Spirituality in Cancer Care (PDQ®): Supportive care - Health Professional Information [NCI]

Overview

National surveys consistently support the idea that religion and spirituality are important to most individuals in the general population. More than 90% of adults express a belief in God, and slightly more than 70% of individuals surveyed identified religion as one of the most important influences in their lives.[1] Yet even widely held beliefs, such as survival of the soul after death or a belief in miracles, vary substantially by gender, education, and ethnicity.[2]

Research indicates that both patients and family caregivers [3,4] commonly rely on spirituality and religion to help them deal with serious physical illnesses, with a desire to have specific spiritual and religious needs acknowledged or addressed by medical staff. These needs, although widespread, may take different forms between and within cultural and religious traditions.[5,6,7]

A survey of hospital inpatients found that 77% of them reported that physicians should take patients' spiritual needs into consideration, and 37% wanted physicians to address religious beliefs more frequently.[8] A large survey of cancer outpatients in New York City found that a slight majority felt it was appropriate for a physician to inquire about their religious beliefs and spiritual needs, although only 1% reported that this had occurred. Patients who reported that spiritual needs were not being met gave lower ratings to quality of care (P < .01) and reported lower satisfaction with care (P < .01).[7] A pilot study of 14 African American men with a history of prostate cancer found that most had discussed spirituality and religious beliefs with their physicians. They expressed a desire for their doctors and clergy to be in contact with each other.[9]

In addition, 61% of 57 inpatients with advanced cancer receiving end-of-life care in a hospital supported by the Catholic archdiocese reported spiritual distress when interviewed by hospital chaplains. The intensity of spiritual distress correlated with self-reports of depression but not with physical pain or perceived severity of illness.[10] Another study[11] of patients with advanced cancer (N = 230) in New England and Texas assessed spiritual needs. Almost half (47%) reported that their spiritual needs were not being met by a religious community, and 72% reported that these needs were not supported by the medical system. When such support existed, it was positively related to improved quality of life. Furthermore, having the medical care team address spiritual issues had more impact than did pastoral counseling on increasing hospice use and decreasing aggressive end-of-life measures.[12]

This summary will review the following topics:

• How religion and spirituality can be conceptualized within the medical setting.
• The empirical evidence for the importance of religious and spiritual factors in adjustment to illness in general and to cancer in particular, throughout the course of illness and at the end of life, for both patients and family caregivers.[3]
• The range of assessment approaches that may be useful in a clinical environment.
• Various models for management and intervention.
• Resources for clinical care.

Paying attention to the religious or spiritual beliefs of seriously ill patients has a long tradition within inpatient medical environments. Addressing such issues has been viewed as the domain of hospital chaplains or a patient's own religious leader. In this context, systematic assessment has usually been limited to identifying a patient's religious preference, while responsibility for management of apparent spiritual distress has fallen to the chaplain service.[13,14,15] Although health care providers may address such concerns themselves, they are generally very ambivalent about doing so,[16] and there has been relatively little systematic investigation addressing the physician's role. These issues, however, are increasingly addressed in medical training.[17] Acknowledging the role of all health care professionals in spirituality, a multidisciplinary group from one cancer center developed a four-stage model that allows health care professionals to deliver spiritual care consistent with their knowledge, skills, and actions at one of four skill levels.[18]

Interest in and recognition of the function of religious and spiritual coping in adjustment to serious illness, including cancer, has been growing.[19,20,21,22,23] New ways to assess and address religious and spiritual concerns as part of overall quality of life are being developed and tested. Limited data support the possibility that spiritual coping is one of the most powerful means by which patients draw on their own resources to deal with a serious illness such as cancer. However, patients and their family caregivers may be reluctant to raise religious and spiritual concerns with their professional health care providers.[24,25,26] Increased spiritual well-being in a seriously ill population may be linked with lower anxiety about death,[27] but greater religious involvement may also be linked to an increased likelihood of desire for extreme measures at the end of life.[28] Given the importance of religion and spirituality to patients, integrating systematic assessment of such needs into medical care, including outpatient care, is crucial. The development of better assessment tools will make it easier to discern which aspects of religious and spiritual coping may be important in a particular patient's adjustment to illness.

Of equal importance is the consideration of how and when to address religion and spirituality with patients and the best ways to do so in different medical environments.[29,30,31] Although addressing spiritual concerns is often considered an end-of-life issue, such concerns may arise at any time after diagnosis.[24] Acknowledging the importance of these concerns and addressing them, even briefly, at diagnosis may facilitate better adjustment throughout the course of treatment and create a context for richer dialogue later in the illness. One study of 118 patients seen in follow-up by one of four oncologists suggests that a semistructured inquiry into spiritual concerns related to coping with cancer is well accepted by patients and oncologists and is associated with positive perceptions of care and well-being.[32]

In this summary, unless otherwise stated, evidence and practice issues as they relate to adults are discussed. The evidence and application to practice related to children may differ significantly from information related to adults. When specific information about the care of children is available, it is summarized under its own heading.

References:

1. Gallup GH Jr: Religion In America 1996: Will the Vitality of the Church Be the Surprise of the 21st Century? Princeton Religion Research Center, 1996.
2. Taylor H: The Religious and Other Beliefs of Americans 2003. The Harris Poll #11, February 26, 2003. Rochester, NY: Harris Interactive Inc., 2003.
3. 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.
4. 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.
5. Taleghani F, Yekta ZP, Nasrabadi AN: Coping with breast cancer in newly diagnosed Iranian women. J Adv Nurs 54 (3): 265-72; discussion 272-3, 2006.
6. Blocker DE, Romocki LS, Thomas KB, et al.: Knowledge, beliefs and barriers associated with prostate cancer prevention and screening behaviors among African-American men. J Natl Med Assoc 98 (8): 1286-95, 2006.
7. Astrow AB, Wexler A, Texeira K, et al.: Is failure to meet spiritual needs associated with cancer patients' perceptions of quality of care and their satisfaction with care? J Clin Oncol 25 (36): 5753-7, 2007.
8. King DE, Bushwick B: Beliefs and attitudes of hospital inpatients about faith healing and prayer. J Fam Pract 39 (4): 349-52, 1994.
9. Bowie J, Sydnor KD, Granot M: Spirituality and care of prostate cancer patients: a pilot study. J Natl Med Assoc 95 (10): 951-4, 2003.
10. Mako C, Galek K, Poppito SR: Spiritual pain among patients with advanced cancer in palliative care. J Palliat Med 9 (5): 1106-13, 2006.
11. 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.
12. Balboni TA, Paulk ME, Balboni MJ, et al.: Provision of spiritual care to patients with advanced cancer: associations with medical care and quality of life near death. J Clin Oncol 28 (3): 445-52, 2010.
13. Zabora J, Blanchard CG, Smith ED, et al.: Prevalence of psychological distress among cancer patients across the disease continuum. Journal of Psychosocial Oncology 15 (2): 73-87, 1997.
14. Fitchett G, Meyer PM, Burton LA: Spiritual care in the hospital: who requests it? Who needs it? J Pastoral Care 54 (2): 173-86, 2000 Summer.
15. Handzo G: Where do chaplains fit in the world of cancer care? J Health Care Chaplain 4 (1-2): 29-44, 1992.
16. Kristeller JL, Zumbrun CS, Schilling RF: 'I would if I could': how oncologists and oncology nurses address spiritual distress in cancer patients. Psychooncology 8 (5): 451-8, 1999 Sep-Oct.
17. Puchalski C, Romer AL: Taking a spiritual history allows clinicians to understand patients more fully. J Palliat Med 3(1): 129-137, 2000.
18. Gordon T, Mitchell D: A competency model for the assessment and delivery of spiritual care. Palliat Med 18 (7): 646-51, 2004.
19. Pargament KI: The Psychology of Religion and Coping: Theory, Research, Practice. Guilford Press, 1997.
20. Koenig HG: Spirituality in Patient Care: Why, How, When, and What. Templeton Foundation Press, 2002.
21. Koenig HG, McCullough ME, Larson DB: Handbook of Religion and Health. Oxford University Press, 2001.
22. 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.
23. 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.
24. Murray SA, Kendall M, Boyd K, et al.: Exploring the spiritual needs of people dying of lung cancer or heart failure: a prospective qualitative interview study of patients and their carers. Palliat Med 18 (1): 39-45, 2004.
25. McCullough ME, Hoyt WT, Larson DB, et al.: Religious involvement and mortality: a meta-analytic review. Health Psychol 19 (3): 211-22, 2000.
26. Jenkins RA, Pargament KI: Religion and spirituality as resources for coping with cancer. Journal of Psychosocial Oncology 13 (1/2): 51-74, 1995.
27. Chibnall JT, Videen SD, Duckro PN, et al.: Psychosocial-spiritual correlates of death distress in patients with life-threatening medical conditions. Palliat Med 16 (4): 331-8, 2002.
28. Phelps AC, Maciejewski PK, Nilsson M, et al.: Religious coping and use of intensive life-prolonging care near death in patients with advanced cancer. JAMA 301 (11): 1140-7, 2009.
29. Post SG, Puchalski CM, Larson DB: Physicians and patient spirituality: professional boundaries, competency, and ethics. Ann Intern Med 132 (7): 578-83, 2000.
30. Sloan RP, Bagiella E, VandeCreek L, et al.: Should physicians prescribe religious activities? N Engl J Med 342 (25): 1913-6, 2000.
31. Dagi TF: Prayer, piety and professional propriety: limits on religious expression in hospitals. J Clin Ethics 6 (3): 274-9, 1995 Fall.
32. Kristeller JL, Rhodes M, Cripe LD, et al.: Oncologist Assisted Spiritual Intervention Study (OASIS): patient acceptability and initial evidence of effects. Int J Psychiatry Med 35 (4): 329-47, 2005.

Definitions

Specific religious beliefs and practices should be distinguished from the idea of a universal capacity for spiritual and religious experiences. Although this distinction may not be salient or important on a personal basis, it is important conceptually for understanding various aspects of evaluation and the role of different beliefs, practices, and experiences in coping with cancer.

The most useful general distinction in this context is between religion and spirituality. There is no general agreement on definitions of either term, but there is general agreement on the usefulness of this distinction.[1,2,3]

• Religion can be viewed as a specific set of beliefs and practices associated with a recognized religion or denomination.
• Spirituality is generally recognized as encompassing experiential aspects, whether related to engaging in religious practices or acknowledging a general sense of peace and connectedness. Found in all cultures, the concept of spirituality is often considered to encompass a search for ultimate meaning through religion or other paths.[4]

In health care, concerns about spiritual or religious well-being have sometimes been viewed as an aspect of complementary and alternative medicine (CAM), but this perception may be more characteristic of providers than of patients. In one study,[5] virtually no patients but about 20% of providers said that CAM services were sought to assist with spiritual or religious issues.

Religion is highly culturally determined. Spirituality is considered a universal human capacity, usually—but not necessarily—associated with and expressed in religious practice. Most individuals consider themselves both spiritual and religious. Some may consider themselves religious but not spiritual; others, including some atheists (people who do not believe in the existence of God) or agnostics (people who believe that God cannot be shown to exist), may consider themselves spiritual but not religious. In a sample of 369 representative cancer outpatients in New York City (33% minority groups), 6% identified themselves as agnostic or atheist, 29% attended religious services weekly; and 66% represented themselves as spiritual but not religious.[6]

One effort to characterize individuals by types of spiritual and religious experience [7] identified the following three groups, using cluster analytic techniques:

1. Religious individuals who highly value religious faith, spiritual well-being, and the meaning of life.
2. Existential individuals who highly value spiritual well-being but not religious faith.
3. Nonspiritual individuals who have little value for religiousness, spirituality, or a sense of the meaning of life.

Individuals in the third group were far more distressed about their illness and experienced worse adjustment than the other two groups. There is not yet consensus on the number or types of underlying dimensions of spirituality or religious engagement.

From the perspective of both the research and clinical literature on the relationships among religion, spirituality, and health, it is important to consider how investigators and authors define and use these concepts. Much of the epidemiological literature that indicates a relationship between religion and health is based on definitions of religious involvement such as:

• Membership in a religious group.
• Frequency of attendance at religious services.

Assessing specific beliefs or religious practices such as belief in God, frequency of prayer, or reading religious material is somewhat more complex. Individuals may engage in such practices or believe in God without necessarily attending services. Terminology also carries certain connotations. The term religiosity, for example, has a history of implying fervor and perhaps undue investment in particular religious practices or beliefs. The term religiousness may be a more neutral way to refer to the dimension of religious practice.

Spirituality and spiritual well-being are more challenging to define. Some definitions limit spirituality to mean profound mystical experiences. However, in effects on health and psychological well-being, the more helpful definitions focus on accessible feelings, such as:

• A sense of inner peace.
• Existential meaning.
• Awe when walking in nature.

This discussion assumes a continuum of meaningful spiritual experiences, from the common and accessible to the extraordinary and transformative. Both type and intensity of experience may vary. Other aspects of spirituality that have been identified by those working with patients include the following:

• A sense of meaning and peace.
• A sense of faith.
• A sense of connectedness to others or to God.

Low levels of these experiences may be associated with poorer coping.[3] For more information, see the Religion, Spirituality, and Living With Cancer section.

The definition of acute spiritual distress must be considered separately. Spiritual distress may result from the belief that cancer reflects punishment by God or may accompany a preoccupation with the question "Why me?" A cancer patient may also suffer a loss of faith.[8] Although many individuals may have such thoughts at some point after diagnosis, only a few become obsessed with these thoughts or score high on a general measure of religious and spiritual distress (such as the Negative subscale of the Religious Coping Scale).[8] High levels of spiritual distress may contribute to poorer health and psychosocial outcomes.[9,10] The tools for measuring these dimensions are described in the Screening and Assessment of Spiritual Concerns section.

References:

1. Halstead MT, Mickley JR: Attempting to fathom the unfathomable: descriptive views of spirituality. Semin Oncol Nurs 13 (4): 225-30, 1997.
2. Zinnbauer BJ, Pargament KL: Spiritual conversion: a study of religious change among college students. J Sci Study Relig 37 (1): 161-80, 1998.
3. Breitbart W, Gibson C, Poppito SR, et al.: Psychotherapeutic interventions at the end of life: a focus on meaning and spirituality. Can J Psychiatry 49 (6): 366-72, 2004.
4. Task force report: spirituality, cultural issues, and end of life care. In: Association of American Medical Colleges: Report III. Contemporary Issues in Medicine: Communication in Medicine. Association of American Medical Colleges, 1999, pp 24-9.
5. Ben-Arye E, Bar-Sela G, Frenkel M, et al.: Is a biopsychosocial-spiritual approach relevant to cancer treatment? A study of patients and oncology staff members on issues of complementary medicine and spirituality. Support Care Cancer 14 (2): 147-52, 2006.
6. Astrow AB, Wexler A, Texeira K, et al.: Is failure to meet spiritual needs associated with cancer patients' perceptions of quality of care and their satisfaction with care? J Clin Oncol 25 (36): 5753-7, 2007.
7. Riley BB, Perna R, Tate DG, et al.: Types of spiritual well-being among persons with chronic illness: their relation to various forms of quality of life. Arch Phys Med Rehabil 79 (3): 258-64, 1998.
8. Pargament KI: The Psychology of Religion and Coping: Theory, Research, Practice. Guilford Press, 1997.
9. 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.
10. Hills J, Paice JA, Cameron JR, et al.: Spirituality and distress in palliative care consultation. J Palliat Med 8 (4): 782-8, 2005.

Religion, Spirituality, and Living With Cancer

Religion and spirituality have been shown to be significantly associated with measures of adjustment to cancer and with management of cancer symptoms in patients. Religious and spiritual coping have been associated with lower levels of patient discomfort as well as reduced hostility, anxiety, and social isolation in patients with cancer [1,2,3,4] and 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 patients with cancer 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 survivors of prostate cancer; 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 the sense of 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 (52% women) and caregivers (including 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.[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) found 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 the stress caused by caregiving increased, while those with lower levels of spirituality showed the opposite pattern. This finding suggests a strong stress-buffering effect of spiritual well-being and reinforces the need to identify low spiritual well-being when assessing the coping capacity of family caregivers as well as patients.[5]

Data from the National Quality of Life Survey for Caregivers were used to examine the effects of spirituality on caregiving motivation and satisfaction. Caregivers received a baseline survey to measure motivation 2 years after a family member's cancer diagnosis and again at 5 years after diagnosis. Male caregivers were more likely to report internal/spiritual motives for caregiving, whereas the motives of female caregivers were not related to internal/spiritual reasons. However, both men and women who were able to identify a sense of spiritual peace in their caregiving efforts had better mental health after 5 years of caregiving. Evidence suggests that caregiver motivation affects long-term mental health and quality of life.[20][Level of evidence: II]

One author [21] 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 finding was echoed in a survey study of 100 well-educated, mostly married/partnered White women with early-stage breast cancer, recruited from an Internet website. The study found that increasing levels of spiritual struggle were related to poorer emotional adjustment, though not to other aspects of cancer-related quality of life.[22] 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.[23] 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).[23]

Engaging in prayer is often cited as an adaptive tool,[24] but qualitative research [25] 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 another study, 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.[26] A useful discussion of how patients with cancer use prayer and how clinicians might conceptualize prayer has been published.[27]

Ethnicity and spirituality were investigated in a qualitative study of 161 breast cancer survivors.[28] In individual interviews, most participants (83%) spoke about some aspect of their spirituality. A higher percentage of African American, Latina, and Christian participants felt comforted by God than did those in other groups. Seven themes were identified:

• God as a comforting presence.
• Questioning faith.
• Anger at God.
• Spiritual transformation of self and attitude toward others/recognition of own mortality.
• Deepening of faith.
• Acceptance.
• Prayer by self.

One meta-analysis showed that positive religious involvement and spirituality appeared to be associated with better health and longer life expectancy, even after researchers controlled for other variables, such as health behaviors and social support.[29] 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.[30] Most study participants (88%) considered religion either very important (68%) or somewhat important (20%), and more African American and Hispanic individuals than White individuals 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, 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 preference of "wanting all measures taken to extend life" at the end of life.

Another study [31] found that helper and cytotoxic T-cell counts were higher among women with metastatic breast cancer who reported greater importance of spirituality. Other investigators [32] found that attendance at religious services was associated with better immune system functioning. Still other research [33,34] suggests that religious distress negatively affects health status. These associations, however, have been criticized as weak and inconsistent.[35]

Several randomized trials with cancer patients have suggested that group support interventions benefit survival.[36,37] 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.[38]

References:

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.
3. McCullough ME, Hoyt WT, Larson DB, et al.: Religious involvement and mortality: a meta-analytic review. Health Psychol 19 (3): 211-22, 2000.
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.
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.
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.
7. Pargament KI: The Psychology of Religion and Coping: Theory, Research, Practice. 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.
9. Hills J, Paice JA, Cameron JR, et al.: Spirituality and distress in palliative care consultation. J Palliat Med 8 (4): 782-8, 2005.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
20. Kim Y, Carver CS, Cannady RS: Caregiving Motivation Predicts Long-Term Spirituality and Quality of Life of the Caregivers. Ann Behav Med 49 (4): 500-9, 2015.
21. 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.
22. 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.
23. 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.
24. Halstead MT, Fernsler JI: Coping strategies of long-term cancer survivors. Cancer Nurs 17 (2): 94-100, 1994.
25. Taylor EJ, Outlaw FH, Bernardo TR, et al.: Spiritual conflicts associated with praying about cancer. Psychooncology 8 (5): 386-94, 1999 Sep-Oct.
26. 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.
27. Taylor EJ, Outlaw FH: Use of prayer among persons with cancer. Holist Nurs Pract 16 (3): 46-60, 2002.
28. Levine EG, Yoo G, Aviv C, et al.: Ethnicity and spirituality in breast cancer survivors. J Cancer Surviv 1 (3): 212-25, 2007.
29. Mueller PS, Plevak DJ, Rummans TA: Religious involvement, spirituality, and medicine: implications for clinical practice. Mayo Clin Proc 76 (12): 1225-35, 2001.
30. 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.
31. 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.
32. 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.
33. 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.
34. 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.
35. Sloan RP, Bagiella E: Claims about religious involvement and health outcomes. Ann Behav Med 24 (1): 14-21, 2002 Winter.
36. Spiegel D, Bloom JR, Kraemer H, et al.: Psychological support for cancer patients. Lancet 2 (8677): 1447, 1989.
37. 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.
38. 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.

Screening and Assessment of Spiritual Concerns

Raising spiritual concerns with patients can be accomplished by the following approaches:[1,2]

• Wait for the patient to bring up spiritual concerns.
• Request that the patient complete a paper-and-pencil assessment.
• Have the physician do a spiritual inquiry or assessment by indicating his or her openness to a discussion.

These approaches have different potential value and limitations. Patients may be reluctant to bring up spiritual issues and prefer to wait for the provider to broach the subject. Standardized assessment tools vary, have generally been designed for research purposes, and need to be reviewed and utilized appropriately by the provider. Physicians, unless trained specifically to address such issues, may feel uncomfortable raising spiritual concerns with patients.[3] However, an increasing number of models are available for physician use and training.[4]

Table 1 summarizes a selection of tools to assess religion and spirituality. Several factors should be considered before choosing an assessment tool:

• Focus of the evaluation (religious practice or spiritual well-being/distress).
• Purpose of the assessment (e.g., screening for distress vs. evaluation of all patients as part of care).
• Modality of the assessment (interview or questionnaire).
• Feasibility of the assessment (staff and patient burden).

The line between assessment and intervention is blurred, and simply inquiring about an area such as religious or spiritual coping may prompt the patient's desire to further explore and validate this experience. Evidence suggests that only a small proportion of patients view such an inquiry as intrusive and distressing. Key assessment approaches are briefly reviewed below; pertinent characteristics are summarized in Table 1.

Standardized Assessment Measures

One of several paper-and-pencil measures can be given to patients to assess religious and spiritual needs. These measures have the advantage of being self-administered; however, they were mostly designed as research tools, and their role for clinical assessment purposes is not as well understood. These measures may be helpful in opening up the topic for exploration and for ascertaining basic levels of religious engagement or spiritual well-being (or spiritual distress). Most tools assume a belief in God and may seem inappropriate for an atheist or agnostic patient, who may still be spiritually oriented. All of the measures have undergone varying degrees of psychometric development, and most are being used in investigations of the relationship between religion or spirituality, health indices, and adjustment to illness.

• Duke Religious Index (DRI): The DRI (or DUREL) [5][Level of evidence: II][6] is short (five items) and has reasonable psychometric properties [5] examined in patients with cancer. It is best used as an indicator of religious involvement rather than spirituality and has low or modest correlations with psychological well-being.
• Systems of Belief Inventory (SBI-15R): The SBI-15R [7][Level of evidence: II] has undergone careful psychometric development and measures two domains:
  1. Presence and importance of religious and spiritual beliefs and practices.
  2. Value of support from a religious/spiritual community.

  The questions are worded well and may provide a good initiation for further discussion and exploration.

• Brief Measure of Religious Coping (RCOPE): The Brief RCOPE [8][Level of evidence: II] has two dimensions: positive religious coping and negative religious coping, with five items each. The second factor appears to uniquely identify an important aspect of spiritual adjustment, i.e., the degree to which conflict, self-blame, or anger at God is present for an individual. A longer form of the scale, with additional dimensions, would be suitable for a more comprehensive assessment of religious/spiritual concerns. Psychometric development is high. While high scores in negative religious coping are unusual, they are particularly powerful in predicting poor adjustment to disease.[9]
• Functional Assessment of Chronic Illness Therapy—Spiritual Well-Being (FACIT-Sp):[10] The FACIT-Sp is part of the widely used Functional Assessment of Cancer Therapy quality-of-life battery.[11] Developed with an ethnically diverse cancer population, it contains 12 items and 2 factors (faith, and meaning and peace), with good to excellent psychometric properties. Although some evidence suggests that inner meaning and inner peace can be identified as two separate factors, such identification does not appear to substantially improve associations with other indicators of well-being.[12] One characteristic of this scale is that the wording of items does not assume a belief in God. Therefore, it can be comfortably completed by an atheist or agnostic, yet it taps into both traditional religiousness dimensions (faith factor) and spiritual dimensions (meaning and peace factor).

  The meaning and peace factor has been shown to have particularly strong associations with psychological adjustment, in that individuals who score high on this scale are much more likely to report enjoying life despite fatigue or pain, are less likely to desire a hastened death at the end of life,[13][Level of evidence: II] report better disease-specific and psychosocial adjustment,[14,15,16] and report lower levels of helplessness/hopelessness.[16] These associations have been shown to be independent of other indicators of adjustment, supporting the value of adding religious and spiritual assessment to standard quality-of-life evaluations.[10,16] Total scores on the FACIT-Sp correlated highly over time (27 weeks) with a 10-point linear analogue scale of spiritual well-being in a sample of patients with advanced cancer. The linear scale (Spiritual Well-Being Linear Analogue Self-Assessment ) was worded, "How would you describe your overall spiritual well-being?" Ratings ranged from 0 (as bad as it can be) to 10 (as good as it can be).[17]

• Spiritual Transformation Scale (STS):[18] The STS is a 40-item measure of change in spiritual engagement after a cancer diagnosis. It has two subscales:
  1. Spiritual Growth (SG): The SG factor is highly correlated with the Positive subscale of the Religious Coping Scale (the RCOPE–Positive) (r = .71) and the Post-traumatic Growth Inventory (r = .68).
  2. Spiritual Decline (SD): The SD factor is correlated with the Negative subscale of the Religious Coping Scale (the RCOPE–Negative) (r = .56) and the Center for Epidemiologic Studies Depression Scale (CES-D) (r = .40).

  Analyses show that the STS accounts for additional variance on depression, other measures of adjustment (Positive and Negative Affect Schedule), and the Daily Spiritual Experience Scale.[18] Individuals with stage III or IV cancer had higher SG scores, as did individuals with a recurrence rather than a new diagnosis. Individuals with higher SD scores were more likely to have not graduated from high school. A unique strength of this scale is that it is specific to change in spirituality since diagnosis; the wording of items is also generally appropriate for individuals who identify as spiritual rather than religious. Among the limitations is that development to date includes mostly observant Christians, with few minority individuals in the sample.

Interviewing Tools

The following semistructured interviewing tools are designed to facilitate an exploration of religious beliefs and spiritual experiences or issues by the physician or other health care provider. The tools take the spiritual history approach and have the advantage of engaging the patient in dialogue, identifying possible areas of concern, and indicating the need to provide for further resources such as referral to a chaplain or support group. These approaches, however, have not been systematically investigated as empirical measures or indices of religiousness or of spiritual well-being or distress.

• The SPIRITual History.[19]SPIRIT is an acronym for the six domains explored by this tool:
  1. S, spiritual belief system.
  2. P, personal spirituality.
  3. I, integration with a spiritual community.
  4. R, ritualized practices and restrictions.
  5. I, implications for medical care.
  6. T, terminal events planning.

  The six domains cover 22 items, which may be explored in as little as 10 or 15 minutes or integrated into general interviewing over several appointments. A strength of this tool is the number of questions pertinent to managing serious illness and understanding how patient religious beliefs may affect patient care decisions.

• Faith, Importance/Influence, Community, and Address (FICA) Spiritual History.[1,20] A set of questions explores each area (e.g., What is your faith? How important is it? Are you part of a religious community? How would you like me as your provider to address these issues in your care?). Although developed as a spiritual history tool for primary care settings, it lends itself to any patient population. The relative simplicity of the approach has led to its adoption by many medical schools.

Table 1. Assessment of Religion and Spirituality in Cancer Patients

Tool	Developer	Purpose/ Focus/ Subscale (No.)	Specific to Cancer Patients?	Level of Psychometric Development	Length/ Other Characteristics/ Comments
DRI/DUREL = Duke Religious Index; FACIT-Sp = Functional Assessment of Chronic Illness Therapy–Spiritual Well-Being; FACT-G = Functional Assessment of Cancer Therapy–General; FICA = Faith, Importance/Influence, Community, and Address Spiritual History; RCOPE = Brief Measure of Religious Coping; SPIRIT = The SPIRITual History.
Systems of Belief Inventory (SBI-15R)[7]	Holland et al.	Two factors: Beliefs/experience (10); religious social support (5)	Yes	High	Four items assume belief in God
DRI/DUREL[5]	Sherman et al.	Religious involvement (5)	Yes	Moderate
FACIT-Sp[10,15]	Brady et al.; Peterman	Two factors: Meaning & peace (8), faith (4)	Yes	High. Limited cross-validation data.	Part of FACT-G quality-of-life battery[11]
Brief RCOPE[8]	Pargament et al.	Two factors: Positive coping; negative coping/distress	No	Very High
Fetzer Multidimensional Scale[21]	Fetzer	Multiple subscales	No	High. Under development.
FICA: Spiritual history[1]	Puchalski et al.	Brief spiritual history	No	Low	MD interview assessment
SPIRIT[19]	Maugans	In-depth interview with guided questions	No	Low	MD interview assessment
Spiritual Transformation Scale (STS)[18]	Cole et al.	Two factors: Spiritual Growth and Spiritual Decline	Yes	Moderate	Forty items. Unique to assessing change in spiritual experience post–cancer diagnosis.

References:

1. Puchalski C, Romer AL: Taking a spiritual history allows clinicians to understand patients more fully. J Palliat Med 3(1): 129-137, 2000.
2. Kristeller JL, Zumbrun CS, Schilling RF: 'I would if I could': how oncologists and oncology nurses address spiritual distress in cancer patients. Psychooncology 8 (5): 451-8, 1999 Sep-Oct.
3. Sloan RP, Bagiella E, VandeCreek L, et al.: Should physicians prescribe religious activities? N Engl J Med 342 (25): 1913-6, 2000.
4. Puchalski CM, Larson DB: Developing curricula in spirituality and medicine. Acad Med 73 (9): 970-4, 1998.
5. Sherman AC, Plante TG, Simonton S, et al.: A multidimensional measure of religious involvement for cancer patients: the Duke Religious Index. Support Care Cancer 8 (2): 102-9, 2000.
6. Koenig H, Parkerson GR, Meador KG: Religion index for psychiatric research. Am J Psychiatry 154 (6): 885-6, 1997.
7. Holland JC, Kash KM, Passik S, et al.: A brief spiritual beliefs inventory for use in quality of life research in life-threatening illness. Psychooncology 7 (6): 460-9, 1998 Nov-Dec.
8. Pargament KI, Smith BW, Koenig HG, et al.: Patterns of positive and negative religious coping with major life stressors. J Sci Study Relig 37 (4): 710-24, 1998.
9. Hills J, Paice JA, Cameron JR, et al.: Spirituality and distress in palliative care consultation. J Palliat Med 8 (4): 782-8, 2005.
10. 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.
11. Cella DF, Tulsky DS, Gray G, et al.: The Functional Assessment of Cancer Therapy scale: development and validation of the general measure. J Clin Oncol 11 (3): 570-9, 1993.
12. Canada AL, Murphy PE, Fitchett G, et al.: A 3-factor model for the FACIT-Sp. Psychooncology 17 (9): 908-16, 2008.
13. 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.
14. Krupski TL, Saigal CS, Hanley J, et al.: Patterns of care for men with prostate cancer after failure of primary treatment. Cancer 107 (2): 258-65, 2006.
15. Peterman AH, Fitchett G, Brady MJ, et al.: Measuring spiritual well-being in people with cancer: the functional assessment of chronic illness therapy--Spiritual Well-being Scale (FACIT-Sp). Ann Behav Med 24 (1): 49-58, 2002 Winter.
16. 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.
17. Johnson ME, Piderman KM, Sloan JA, et al.: Measuring spiritual quality of life in patients with cancer. J Support Oncol 5 (9): 437-42, 2007.
18. Cole BS, Hopkins CM, Tisak J, et al.: Assessing spiritual growth and spiritual decline following a diagnosis of cancer: reliability and validity of the spiritual transformation scale. Psychooncology 17 (2): 112-21, 2008.
19. Maugans TA: The SPIRITual history. Arch Fam Med 5 (1): 11-6, 1996.
20. Borneman T, Ferrell B, Puchalski CM: Evaluation of the FICA Tool for Spiritual Assessment. J Pain Symptom Manage 40 (2): 163-73, 2010.
21. Multidimensional Measurement of Religiousness/Spirituality for Use in Health Research: A Report of the Fetzer Institute/National Institute on Aging Working Group. Fetzer Institute, 1999.

Modes of Intervention

Various modes of intervention or assistance might be considered to address the spiritual concerns of patients, including the following:

• Exploration by the physician or other health care provider within the context of usual medical care.
• Encouragement for patients to seek assistance from their own clergy.
• Formal referral to a hospital chaplain.
• Referral to a religious or faith-based therapist.
• Referral to support groups known to address spiritual issues.

Two survey studies [1,2] found that physicians consistently underestimate the degree to which patients want spiritual concerns addressed. An Israeli study found that patients expressed the desire that 18% of a hypothetical 10-minute visit be spent addressing such concerns, while their providers estimated that 12% of the time should be spent in this way.[2] This study also found that while providers perceived that a patient's desire to address spiritual concerns related to a broader interest in complementary and alternative medicine (CAM) modalities, patients viewed CAM-related issues and spiritual/religious concerns as quite separate.

Physicians

A task force [3] of physicians and end-of-life specialists suggested several guidelines for physicians who wish to respond to patients' spiritual concerns:

• Respect the patient's views and follow the patient's lead.
• Make a connection by listening carefully and acknowledging the patient's concerns, but avoid theological discussions or specific religious rituals.
• Maintain one's own integrity in relation to one's own religious beliefs and practices.
• Identify common goals for care and medical decisions.
• Mobilize other resources of support for the patient, such as referral to a chaplain or contact with the patient's own clergy.

Inquiring about religious or spiritual concerns may provide valuable and appreciated support to patients. Most cancer patients appear to welcome a dialogue about such concerns, regardless of diagnosis or prognosis. In a large survey, 20% to 35% of outpatients with cancer expressed the following:[4][Level of evidence: II]

• A desire for religious and spiritual resources.
• Help with talking about finding meaning in life.
• Help with finding hope.
• Talking about death and dying.
• Finding peace of mind.

It is appropriate to initiate such an inquiry once initial diagnosis and treatment issues have been discussed and considered by the patient (approximately a month after diagnosis or later). In a large, multisite, longitudinal study of patients with advanced cancer,[5][Level of evidence: II] there was considerable variation in whether medical staff addressed spiritual concerns, with about 50% reporting at least some support at three of the settings, in contrast with fewer than 15% reporting some support at the other four settings.

Support from the medical team predicted the following:

• Greater quality of life.
• Greater likelihood of receiving hospice care at the end of life.
• Less-aggressive care for patients who have high levels of religious coping.

One trial,[6][Level of evidence: II] with a sample of 115 mixed-diagnosis patients (54% under active treatment), evaluated a 5-minute semistructured inquiry into spiritual and religious concerns. The four physicians' personal religious backgrounds included two Christians, one Hindu, and one Sikh; 81% of patients were Christian. Unlike the history-oriented interviews noted above, this inquiry was informed by brief patient-centered counseling approaches that view the physician as an important source of empowerment to help patients identify and address personal concerns (see Table 2 below for the content). After 3 weeks, the intervention group had larger reductions in depression, had more improvement in quality of life, and rated their relationship with the physician more favorably. Effects for quality of life remained after statistically adjusting for change in other variables. More improvement was also seen in patients who scored lower in spiritual well-being, as measured by the Functional Assessment of Chronic Illness Therapy—Spiritual Well-Being (FACIT-Sp) at baseline. Acceptability was high, with physicians rating themselves as "comfortable" in providing the intervention during 85% of encounters. Seventy-six percent of patients characterized the inquiry as "somewhat" to "very" useful. Physicians were twice as likely to underestimate the usefulness of the inquiry to patients rather than to overestimate it, in relation to patient ratings.

The statements in Table 2 may be used to initiate a dialogue between health care provider and patient.

Table 2. Exploring Spiritual/Religious Concerns in Adults With Cancer^a

Health Care Provider Inquiry	Question for Patient
a Adapted from Kristeller et al.[6]
Introduce issue in neutral inquiring manner.	"When dealing with a serious illness, many people draw on religious or spiritual beliefs to help cope. It would be helpful to me to know how you feel about this."
Inquire further, adjusting inquiry to patient's initial response.	Positive-Active Faith Response: "What have you found most helpful about your beliefs since your illness?"
	Neutral-Receptive Response: "How might you draw on your faith or spiritual beliefs to help you?"
	Spiritually Distressed Response (e.g., expression of anger or guilt): "Many people feel that way…what might help you come to terms with this?"
	Defensive/Rejecting Response: "It sounds like you're uncomfortable I brought this up. What I'm really interested in is how you are coping…can you tell me about that?"
Continue to explore further as indicated.	"I see. Can you tell me more (about…)?"
Inquire about ways of finding meaning and a sense of peace.	"Is there some way in which you are able to find a sense of meaning or peace in the midst of this?"
Inquire about resources.	"Who can you talk to about these concerns?"
Offer assistance as appropriate and available.	"Perhaps we can arrange for you to talk to someone/There's a support group I can suggest/There are some reading materials in the waiting room."
Bring inquiry to a close.	"I appreciate you discussing these issues with me. May I ask about it again?"

A common concern is whether to offer to pray with patients. Although one study [7] found that more than one-half of the patients surveyed expressed a desire to have physicians pray with them, a large proportion did not express this preference. A qualitative study of cancer patients [8] found that they were concerned that physicians are too busy, not interested, or even prohibited from discussing religion. At the same time, patients generally wanted their physicians to acknowledge the value of spiritual and religious issues. A suggestion was made that physicians might raise the question of prayer by asking, "Would that comfort you?"

In a study of 70 patients with advanced cancer, 206 oncology physicians, and 115 oncology nurses, all participants were interviewed about the appropriateness of patient-practitioner prayer in the advanced-cancer setting. Results showed that 71% of patients, 83% of nurses, and 65% of physicians reported that it is occasionally appropriate for a practitioner to pray with a patient when the patient initiates the request. Similarly, 64% of patients, 76% of nurses, and 59% of physicians reported that they consider it appropriate for a religious/spiritual health care practitioner to pray for a patient.[9]

The most important guideline is to remain sensitive to the patient's preference. Asking patients about their beliefs or spiritual concerns in the context of exploring how they are coping in general is the most viable approach in exploring these issues.

Hospital Chaplains

Traditionally, hospital chaplains deliver religious or spiritual assistance to patients.[10,11] Hospital chaplains can play a key role because they are trained to work with a wide range of issues as they arise for patients and to be sensitive to patients' diverse beliefs and concerns.[12] Chaplains are generally available in large medical centers but may not be reliably available in smaller hospitals. Chaplains are rarely available in outpatient settings where most cancer care is now delivered (especially early in the course of cancer treatment, when these issues may first arise). In a large, multisite, longitudinal study of patients with advanced cancer,[5][Level of evidence: II] only 46% of patients reported receiving pastoral care visits. While these visits were not associated with receiving end-of-life care (either hospice or aggressive measures), they were associated with better quality of life near death.

Another traditional approach in outpatient settings is having spiritual/religious resources available in waiting rooms. This activity is relatively easy to do, and many resources exist. A breadth of resources covering all faith backgrounds of patients is highly desirable. For more information, see the Additional Resources section.

Support Groups

Support groups may provide a setting where patients may explore spiritual concerns. The health care provider may need to identify whether an in-person or online group addresses these issues. The published data on the specific effects of support groups on assisting with spiritual concerns is relatively sparse, partly because this aspect of adjustment has not been systematically evaluated. A randomized trial [13][Level of evidence: I] compared the effects of a mind-body-spirit group to a standard support group for women with breast cancer. Both groups showed improvement in spiritual well-being, although there were appreciably more differential effects for the mind-body-spirit group in the area of spiritual integration.

A study of 97 lower-income women with breast cancer who were participating in an online support group examined the relationship between a variety of psychosocial outcomes and religious expression (as indicated by the use of religious words such as faith, God, pray, holy, or spirit). Results showed that women who communicated a deeper religiousness in their online writing to others had lower levels of negative emotions, higher levels of perceived health self-efficacy, and higher functional well-being.[14] An exploratory study of a monthly spirituality-based support group program for African American women with breast cancer suggested high levels of satisfaction in a sample that already had high levels of religious and spiritual engagement.[15][Level of evidence: III]

One author [16] presents a well-developed model of adjuvant psychological therapy that uses a large group format and addresses both basic coping issues and spiritual concerns and healing, using a combination of group exploration, meditation, prayer, and other spiritually oriented exercises. In a carefully conducted, longitudinal, qualitative study of 22 patients enrolled in this type of intervention,[17] researchers found that patients who were more psychologically engaged with the issues presented were more likely to survive longer. Other approaches are available but have yet to be systematically evaluated,[18,19] have not explicitly addressed religious and spiritual issues, or have failed to evaluate the effects of the intervention on spiritual well-being.[20]

Other Interventions

Other therapies may also support spiritual growth and post-traumatic benefit finding. For example, in a nonrandomized comparison of mindfulness-based stress reduction (n = 60) and a healing arts program (n = 44) in cancer outpatients with a variety of diagnoses, both programs significantly improved facilitation of positive growth in participants, although improvements in spirituality, stress, depression, and anger were significantly larger for the mindfulness-based stress reduction group.[21][Level of evidence: II]

References:

1. Kristeller JL, Zumbrun CS, Schilling RF: 'I would if I could': how oncologists and oncology nurses address spiritual distress in cancer patients. Psychooncology 8 (5): 451-8, 1999 Sep-Oct.
2. Ben-Arye E, Bar-Sela G, Frenkel M, et al.: Is a biopsychosocial-spiritual approach relevant to cancer treatment? A study of patients and oncology staff members on issues of complementary medicine and spirituality. Support Care Cancer 14 (2): 147-52, 2006.
3. Lo B, Ruston D, Kates LW, et al.: Discussing religious and spiritual issues at the end of life: a practical guide for physicians. JAMA 287 (6): 749-54, 2002.
4. Astrow AB, Wexler A, Texeira K, et al.: Is failure to meet spiritual needs associated with cancer patients' perceptions of quality of care and their satisfaction with care? J Clin Oncol 25 (36): 5753-7, 2007.
5. Balboni TA, Paulk ME, Balboni MJ, et al.: Provision of spiritual care to patients with advanced cancer: associations with medical care and quality of life near death. J Clin Oncol 28 (3): 445-52, 2010.
6. Kristeller JL, Rhodes M, Cripe LD, et al.: Oncologist Assisted Spiritual Intervention Study (OASIS): patient acceptability and initial evidence of effects. Int J Psychiatry Med 35 (4): 329-47, 2005.
7. King DE, Bushwick B: Beliefs and attitudes of hospital inpatients about faith healing and prayer. J Fam Pract 39 (4): 349-52, 1994.
8. Hebert RS, Jenckes MW, Ford DE, et al.: Patient perspectives on spirituality and the patient-physician relationship. J Gen Intern Med 16 (10): 685-92, 2001.
9. Balboni MJ, Babar A, Dillinger J, et al.: "It depends": viewpoints of patients, physicians, and nurses on patient-practitioner prayer in the setting of advanced cancer. J Pain Symptom Manage 41 (5): 836-47, 2011.
10. Fitchett G, Meyer PM, Burton LA: Spiritual care in the hospital: who requests it? Who needs it? J Pastoral Care 54 (2): 173-86, 2000 Summer.
11. Handzo G: Where do chaplains fit in the world of cancer care? J Health Care Chaplain 4 (1-2): 29-44, 1992.
12. Association of Professional Chaplains, Association for Clinical Pastoral Education, Canadian Association for Pastoral Practice and Education, et al.: A White Paper. Professional chaplaincy: its role and importance in healthcare. J Pastoral Care 55 (1): 81-97, 2001 Spring.
13. Targ EF, Levine EG: The efficacy of a mind-body-spirit group for women with breast cancer: a randomized controlled trial. Gen Hosp Psychiatry 24 (4): 238-48, 2002 Jul-Aug.
14. Shaw B, Han JY, Kim E, et al.: Effects of prayer and religious expression within computer support groups on women with breast cancer. Psychooncology 16 (7): 676-87, 2007.
15. Antle B, Collins WL: The impact of a spirituality-based support group on self-efficacy and well-being of African American breast cancer survivors: a mixed methods design. Social Work and Christianity 36 (3): 286-300, 2009.
16. Cunningham AJ: Group psychological therapy: an integral part of care for cancer patients. Integrative Cancer Therapies 1(1): 67-75, 2002.
17. Cunningham AJ, Edmonds CV, Phillips C, et al.: A prospective, longitudinal study of the relationship of psychological work to duration of survival in patients with metastatic cancer. Psychooncology 9 (4): 323-39, 2000 Jul-Aug.
18. Breitbart W: Spirituality and meaning in supportive care: spirituality- and meaning-centered group psychotherapy interventions in advanced cancer. Support Care Cancer 10 (4): 272-80, 2002.
19. Cole B, Pargament K: Re-creating your life: a spiritual/psychotherapeutic intervention for people diagnosed with cancer. Psychooncology 8 (5): 395-407, 1999 Sep-Oct.
20. Spiegel D, Bloom JR, Kraemer H, et al.: Psychological support for cancer patients. Lancet 2 (8677): 1447, 1989.
21. Garland SN, Carlson LE, Cook S, et al.: A non-randomized comparison of mindfulness-based stress reduction and healing arts programs for facilitating post-traumatic growth and spirituality in cancer outpatients. Support Care Cancer 15 (8): 949-61, 2007.

Increasing Personal Awareness in Health Care Providers

Many health care providers may regard spirituality, religion, death, and dying as a taboo subject. The meaning of illness and the possibility of death are often difficult to address. The assessment resources noted above may help introduce the topic of spiritual concerns, death, and dying to a patient in a supportive manner. In addition, reading clinical accounts by other health care providers can be helpful. For example, a qualitative study using an autoethnographic approach to explore spirituality in members of an interdisciplinary palliative care team. Findings from this work yielded a collective spirituality that emerged from the common goals, values, and belonging shared by team members. Participants' reflections offer insights into patient care for other health care professionals.[1]

References:

1. Sinclair S, Raffin S, Pereira J, et al.: Collective soul: the spirituality of an interdisciplinary palliative care team. Palliat Support Care 4 (1): 13-24, 2006.

Issues to Consider

Although a considerable number of anecdotal accounts suggest that prayer, meditation, imagery, or other religious activity can have healing power, the empirical evidence is extremely limited and inconsistent.[1] On the basis of current evidence, it is questionable whether any patient with cancer should be encouraged to seek such resources as a means to heal or to limit the physical effects of disease. However, the psychological value of support and spiritual well-being is increasingly well documented, and evidence that spiritual distress can have a negative impact on health is growing. Health care providers need to frame these resources in terms of self-understanding, clarifying questions of belief with an appropriate spiritual or religious leader, or seeking a sense of inner peace or awareness.

References:

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

Additional Resources

• University of Florida Center for Spirituality and Health. Conducts courses, research projects, and programs that focus on the interface between religious traditions, spirituality, and health.
• George Washington Institute for Spirituality and Health. Focuses on medical education in the area of religion, spirituality, and medicine.
• Benson-Henry Institute for Mind Body Medicine at Massachusetts General Hospital. Provides outpatient medical services, training for health professionals, corporate and school-based programs, women's health services, and affiliation for national and international health care systems.
• Duke University Center for Spirituality, Theology, and Health. Conducts interdisciplinary research, scholarship, and education on spirituality, theology, and health.

These reference citations are included for informational purposes only. Their inclusion should not be viewed as an endorsement by the PDQ Supportive and Palliative Care Editorial Board or the National Cancer Institute.

Current Clinical Trials

Use our advanced clinical trial search to find NCI-supported cancer clinical trials that are now enrolling patients. The search can be narrowed by location of the trial, type of treatment, name of the drug, and other criteria. General information about clinical trials is also available.

Latest Updates to This Summary (12 / 12 / 2023)

The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.

Editorial changes were made to this summary.

This summary is written and maintained by the PDQ Supportive and Palliative Care Editorial Board, which is editorially independent of NCI. The summary reflects an independent review of the literature and does not represent a policy statement of NCI or NIH. More information about summary policies and the role of the PDQ Editorial Boards in maintaining the PDQ summaries can be found on the About This PDQ Summary and PDQ® Cancer Information for Health Professionals pages.

About This PDQ Summary

Purpose of This Summary

This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about religious and spiritual coping in cancer care. It is intended as a resource to inform and assist clinicians in the care of their patients. It does not provide formal guidelines or recommendations for making health care decisions.

Reviewers and Updates

This summary is reviewed regularly and updated as necessary by the PDQ Supportive and Palliative Care Editorial Board, which is editorially independent of the National Cancer Institute (NCI). The summary reflects an independent review of the literature and does not represent a policy statement of NCI or the National Institutes of Health (NIH).

Board members review recently published articles each month to determine whether an article should:

• be discussed at a meeting,
• be cited with text, or
• replace or update an existing article that is already cited.

Changes to the summaries are made through a consensus process in which Board members evaluate the strength of the evidence in the published articles and determine how the article should be included in the summary.

The lead reviewer for Spirituality in Cancer Care is:

• Amy Wachholtz, PhD, MDiv, MS, ABPP (University of Colorado)

Any comments or questions about the summary content should be submitted to Cancer.gov through the NCI website's Email Us. Do not contact the individual Board Members with questions or comments about the summaries. Board members will not respond to individual inquiries.

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Some of the reference citations in this summary are accompanied by a level-of-evidence designation. These designations are intended to help readers assess the strength of the evidence supporting the use of specific interventions or approaches. The PDQ Supportive and Palliative Care Editorial Board uses a formal evidence ranking system in developing its level-of-evidence designations.

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The preferred citation for this PDQ summary is:

PDQ® Supportive and Palliative Care Editorial Board. PDQ Spirituality in Cancer Care. Bethesda, MD: National Cancer Institute. Updated <MM/DD/YYYY>. Available at: https://www.cancer.gov/about-cancer/coping/day-to-day/faith-and-spirituality/spirituality-hp-pdq. Accessed <MM/DD/YYYY>. [PMID: 26389436]

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Last Revised: 2023-12-12