Our study explored the interplay between spirituality and religiosity as it relates to the physical and mental well-being of cancer survivors. Our study showed that higher spirituality had an impact on the physical well-being of highly religious cancer. Conversely, spirituality alone improves the mental well-being of cancer survivors, regardless of the level of religiosity. While our results are consistent with findings from other authors [4–7, 16, 27], our study further elucidated the interplay between spirituality/religiosity as it affects QOL by evaluating the influence of spirituality and religiosity over time in a large sample.
Kristeller et. al explored the impact of spiritual and religious influences on the adjustment to cancer diagnosis with the same four groups presented in our study. The breakdown of their cohort (n = 114) consisted of: HSHR (45%), HSLR (25%), Negative Religious Coper (termed LSHR in our study) (14%) and LSLR (16%) [27]. Although our LSLR cluster was smaller (6%), this difference is likely due to the definition of religiosity. Therefore, the scheme employed to classify patients in this study is validated given the similarities between our study and the Kristeller study.
The mental well-being of cancer survivors increased over the 12-month study period, with highly spiritual individuals registering higher baseline mQOL scores. Spirituality appears to facilitate patients’ adjustment to coping with serious illness. Vallurupalli studied 69 patients with advanced cancer receiving palliative radiation and found that religious coping and spirituality both had significant positive associations with patients' QOL, with spirituality demonstrating a more robust association [28]. Spirituality has been associated with cancer patients continuing to enjoy life despite high levels of pain or fatigue [29]. Highly spiritual individuals possess an intrinsic mental framework through which they process their illness, leading to positive adaptation and increased ability to thrive over time. While patients with lower levels of spirituality are able to live with and survive severe illness, their awareness or ability to ascribe purpose and find peace is less advanced, explaining their lower overall mQOL scores as well as smaller improvements in mQOL over time.
We observed that pQOL decreased over time for all SRI groups. Cancer has well known associations with long-term sequelae that adversely impact functional status, including the development of infections, second malignancies, cardiovascular disease, diabetes, osteoporosis, and functional decline [30]. As physical health deteriorates, spirituality plays a significant role in mitigating, but not preventing, the decline in pQOL caused by the health implications of cancer. However, spirituality’s effect on pQOL was only significant among highly religious participants (HSHR vs. LSHR). Our definition of religiosity that includes both belief and practice or attendance, likely required participants to have a certain level of mobility and independence to fit our definition of ‘highly religious.’ However, within the group of highly religious patients, the less pronounced decline of pQOL for highly spiritual patients, compared to low spirituality patients, might also be explained by the highly spiritual patients’ meaning-filled belonging in a faith community that simultaneously modulates their spirituality and involves them in a religious community, whose means of providing social support like transportation, or assistance in meal preparation, can circumvent the cancer-provoked decline in pQOL. Benefits that might not be available to individuals who are spiritual, but not religious. As a corollary, individuals who are highly religious but not spiritual may view religion as devoid of meaning and therefore don't pursue resources within that community that could otherwise augment pQOL.
It is known that medical illness can strengthen an individual’s spiritual resolve; however, illness can also shake an individual’s spiritual assumptions [31]. Our finding of spirituality showing a greater positive relationship with mental QOL, regardless of the level of religiosity, prompts consideration of whether religiosity has any impact on mQOL of cancer patients. Stressful situations, like medical illness, can be used as an opportunity for religious growth, facilitating an understanding of the implications of illness as well as improving mQOL through reappraising religious belief, reminding patients of their relationship with a loving God. However, religious belief may also interpret medical illness as a form of punishment. This type of belief adds stress for patients struggling to cope with cancer, leading to poorer mQOL. Seeking an understanding of the meanings of medical illness may prompt existential questions of both a spiritual and religious nature that evaluate personal values and beliefs, the nature of an individual's relationship with God, and a given individual's role in the religious community. These intimate and fragile questions, if not adequately dealt with, have been associated with harmful consequences, such as depression, anxiety, and other forms of psychological distress [32]. A study by Wikelman hypothesized that spiritual struggles might lead to poor QOL due to the lack of spiritual peace implied by such struggles [33]. Being at peace with God and being free from pain ranked highest in importance by patients in end-of-life care. This suggests that a framework for expedient navigation and resolution of the existential questions posed by severe illness would be embraced by patients [34]. Our results show that interventions aimed at fostering an individual's spirituality, may improve mQOL because the distress associated with existential questioning is more adeptly navigated through an internally generated interpretive framework that is highly salient for each individual.
Being highly religious does not necessarily foster this interpretive framework. Kristeller, et al showed that LSHR individuals (termed negative religious copers in their study) had the highest prevalence of depressed mood of the four SRI groups, despite high levels of positive religious involvement. It was hypothesized that this group internalizes their struggle of coping with cancer. LSHR individuals acknowledge their engagement with a religion, but cannot translate a connection to God into solace during their illness [27]. This finding supports our claim that spirituality, and not religiosity, is the most important determinant of mental well-being in cancer patients. Highly religious, but spiritually impoverished individuals are unable to find meaningful connections and therefore rely on religion, an external superimposition of belief and practice as an attempt to ameliorate their poor QOL. Low mQOL may be further compounded by a how a particular religious sect interprets severe illness, especially if illness is retribution for a moral failing.
Distinguishing the separate impact of spirituality from religiosity on clinical outcomes, such as QOL, can also inform physicians on how to best communicate with patients about existential questions posed by illness. Surveys have shown that a majority of patients with advanced illness desire spiritual care to be incorporated into their medical care, but this attention to spiritual needs occurs infrequently in cancer patients [21, 35, 36]. This might be due to medical team’s perceived inability to handle spiritual concerns, perceived lack of time, insufficient training, or the dismissal of spiritual/religious needs as valid health determinants [37–39]. The objective of discussing spirituality, is to provide a venue for the incorporation of spiritual/religious beliefs, practices and concerns into the overall scheme of care, rendering the treatment more complete. This topic can be approached by asking: “Spirituality often influences how people deal with illness. How, if at all, has your spirituality influenced how you have dealt with your medical condition?” [31]. This open-ended query allows freer communication about beliefs, giving the clinician a sense of the overall effect of illness on the patient, and also whether the patient could benefit from interventions aimed at enhancing spiritual awareness. Kristeller identified four types of patients with different spiritual/religious needs enabling physicians to better focus their inquiries when talking to patients: highly religious/spiritual, spiritual but less religious, religiously distressed and religiously/spiritually distressed. This classification enables better identification of needs and leads to provision or referral for more tailored, useful, and effective interventions [27]. The prominent influence of spirituality over religiosity on QOL assures clinicians who are conflicted about the role of religion in medical care, that initiating dialogue about spiritual beliefs is not a religious endorsement and has measurable clinical benefit. Therefore, the incorporation of spirituality leads to more complete medical care with genuine and measurable improvements in QOL for patients [40, 41].
Our study has several strengths and weaknesses. Strengths include a large number of respondents who were followed for 12 months. Also, our study measured spirituality and religiosity, with validated instruments/questions used in previous studies. The outcome, QOL, was measured repeatedly and concurrently on all study participants. While our sample consisted of participants representing a diverse range of what is broadly defined as cancer survivors, the sample was predominantly Caucasian.
One of our study's major limitations is the preponderance of Christian participants (84%). This may have decreased the observed differences between low and high spirituality among those who had low religiosity. This homogeneity limits the generalizability of our findings to other religions, particularly those that are non-theocentric with highly spiritual aspects to their belief system. In addition to the heterogeneity of religious belief systems, religious experience can be heterogenous among individuals within a particular religion. Future studies should aim to include a more diverse array of religious belief systems to gain a better understanding of the heterogeneity of religious experience, its impact on QOL, and whether theocentrism has any impact on the separateness of spirituality and religiosity.
Our study adds to the body of evidence that spirituality, as a construct separate from religion, has a role in the care of cancer survivors imparting significant improvements in mQOL. A decline in pQOL was observed across all SRI groups, though religiosity, in concert with spirituality appeared to blunt this decline, potentially rendering both religiosity and spirituality as important components in slowing physical decline in cancer. Our findings support the inclusion of inquiries aimed at understanding the role of spirituality and religiosity in patients' lives, and should not be overlooked when planning cancer treatment. By incorporating a recognition of the spiritual/religious needs of each patient, the far-reaching implications of cancer come into clearer focus, and clinicians have a broader menu from which to choose meaningful and tailored interventions to ameliorate distress, generate meaning, and improve quality of life.