Your Best Solution for Anxiety

woman using mindfulness meditation to relieve anxiety
Meditation is not just for hippies any more

The Benefits of Meditation For Anxiety in Difficult Times

Do you have tense muscles? Are your shoulders creeping up toward your ears? Do you obsess about the news? Do you have anxiety about your future? Difficulty sleeping? All of the above? You’re definitely not alone. There’s no doubt that we are all living with a lot of uncertainty right now.

So how can we cope when we don’t know if we’ll keep our job if we can pay our rent or mortgage, if we can keep putting food on the table, if we can save for our retirement or our children’s education?

How Doing Nothing Helps You Cope with Everything

The answer might be as simple as doing nothing, simply sitting still and purposefully clearing your thoughts through meditation. Studies show that it has an astounding number of benefits that are vital in situations just like this.

In fact, fostering an ongoing meditation practice actually changes the structure of your brain. That change provides benefits that continue even when you have finished meditating.

In short, meditation just may be one of the best things you can do for yourself in these troubled times. Will it put food on the table? No. But, it may get your brain out of the current “fight or flight” pattern that makes clear-headed decision making next to impossible. That way you can make a clear and decisive path forward.

Five Benefits Of Meditation

Here are just a few of the many positive things that happen when you meditate:

Lower Blood Pressure

As I mentioned, meditation decreases the “flight or fight” hormones in your body. As a result of this relaxation response, your blood vessels open up, which in turn improves your blood pressure if it tends to be high.

Less Stress-Induced Inflammation

Excess cortisol, one of your main stress hormones, increases blood sugar, which then increases insulin, which leads to inflammation in many parts of your body. A common example of this is in your gut. Digestive issues are common during times of high stress. Because meditation lowers the amount of cortisol you produce, inflammation is reduced.

Embracing Uncertainty

Despite all of the health benefits, the ultimate goal of meditation isn’t necessarily focused on physical results. It’s more a process of learning to embrace uncertainty. It’s not about eliminating or controlling the storm, it’s about learning to be still and calm despite the storm going on around you.

A More Optimistic Outlook

Who doesn’t need a more positive outlook right now? Meditation has been found to actually alter (in a good way) the parts of your brain responsible for positive thoughts. As well, by becoming more aware of your thoughts, you can fend off negativity. There are many health benefits to having a positive, optimistic attitude. In fact, studies show that higher optimism is a significant predictor of better survival, better cardiovascular outcomes, improved physiological markers (including immune function), better outcomes related to pregnancy, fewer physical symptoms, and reduced pain.

Reduced Anxiety And Rumination

It’s perfectly normal to be experiencing anxiety and worries about health and financial security when you are faced with something as stressful as a pandemic. However, when those thoughts spiral out of control they can negatively affect your family members as well as your own mental and physical health. High cortisol levels even lower your immune response, and we all need a strong immune system right now.

How Does Meditation Help With Negative Thoughts?

It may be difficult to imagine reining in the out-of-control, off-the-rails thought train when world events, and substantial changes to our daily lives, are so overwhelming.

However, meditation teaches us how to experience those thoughts without panicking or feeling the need to repress them. With a little practice, you should be able to just sit with your thoughts and feelings, without judgment or analysis, and start to process them without spiralling out of control. You can be present in the moment without projecting into the future or ruminating on the past.

And right now, faced with so many uncertainties, that’s particularly beneficial.

Why Start Meditating Now?

You might feel that now is not a good time to start meditation. After all, you’re likely stuck at home and perhaps feel antsy and confined. Who wants to sit still? However, meditation has proven to be an effective mental health treatment. Right now we need to be focusing not just on keeping a healthy body but also maintaining a healthy mind.

How To Meditate

Many people find the thought of taking up meditation a bit intimidating. After all, it has had a reputation of being “weird” and “fringe” throughout the ages. It’s important to know that you don’t have to “master” meditation. It’s OK to be imperfect. Your mind will probably wander, and you may feel uncomfortable at first. That’s perfectly normal.

Setting Up Your Practice

The good news is that it’s surprisingly simple to get started. In basic terms, you just need to:

  • Find a comfortable place. Ideally, somewhere that is quiet.
  • Sit in a natural, relaxed position.
  • Breathe normally.
  • Focus on your breath.

Try not to overthink this: just focus on each exhalation and inhalation. It’s not necessary to force anything.

  • If your mind wanders (and since you’re human, there’s a good chance that it will) try to sit back and “observe” your thoughts. Don’t analyze them. And don’t berate yourself for losing focus. It’s all part of the process. They are just passing through your brain.

How Long Should You Meditate For?

You may have heard of people going on week-long meditation retreats. That’s great – but it’s not really necessary. Just a few minutes a day is a good start. In fact, studies have found that just five minutes of meditation has significant benefits.

And who can’t fit 5 minutes of meditation into their day?

How Often Should You Meditate?

As with many things, consistency is a key component of a successful meditation practice. Try to carve out a few minutes per day to dedicate to your mental health. Some people find that it helps to make it the same time every day. Some find that doing 5 minutes in the morning as soon as they wake up and setting an intention for the day helps. Others will do 5 minutes as they are going to bed at night. And other people find it beneficial to do 5 minutes here and there throughout the day when they are feeling the most anxious. There is no hard and fast rule. Do what works for you.

Ok, full disclosure here, I have a hard time with meditating. I find it hard to just be still and “do nothing”. But here’s what I can do. After I have done my morning yoga, and I reach the end. I’m lying on my back in Shavasana or Corpse pose, then I can add 5 more minutes to just clear my mind and prepare for the rest of my day. That’s what works best for me with meditation.

Resources To Get Your Meditation Practice Started

There are quite a few wonderful resources available to help you get started with meditation should you need a little help – here are a few of our favourites:

Headspace

Calm

Wherever You Go, There You Are

Meditation for Fidgety Skeptics

There are many reasons to start meditation. Why not start now? Let us know how it works for you and remember that we are here to support your health and wellness.

Need more help?

Our clinic is still (virtually) open via telehealth (phone or video call) with our naturopaths, our chiropractor, our dietitian, and our psychotherapist. Chiropractor Dr. Darlene Buan-Basit is available for in-person essential care appointments. Simply send us an email at Maria@ForcesofNature.ca, leave a message 416-481-0222 or book online.

By Dr. Pamela Frank, BSc(Hons), ND

Meditation Research

https://www.ncbi.nlm.nih.gov/pubmed/25390009

https://www.npr.org/2008/08/21/93796200/to-lower-blood-pressure-open-up-and-say-om

https://www.sciencedirect.com/science/article/pii/S0889159112004758

https://www.sciencedirect.com/science/article/pii/S0889159112004758

https://www.researchgate.net/publication/5946075_Relationships_between_mindfulness_practice_and_levels_of_mindfulness_medical_and_psychological_symptoms_and_well-being_in_a_mindfulness-based_stress_reduction_program

https://journals.sagepub.com/doi/full/10.1177/0306624X19856232

https://www.semanticscholar.org/paper/Effects-of-Five-Minute-Mindfulness-Meditation-on-Lam-Sterling/7a7529a9e6401679016ab78f398eaaf4487aff84

https://journals.lww.com/psychosomaticmedicine/Abstract/2003/07000/Alterations_in_Brain and_Immune_Function_Produced.14.aspx

https://www.ncbi.nlm.nih.gov/pubmed/19711142

Beating Burnout

pic showing rocks balancing with words is your body out of balance
How to Balance Your Life

How to Restore Balance to Your Life

Are you feeling burnt out and overwhelmed? You’re not alone. Let’s face it: We’re all busy, dealing with endless to-do lists and struggling to balance it all. The result is often a day-to-day life that feels too hectic. We feel pulled away from the things that really matter most. We may have even forgotten what those things are!

Many people find their way to our wellness clinic at a point in their lives where they feel compelled to take charge of their well-being before it gets even further out of control. Sometimes they’re experiencing health problems that they just can’t shake. Some have symptoms but no one can figure out what is wrong with them. Others are ready to take their health to the next level because they know that their health is their greatest asset. By seeking the kind of holistic help all of our wellness experts provide, they’re claiming ownership of their current and future health.

A Fork In The Road

The inescapable truth is that good health is vital to living a rich and meaningful life. Fortunately, our bodies let us know when we’re jeopardizing our present and future health by giving us warning signs in the form of unpleasant symptoms. However, many of us don’t listen to those signs or we try to cover them up with band-aid solutions and carry on. This propels our health even further down a slippery slope.

Here’s a key fact: Disease doesn’t develop overnight. It often begins when we’re out of balance and burnt out. We need to pay attention to the warning signs before they escalate into something much worse.

Five Signs That Your Body Is Out Of Balance

You Feel Incredibly Stressed

We all feel stressed from time to time. Some stress is actually beneficial to motivate us to get things done. However, chronic stress leads to many health issues, including muscle pain, fibromyalgia, chronic fatigue, cardiovascular and digestive issues, hormonal imbalance, depression, anxiety, and low immune system function.

From a survival standpoint, the “fight or flight” response produced by stress hormones like cortisol and adrenaline makes sense. By putting your body into overdrive, those hormones help you physically if you are in danger. For example, when our ancestors were under attack by a predator, the fight or flight hormones helped them fight back or escape. However, in today’s world, stress tends to be more mental or emotional than physical, and more chronic than acute. As a result, your hormone levels end up way out of balance.

Irritability and Mood Swings are Signs of Burnout

Are you ready to fly off the handle at any moment? Do the things that used to make you laugh now irritate you? You could have an imbalance in the neurotransmitters that affect your moods, such as serotonin or GABA. Changes in estrogen, progesterone and testosterone levels and thyroid hormone imbalances also lead to irritability.

You are Experiencing Sleep Disturbances: Difficulty Falling or Staying Asleep

Sleep problems can become a vicious cycle. We need sleep to refresh our minds and restore balance, but when our bodies are out of balance, it is difficult to sleep well. If you toss and turn for hours, or wake up in the night with your mind racing, it may be time to listen to your body and start practicing better sleep hygiene.

Following these steps to improve sleep resolves most issues:

  1. Maintain a regular bedtime, try to go to bed by 10 p.m.
  2. Shut down electronic devices by 8 p.m. and keep them out of your bedroom
  3. Keep your bedroom cool, quiet and dark. Invest in blackout curtains.
  4. Avoid eating for at least 2 hours before bed
  5. Avoid sugar and alcohol in the evening. These destabilize your blood sugar at night. The resultant dips in blood sugar wake you up in the night or keep you in a light, restless sleep.
  6. Do something that relaxes you in the evening. Read a book. Have a bath. Knit.
  7. Have a little protein (eggs, fish, nuts/nut butter) before bed. These help to stabilize your blood sugar to help you get to sleep, get into a deeper sleep and stay asleep longer.
  8. Balance your hormones. Hormone balance is crucial to good quality sleep.

Your Body is Changing and you Can’t Figure Out Why

Many patients experience mysterious symptoms that can’t be explained by conventional medicine. These symptoms may include rapid, unexplained weight gain, debilitating fatigue, and skin problems. Weight gain is a common symptom of imbalance. If you find you’ve gained weight without any change to your lifestyle, your body might be telling you that it’s out of balance. Similarly, unexplained fatigue or sudden acne (long past the teen years) are symptoms you shouldn’t just ignore.

There is an explanation for symptoms like these. If you’re being told it’s “just stress“, our naturopaths will dig deeper to get to the root cause of your problem.

You Rely on External Substances to “Manage” Life

If you feel like you can’t make it through the day without your morning coffee, mid-morning macchiato, and afternoon pumpkin spice latte and muffin, ask yourself what purpose those caffeinated drinks and sugar are serving. Relying on a substance, be it sugar, caffeine, or even alcohol, marijuana or cigarettes is not a sustainable way of coping with life’s difficulties. The short-term boost they provide soon gives way to imbalance and disease. It’s important to seek help to nip these habits in the bud.

Does anything on that list sound familiar? If so, you’re not alone! Feeling overwhelmed is often the result of our natural instinct to try to do everything or please everyone. The good news is that there’s a better way.

Recovering From Burnout: How To Bring Your Health Back Into Balance

How can you start the process of restoring balance? When you’re feeling overwhelmed, it may seem like a daunting task. But, it’s simpler than you might think.

Step One. Prioritize What’s Really Important.

What matters most to you? Chances are that it’s not the housework, what’s happening on Instagram, your emails, buying a nicer couch, or any of the other things that take up space on your to-do list. Ultimately, for most of us, the important things are more intangible: our health, relationships, and family. In order to prioritize the things that matter, we need to put self-care at the top of our to-do list. Simply put, we can’t devote energy to the truly important things or people if we’re not looking after ourselves.

Interestingly, many people find that when they adjust their priorities, the other things cease to feel like such a struggle. It may seem like a bit of a paradox, but when we look after ourselves, everything else in life just falls into place.

If you want to reconnect with your priorities and figure out what really matters, mindfulness meditation helps. You can also try journaling. Writing down your thoughts is a great way to sort them out. In fact, writing down your emotions can be the outlet you need to ease the harmful physical effects of stress. Remember to include what you are thankful for in your journal. Take time for expressing gratitude daily. Studies show that higher levels of gratitude are associated with higher levels of subjective well-being.

Three vital self-care tips

  1. Take time to make healthy meals. Then take the time to sit down together with friends and family to enjoy them. Meal prep on Sundays with a meal prep menu so that making a healthy dinner isn’t rushed at the end of a long work-day.
  2. Schedule time with your wellness team and explore all of your health options. Why not try someone new? Have you ever seen an osteopath? A psychotherapist? An acupuncturist? A chiropractor? A naturopath? Why not have all hands on deck to optimize your health?
  3. Fit exercise into your busy schedule. Get up earlier to workout, take stairs, walk, take transit instead of taking the car. Taking the TTC builds exercise into your day by walking more and taking stairs and helps our environment too.

Step 2: Prioritize Down-time

Despite having busy lives, our bodies need a certain amount of downtime every day. If you are working all day, doing chores in the evening, answering email until you go to bed, your body doesn’t get the time it needs to recover. Disconnect from your devices and make a point of relaxing from 8 p.m. until you go to bed, every night. Get a full 8 hours of good quality sleep every night.

Step 3: Get the Right Nutrition

When you are constantly on the go and under pressure, your body’s demand for certain vitamins and minerals increases. Coping with stress necessitates adequate stores of vitamin C, vitamin B5, vitamin B6, magnesium and zinc. Good food sources of vitamin C include citrus fruits, kiwi, berries, peppers, and melons. Foods rich in vitamin B5 include mushrooms, eggs, salmon, beef, chicken, turkey, sunflower seeds, pork, sweet potato, and avocados. Vitamin B6 is found in foods like salmon, chicken, beef, pork, avocados, sweet potato, and pistachios. Magnesium-rich foods include dark, green leafy vegetables like kale, spinach, Swiss chard, and beet greens, as well as seeds, beans, nuts, fish and chocolate. Zinc is abundant in egg yolks, beef, shellfish, and pumpkin seeds.

The amount of these vitamins and minerals that you need under stress may be more than you can provide through diet alone, however. In that case, supplementation with good quality vitamins and minerals becomes vital.

Step 4: Recognize Where you Need Help and Ask For It

This step can be hard for many people. After all, as adults, we’re supposed to be self-sufficient, right? However, consider this: Many highly successful people have help. Athletes have health and fitness coaches; musicians have teachers; many business owners have mentors. And they often credit their success to that support and guidance.

The real strength is in identifying the areas of your life that feel out of control or could be better, and admitting that you could do with a helping hand. Then finding the right person to guide you in that area.

A good first step is to book a thorough review of your health and wellness status with your Naturopathic Doctor. We’re here to help you better understand where these feelings of overwhelm and troublesome symptoms are coming from. We’ll give you the tools that you need to find balance again. We can also direct you to the other healthcare practitioners that would be most beneficial for you.

Functional testing is available to remove the guesswork. Tests identify any possible underlying physical issues, such as hormonal imbalances. This holistic approach allows us to support you with an effective plan of action for your health and well-being that’s tailored specifically to you.

If you are ready to dive deeper into your health and rebalance your life, give us a call at 416-481-0222!

Authored By Dr. Pamela Frank


References

https://www.sciencedaily.com/releases/2012/04/120402162546.htm

https://www.psychologytoday.com/us/blog/raising-happiness/201609/9-ways-ease-overwhelm

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3341916/

https://www.researchgate.net/profile/Edo_De_Kloet/publication/7849122_De_Kloet_ER_Joels_M_Holsboer_F_Stress_and_the_brain_from_adaptation_to_disease_Nat_Rev_Neurosci_6_463-475/links/53f477e80cf2888a7490fcf9/De-Kloet-ER-Joels-M-Holsboer-F-Stress-and-the-brain-from-adaptation-to-disease-Nat-Rev-Neurosci-6-463-475.pdf

https://www.cambridge.org/core/journals/advances-in-psychiatric-treatment/article/emotional-and-physical-health-benefits-of-expressive-writing/ED2976A61F5DE56B46F07A1CE9EA9F9F

https://www.ncbi.nlm.nih.gov/pubmed/31105762

Hormones: Common Symptoms

picture of glands that produce hormones

Are your Hormones the Cause of your Health Issues?

Have you been experiencing nagging symptoms, affecting your daily life that you just can’t shake? It may be that the balance (or imbalance) of your hormones is the culprit.

Often we think of hormones as only being related to sexual function, but the truth is that a variety of hormones govern all of our body’s functions in some way or another.  Because of the interplay of messages that they relay to your brain and body, they regulate more than just sexual function.

If you thought that the only hormones we have are estrogen, progesterone, and testosterone, well, you’d be in a majority. In actuality, a number of other chemicals that we talk about all the time at Forces of Nature are also hormones and have a lot to say in helping our bodies to experience optimal health.

There are several hormones that, depending on their current balance, most readily affect your overall health.

Some common symptoms and their hormones:

Our hormones are like an orchestra.  They play together to synchronize and harmonize our beings to create optimal health patterns throughout the day and night. Their job is to keep us healthy and balanced, physically and emotionally. Sometimes, our modern lifestyle creates habits and workloads that can disrupt our body’s natural ability to balance our hormones.

So, when we start to exhibit symptoms that just won’t go away, such as long-term anxiety or stress, brain fog, sleep or weight management issues, mood swings, and long-term shifts in libido, investigating and caring for the glands that produce our hormones could address and solve the root of the problem.

Symptom Glands Associated Hormones
Adult Acne/Cystic Acne Ovaries

Testes

Estrogen and Androgens (Testosterone, DHT, DHEAs, Androstenedione)
Anxiety/Stress Adrenals Epinephrine/Adrenaline, Norepinephrine, Glucocorticoids, Mineralocorticoids,  Cortisol, Cortisone
Concentration Issues/Brain Fog Pineal, Enterochromaffin Cells in the Gastrointestinal Tract, Hypothalamus, Pituitary, Thyroid, Ovaries, Testes Melatonin, Serotonin, Dopamine, Epinephrine, Norepinephrine, Estrogen, Testosterone, T4/T3
Digestive Issues Thyroid, Pancreas Thyroxine (T4), T3, Insulin
Libido Adrenals, Testes, Ovaries Estrogen, Progesterone, Testosterone, DHEAs, DHT
Mood Swings Pituitary, Enterochromaffin Cells in Gastrointestinal Tract, Ovaries, Testes Endorphins, Serotonin, Dopamine, Estrogen, Testosterone, DHEAs, DHT
Sleep Issues/Insomnia Pineal, Adrenals Melatonin, Epinephrine, Norepinephrine, Aldosterone, Cortisol, Cortisone
Weight Maintenance Adrenals, Adipose tissue, Pancreas Cortisol, DHEA/DHEAs (as a precursor to Estrogen and Testosterone), Leptin, Insulin

How you can help your hormones

Your General Practitioner will have many suggestions to help treat the symptoms you’re experiencing.  But working with your whole health team including our integrative medicine practitioners (naturopathic doctors, chiropractor, acupuncturist, massage therapists & psychotherapist) will yield the greatest benefits because the therapies can complement each other.

For example, your GP might prescribe antidepressants or sleep aids to help manage your symptoms and ‘get you over the hump’ and on your way to recovery. Our Naturopathic and Integrative Health Practitioners will work on utilizing nutrition, supplements, stress reduction, exercise, lifestyle changes, acupuncture, massage and herbs to get at the root cause of the problems you’re experiencing and get your hormones back into balance.

Naturopathic medicine looks extensively at the whole body to determine what is causing your problem.  We often uncover a myriad of issues that all work together to create the person’s current health condition. Hormones often play a role but we also must uncover why they are imbalanced.

What Causes Hormones to Become Imbalanced?

There are a number of factors that may cause or contribute to hormone imbalance:

  • Chronic stress
  • Nutrient deficiencies – particularly vitamins B5 & B6, magnesium, zinc, L-5MHF (active folic acid) and vitamin B12
  • Poor diet – diets high in carbs and sugar provoke the need for plenty of insulin that then creates a hormone imbalance
  • Lifestyle – lack of exercise, lack of sleep, working long hours, lack of exposure to sunlight, exposure to artificial light in the evening
  • Environmental pollutants – BPA from plastic, dioxin, PCB’s etc are all endocrine disruptors

How can we help your hormonal imbalance?

Once you’ve had a chance to share with your naturopathic doctor or integrative health practitioner the series of symptoms, situations, and concerns you’ve been experiencing, we can then start putting the pieces together to outline the best options for treatment just for you.

The first set of treatment and care options that your healthcare team will look at are nutrient deficiencies and habit patterns. It’s amazing how many maladies can be remedied when we have greater focus and dedication to providing our bodies with the right nutrition, nutrients, hydration, stress management, exercise, and adequate sleep.

The next set of options could be supplements and herbs. When you’ve begun to line up a more healthy routine of nutrition, exercise, and sleep, supplementation of key nutrients, minerals and herbs could yield even greater results. We have many tools in our toolbox to help get you on the right path to a balanced system, which in turn means a balanced life!

We’re here to help you. If you’re experiencing symptoms that you just can’t beat, it’s a good time to call us to investigate your hormones and provide you with a pathway to health. Our door is always open and your road to optimal health is just a phone call (416-481-0222) or email away.

Hormones Research

Schwartz DH, Romans SE, Meiyappan S, De Souza MJ, Einstein G. The role of ovarian steroid hormones in mood. Horm Behav. 2012 Sep;62(4):448-54. doi: 10.1016/j.yhbeh.2012.08.001. Epub 2012 Aug 8.

Stressed?

tips for man feeling stressed

Feeling Stressed?

We all experience stress in our lives from time to time. Stress is a normal physical response to events that threaten us, or upset our balance in some way. In these situations, our body kicks into high gear with the “fight or flight” response, the feeling of being stressed. This response can actually be helpful in certain stressful situations where you need to defend yourself, or stay focused (like in an emergency situation).

However, because the body doesn’t distinguish between physical and emotional threats, some of us can become stuck in a “stressed-out” state . Long-term exposure to stress can lead to serious health problems.

Chronic stress disrupts nearly every system in your body. It can raise blood pressure, suppress the immune system, as well as increase the risk of heart attack and stroke.

There are many ways in which we can relieve tension, stress, and anxiety. Massage therapy is an excellent way to help manage stress. Massage can help to get rid of muscle tension (often a direct physical symptom of stress), reduce stress and anxiety, and it’s thought to even boost your body’s immune system. More research is needed into the subject of stress and massage, but studies have shown that patients being treated for cancer who received regular massage reported less anxiety, pain, and fatigue than those who did not receive regular massage.  Six out of nine studies on children and adolescents found that they were less stressed and fatigued with the addition of complementary treatments like massage therapy to conventional cancer treatment.

Talk to your RMT about massage therapy for stress management.

Here are 5 tips for relaxation between your massage treatments:

  1. Schedule downtime.  Relaxation time every day is as important as eating well and exercising.
  2. Yoga or meditation.  Research on both shows reductions in stress hormones with regular practice.
  3. Socialize.  Social interaction can help relieve stressful situations and provide much needed support.
  4. Reduce your caffeine intake.  Caffeine is a stimulant and while it may give you a boost, at the same time it taxes your adrenal (stress) glands.
  5. Sleep.  Make sleep a priority.  Research shows that at least 7-7.5 hours per night is ideal.

Massage and Stress References:

Garner B, Phillips LJ, Schmidt HM, Markulev C, O’Connor J, Wood SJ, Berger GE, Burnett P, McGorry PD. Pilot study evaluating the effect of massage therapy on stress, anxiety and aggression in a young adult psychiatric inpatient unit. Aust N Z J Psychiatry. 2008 May;42(5):414-22. doi: 10.1080/00048670801961131.

Lopes-Júnior LC, Bomfim EO, Nascimento LC, Nunes MD, Pereira-da-Silva G, Lima RA. Non-pharmacological interventions to manage fatigue and psychological stress in children and adolescents with cancer: an integrative review. Eur J Cancer Care (Engl). 2015 Sep 16. doi: 10.1111/ecc.12381.