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Spirituality in Cancer Care (PDQ®)

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Relation of Religion and Spirituality to Adjustment, Quality of Life, and Health Indices

Religion and spirituality have been shown to be significantly associated with measures of adjustment and with the management of symptoms in cancer patients. Religious and spiritual coping have been associated with lower levels of patient discomfort as well as reduced hostility, anxiety, and social isolation in cancer patients [1-4] and in family caregivers.[5] Specific characteristics of strong religious beliefs, including hope, optimism, freedom from regret, and life satisfaction, have also been associated with improved adjustment in individuals diagnosed with cancer.[6,7]

Type of religious coping may influence quality of life. In a multi-institutional cross-sectional study of 170 patients with advanced cancer, more use of positive religious coping methods (such as benevolent religious appraisals) was associated with better overall quality of life and higher scores on the existential and support domains of the McGill Quality of Life Questionnaire. In contrast, more use of negative religious coping methods (such as anger at God) was related to poorer overall quality of life and lower scores on the existential and psychological domains.[8,9] A study of 95 cancer patients diagnosed within the past 5 years found that spirituality was associated with less distress and better quality of life regardless of perceived life threat, with existential well-being but not religious well-being as the major contributor.[10]

Spiritual well-being, particularly a sense of meaning and peace,[11] is significantly associated with an ability of cancer patients to continue to enjoy life despite high levels of pain or fatigue. Spiritual well-being and depression are inversely related.[12,13] Higher levels of a sense of inner meaning and peace have also been associated with lower levels of depression, whereas measures of religiousness were unrelated to depression.[14]

This relationship has been specifically demonstrated in the cancer setting. In a cross-sectional survey of 85 hospice patients with cancer, there was a negative correlation between anxiety and depression (as measured by the Hospital Anxiety and Depression Scale) and overall spiritual well-being (as measured by the Spiritual Well-Being Scale) (P < .0001). There was also a negative correlation between the existential well-being scores and the anxiety and depression scores but not with the religious well-being score (P < .001).[15] These patterns were also found in a large study of indigent prostate cancer survivors; the patterns were consistent across ethnicity and metastatic status.[16]

In a large (N = 418) study of breast cancer patients, a higher level of meaning and peace was associated with a decline in depression over 12 months, whereas higher religiousness predicted an increase in depression, particularly if meaning/peace was lower.[17][Level of evidence: II] A second study with mixed gender/mixed cancer survivors (N = 165) found similar patterns. In both studies, high levels of religiousness were linked to increases in perceived cancer-related growth.[17][Level of evidence: II] In a convenience sample, 222 low-income men with prostate cancer were surveyed about spirituality and health-related quality of life. Low scores in spirituality, as measured by the peace/meaning and faith subscale of the Functional Assessment of Chronic Illness Therapy—Spiritual Well-Being (FACIT-Sp), were associated with significantly worse physical and mental health than were high scores in spirituality.[18]

A large national survey of 361 paired U.S. survivors and caregivers (caregivers included spouses and adult children) found that for both survivors and caregivers, the peace factor of the FACIT-Sp was strongly related to mental health but negligibly or not at all related to physical well-being. The faith factor (“religiousness”) was unrelated to physical or mental well-being. Fifty-two percent of the survivors in this survey were women.[19] These findings support the value of the FACIT-Sp in separating people’s religious involvement from their sense of spiritual well-being and that it is this sense of spiritual well-being that seems to be most related to psychological adjustment.

Another large national survey study of female family caregivers (N = 252; 89% white) identified that higher levels of spirituality, as measured by the FACIT-Sp, were associated with much less psychological distress (measured by the Pearlin Stress Scale). Participants with higher levels of spirituality actually had improved well-being even as caregiving stress increased, while those with lower levels of spirituality showed the opposite pattern, suggesting a strong stress-buffering effect of spiritual well-being. This finding reinforces the need to identify low spiritual well-being when assessing the coping capacity of family caregivers as well as patients.[5]

One author [20] found that cancer survivors who had drawn on spiritual resources reported substantial personal growth as a function of dealing with the trauma of cancer. This was also found in a survey study of 100 well-educated, mostly married/partnered white women with early-stage breast cancer, recruited for the study from an Internet Web site, in which increasing levels of spiritual struggle were related to poorer emotional adjustment, though not to other aspects of cancer-related quality of life.[21] Using path analytic techniques, a study of women with breast cancer found that at both prediagnosis and 6 months postsurgery, holding negative images of God was the strongest predictor of emotional distress and lower social well-being.[22] However, longitudinal analyses failed to find sustained effects for baseline positive or negative attitudes toward God at either 6 or 12 months. One possible explanation for these findings is that such attitudes are somewhat unstable during a period of uncertainty (e.g., at prediagnosis).[22]

Engaging in prayer is often cited as an adaptive tool,[23] but qualitative research [24] found that for about one third of cancer patients interviewed, concerns about how to pray effectively or the questions raised about the effectiveness of prayer also caused inner conflict and mild distress. In a study of reported use of spiritual healing and prayer by a sample of 123 patients hospitalized on a palliative care unit, 26.8% reported having used spiritual healing and prayer for curative purposes, 35% for improving survival, and 36.6% for improving symptoms (note: these percentages overlap). Higher levels of faith on the FACIT-Sp were associated with greater use of complementary and alternative medicine techniques in general and with interest in future use, whereas the level of meaning/peace was not. The study also looked at the general use of complementary therapies.[25] A useful discussion of how prayer is used by cancer patients and how clinicians might conceptualize prayer has been published.[26]

Ethnicity and spirituality were investigated in a qualitative study of 161 breast cancer survivors. In individual interviews, most participants (83%) spoke about some aspect of their spirituality. Seven themes were identified: “God as a Comforting Presence,” “Questioning Faith,” “Anger at God,” “Spiritual Transformation of Self and Attitude Towards Others/Recognition of Own Mortality,” “Deepening of Faith,” “Acceptance,” and “Prayer by Self.” A higher percentage of African Americans, Latinas, and persons identified as Christians were more likely to feel comforted by God than were other groups.[27]

Positive religious involvement and spirituality appear to be associated with better health and longer life expectancy, even after controlling for other variables such as health behaviors and social support, as shown in one meta-analysis.[28] Although little of this research is specific to cancer patients, one study of 230 patients with advanced cancer (expected prognosis <1 year) investigated a variety of associations between religiousness and spiritual support.[29] Most study participants (88%) considered religion either very important (68%) or somewhat important (20%); more African Americans and Hispanics than whites reported religion to be very important. Spiritual support by religious communities or the medical system was associated with better patient quality of life. Age was not associated with religiousness. At the time of recruitment to participate in the study, increasing self-reported distress was associated with increasing religiousness, and private religious or spiritual activities were performed by a larger percentage of patients after their diagnosis (61%) than before (47%). Regarding spiritual support, 38% reported that their spiritual needs were supported by a religious community “to a large extent or completely,” while 47% reported receiving support from a religious community “to a small extent or not at all.” Finally, religiousness was also associated with the end-of-life treatment preference of “wanting all measures taken to extend life.” Another study [30] found that helper and cytotoxic T-cell counts were higher among women with metastatic breast cancer who reported greater importance of spirituality. Other investigators [31] found that attendance at religious services was associated with better immune system functioning. Other research [32,33] suggests that religious distress negatively affects health status. These associations, however, have been criticized as weak and inconsistent.[34]

Several randomized trials with cancer patients have suggested that group support interventions benefit survival.[35,36] These studies must be interpreted cautiously, however. First, the treatments focused on general psychotherapeutic issues and psychosocial support. Although spiritually relevant issues undoubtedly arose in these settings, they were not the focus of the groups. Second, there has been difficulty replicating these effects.[37]

  1. Acklin MW, Brown EC, Mauger PA: The role of religious values in coping with cancer. J Relig Health 22 (4): 322-333, 1983. 

  2. Kaczorowski JM: Spiritual well-being and anxiety in adults diagnosed with cancer. Hosp J 5 (3-4): 105-16, 1989.  [PUBMED Abstract]

  3. McCullough ME, Hoyt WT, Larson DB, et al.: Religious involvement and mortality: a meta-analytic review. Health Psychol 19 (3): 211-22, 2000.  [PUBMED Abstract]

  4. Janiszewska J, Buss T, de Walden-Gałuszko K, et al.: The religiousness as a way of coping with anxiety in women with breast cancer at different disease stages. Support Care Cancer 16 (12): 1361-6, 2008.  [PUBMED Abstract]

  5. Kim Y, Wellisch DK, Spillers RL, et al.: Psychological distress of female cancer caregivers: effects of type of cancer and caregivers' spirituality. Support Care Cancer 15 (12): 1367-74, 2007.  [PUBMED Abstract]

  6. Weisman AD, Worden JW: The existential plight in cancer: significance of the first 100 days. Int J Psychiatry Med 7 (1): 1-15, 1976-77.  [PUBMED Abstract]

  7. Pargament KI: The Psychology of Religion and Coping: Theory, Research, Practice. New York, NY: Guilford Press, 1997. 

  8. Tarakeshwar N, Vanderwerker LC, Paulk E, et al.: Religious coping is associated with the quality of life of patients with advanced cancer. J Palliat Med 9 (3): 646-57, 2006.  [PUBMED Abstract]

  9. Hills J, Paice JA, Cameron JR, et al.: Spirituality and distress in palliative care consultation. J Palliat Med 8 (4): 782-8, 2005.  [PUBMED Abstract]

  10. Laubmeier KK, Zakowski SG, Bair JP: The role of spirituality in the psychological adjustment to cancer: a test of the transactional model of stress and coping. Int J Behav Med 11 (1): 48-55, 2004.  [PUBMED Abstract]

  11. Brady MJ, Peterman AH, Fitchett G, et al.: A case for including spirituality in quality of life measurement in oncology. Psychooncology 8 (5): 417-28, 1999 Sep-Oct.  [PUBMED Abstract]

  12. O'Mahony S, Goulet J, Kornblith A, et al.: Desire for hastened death, cancer pain and depression: report of a longitudinal observational study. J Pain Symptom Manage 29 (5): 446-57, 2005.  [PUBMED Abstract]

  13. Whitford HS, Olver IN, Peterson MJ: Spirituality as a core domain in the assessment of quality of life in oncology. Psychooncology 17 (11): 1121-8, 2008.  [PUBMED Abstract]

  14. Nelson CJ, Rosenfeld B, Breitbart W, et al.: Spirituality, religion, and depression in the terminally ill. Psychosomatics 43 (3): 213-20, 2002 May-Jun.  [PUBMED Abstract]

  15. McCoubrie RC, Davies AN: Is there a correlation between spirituality and anxiety and depression in patients with advanced cancer? Support Care Cancer 14 (4): 379-85, 2006.  [PUBMED Abstract]

  16. Krupski TL, Kwan L, Afifi AA, et al.: Geographic and socioeconomic variation in the treatment of prostate cancer. J Clin Oncol 23 (31): 7881-8, 2005.  [PUBMED Abstract]

  17. Yanez B, Edmondson D, Stanton AL, et al.: Facets of spirituality as predictors of adjustment to cancer: relative contributions of having faith and finding meaning. J Consult Clin Psychol 77 (4): 730-41, 2009.  [PUBMED Abstract]

  18. Krupski TL, Kwan L, Fink A, et al.: Spirituality influences health related quality of life in men with prostate cancer. Psychooncology 15 (2): 121-31, 2006.  [PUBMED Abstract]

  19. Kim Y, Carver CS, Spillers RL, et al.: Individual and dyadic relations between spiritual well-being and quality of life among cancer survivors and their spousal caregivers. Psychooncology 20 (7): 762-70, 2011.  [PUBMED Abstract]

  20. Carpenter JS, Brockopp DY, Andrykowski MA: Self-transformation as a factor in the self-esteem and well-being of breast cancer survivors. J Adv Nurs 29 (6): 1402-11, 1999.  [PUBMED Abstract]

  21. Manning-Walsh J: Spiritual struggle: effect on quality of life and life satisfaction in women with breast cancer. J Holist Nurs 23 (2): 120-40; discussion 141-4, 2005.  [PUBMED Abstract]

  22. Gall TL, Kristjansson E, Charbonneau C, et al.: A longitudinal study on the role of spirituality in response to the diagnosis and treatment of breast cancer. J Behav Med 32 (2): 174-86, 2009.  [PUBMED Abstract]

  23. Halstead MT, Fernsler JI: Coping strategies of long-term cancer survivors. Cancer Nurs 17 (2): 94-100, 1994.  [PUBMED Abstract]

  24. Taylor EJ, Outlaw FH, Bernardo TR, et al.: Spiritual conflicts associated with praying about cancer. Psychooncology 8 (5): 386-94, 1999 Sep-Oct.  [PUBMED Abstract]

  25. Trinkaus M, Burman D, Barmala N, et al.: Spirituality and use of complementary therapies for cure in advanced cancer. Psychooncology 20 (7): 746-54, 2011.  [PUBMED Abstract]

  26. Taylor EJ, Outlaw FH: Use of prayer among persons with cancer. Holist Nurs Pract 16 (3): 46-60, 2002.  [PUBMED Abstract]

  27. Levine EG, Yoo G, Aviv C, et al.: Ethnicity and spirituality in breast cancer survivors. J Cancer Surviv 1 (3): 212-25, 2007.  [PUBMED Abstract]

  28. Mueller PS, Plevak DJ, Rummans TA: Religious involvement, spirituality, and medicine: implications for clinical practice. Mayo Clin Proc 76 (12): 1225-35, 2001.  [PUBMED Abstract]

  29. Balboni TA, Vanderwerker LC, Block SD, et al.: Religiousness and spiritual support among advanced cancer patients and associations with end-of-life treatment preferences and quality of life. J Clin Oncol 25 (5): 555-60, 2007.  [PUBMED Abstract]

  30. Sephton SE, Koopman C, Schaal M, et al.: Spiritual expression and immune status in women with metastatic breast cancer: an exploratory study. Breast J 7 (5): 345-53, 2001 Sep-Oct.  [PUBMED Abstract]

  31. Koenig HG, Cohen HJ, George LK, et al.: Attendance at religious services, interleukin-6, and other biological parameters of immune function in older adults. Int J Psychiatry Med 27 (3): 233-50, 1997.  [PUBMED Abstract]

  32. Koenig HG, Pargament KI, Nielsen J: Religious coping and health status in medically ill hospitalized older adults. J Nerv Ment Dis 186 (9): 513-21, 1998.  [PUBMED Abstract]

  33. Pargament KI, Koenig HG, Tarakeshwar N, et al.: Religious struggle as a predictor of mortality among medically ill elderly patients: a 2-year longitudinal study. Arch Intern Med 161 (15): 1881-5, 2001 Aug 13-27.  [PUBMED Abstract]

  34. Sloan RP, Bagiella E: Claims about religious involvement and health outcomes. Ann Behav Med 24 (1): 14-21, 2002 Winter.  [PUBMED Abstract]

  35. Spiegel D, Bloom JR, Kraemer H, et al.: Psychological support for cancer patients. Lancet 2 (8677): 1447, 1989.  [PUBMED Abstract]

  36. Fawzy FI, Fawzy NW, Hyun CS, et al.: Malignant melanoma. Effects of an early structured psychiatric intervention, coping, and affective state on recurrence and survival 6 years later. Arch Gen Psychiatry 50 (9): 681-9, 1993.  [PUBMED Abstract]

  37. Cunningham AJ, Edmonds CV, Jenkins GP, et al.: A randomized controlled trial of the effects of group psychological therapy on survival in women with metastatic breast cancer. Psychooncology 7 (6): 508-17, 1998 Nov-Dec.  [PUBMED Abstract]