Elizabeth L. Kacel, PhD
Clinical Health Psychologist
Kellogg Cancer Center
Department of Psychiatry & Behavioral Sciences
NorthShore – Edward-Elmhurst Health
The American Cancer Society publishes frequently updated guidelines for a cancer-preventing lifestyle (Rock et al., 2020; American Cancer Society, 2020). These include: (1) abstaining from tobacco use, (2) maintaining a healthy weight, (3) engaging in regular physical activity, (4) maintaining a healthy diet, and (5) avoiding excess alcohol consumption.
These days, much of the general population is likely aware of the role of lifestyle contributors to cancer risk and prevention. Knowledge of factors in cancer survivorship is necessary but not sufficient to ensure sustainable lifestyle change during cancer treatment or as a cancer survivor. Here are a few examples:
- The person with lung cancer who continues using tobacco to cope with anxiety and guilt about having cancer
- The woman with estrogen sensitive breast cancer who knows physical activity helps recurrence risk but feels limited by fatigue and joint pain from hormone therapy
- The individual with colorectal cancer who has struggled with weight management well before cancer and isn’t sure where to begin changing nutrition after completing treatment
I see often in my psycho-oncology practice that after a cancer diagnosis, many attempt to enact swift and dramatic lifestyle changes due to fear about cancer recurrence or progression. Some place great pressure on themselves to exercise more often or at greater intensity than they have in years or even decades. Some “meat and potatoes” folks commit to a vegan diet. Frequently these changes are burdensome to maintain and, after a period of time, old habits become dominant again. Some individuals may double-down with unhealthy behaviors due to the distress associated with cancer diagnosis or after feelings of failure associated with attempts at extreme change that are not sustained.
As health psychologists, we know that sustained behavioral change is a complex phenomenon (Prochaska & Velicer, 1997). There are preparatory steps that individuals must take before committing to action, such as purchasing a gym membership, stocking the kitchen with fresh produce, or removing cigarettes from the home. Preparation often requires time, money, and support from loved ones. Trying to optimize cancer survivorship through lifestyle without proper access or preparation can impact likelihood of success.
When early attempts at behavior change are unsuccessful many patients often blame themselves and their ‘will-power’ for the inability to stick with the plan. They may even feel as if they are responsible for their cancer to begin with, due to a unique and personal flaw (e.g., that they are ‘stupid,’ ‘weak,’ or should be able to make healthy changes without professional help). These all-or-nothing approaches rarely promote persistent change. Each time a person feels they have failed, their motivation for change may decrease. Their confidence in their ability to try again may decrease too.
Practicing self-compassion can help increase motivation, confidence, and success with lifestyle change. Several studies have examined the impact of self-compassion on health behaviors in general, though no known studies have looked specifically at using self-compassion as part of lifestyle change in cancer survivorship and with an eye toward reducing risk of disease recurrence. Self-compassion, as described by Kristin Neff (2003) includes three major principles paraphrased here as relevant to health behavior change:
- Self-kindness: being gracious and forgiving of oneself when facing perceived failure rather than being excessively self-critical
- Common humanity: considering one’s challenges as profoundly human, not isolating or unique to perceived individual flaws
- Mindfulness: accepting unpleasant experiences as ephemeral, reducing rumination that facilitates depression and reduces motivation, and mitigating self-comparisons.
As it pertains to health behavior change, self-compassion includes recognition that perceived barriers to changing one’s diet or weight, exercise level, or substance use are common and completely human; that personal strength or willpower is not the only predictor of success, and that changes will most likely come one small step at a time.
This is where many of my patients get stuck. For example, they may be deconditioned from chemotherapy but want to walk three miles daily. They feel any less would be too easy, not get them toward their goal urgently enough, or represent personal weakness as compared to lived experience of physical prowess prior to cancer. Through conversations around self-compassion, many are able to reframe their expectations. There is no starting goal that is too low or too small. As I frequently say to my patients, “anything greater than zero is progress.” You couldn’t do two 10-minute walks but you did one? Fantastic. You didn’t do any ‘planned’ exercise but spent an hour walking at the farmer’s market? Excellent.
Additionally, if a patient is not able to achieve a goal at all at first pass, demonstrating self-compassion is critical. After a perceived failure, instead of playing the ‘shame and blame game,’ we dig into what barriers arose that made it difficult to achieve the health goal for the week. We problem-solve and set goals around those factors, including proactively brainstorming and addressing potential future obstacles. One of my cancer patients found that the best way to stay active over the summer was swimming in Lake Michigan, which was a short walk from her home. However, as the Fall season approaches and temperatures start dropping, we discussed how to maintain her progress when the lake would be too cold to enjoy. Ultimately it was important to her to continue swimming, so she researched local gyms with pools and got a good deal with her partner that would allow them to enjoy exercise together year round.
Self-compassion helps individuals focus on the big picture even when specific goals are not achieved. Reducing self-criticalness and promoting self-forgiveness can help prevent a small setback (e.g., a missed work-out, an unplanned cigarette or extra alcoholic beverage) from leading to resignation, generalization about one’s ability to lead a healthy lifestyle, or catastrophic fears that minor deviations from the plan will accelerate cancer recurrence or progression. It is critical to normalize and humanize setbacks to build scaffolding for greater change over time. This is consistent with the Transtheoretical Model of Change (Prochaska & Velicer, 1997); forming and maintaining healthy habits is an iterative process for all.
Small goal-setting, when done strategically and with the proper preparation, can significantly increase the likelihood of success. This produces intrinsic reward and self-reinforcement that boosts motivation to take another step forward. With time and progress, significant momentum can be cultivated toward important and sustainable healthy lifestyle change. This approach uses elements of “SMART” goal-setting, originally coined in the business world (Doran, 1981) and later applied to health behavior (White et al., 2020). While I have found this framework helpful in practice, the formation and achievement of SMART goals can be impacted by a lack of self-compassion if a person is unwilling to break down a goal to be appropriately small, specific, realistic, and meaningful to them as an individual.
Healthy behavior and lifestyle are an important part of cancer survivorship to promote long-term physical and psychological well-being. Healthy lifestyle may also include participating in psychotherapy to optimize sleep, mood, and stress management and/or receiving other supportive services to address unmet needs following cancer treatment. Another benefit of self-compassion in working toward a cancer-preventing lifestyle is that goals can be completely unique to an individual’s health status, socioeconomic resources, and intersectional identities (e.g., race/ethnicity/culture, gender, relationship status, etc). When you combine self-compassion with creativity, most people are able to identify personalized and meaningful ways to pursue a healthier lifestyle and to optimize their quality of life in cancer survivorship.
American Cancer Society. (2020). Is any type of tobacco product safe? https://www.cancer.org/cancer/risk-prevention/tobacco/is-any-type-of-smoking-safe.html
Doran, G. T. (1981). There’s a SMART Way to write management’s goals and objectives. Journal of Management Review, 70, 35-36.
Neff, K. (2003). Self-compassion: An alternative conceptualization of a health attitude toward oneself. Self and Identity, 2, 85-101.
Prochaska, J. O., & Velicer, W. F. (1997). The transtheoretical model of health behavior change. American Journal of Health Promotion, 12(1), 38-48.
Rock, C. L., Thomson, C., Gansler, T., Gapstur, S. M., McCullough, M. L., Patel, A. P., Andrews, K. A., Bandera, E. V., Spees, C.K., Robien, K., Hartman, S., Sullivan, K., Grant, B. L., Hamilton, K. K., Kushi, L. H., Caan, B. J., Kibbe, D., Donze Black, J., Wiedt, T. L. … Doyle, C. (2020). American Cancer Society guideline for diet and physical activity for cancer prevention. CA: A Cancer Journal for Clinicians, 70, 245-271.
White, N. D., Bautista, V., Lenz, T., & Cosimano, A. (2020). Using the SMART-EST goals in lifestyle medicine prescription. American Journal of Lifestyle Medicine, 14(3), 271-273.