To the best of our knowledge, this is the first study to explore spiritual well-being in individuals with advanced cancer during the COVID-19 pandemic and to scrutinize the mediating role of spirituality between psychological distress and resilience in this population. The results established that spirituality played a 12.1% mediating role and, as expected, found a negative correlation between psychological distress, spirituality, and resilience.
Many psychosocial studies have been conducted in patients with cancer in recent years . Psychological distress and depression have been proven to be risk factors [13, 21] and spirituality to be protective in the development of depression [14, 22]. A systematic review of studies in cases of advanced cancer revealed that resilience is associated with spirituality, social support, the search for meaning, accepting their disease, positive attitude, and quality of life [12, 23]. During the COVID-19 pandemic, female breast cancer survivors who scored high on spirituality and resilience experienced less fear of recurrence, despite not receiving their usual medical follow-up [12, 23].
Despite the positive correlation between spirituality and resilience, they are considered to have their own, distinct characteristics [22, 24]. Recent research points toward spirituality potentially increasing resilience in different ways: favoring interpersonal relationships, as a source of strength and inner solace, or deceasing feelings of anger and social isolation [25, 26]. In this manner, spirituality could nurture resilience in patients with advanced cancer, but not vice versa, insofar as there can be resilient individuals without high levels of spirituality. This was found in the present study in which subjects > 70 years were not the most resilient despite exhibiting higher levels of spirituality. The greater frailty and vulnerability (comorbidities, lower functionality) and dependency, and poorer tolerance to cancer treatment of the elderly may account for this finding. [27, 28]. Similarly, our results indicate that seniors (> 70 years) display less resilience and greater psychological distress. This is in line with earlier investigations that demonstrate that seniors have less resilience and more psychological issues like depression, attributable to their loneliness with less social support, lack of energy, and physical decline [29, 30].
Our study reveals that, graphically, psychological distress is U-shaped; i.e., it is highest in patients ≤ 50 and > 70 years. This could be due to young adults finding their chances of achieving their life goals limited by their diagnosis of advanced cancer . In seniors, psychological distress has been associated with them being physically weaker and suffering greater psychological affliction given the loss of significant people in their surroundings . Our study also displayed greater psychological distress among women than men, which is in keeping with the literature that point toward females with cancer being more prone to psychological problems and suffering more from the repercussions on their family and milieu, given the organic, cosmetic, functional, and cognitive sequelae following their cancer diagnosis and treatment, as well as presenting more sexual problems [32, 33].
The study has a series of strengths and limitations. First, while the COVID-19 outbreak was a fundamental motivator in this study, it was designed before then and none of the variables collected was associated with the pandemic nor were infected individuals included, given that they had to overcome the disease in order to attend their oncology appointment. Secondly, given its cross-sectional nature, we were unable to draw causal relations across study variables. The findings of the current study should be confirmed by longitudinal cohort studies in the future. Third, all data were obtained through self-report questionnaires, which could introduce response bias. The participants may have underestimated or overestimated the relationship between the study variables. Fourth, the study did not seek to nor was it statistically powered to compare behavior of patients with different neoplasms; hence, the weight of tumor type has not been analyzed in the findings. Finally, despite the fact that the sample is representative of the Spanish geography, any generalization of the results to other cultures and societies must be made with caution.
People with advanced, unresectable cancer find their life expectancy shortened and confront a situation in which spiritual concerns arise. Spirituality can help in the face of end-of-life despair, endowing the situation and one’s own existence with meaning and a sense of transcendence [12,22]. The importance of spirituality notwithstanding, it is not easy for physicians to talk about the spiritual concerns of patients with advanced cancer.
Spirituality-based coping mechanisms can help to promote subjective wellbeing and greater resilience in cases of incurable cancer. Resilience, underpinned by spirituality, can help in the process of adapting to the disease and at the end of life.
Regardless of society’s secularization over the las 50 years, studies show that there is increased interest in spiritual growth and religious activity in older adults . Including spirituality in interventions and the training of healthcare professionals who work with subjects with advanced cancer and in palliative care can contribute to maintaining and enhancing the resilience and wellbeing of patients and their caregivers [34,35]. Moreover, finding meaning to life, reformulating the narratives of loss, and being a member of a community, such as a religious community, are some ways in which spirituality can bolster resilience and help people handle the challenges of the disease. In conclusion, spirituality can help promote subjective wellbeing and resilience in individuals with advanced cancer.