One of the purposes of this study was to characterize spiritual well-being in newly-diagnosed survivors of colorectal and lung cancer. These two understudied cancer sites are responsible for a significant portion of the annual cancer incidence and overall percentage of cancer survivors. In general, our study found that spiritual well-being scores were high across both colorectal cancer and lung cancer survivors. The cross-sectional data presented here lend support to earlier studies that report high spiritual well-being scores in those individuals coping with illness (Morgan, Gaston-Johansson, & Mock, 2006
; Peterman et al., 2002
; Rippentrop et al., 2005
). Participants in this study reported higher spiritual well-being scores (total scale: M=80.32; meaning/peace and faith subscales: M=40.29) than that reported in previous research on patients with colorectal cancer (Fernsler, Klemm, & Miller, 1999
), HIV (Cotton et al., 2006
), women with breast cancer (Cotton et al., 1999
; Manning-Walsh, 2005
), and prostate cancer (Tate & Forchheimer, 2002
). The high level of spiritual well-being in this study may be related to the fact that a significant number of participants were older (mean age=64.24), female (N=187) and married (N=181); factors that have been associated with reports of higher level of spiritual well-being (Meraviglia, 2004
; Mystakidou et al., 2008
; Peterman et al., 2002
The current study also found significant differences in scores on the meaning/peace subscale, where colorectal cancer survivors scored higher compared to lung cancer survivors. The finding that lung cancer survivors had lower meaning/peace subscale scores than colorectal cancer survivors may be attributed to the fact that lung cancer survivors often experience distressful symptoms (e.g., dyspnea, fatigue), are frequently diagnosed at a more advanced disease stage, and have limited survival. Additionally, lung cancer survivors are confronted with the stress of societal stigmatization of the disease because of its association with cigarette smoking. For example, in a qualitative study exploring the perceptions and experiences of stigma experienced by survivors of lung cancer, survivors reported that they felt stigmatized whether they smoked or not because of the association of the disease with smoking (Chapple, Ziebland, & McPherson, 2004
). Participants also reported that they felt the diagnosis affected their interaction with family, friends, and physicians; particularly for those who had never smoked.
In previous studies using the FACIT-Sp, a 12-item scale of spiritual well-being, greater depression was associated with lower FACIT-Sp total scores (Bekelman et al., 2007
; Krupski et al., 2006
; Simonelli, Fowler, Maxwell, & Andersen, 2008
). In persons diagnosed with cancer, depression rates of 10% to 25% have been reported (Kessler et al., 2003
; Pirl, 2004
). In lung cancer survivors, depression rates of 10% to 33% have been reported (Hopwood & Stephens, 2000
; Pirl et al., 2008
; Walker, Zona, & Fisher, 2006
). These finds imply that depression is an important factor for consideration in relationship to spiritual well-being, particularly among cancer survivors.
A growing research literature associates various religious factors with positive mental and physical health, and even suggests that aspects of religious involvement may reduce mortality (Hummer, Ellison, Rogers, Moulton, & Romero, 2004
). Schnall and colleagues (2008)
recently studied data on the religious practices of nearly 100,000 postmenopausal women participating in the Women’s Health Initiative (WHI) Study. Results showed that women who attended a religious service at least once a week had a 20% lower risk of death from all causes, compared with women who did not attend any religious services. Previous data indicate that there is a significant relationship between the total FACIT-Sp-Ex score and age, gender, marital status, ethnicity, and type of disease (Peterman et al., 2002
). In our study, faith subscale scores were significantly higher among African Americans and women, regardless of cancer site. Our findings provide support for those of Peterman (2002)
in terms of race and gender. Our results were also generally consistent with earlier studies which demonstrate that African Americans are more religious than Whites (Taylor & Chatters, 1991
; Mattis & Jagers, 2001
; Holt, Schulz, & Wynn, 2009
). Thus, it can be assumed that the degree of spiritual well-being may be lower among African Americans who are not highly religious. However, it is difficult to determine this using the current sample for which no baseline measure of intrinsic religiosity or spirituality was taken for comparison with the larger sample in the parent study. Furthermore, when controlling for race, most participants in our study (N = 269; 90%) reported belonging to a Christian religion (e.g., Baptist, Methodist), 2 (1%) were Jehovah’s Witness (also a Christian religion), 7 (2%) reported another (unspecified) affiliation, and 22 (7%) reported no religious affiliation.
Similarly, spirituality has been identified as a significant protective and mediating factor in coping with health problems for African Americans, in particular (Hamilton, Powe, Pollard, Lee, & Felton, 2007
; Newlin, Knafl, & Melkus, 2002
). In a study of 114 African American breast cancer survivors, Ashing-Giwa, Ganz, and Peterson (1999)
found that most of the participants (86%) rated spirituality as “important” to “very important” in coping with their illness. The role of faith as a coping resource among African Americans and women in the current study is also consistent with previous studies investigating the role of spiritual well-being (Hamilton et al., 2007
; Morgan et al., 2006
; Thoresen & Harris, 2002
). As in this study, women in previous studies have reported higher levels of spirituality (Fernsler, Klemm, & Miller, 1999
; Schnoll, Harlow, & Brower, 2000
The findings from our study raise the question of whether improving the colorectal and lung cancer survivors’ sense of meaning/peace might be an intervention that may enhance psychosocial adjustment and quality of life. Spirituality is the least understood domain of quality of life in cancer survivors as it relates to well-being, yet there is some consensus that it is a very important construct for understanding how survivors cope. In other cancer populations, spirituality has been associated with adjustment to cancer (Schnoll, Harlow, & Brower, 2000
), lower levels of discomfort (Leak, Hu, & King, 2008
), decreased anxiety and social isolation (Krupski et al., 2006
), and quality of life (Balboni et al., 2007
; Brady et al., 1999
; Cotton et al., 1999
). Given the large number of studies indicating the importance of spirituality and spiritual support in promoting a sense of well-being, it is surprising that little research has examined these variables in colorectal and lung cancer survivors. This underscores the importance of incorporating spirituality in the care of colorectal and lung cancer survivors.
Limitations of the Study
Several limitations of this study require acknowledgement. First, this study used a cross-sectional descriptive, correlation design which only identifies associations at a specific point in time. This limitation does not permit a clear picture of differences over time or the assessment of causal relationships, nor does it provide understanding of how the subscales relate to each other and whether meaning/peace and faith change over time with extended survival. Second, an additional limitation to be considered may be that of selection bias. This study did not attempt to address or control potential self-selection bias, where differences may exist between those who volunteered and those who refused participation in our study. For instance, the population in the current study may be biased because survivors with low levels of spiritual well-being may not have been motivated to participate in a study of this nature. Likewise, the theoretical direction of the bias could reflect either positive or negative selection, although there is evidence that suggests that African Americans are more likely to report as more religious than Whites. Regardless of the direction of the bias, future studies should consider statistical methods that control for self-selection. Finally, a third limitation considers the fact that many of the lung survivors recruited to participate in this study were deceased at the time of study initiation; consequently, the accrual of lung cancer survivors was lower than that of colorectal cancer survivors.
Despite these methodological limitations, the current study has notable strengths and makes important contributions to the literature. Although there have been many studies which examine the link between spiritual well-being and breast cancer survivorship, there are no published studies of which we are aware that have examined spiritual well-being among survivors of colorectal and lung cancers. Secondly, spiritual well-being was examined using standardized measures. This feature of the current study allows for comparisons with published studies that examined these variables in other populations. Lastly, the current study sample size was relatively large and included a higher proportion of women and African Americans than has often been the case in similar studies. Furthermore, this study was adequately powered to detect differences; a minimum sample size of 100 was determined by power analysis.
Implications for Social Work Practice
This study has important implications toward improving quality of life in cancer survivors. Social workers and other helping professionals should use results from this study to develop therapeutic and lifestyle programs (e.g., meditation, prayer, exercise, social support) which aid spiritual well-being. It has been recommended that spiritual concerns be raised with cancer survivors, and that appropriate measures be developed to further explore and validate the importance of the spiritual domain for cancer survivorship (Ameling & Povilonis, 2001
). The findings of this study provide preliminary insight into spiritual well-being in newly-diagnosed survivors of colorectal and lung cancers. Results suggest that this understudied cancer population has high levels of overall spiritual well-being – particularly, among African Americans, women, and survivors of colorectal cancer. This finding strengthens similar results from previous studies in breast cancer survivors (Ferrell, Grant, Funk, Otis-Green, & Garcia, 1998
) and further supports the important role of spiritual well-being within the context of qualify of life for cancer survivors.
While these findings support results from previous studies conducted in similar populations of breast cancer survivors, it is important to document and describe the spiritual characteristics of colorectal and lung cancer survivors. The study findings presented in this article confirm that survivors of colorectal and lung cancers have unique responses to cancer. Like previous research, this study has shown that spirituality is an important dimension of quality of life in survivors of colorectal and lung cancers. Therefore, social workers, especially those working in oncology, must be aware of spiritual concerns and integrate spirituality in the care of this understudied cancer population.
A number of other researchers, including Gilbert, have demonstrated the importance that social work practitioners recognize spiritual issues as essential to a holistic clinical approach (Gilbert, 2000
). By incorporating the findings of previous work done in this field, oncology social workers and other health care professionals are in a unique position to advance the future well-being of newly-diagnosed cancer survivors by also recognizing the importance that spirituality can have in helping cancer survivors find new meaning and life purpose (Messick-Svare, Hylton, & Albers, 2007
). Oncology social workers and other health care professionals should not seek to question whether or not they should attempt to incorporate spirituality in treatment and survivorship plans of cancer survivors, but rather, seek the most effective means of intervention to help cancer survivors move from acute survivorship to long-term, permanent survivorship (Praglin, 2004
The National Cancer Institute (2008)
suggests that spiritual screening and assessment is an important starting point for integrating spirituality in cancer care. Raising spiritual concerns with patients may be helpful in ascertaining basic levels of religious practice or spiritual well-being as the social worker or other health care professional seeks to identify possible areas of concern and need for further resources. A number of standardized assessment measures and open-ended interviewing tools have been offered to facilitate an exploration of religious beliefs and spiritual experiences or issues in cancer survivors (National Cancer Institute, 2008
). Similarly, the National Cancer Institute has identified a variety of interventions that address the spiritual concerns of cancer survivors. For the social worker, specific interventions may include inquiring about religious or spiritual concerns within the context of usual medical care; encouraging the survivor to seek assistance from his or her own minister or faith leader; providing assistance through the services of a hospital chaplain; referring the survivor to a religious or faith-based therapist who is specially trained to address these issues; and linking the survivor to a support group that addresses spiritual matters (National Cancer Institute, 2008
). Whatever the intervention, it needs to be done early and throughout treatment and long-term survivorship in a manner that recognizes and honors the religious and spiritual beliefs and practices of the cancer survivor.
Researchers are particularly suited to advance scientific knowledge related to quality of life in survivors of colorectal and lung cancers. Further research is needed on survivors of colorectal or lung cancer, and spiritually-based therapeutic and lifestyle interventions must be developed to potentially treat or ameliorate the physiologic and psychosocial late effects of cancer in general (Aziz, 2002
). Furthermore, future research with this population of cancer survivors should explore the diagnoses of colorectal and lung cancer separately. A more homogeneous sample allows for the potential to derive more meaningful findings specific to survivor and family needs based on diagnosis. Secondly, more empirical studies are needed which investigate these potential relationships to enhance the literature where studies of this nature are relatively recent and very few in number. Thirdly, future research exploring spiritual well-being and quality of life in this population must include spirituality as a moderator of overall quality of life. Finally, outcome studies that evaluate the relationship between spiritual well-being and psychosocial adjustment and the influence of this relationship on treatment-related outcomes in this population would be of great benefit in assessing the impact of spirituality on overall survivorship and quality of life.
As Yoon & Lee (2007)
has reported elsewhere in the literature, social work practitioners who fail to incorporate the dimensions of spirituality in treating survivors with adverse diagnoses also fall short in their ability to utilize enhanced strengths that survivors possess as coping mechanisms which improve their own sense of well-being. It is increasingly important that future studies build upon the present findings of this investigation as they seek to help inform and advance the effectiveness of social workers in oncology while advancing the fields of public health and social work.