This information is produced and provided by the National Cancer Institute (NCI). The information in this topic may have changed since it was written. For the most current information, contact the National Cancer Institute via the Internet web site at http://cancer.gov or call 1-800-4-CANCER.
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. 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.
Research indicates that both patients and family caregivers [3,4] commonly rely on spirituality and religion to help them deal with serious physical illnesses, expressing a desire to have specific spiritual and religious needs and concerns 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 patients reported that physicians should take patients' spiritual needs into consideration, and 37% wanted physicians to address religious beliefs more frequently. 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. Those 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). 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.
Sixty-one percent 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. Intensity of spiritual distress correlated with self-reports of depression but not with physical pain or with perceived severity of illness. Another study  of advanced cancer patients (N = 230) in New England and Texas assessed their 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 spiritual issues addressed by the medical care team had more impact on increasing the use of hospice and decreasing aggressive end-of-life measures than did pastoral counseling.
This summary will review the following topics:
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; responsibility for management of apparent spiritual distress has been focused on referring patients to the chaplain service.[13,14,15] Although health care providers may address such concerns themselves, they are generally very ambivalent about doing so, and there has been relatively little systematic investigation addressing the physician's role. These issues, however, are being increasingly addressed in medical training. 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.
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-member 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, but greater religious involvement may also be linked to an increased likelihood of desire for extreme measures at the end of life. 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. 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.
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.
|1.||Gallup GH Jr: Religion In America 1996: Will the Vitality of the Church Be the Surprise of the 21st Century? Princeton, NJ: 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. Available online. Last accessed August 29, 2012.|
|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. New York, NY: Guilford Press, 1997.|
|20.||Koenig HG: Spirituality in Patient Care: Why, How, When, and What. Philadelphia, Pa: Templeton Foundation Press, 2002.|
|21.||Koenig HG, McCullough ME, Larson DB: Handbook of Religion and Health. New York, NY: 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.|
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 to make 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. A number of reviews address matters of definition.[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 to acknowledging a general sense of peace and connectedness. The concept of spirituality is found in all cultures and is often considered to encompass a search for ultimate meaning through religion or other paths. Within 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, 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), while only 6% identified themselves as agnostic or atheist, only 29% attended religious services weekly; 66% represented themselves as spiritual but not religious.
One effort to characterize individuals by types of spiritual and religious experience  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 were experiencing worse adjustment. There is as yet no consensus on the number or types of underlying dimensions of spirituality or religious engagement.
From the prospective of both the research and clinical literature on the relationships between religion, spirituality, and health, it is important to consider how these concepts are defined and used by investigators and authors. Much of the epidemiological literature that has indicated a relationship between religion and health has been based on definitions of religious involvement such as membership in a religious group or frequency of church attendance. Somewhat more complex is assessing specific beliefs or religious practices such as belief in God, frequency of prayer, or reading religious material. Individuals may engage in such practices or believe in God without necessarily attending church 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. 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 considerations of effects on health and psychological well-being, the more helpful definitions focus on accessible feelings, such as a sense of inner peace, existential meaning, and purpose in life, or awe when walking in nature. For the purposes of this discussion, it is assumed that there is 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 medical patients include a sense of meaning and peace, a sense of faith, and a sense of connectedness to others or to God. Low levels of these experiences may be associated with poorer coping (refer to the Relation of Religion and Spirituality to Adjustment, Quality of Life, and Health Indices 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. Although many individuals may have such thoughts at some time following diagnosis, only a few individuals 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 [the R-Cope–Negative]). 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.
|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): 161-180, 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. Washington, DC: 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. New York, NY: 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 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 [1,2,3,4] and in family caregivers. 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.
Spiritual well-being, particularly a sense of meaning and peace, 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.
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). These patterns were also found in a large study of indigent prostate cancer survivors; the patterns were consistent across ethnicity and metastatic status.
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.[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.[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.
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. 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.
One author  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. 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. 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).
Engaging in prayer is often cited as an adaptive tool, but qualitative research  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. A useful discussion of how prayer is used by cancer patients and how clinicians might conceptualize prayer has been published.
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.
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. 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. 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  found that helper and cytotoxic T-cell counts were higher among women with metastatic breast cancer who reported greater importance of spirituality. Other investigators  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.
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.
|1.||Acklin MW, Brown EC, Mauger PA: The role of religious values in coping with cancer. J Relig Health 22 (4): 322-333, 1983.|
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|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.|
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|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.|
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|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.|
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|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.||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.|
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|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.|
|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.|
|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.|
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|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.|
|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.|
These approaches have different potential value and limitations. Patients may express reluctance to bring up spiritual issues, noting that they would 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. However, an increasing number of models are becoming available for physician use and training.
Numerous assessment tools are pertinent to performing a religious and spiritual assessment. Table 1 summarizes a selection of assessment tools. Several factors should be considered before choosing an assessment tool:
The line between assessment and intervention is blurred, and simply inquiring about an area such as religious or spiritual coping may be experienced by the patient as an opening for further exploration and validation of the importance of this experience. Evidence suggests that such an inquiry will be experienced as intrusive and distressing by only a very small proportion of patients. 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 area for exploration and for ascertaining basic levels of religious engagement or spiritual well-being (or spiritual distress). Most also assume a belief in God and therefore 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.
|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.
The following are semistructured interviewing tools designed to facilitate an exploration, by the physician or other health care provider, of religious beliefs and spiritual experiences or issues. 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 for provision of 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.
|Tool||Developer||Purpose/ Focus/ Subscale (No.)||Specific to Cancer Patients?||Level of Psychometric Development||Length/ Other Characteristics/ Comments|
|Systems of Belief Inventory (SBI-15R)||Holland et al.||Two factors: Beliefs/experience (10); religious social support (5)||Yes||High||Four items assume belief in God|
|DRI/DUREL||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|
|Brief R-COPE||Pargament et al.||Two factors: Positive coping; negative coping/distress||No||Very High|
|Fetzer Multidimensional Scale||Fetzer||Multiple subscales||No||High. Under development.|
|FICA: Spiritual history||Puchalski et al.||Brief spiritual history||No||Low||MD interview assessment|
|SPIRIT||Maugans||In-depth interview with guided questions||No||Low||MD interview assessment|
|Spiritual Transformation Scale (STS)||Cole et al.||Two factors: Spiritual Growth and Spiritual Decline||Yes||Moderate||Forty items. Unique to assessing change in spiritual experience post–cancer diagnosis.|
|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 Jr, 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. Kalamazoo, Mich: Fetzer Institute, 1999.|
Various modes of intervention or assistance might be considered to address the spiritual concerns of patients. These include the following:
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. This study also found that while providers perceived that a patient's desire for addressing 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.
A task force  of physicians and end-of-life specialists suggested several guidelines for physicians who wish to respond to patients' spiritual concerns:
Inquiring about religious or spiritual concerns by physicians or other health care professionals 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 of cancer outpatients, between 20% and 35% expressed a desire for religious and spiritual resources, help with talking about finding meaning in life, help with finding hope, talking about death and dying, and finding peace of mind.[Level of evidence: II] 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,[Level of evidence: II] there was considerable variation in whether spiritual concerns were addressed by medical staff, with about 50% reporting at least some support at three of the settings, in contrast to fewer than 15% reporting some support at the other four settings. Support received from the medical team predicted greater quality of life, greater likelihood of receiving hospice care at the end of life, and for patients who have high levels of religious coping, less aggressive care.
One trial,[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 the patient ratings.
The statements in Table 2 may be used to initiate a dialogue between health care provider and patient.
|Health Care Provider Action||Possible Patient Response||Health Care Provider Reply|
|a Adapted from Kristeller et al.|
|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 that 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.||Whom do you have to talk to about this/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  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  found that patients 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 their opinions regarding the appropriateness of patient-practitioner prayer in the advanced-cancer setting. Results showed that 71% of advanced-cancer patients, 83% of oncology nurses, and 65% of physicians reported that it is occasionally appropriate for a practitioner to pray with a patient when the request to pray is initiated by the patient. 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.
The most important guideline is to remain sensitive to the patient's preference; therefore, 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.
Traditional means of providing assistance to patients has generally been through the services of hospital chaplains.[10,11] Hospital chaplains can play a key role in addressing spiritual and religious issues; chaplains are trained to work with a wide range of issues as they arise for medical patients and to be sensitive to the diverse beliefs and concerns that patients may have. Chaplains are generally available in large medical centers, but they may not be available in smaller hospitals on a reliable basis. Chaplains are rarely available in the outpatient settings where most 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,[Level of evidence: II] only 46% of patients reported receiving pastoral care visits. While these visits were not associated with receipt of 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 is relatively easy to do, and many such resources exist; however, a breadth of resources covering all faith backgrounds of patients is highly desirable (refer to the Additional Resources section).
Support groups may provide a setting in which patients may explore spiritual concerns. If spiritual concerns are important to a patient, the health care provider may need to identify whether a locally available 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 [Level of evidence: I] compared the effects of a mind-body-spirit group to a standard group support program 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 were found to have lower levels of negative emotions, higher levels of perceived health self-efficacy, and higher functional well-being. 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 engagement in the religious and spiritual aspects of their lives.[Level of evidence: III]
One author  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, 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.
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 improvement in spirituality, stress, depression, and anger was significantly larger for the mindfulness-based stress reduction group.[Level of evidence: II]
|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.|
Spirituality, religion, death, and dying may be experienced by many providers as a taboo subject. The meaning of illness and the possibility of death are often difficult to address. The assessment resources noted above may be of value in introducing 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 very helpful. One such example is a qualitative study utilizing 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. Reflections of the participants offer insights into patient care for other health care professionals.
|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.|
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 by no means consistent. 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 healing or to limiting 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. Therefore, in exploring these issues with patients or encouraging the use of such resources, health care providers need to frame these resources in terms of self-understanding, clarifying questions of beliefs with an appropriate spiritual or religious leader, or seeking a sense of inner peace or awareness.
|1.||Sloan RP, Bagiella E: Claims about religious involvement and health outcomes. Ann Behav Med 24 (1): 14-21, 2002 Winter.|
These reference citations are included for informational purposes only. Their inclusion should not be viewed as an endorsement of the content of the Web sites by the PDQ Cancer Supportive Care Editorial Board or the National Cancer Institute.
Check NCI's list of cancer clinical trials for U.S. supportive and palliative care trials about spiritual concerns and spiritual therapy that are now accepting participants. The list of trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
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.
Relation of Religion and Spirituality to Adjustment, Quality of Life, and Health Indices
Added text about a study of spirituality and the use of complementary therapies in advanced cancer (cited Trinkaus et al. as reference 25).
Modes of Intervention
Added text about a study on the viewpoints of patients, physicians, and nurses on patient-practitioner prayer in the setting of advanced cancer (cited Balboni et al. as reference 9).
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