weeks of fluoxetine treatment. Notable reductions were observed in symptoms such as pain, shortness of breath, fatigue, loss of appetite, insomnia, and depression, along with improvements in immune function indicators[42]. Although systematic reviews have found no evidence of significant adverse outcomes associated with antidepressant use (e.g., SSRIs and SNRIs) in patients with various cancers[43], nor a significantly increased risk of severe cardiovascular/cerebrovascular events in older patients with depression has been noted[44], the application of antidepressants in patients with cancer still requires careful consideration of individual patient conditions and potential drug interactions. Particular precautions include avoiding antidepressants with greater side effect profiles (e.g., monoamine oxidase inhibitors and tricyclic antidepressants) and exercising caution for critically ill patients presenting with cardiac, hepatic, or renal failure; bone marrow suppression; hemorrhagic tendencies; and end-stage disease. An overall assessment should be conducted to assess the risk-benefit ratio of antidepressant therapy. Preference should be given to agents with fewer drug interactions and higher safety profiles, accompanied by regular monitoring of treatment efficacy and adverse effects.

Traditional Chinese medicine and its synergistic intervention with antidepressants

Traditional Chinese medicines (TCM) generally have fewer side effects, and reports suggest that TCM such as black cohosh, chamomile, vitex, lavender, passionflower, and saffron can help alleviate anxiety and depression symptoms in patients with cancer and benefit them by reducing side effects[45]. Combination therapy using Chinese patent medicines alongside antidepressants has demonstrated superior efficacy and better safety profiles compared to antidepressant monotherapy. Specific effective combinations include Jiawei Xiaoyao pills with SSRIs, Danzhi Xiaoyao pills with SNRIs, Xiaoyao pills with SSRIs, and Jieyu pills with SNRIs[46]. TCM offer the advantage of fewer side effects. Further optimal combinations include Shugan Jieyu capsule with SSRIs and Jieyu Anshen pill with SSRIs[47].

CONCLUSION

Low resilience exerts substantial detrimental effects on both QoL and medical prognosis in cancer patients, mandating systematic clinical attention. We therefore recommend incorporating resilience enhancement into comprehensive treatment protocols as a key component of cancer management. Existing research suggests that an integrated multidisciplinary approach combining psychology, oncology, neuroscience, psychosomatic medicine, TCM, and sports medicine may optimize therapeutic efficacy and improve long-term prognosis. However, this study has several limitations: The included evidence was not restricted to randomized controlled trials and large-scale studies, potentially introducing publication bias and methodological heterogeneity, thus requiring validation through higher-level evidence. Furthermore, mechanistic studies on how resilience affects cancer prognosis, and the tolerability, safety, and long-term effectiveness of both pharmacological and non-pharmacological interventions require further investigation. Future research should incorporate emerging evidence (e.g., neuroendocrine mechanisms, neurobiological correlates of reduced resilience, adaptive randomized trials of intervention sequences for low-resilience cancer patients) to continually refine personalized intervention strategies, potentially offering novel perspectives for integrative cancer care.