The aim of this study, among many studies demonstrating the effect of spirituality on the cancer experience, was to examine patient spirituality over the course of radiation therapy. Although spirituality is by definition very personal, the available literature indicates that many cancer patients find spirituality to be an important part of coping with their cancer experience and we wondered whether the experience of completing a course of radiation therapy for cancer would provide these patients with an opportunity for spiritual growth. Therefore, we hypothesized that we would see an increase in spirituality scale scores at the end of radiation therapy. Our results demonstrated that other than in patients with breast cancer, spirituality did not change significantly over the course of treatment.
There are several possible explanations for the lack of change. First, while FACIT-Sp has been psychometrically validated as a measure of spirituality in research for people with chronic and/or life threatening illnesses,11
we are currently unaware of any studies proving Sp-12’s responsiveness to change or its ability to measure changes in spirituality over time. However, the FACIT-Sp was used by Johnson et al to examine changes in spiritual well-being in a group of 103 patients with advanced cancer undergoing RT. Their study successfully utilized the FACIT-Sp to measure changes in a number of elements of spiritual well-being over time and demonstrated strong correlations with the patients’ own assessment of their spiritual well-being as measured by a single-item spiritual well-being linear analogue self-assessment.7
The majority of other studies utilizing the FACIT-Sp have been cross-sectional and not longitudinal.13
Second, perhaps immediately after completing radiotherapy is too soon to see the ‘spiritual impact’ of the experience. Patients may need time to take stock of their health and lives before the impact of that experience is realized. While measurements were taken at two of the key transition points previously identified,10
our attempt to collect data from patients at a 6 week post-treatment follow-up visit garnered a poor participation rate because most patients followed up with physicians in their local communities rather than return to OHSU, a tertiary academic medical center. Often, the follow-up visit is when patients anticipate learning the most meaningful information about their response to treatment, and most of the short-term side effects, particularly fatigue, have peaked and begun to improve for many patients.
Another question raised by our data is why significant changes were noted in breast cancer patients and no other groups? Previous studies utilizing the FACIT-Sp have demonstrated that women often report higher scores on both the Sp-12 and its two subscales,11
and a number of studies have been done on the importance of spirituality to breast cancer patients and specific sub-populations.14,15, 16,17,18
One such study actually demonstrated that the use of spirituality as a coping mechanism decreased over time in young women with breast cancer, although this data was collected up to 12 months after initial diagnosis, a different timing strategy than the one employed in our study.19
Another study demonstrated that women with breast cancer actually had lower self-reported spirituality scores than healthy comparisons, although this difference became nonstatistically significant when corrected for having children.20
Yet another study comparing breast cancer patients to those with benign breast problems demonstrated that women with breast cancer reported increased religious satisfaction significantly more often than those with benign breast problems,12
results more similar to our own. Other studies have demonstrated that up to 76% of breast cancer patients use prayer as a healing modality,22
and that 88% felt that spiritual or religious practice was important in coping with their illness.23
The importance of this apparent difference in spiritual well-being demonstrated by our data is emphasized by the parallel improvements in overall quality of life for these women. This finding is consistent with a number of previous studies demonstrating strong correlations between spiritual well-being and QOL in patients with chronic and/or life-threatening illnesses,2,4,5,6
although it does pose a contrast to a few studies and analyses which have been unable to identify such a correlation.13,24
If the increased spiritual well-being scores in breast cancer patients demonstrated by our data represents, rather than a disease-specific phenomenon, one caused by other factors, such as available resources and support, these findings may represent an area of opportunity to increase both spiritual well-being and overall well-being for patients with non-breast malignancies. Until recently, there has been little available research on methods of supporting and improving spiritual well-being in patients with cancer, the majority of which had been performed in small groups of Japanese patients,25,26,27,28
and may or may not have been applicable to patients of different cultural backgrounds. In the last few years, a few additional groups have studied potential methods of intervention to improve spiritual well-being. One study of an Oncologist Assisted Spiritual Intervention demonstrated that inquiries regarding spiritual concerns of patients by oncologists may be both acceptable and beneficial.9
Another study sponsored by the Pathfinders National organization demonstrated positive outcomes and feasibility of a multi-faceted psychosocial care program on a group of 50 breast cancer patients at a major academic institution.29
Changes in spirituality were then correlated with improvements in other PROs.30
Further research into disparities between resources available for patients with different diagnoses, as well as which resources contribute most directly to increased spirituality and increased quality of life could potentially provide more opportunities to improve spirituality and other outcomes for non-breast cancer patients.
The current study has some limitations, chiefly and as mentioned above, the lack of follow-up data. Part of this is likely a phenomenon of patients who undergo treatment at tertiary care centers, as well as those of our patients within the Veterans Administration system. These patients often travel long distances, or even find temporary housing arrangements nearer to treatment centers and may find it difficult to return for follow-up visits.
Additional limitations include our poor response rate, lack of information about religious affiliation, and the fact that this study was conducted in an institution with limited social work support and no chaplain support for radiotherapy patients. Additionally, the majority of our patients are residents of Oregon, the state with the largest percentage of self-reported non-religious residents31
and may not represent patient populations in areas with higher levels of self-reported religiosity.
Despite these potential limitations, this study also had a number of strengths, including the broad view of spirituality and meaning, independent of religiousness, assessed by the Sp-12, the variety of diseases our patients were treated for, and the power conferred by our population of 406, larger than many of the currently available studies. Additionally, our study took a longitudinal approach, where as much of the previously available data arose largely from cross-sectional studies.13
In conclusion, this study has demonstrated that spiritual well-being does not appear to change significantly for most patients over the course of radiotherapy, with the notable exception of patients with breast cancer, who report increased spiritual well-being over the course of treatment. Additionally, this study confirms the previously identified positive correlation between change in spiritual well-being and changes in overall quality of life, with those reporting increased spiritual well-being also reporting improved overall quality of life. Further research into methods of prospectively measuring, addressing, and improving spiritual well-being for patients undergoing radiotherapy is warranted and has the potential for broader-reaching improvements in overall well-being for these patients.