COVID-19 Resource Center

COVID-19 Resource Center

Disclosures: Johns reports no relevant financial disclosures.
March 27, 2020
6 min read

‘Clarity with kindness’ key to easing COVID-19 anxiety among those with cancer

Disclosures: Johns reports no relevant financial disclosures.
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Shelley A. Johns, PsyD, HSPP, ABPP
Shelley A. Johns

The global COVID-19 pandemic has evoked fear and anxiety among people of all ages and health statuses.

These emotions are far more extreme among many people with cancer.

This can have a bidirectional effect, according to Shelley A. Johns, PsyD, HSPP, ABPP, associate member at Indiana University Melvin and Bren Simon Comprehensive Cancer Center and assistant professor of medicine at Indiana University School of Medicine.

Chronic stress from long-term crises that have no definite endpoint can weaken the immune system, and hormones the body produces as a response to chronic stress have been shown to contribute to cancer growth, according to Johns, also a research scientist at the Center for Health Services Research at Regenstrief Institute and a board-certified clinical health psychologist.

“We’re all under some chronic stress right now,” Johns told Healio. “When people are already fragile and compromised in terms of their immune systems, as are people with cancer under active or recent treatment, this stress may be compounded and may have more harmful effects. It’s like asking our patients with cancer to run a marathon with a broken foot.”

Preliminary data from China suggest individuals with cancer may be more likely than the general population to contract the novel coronavirus. Also, those who are undergoing or recently completed immunosuppressive treatment are believed to be at greater risk for serious complications should they contract it.

Johns spoke with Healio about how clinicians can talk with their patients — many of whom already are grappling emotionally with their cancer diagnosis — about the stress, anxiety or depression they may be experiencing due to the COVID-19 pandemic.

Question: When members of the cancer care team discuss COVID-19 with patients, how can they convey the importance of risk-reduction strategies while not compounding stress?

Answer: The most important thing my patients are telling me is that they want clear, direct information that can help them reduce their risk. They want clarity, but they want it delivered with kindness, sensitivity and respect. Many health care providers are overwhelmed right now and are pushed to the limit. We may not be communicating with as much patience and kindness as we might under normal circumstances.

Before we communicate with patients, we need to settle ourselves. Before meeting with a patient, making a telephone call or doing a video visit with a patient, every health care provider can take a breath and get centered. It is important to connect with the present moment and prepare ourselves for the patient we are about to speak with, who may be feeling understandably vulnerable and frightened. Pausing in this way will help us be more in tune with the patient’s emotional state and respond in a more effective and compassionate manner.


It is important simply to ask questions such as, “How can I be of support to you right now? What do you need most from me today?”

Most patients want answers. They might say, “I need to know if I can leave my house” or “I need to know if I can be around my children or grandchildren.” Most patients know what they want to ask; providers just need to listen and respond with clarity and compassion in the time available.

Q: How should clinicians advise patients to manage their stress?

A. Stress can’t be eliminated, but anything we can do to help our patients turn down the volume of stress by using effective coping skills is beneficial. Mind-body techniques like mindfulness meditation or yoga are evidence-based strategies that can be helpful as we each make informed choices about what we do to minimize exposure to the virus. Consistent with personalized medicine, we can ask each patient with cancer what types of coping skills, tools or resources have worked for them when they have been under stress in the past. Are they interested in drawing on some of those approaches, or are they interested in learning something new that might be of support right now? If someone has never tried mindfulness before but is interested, a health care provider could recommend they check out The website offers many no-cost resources, including guided meditation practices.

There is evidence to support that mindfulness meditation can be helpful in terms of cancer-related distress and symptom management. My research has tested mindfulness-based interventions for cancer-related fatigue and fear of recurrence, and the results have been quite promising. A clinician can recommend a patient try mindfulness for a week or two and see if it helps them in coping with COVID-19 stress with greater ease.

Q: What are the benefits of mindfulness meditation?

A: Mindfulness is the ability to be fully “awake” in our lives — aware of where we are and what we are doing without getting caught up in our thoughts or feelings. Many of us are painfully aware of the uncertainties of the future, which can heighten our stress and anxiety. Mindfulness can connect us to our inner wisdom so we can respond to challenges like COVID-19 skillfully. Mindfulness is about being present in this moment, and it can be done from home using resources that are freely available. In addition to, there are a variety of smartphone apps, and many are free (eg, Headspace, Calm, Insight Timer).


Q: What other coping strategies would you recommend?

A: There is substantial evidence that physical activity can help with stress management. For patients able to go outside, taking a brisk walk — noticing signs of spring — may be helpful. We need to maintain social distance as we walk, yet we can still offer a friendly wave to our neighbors. Some patients might enjoy trying a few gentle yoga stretches that can be done standing, seated or lying in bed. It’s also great to use music to brighten our mood. I have been putting on music that reminds me of easier times in my life when I felt vitally alive and wasn’t as stressed. You can make this more fun by dancing — there’s just something about moving your body that improves mood. It’s also important for patients to find creative ways to stay connected with others, whether by phone, online or another approach. One of my patients shared that she is sending cards and postcards to her five best friends from high school whom she had not spoken with in years. This is a values-consistent action for her that is brightening her mood and the mood of the recipients. Patients can use this difficult time as an opportunity to reconnect with people they care about.

Q: What about patients who are depressed or feel a sense of grief about COVID-19?

A: For patients with cancer, the sense of loss from COVID-19 compounds the loss that may already have existed due to the cancer diagnosis. When patients are struggling with a sense of loss, the first thing I recommend is that they name the loss and acknowledge it. Second, it is important to seek support. This can be through supportive friends or family, or through an oncology social worker, psychologist or chaplain. Many of these professionals are providing telehealth services right now to reduce risk of infection.

Another great tool that many oncologists and hematologists are already familiar with is the use of VitalTalk communication skills. Many hematologists and oncologists have been trained in VitalTalk, which teaches how to communicate with patients about serious illness in an effective, empathic and honest way. There is no better time to use VitalTalk skills than now as we talk with patients who are understandably afraid about their body’s ability to ward off infection, rationing of treatments as the pandemic spreads and delays in receiving life-saving treatments. The developers of VitalTalk are generously sharing practical advice on how to talk with patients about these and other difficult topics related to COVID-19. There are many examples of questions patients may ask, and how clinicians can respond in helpful, informative ways.


Q: How can a clinician combat the negative and/or inaccurate information a patient might encounter about COVID-19 on the news or social media?

A: The best approach is to calmly provide the most accurate information possible. I also have been asking my patients with cancer how much news and social media they’re consuming each day. If someone says they are doing much more than an hour, I gently advise against it. I say, “Don’t take my word for it, but do a little test to find your personal ‘sweet spot’ for news.” I ask them to rate their mood on a 0-10 scale before watching the news or going on social media, and then rate their mood on the same scale afterward. If news consumption is making your mood worse, you might want to scale back on the number of minutes you consume. I also suggest that if there’s anything major they need to know, they are likely to hear about it from someone in their life. I don’t think anyone needs more than an hour of news or social media in the course of a day, particularly when we start to hear the same details being rehashed. – by Jennifer Byrne

For more information:

Shelley A. Johns, PsyD, HSPP, ABPP, can be reached at Regenstrief Institute, 1101 W. 10th St., RF-226, Indianapolis, IN 46202; email:

Disclosure: Johns reports no relevant financial disclosures.