One of the leading causes of reduction in global life expectancy is cancer, and its prevalence is rising (Ferlay et al., 2015). In 2008 its prevalence was estimated to be around 7.6 million globally, and in 2020 it reached approximately 19.3 million (Sung et al., 2021; World Health Organization, 2008). In 2012, the cancer prevalence in Europe was estimated to be around 1.75 million, with 56% men and 44% women (Gabriele et al., 2016). Moreover, about 17–23% of all cancer deaths are due to lung cancer (Koyama et al., 2016). According to a landmark report of 50 countries of the world published by the World Cancer Research Fund and American Institute for Cancer Research (2018), the average global incidence of cancer was around 197.9/100,000, with men having the cancer incidence of around 218.6/100,000 and women having it at around 182.6/100,000. Furthermore, as per the report mentioned above, Australia was ranked at the top with the highest overall cancer incidence of 468.0/100,000. New Zeeland had the second-highest number, i.e., 438.0/100,000, and Israel was at the lowest rank with the cancer incidence of 233.6/100,000. Compared with European countries, the cancer prevalence is comparatively higher in developing Asian countries (Takahiro & Shin, 2018). In China, cancer incidence has been reported to be around 278.07/100,000, which indicates a higher risk of cancer (Chen et al., 2018). In Pakistan, estimates from 2012 suggest that the overall 1-year incidence of cancers was somewhat around 80/100,000 with females having a relatively higher prevalence of 93.2/100,000 than men, i.e., 66/100,000 (Sarwar, & Saqib, 2017). A recent estimate suggests that around 0.18 million new cases were reported in Pakistan, and approximately 0.12 million deaths occurred out of 220 million population in the year 2020, which could be considered high (International Agency for Research on Cancer, 2020). Whereas in 2005, an estimated 85000 people died in Pakistan because of cancer; this could indicate a rise in the problem of cancer in Pakistan (Bhurgri et al., 2006).
Breast cancer is one of the biggest worries for Pakistani women; in one study, it was noted that, of all the cancers found in women, 79.2% were suffering from breast cancer (Badar & Mahmood, 2017). Furthermore, Atomic Energy Cancer Hospitals in Pakistan estimated that 40% of patients they treated came in with breast cancer in 2015–2016, which is alarming (Firdous, 2017). According to a World Cancer Report (Boyle & Levin, 2008), 31.5 breast cancer cases per 100,000 women are reported yearly in Pakistan. As per another study, breast cancer is the most widespread, most serious, and most frequently diagnosed cancer of women (affecting about one in nine women) in Pakistan that causes the most number of deaths of women compared to any other cancer; more concerning is that this rate of prevalence is more than twofold of its neighboring countries Iran and India (Asif, Sultana, Akhtar, Rehman, & Rehman, 2014). Hence focusing on cancer and its related psychological factors is of utmost importance for Pakistani people, especially women suffering from it.
Life-threatening disease such as cancer significantly affects a person both anatomically and psychologically (Pizzoli et al., 2019). Psychological problems like continuous stressful life experiences, physical fatigue, sleep disturbance, body pain, muscle tension, headache, irritable mood, and lack of interest have commonly been reported among cancer patients (Craft et al., 2012; Ho et al., 2015). A general fear is usually present in the patient during the diagnostic procedures when s/he suspects that s/he is at risk of being diagnosed with cancer, however in some cases, this fear becomes very problematic; furthermore, psychiatric disorders such as depression and anxiety-related disorders are also commonly reported in patients with cancer (Gregurek et al., 2010). Depression has been observed as one of the comorbid biopsychological factors in oncology patients but is often overlooked by health providers when patients require immediate emotional support (Ng & Zainal, 2014). Estimates of depression rate in cancer patients vary widely, i.e., from 1.5–50% (Khamechian, Alizargar, & Mazoochi, 2013). Moreover, cancer patients with depression use more negative coping methods (Ng et al., 2017). Therefore, healthy coping strategies are essential for managing depression and stress in such patients; in this vein, many researchers have identified religion as one of the more beneficial coping strategies (Aflakseir & Mahdiyar, 2016; Meer & Mir, 2014). In religious coping, people displace environmental stressors, which are not in their control, towards God, which helps them against feeling helpless and developing learned haplessness (Thune et al., 2006). Furthermore, religious involvement has been shown to induce a sense of optimism and an array of constructive behavior strategies which seem to buffer the cancer patient from developing psychiatric problems (Ellison et al., 2008). A person’s involvement in religious activities can help them become mentally stronger, contented, conflict-free, stable, realistic, and optimistic (Ellison et al., 2008; Koenig et al., 1988; Thune et al., 2006;). Being optimistic, in turn, is a positive and active trait that creates healthy beliefs in a person (Rajandram et al., 2011).
Religious practices usually play a fundamental role in the life of a practicing religious person (Aflakseir & Mahdiyar, 2016). Islam is a religion whose followers identify themselves as Muslims; it has more than 1.5 billion followers worldwide and is one of the three largest Abrahamic religions (Longfellow, 2018). However, as per our knowledge, research regarding Muslim religiosity and its role in managing chronic illnesses (like cancer) is relatively scarce (Haghighi, 2013). Islam has been usually referred to as a particular way of life (Basri et al., 2015). Therefore an investigation of its relevance in facing and adjusting to a chronic illness like cancer is needed. A review of ninety-three studies published by psychologists and psychiatrists of the United States of America, Europe, Arab Countries, and Iran by Dadfar and Lester (2017) explored how religiosity and spirituality correlate with death anxiety. They concluded that various studies revealed that religiosity, spirituality, well-being, sex, person's age, and culture are the significant factors that influence or affect death anxiety (Khezri et al., 2015).
Religious involvement develops optimistic behaviors and may help people manage their emotions, thereby making them mentally more stable; frequent involvement in religious activities also helps people overcome negative thinking, developing optimism, hope, and patience, and reducing the fear of death (Haghighi, 2013). A person's lack of religious and spiritual involvement could lead them to become psychologically distressed (Coyne, Tennen, & Ranchor, 2010). Furthermore, low religious involvement contributes to developing depression and anxiety in a person (Basri et al., 2015; Ballenger et al., 2001). To the best of our knowledge and literature search, Muslim religiosity and distress level have not been investigated in oncology patients of Pakistan.
The current study investigates the association between Muslim religiosity, optimism, death anxiety, and depression in cancer patients. We hypothesized that:
- optimism and depression will act as parallel mediators between the relationship between Muslim religiosity and death anxiety.
- depression and death anxiety levels would significantly differ among patients with cancer stages I, II, III, and IV.
- level of depression would be significantly different among low, middle, and high socioeconomic in cancer patients.
- level of death anxiety would be significantly different among different types of cancer