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The role of religion/spirituality for cancer patients and their caregivers.(Featured CME Topic: Spirituality)

Andrew J. Weaver

Southern Medical Journal - December 1, 2004

Abstract: Research has shown that religiosity and spirituality significantly contribute to psychosocial adjustment to cancer and its treatments. Religion offers hope to those suffering from cancer, and it has been found to have a positive effect on the quality of life of cancer patients. Numerous studies have found that religion and spirituality also provide effective coping mechanisms for patients as well as family caregivers. Research indicates that cancer patients who rely on spiritual and religious beliefs to cope with their illness are more likely to use an active coping style in which they accept their illness and try to deal with it in a positive and purposeful way. Faith-based communities also offer an essential source of social support to patients, and religious organizations can play a direct and vital role in cancer prevention by providing screening, counseling, and educational programs, especially in minority communities.

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Cancer ranks among the most dreaded of diseases. A diagnosis can cause extreme fear, helplessness, and psychologic trauma. (1) The unforeseeable outcome of the treatment compounds the anxiety and leads to patients feeling powerless. Both cancer patients and their families may be intimidated and confused by the healthcare delivery system and the technology of modern treatment. (2) Such a diagnosis challenges every dimension of a person's life: physical, emotional, and spiritual.

Cancer is the product of cumulative lifestyle and environmental factors that place everyone at risk. In the United States each year, approximately 1.3 million cancers are diagnosed. (3) The 5-year survival rate for all types combined is 62%, and 8.9 million people have a history of cancer. By 2010 approximately 1 in every 250 Americans will be a survivor of childhood cancer. (4) It is the second leading cause of death, resulting in more than 550,000 deaths--1 of 4 Americans who die each year. (3) Many researchers have found a strong relation between patients' reliance on religious beliefs and practices and the effectiveness of their coping with cancer. (5-7)

Faith can give a suffering person a framework for finding meaning and perspective through a source greater than self, (8) and it can provide a sense of control over feelings of helplessness. (9) Religious practice can provide access to social networks and established forms of assistance, including pastoral care during times of acute distress. (10)

The Importance of Hope

Hope is particularly important for those suffering from cancer, (11-15) and a positive association between various self-reported measures of hope and religiosity has been found in quantitative studies specifically designed to examine this relation. (16-18) For example, in a study of women with gynecologic cancers, 93% said that faith had increased their capacity to be hopeful. (19) Ebright and Lyon, (20) in research on females who were recently diagnosed with breast cancer, found that those who scored higher on the Herth Hope Index reported less anxiety and fear about their disease. Furthermore, the more they felt their religious beliefs helped them to deal with treatment the more positive they felt about their ability to deal with the situation. Another study of breast cancer patients found that their level of hope was primarily a function of their sense of spiritual well-being, as measured by the Spiritual Well-Being Scale, (21) rather than of demographic, prognostic, or treatment variables. (22) Qualitative research also indicates that religion provides hope to oncology patients. (23,24) For example, Saleh and Brockopp (24) found religious practices and family relationships to be the two most frequently identified sources of hope among hospitalized patients with bone cancer.

Most studies indicate that increases in religiosity correlate with increases in hopefulness. However, a 1-year study of women who were newly diagnosed with breast cancer reported a peculiar interaction between hope and religious coping in their psychologic adjustment. (25) In that study, religious coping was related to better psychologic adjustment only among females who were initially rated as being low in hope. Indeed, among women who were initially high in hope, turning to religion was associated with poorer adjustment.

Post-White et al (26) used both quantitative and qualitative methods to examine the relation between spirituality and hope in hospitalized oncology patients. While the patients' scores on the Herth Hope Index were unrelated to their scores on a spirituality scale developed by the researchers themselves, most patients said during interviews that "faith or belief in a higher power helped them feel more hopeful." The discrepancy between the quantitative and qualitative findings provides a cautionary tale about the use of untested attitudinal scales in research on these kinds of concepts.

Spirituality and Quality of Life

Quality of life (QOL) has become increasingly important for patients as treatment advances extend the length of survival. Although relatively few studies have examined the relationship between religion/spirituality and QOL, Mytko and Knight (27) conclude from their review of the research, "... much of the evidence suggests that religiosity and spirituality contribute to psychosocial adjustment to cancer and its treatments."

Perceived QOL has become a common indicator of adjustment, and a variety of scales have been developed to measure this concept. Most commonly used QOL scales in cancer research do not include spirituality as a test component, but some researchers (7,27) have argued for its inclusion because of its importance to patients. (7,27-29) A 1999 special issue of Psycho-Oncology devoted to spirituality contained two articles that are particularly pertinent. (7,30) The sample tested in one study consisted of 142 females with breast cancer, whereas the sample in the other study consisted of 762 men and 848 women with various kinds of cancer. Both studies found a significant positive association between QOL and spirituality, using bivariate statistics, but the smaller study did not find a significant effect of spirituality when multivariate statistics were used to control for other variables that might influence QOL. (30) This is not surprising, given the small sample size. In contrast, the larger study reported that spirituality had a substantial effect on QOL even when other factors were controlled for statistically. (7) Moreover, the study by Brady et al (7) provides evidence that patients' level of spirituality has clinical implications. When patients were divided in half according to their levels of pain and fatigue, those who had higher spirituality scores reported higher QOL than patients with comparable levels of pain or fatigue who had lower spirituality scores.

Coping Strategies

People respond to stress differently and a variety of scales have been developed to assess how people cope with the stress of health problems. (31-33) The various strategies people use to deal with illness and other stressors have been broadly classified into two types of styles: (1) active coping or problem-solving and (2) passive or avoidant coping. (34-38) Freud (38) regarded religious coping as a kind of defense mechanism and viewed religious coping as a regressive, passive, and avoidant psychologic phenomenon. (39)

Recent research has found that religious and spiritual beliefs are associated with active coping, not with avoidant or passive coping strategies, among patients with malignant melanoma. (5,40) One study was conducted in New York City (5) and the other in Jerusalem (40) using identical self-report measures of coping style (Dealing with Illness-Coping Inventory) and religious/spiritual beliefs and practices--the Systems of Belief Inventory (SBI). In both studies, SBI scores had a significant, positive correlation with active cognitive-coping methods, even after controlling for demographic variables and cancer stage. The results indicated that patients who exhibited greater reliance on spiritual and religious beliefs were more likely to use an active-cognitive coping style in which they accepted their illness and tried to deal with it in a positive and purposeful manner. These and other studies support the view that religious and spiritual beliefs can provide a helpful framework for many individuals who face the existential crises of a cancer diagnosis. (41,42)

Prayer can serve as a means of self-soothing and of reducing such negative emotions as anger, depression, and fear, (43) so it may not be surprising that a study by Soderstrom and Martinson (44) found the most common coping strategy for cancer patients was praying alone or with others, as well as having others pray for them. Prayer was also found to be an important coping mechanism for parents of children with cancer. Among 29 different coping strategies that fathers were asked about, prayer was the one they said they used most often and was most helpful to them. (45) Other research indicates that patients also place a high value on interactions with clergy and that pastoral visits and prayers help them maintain hope and optimism. (46)

The frequent use of spirituality when coping with illness or caregiver stress should be no surprise, given the importance of religious community to the majority of Americans. (47,48) Moreover, the 353,000 Christian and Jewish clergy serving congregations in the United States (49) are among the most trusted professionals in society. (48) Surveys by the National Institute of Mental Health found that clergy are more likely than psychologists and psychiatrists combined to have a person with a personal problem see them for assistance. (50) More than 10,000 of these clergy serve as chaplains in hospitals and other healthcare institutions working closely with medical professionals. (51)

Faith Helps Caregivers

Family caregivers of cancer patients often face significant physical, social, and emotional hardships and indicate that they rely heavily on their faith to cope with these burdens. When researchers at Johns Hopkins University surveyed those caring for persons with end-stage cancer and Alzheimer disease, (52) they discovered that successful coping was primarily associated with two variables; number of social contacts and support received from religious faith. When these persons were followed for 2 years to determine the characteristics that predicted faster adjustment to the caregiver role, again only the number of social contacts and support received from personal religious faith predicted better adaptation over time. (53) Having support from one's religion appears to be one of the most important factors responsible for successful coping with the stress of caregiving. Other studies show that family members who are more religious feel more positively about their role as caregivers (54) and get along better with those they care for. (55) This may be due in part to the fact that faith communities foster belief systems of responsibility and compassion that are likely to help the persons doing the emotionally difficult work of caring for others. (56)

Relationship With God Is Valued

The feeling that one has a positive relationship with God can give an individual a sense of self-acceptance and belonging as well as provide a source of emotional comfort when faced with a life-threatening illness. (57) Many of the breast cancer patients who were interviewed by Johnson and Spilka (46) said they had an active and intimate relationship with God, that helped them to feel less alone and gave them courage to deal with their disease. Similarly, many breast cancer patients who were specifically asked to describe how their religion and spirituality helped them cope with their illness said that God was an ever-present support, constant companion, and confidante who helped buttress their self-esteem and sense of personal control throughout their illness. (43) Moreover, a positive relationship with God was associated with greater optimism and hopefulness.

Patients tend to increase their focus on religious issues and their connection to God as their cancer advances. For example, in a study of 108 women with various stages of cancer, about half reported that they had become more religious since they were diagnosed and none said they were less religious. (19) Similarly, when 231 patients with end-stage cancer were asked what maintained their quality of life, their "relationship with God" was the most common response among 28 choices that included "how well I eat," "physical contact with those I care about," and "pain relief." (58) According to these findings, terminal patients maintained their relationship with God in spite of severe functional difficulties and serious physical symptoms.

Faith-based Communities Can Help

Blacks are more likely to have cancer and are 30% less likely to survive it than are whites. During the period from 1990 to 1996, the incidence rate per 100,000 was 442.9 among blacks, 402.9 for whites, and 275.4 in Hispanics. (59) Early detection programs have resulted in a 35% improvement in 5-year survival for colon and for breast cancer patients nationwide. (60,61) Faith communities can play a vital role in preventing deaths by encouraging the use of screening. Researchers have found that the participation of clergy and key lay members in church-based cancer control programs can improve access to and participation in screening for cancer by blacks and Hispanics. (62) As an example, a recent study published in the American Journal of Public Health found that church-based telephone counseling in ethnic minority communities in Los Angeles significantly increased the regular use of mammography screening. (63) Such faith-based programs can have a great impact in promoting regular screening and educating people about cancer. (64) Their support and implementation by religious communities will help ensure congregations that are healthy in both body and soul.

Conclusion

Physicians need to be mindful of research showing that religious beliefs and spiritual practices can be useful to many patients and their caregivers coping with the impact of cancer. Medicine needs to further integrate these scientific findings into clinical practice to promote better patient care.

The vision must be followed by the venture. It is not enough to stare up the steps--we must step up the stairs. --Vance Havner

Accepted September 10, 2004.

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