Spirituality and religiosity: influence on cancer therapy and well-being

Abstract

Religiosity and spirituality provide cancer patients with strength and confidence to face difficult situations during the process of seeking a cure, indicating that faith is an important element at this time. This systematic literature review analyzed the national and international scientific production to assess whether religious and spiritual practices facilitate therapeutic adherence and improve the quality of life of cancer patients. Level of evidence was classified using the Grades of Recommendation, Assessment, Development and Evaluation approach. Some articles showed that spirituality and religiosity positively influence treatment and patient well-being. In conclusion, cancer patients who use religiosity and spirituality as a strategy have grater hope in treatment; however, further in-depth studies are needed to ensure its effectiveness.

Neoplasms; Spirituality; Religion; Religion and medicine

Resumo

A religiosidade e a espiritualidade proporcionam força e confiança a pacientes com neoplasia para encarar situações difíceis ao longo do processo da busca pela cura, indicando que o uso da fé é importante nesse momento. O estudo buscou analisar, por meio de revisão sistemática de literatura, a produção científica nacional e internacional para aferir se práticas religiosas e espirituais facilitam a adesão terapêutica e melhoram a qualidade de vida da população com câncer. O sistema Grades of Recommendation, Assessment, Development and Evaluation foi empregado para classificar o nível de evidência dos estudos. Alguns artigos demonstraram que espiritualidade e religiosidade influenciam positivamente no tratamento e bem-estar dos pacientes. Com base nos resultados, conclui-se que pacientes com câncer que utilizam a religiosidade e espiritualidade como estratégia apresentam maior esperança no tratamento, entretanto são necessários estudos mais aprofundados na área para garantir a eficácia dessa utilização.

Neoplasias; Espiritualidade; Religião; Religião e medicina

Resumen

La religiosidad y la espiritualidad aportan fuerza y confianza a los pacientes con cáncer para enfrentar situaciones difíciles en la búsqueda de la cura, lo que muestra que la fe es importante en este momento. Desde una revisión sistemática de la literatura, este estudio analizó la producción científica nacional e internacional para identificar si las prácticas religiosas y espirituales facilitan la adherencia terapéutica y mejoran la calidad de vida de los pacientes con cáncer. El sistema Grades of Recommendation, Assessment, Development and Evaluation se utilizó para calificar el nivel de evidencia. Algunos artículos indican que la espiritualidad y la religiosidad influyen positivamente en el tratamiento y el bienestar de los pacientes. Los hallazgos permiten concluir que los pacientes con cáncer que usan como estrategia la religiosidad y la espiritualidad tienen mayor esperanza en el tratamiento, sin embargo, se necesitan más estudios para asegurar la efectividad de este uso.

Neoplasias; Espiritualidad; Religión; Religión y medicina

Cancer is the name given to a set of more than 100 diseases in which abnormal cells in the body multiply and spread in an uncontrolled manner, being able to invade organs and tissues and even spread to other regions of the body through metastatic processes. Cancer is a serious public health problem, especially in developing countries. The World Health Organization (WHO) estimates, for the year 2025, an incidence of 20 million cases worldwide, with this condition being the second leading cause of death from chronic diseases in Brazil ¹,².

The neoplasm promotes emotional and physical experiences that last from the discovery of the nodule to the choice of treatment. Religiosity and spirituality provide strength and confidence to patients with neoplasms to face difficult situations throughout the search for a cure, showing the use of faith as necessary in this path. There is evidence linking faith and religious practices to the disease cure process ³.

With regard to the coping with diseases by human beings, it is not common for research to demonstrate that spiritual beliefs influence this process. Therefore, it is considered increasingly necessary to know the spiritual care demands of these people so, we reiterate the importance of the health team preparing a spiritual anamnesis of those patients with chronic conditions and documenting it, as is done in the case of biopsychosocial aspects.

With data collected from the patient’s history, the professional can seek support for the beliefs of individuals in palliative care, providing an environment that enables important religious rituals for the person, in addition to developing a welcoming attitude towards the patient’s faith community. Professionals can integrate spirituality into health care in many ways ⁴.

The management of a chronic disease such as cancer requires individualized attention, as this moment can have different meanings for each person. Care based on spirituality can be essential since spirituality occupies a prominent place in the lives of most individuals. The fact is that its significance must be evaluated regardless of its adoption as a therapeutic tool, since religious/spiritual coping (RSC), defined as the use of religious beliefs and behaviors to facilitate problem solving and prevent or alleviate negative emotional consequences of stressful life situations, can play both a positive and negative role in managing and coping with the disease.

In a culture dominated by religiosity—especially of Christian origin, such as Latin America, including Brazil—, RSC is widely used as a strategy to minimize the stress caused by a pathology, in the search for a sense of control, maintenance of hope and purpose of life ²,³.

It can be said, then, that spirituality is a care approach that aims to improve the quality of life of patients and their families who face a life-threatening clinical condition, through prevention, evaluation and treatment of pain and psychosocial and spiritual support ⁴.

Given the above, and with the purpose of deepening the influence of spirituality and religiosity in cancer patients, this study aimed to analyze the national and international scientific production, seeking to verify whether religious and spiritual practices can facilitate therapeutic adherence and improve the quality of life of people with cancer ⁵.

Method

This is a systematic literature review on the influence of spirituality and religiosity on the therapy and well-being of cancer patients. The search for references was carried out in January 2021 in PubMed, MEDLINE, LILACS, SciELO and other databases covered by the Virtual Health Library (VHL). The keywords “neoplasms,” “spirituality,” “religion” and “religion and medicine” in the title, abstract or subject were used.

From the references obtained, publications from the period 2016 to 2021 were selected, in Portuguese and English (inclusion criteria). In addition, articles that did not address cancer treatment, articles whose full text was not available, duplicate articles or articles that did not fit the established period (exclusion criteria) were excluded. Finally, 20 articles were selected for analysis.

The level of scientific evidence of the references was classified according to the recommendations established by the Grading of Recommendations Assessment, Development and Evaluation (Grade) system ⁶.

The methods addressed in the references were compared regarding the search for support in religious and spiritual practices after the diagnosis of cancer as an aid in coping with the disease; regarding the influence on adherence to treatment (greater or lesser potential for influence); and regarding the importance of religiosity and spirituality in improving patient the quality of life.

To avoid risk of bias, the flowchart and checklist of Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement were adopted ⁷for conducting the review. This recommendation, in its current form, emerged in Canada in 2005 as a result of the revision of a 1996 recommendation guide known as Quality of Reporting of Meta-analyses (Quorom).

Results

In the first search strategy, using the previously established inclusion criteria, 154 articles were identified, of which 17 were duplicates. Following the screening, 137 articles were screened by title and abstract, 94 of which were excluded for not addressing the topic. Forty-three (43) studies were classified for analysis in full; due to eligibility, 18 articles were excluded because they did not include the answer to the research question, 4 for not being found in their full version, and one for not fitting into the specified period, totaling 20 articles included (Figure 1).

Figure 1
Flowchart of the phases of identification, screening, eligibility and inclusion of articles on the influence of religion and spirituality on the treatment and well-being of patients with cancer

During the evaluation of the included articles, according to the Grade system, five were classified as having a high confidence level, ten as moderate, three as low and two as very low. Chart 1 shows this classification, together with the characteristics of the studies reported in the articles.

Chart 1
Description of articles included in the review

Identification	Study method	Grade evidence level	Main results
Merath and collaborators; 2019 8	Qualitative study	Moderate	66.7% of patients reported that religion/spirituality did not influence treatment decisions, and 33% mentioned it as a source of strength to face the disease
Ferreira and collaborators; 2020 5	Literature review	High	Most articles demonstrated religiosity and spirituality as positive influences on the treatment and quality of life of patients.
Ribeiro, Campos, Anjos; 2019 9	Descriptive study with a qualitative and ethnographic approach	High	It was mentioned that religious and spiritual beliefs provided strength, tranquility and confidence during the fight against breast cancer
Ahmadi, Hussin, Mohammad; 2018 10	Qualitative research	Low	Culture and spirituality were superior to religion in terms of patients’ choices for the treatment method, which is entrusted to divine and demonic entities
Yazgan, Demir; 2017 11	Descriptive, cross-sectional and analytical study	High	It is necessary that religious and cultural practices be included in the routine of care for individuals with cancer
Goudarzian and collaborators; 2019 12	Cross-sectional study	Very low	Patients who develop religiosity are able to deal with the disease and strengthen self-care
Silva and collaborators; 2019 4	Qualitative study of the descriptive type	Moderate	The study defined faith as the main way of coping with breast cancer, being used by women for emotional strengthening and coping with therapy
Maciel and collaborators; 2018 13	Quali-quantitative descriptive study	Moderate	A spiritual approach on the part of nursing is essential in the care of cancer patients
Mahayati, Allenidekania, Happy; 2018 14	Qualitative study	High	Adolescents with cancer mention that spirituality provided greater confidence in healing, calm and strength to confront the pathology
Moraes Filho, Khoury; 2018 1	Analytical, observational, cross-sectional study with correlational design	Moderate	All individuals analyzed used religious strategies to experience chemotherapy treatment and its toxicity
Goudarzian and collaborators; 2017 15	Cross-sectional study	Moderate	Patients with religious coping demonstrated a lower level of pain perception
Kunz and collaborators; 2018 3	Qualitative research	Moderate	Women with breast cancer with constant religious practices obtain better emotional control during the course of the disease, and there is a reduction in the number of deaths in this sample
Nelson; 2017 16	Expert opinion	Very low	Religiosity and spirituality can improve the psychological experience of patients and help in decision-making. However, individuals may hesitate to seek treatment because of their belief in God’s will.
Mosque, Chaves, Barros; 2017 17	Literature review	Moderate	Patients have spiritual needs that can help improve physical, emotional and social aspects
Bowie and collaborators; 2017 18	Cross-sectional study	Moderate	African-American men are strongly influenced by religion and spirituality in the treatment of prostate cancer, because of the view of the disease as a punishment from God, and consequently tend to be more passive
Merluzzi, Philip; 2017 19	Descriptive study	Moderate	The use of religion in coping with cancer showed better psychosocial status and tolerance to negative events
Assaf, Holroyd, Lopez; 2017 20	Qualitative research	Moderate	The practice of prayer and reading the Koran brought comfort to women with breast cancer, in addition to helping to build a new purpose in life
Reis, Farias, Quintana; 2017 21	Descriptive and exploratory qualitative research	High	Cancer patients face contradictions caused by religion: they are reassured by faith, but believe that healing is only possible by divine miracle
Sousa and collaborators; 2017 2	Integrative literature review	Moderate	Negative religious coping has been shown to cause damage to mental health; positive religious coping, on the other hand, favored well-being and a good response to chemotherapy
Tsai, Chang, Wang; 2016 22	Qualitative research	Moderate	Religious beliefs influenced active cancer coping and psychological support

The research by Merath and collaborators ⁸pointed out that 58% of the patients interviewed reported that cancer influenced their search for support in religious and spiritual practices. On the other hand, 27.2% mentioned that the disease had a negative impact on religion/spirituality, due to feelings of anger towards God. As for treatment decisions, 66.7% did not perceive a religious and spiritual impact, and another 33% found it to be a means of dealing with it.

The literature review by Ferreira and collaborators ⁵presented religious and spiritual beliefs as means of adherence to chemotherapy, in addition to being able to reduce the stress and anxiety generated by the treatment. Furthermore, most of the studies analyzed in the review pointed to the importance of religiosity and spirituality in coping with cancer and improving patient quality of life.

Ribeiro, Campos and Anjos ⁹, in a descriptive study, interviewed a patient who faced breast cancer and mentioned that the spiritual and religious scope brought about positive emotions related to the search for healing and well-being and helped her face the disease, making her able to persevere in treatment safely and calmly.

Ahmadi, Hussin and Muhammad ¹⁰, in qualitative research with individuals from Malaysia, demonstrated that cultural, religious and spiritual diversity is relevant in that country. Religion induced the population to deal with cancer as an apprenticeship proposed by God, to the point that culture and spirituality are more associated with therapeutic decisions, due to mystical beliefs that make divine and demonic entities responsible for the cure, something that can harm the search for therapeutic methods indicated for this condition.

According to Yazgan and Demir ¹¹, the spiritual and religious needs of cancer patients should be considered and included in the care routine of caregivers and met in institutions that provide care through infrastructure capable of providing this resource. The study revealed a strong religious and spiritual attitude related to the quality of mental health and well-being on the part of individuals affected by the disease.

Gourdazian and collaborators ¹²indicated that the population with cancer who used religion in a positive way had a greater ability to face the pathology and, therefore, showed greater adherence to the conditions imposed by the physical and mental state, in addition to developing self-care. In contrast, some individuals were opposed to this conception because of a sense of belonging to God.

Silva and collaborators ⁴found that the stigma of cancer, linked to suffering and death, causes women diagnosed with breast cancer to acquire feelings of fear and sadness that they fight through faith, making this an artifice to deal with the treatment. Spiritual life was defined as a guide to transform the perspective of the meaning of life and illness and, according to the authors, it is the main means of coping with the disease.

In the field of nursing care, Maciel and collaborators ¹³mention the importance of the spiritual approach in the care of cancer patients, supported by offering biological, social and emotional reinforcement during adversities in the course of the disease. Most nurses interviewed in the study indicated this approach as a necessary part of a positive strategy for maintaining mental health and improving quality of life. However, limitations were observed due to health professionals’ lack of education to deal with this issue.

Young people diagnosed with cancer suffer from various negative feelings, such as fear, anxiety, helplessness and lack of confidence. Mahayati, Allenidekania and Happy ¹⁴show that spiritual strategies contribute as facilitators in coping with these difficulties. The adolescents interviewed reported that religious experiences made it possible to increase confidence in God and in his cures, in addition to encouraging self-care.

Moraes Filho and Khoury ¹analyzed the association between chemotherapy treatment toxicity and the use of religious strategies. All investigated individuals used religious resources: the majority in a positive way, reporting having obtained comfort and well-being, and a minority in a negative way, believing in a punishment from God, which leads to depression and unsatisfactory quality of life, in a general way.

Cross-sectional study by Gourdazian and collaborators ¹⁵found that cancer patients who experience religious coping have low levels of pain perception, as they possibly adapt to the impacts of diagnosis and treatment, including chemotherapy, and are more tolerant, accepting unchangeable situations.

According to Kunz and collaborators ³, women diagnosed with breast cancer who seek support in religion obtain a satisfactory recovery from the disease, even in cases of difficult resolution. Among those with constant religious activity, the decrease in the number of deaths stands out. Through faith, these patients are able to exercise emotional control, due to the reduction of stressors and optimism in God. On the other hand, some religious beliefs take on negative features, characterized by guilt, feelings of revolt and questions about the illness process.

According to Nelson ¹⁶, religious and spiritual beliefs can positively or negatively influence cancer treatment. The positive aspects include the fact that they encourage patients to reflect on therapeutic decisions; in addition, medical care attentive to these beliefs points to better psychological quality. The negative aspects include the fact that individuals attribute the illness to God’s will, which contributes to their not seeking treatment and, therefore, increases the mortality rate.

Most cancer patients need to turn to spirituality to face the disease, and Mesquita, Chaves and Barros ¹⁷describe that this dimension helps to find the meaning and purpose of life and to experience the disease, in addition to allowing the connection with God and other people and favoring physical, social and emotional recovery. The authors also point out clarification about insecurities about the future, the ability to understand death and to be treated as normal people, who have their desires.

The cross-sectional study by Bowie and collaborators ¹⁸compared ethnic-racial differences in the experience of religion and spirituality in the confrontation with prostate cancer. It was found that, in African-American men, the experience of the disease was more permeated by religiosity, which contributed to the belief in a punishment from God that can only be overcome through prayer. This results in passivity in the face of treatment decisions and, consequently, difficulties in monitoring and survival.

Merluzzi and Philip ¹⁹pointed out that many individuals face cancer relying on the support and consolation of religion, which can reduce stressors and improve the psychosocial state. Similarly, religious people portrayed greater tolerance for negative events, as they sought their meaning in faith.

In a qualitative research carried out with Arab women diagnosed with breast cancer, all interviewees pointed to spirituality as an important source of consolation. They claimed to use prayer and reading the Quran to divert negative feelings, find a new meaning for life and feel encouraged to fight ²⁰.

According to Reis, Farias and Quintana ²¹, the population with cancer seeks to solve the lack of meaning in life by resorting to religion. However, along with the tranquility brought by faith, these people place many of their hopes for healing on the divine miracle, and this, therefore, leads to negligence in the treatment.

Sousa and collaborators ²showed that the negative use of religious coping can cause side effects and damage to mental health, while the positive use can stimulate optimistic emotions, in addition to a good response to chemotherapy. Patients included in the review felt bothered because their spiritual needs were not addressed in therapy.

The qualitative research developed by Tsai, Chang and Wang ²²confirms the role of religiosity in psychological support for the population with cancer, facilitating treatment adherence and reducing stress. Christians require strong help from priests and church members, requesting prayers and visits, which influences the ability to actively fight against the disease.

Discussion

The diagnosis of cancer made most of the patients cited in this study use religiosity and spirituality as sources of support in coping with the disease: faith brought strength and meaning to this unknown journey. When well incorporated into the patients’ lives, religiosity helps them with the consequences of cancer in their daily lives and essentially influences their lives and ways of living during treatment ⁵.

From the analysis of the results, it was observed that the spiritual and religious dimension brings constructive emotions and, when experienced in a positive way, helps patients to face the disease. This contributes to the preservation of the physical and mental state and to self-care, reducing the stress and anxiety generated by the treatment ⁵.

Negative responses to treatment are related to experiences of punitive aspects of religion, in which cancer is perceived as divine punishment. In these cases, the belief can contribute to increased anxiety levels and even depression. In addition, it was found that African-American men who face prostate cancer and who consider themselves religious believe that they can be cured only through prayer, which leads to a passive attitude towards treatment decisions, with an impact on the evolution of the patients’ condition and, consequently, their survival ¹⁸.

However, even if some studies confirm the possibility that the spiritual and religious dimension negatively influence the evolution of the disease, most cancer patients evaluated in the studies reported experiencing positive feelings related to their beliefs, which contributes to a good prognosis, since these patients showed greater treatment adherence and, therefore, improved quality of life.

Kunz and collaborators ³observed that religiously active women diagnosed with breast cancer recovered satisfactorily in some cases, even when in an advanced stage of the disease. It is therefore concluded that, through faith, these patients mitigated the stressors by stimulating optimistic emotions, which resulted in a good response to chemotherapy.

Even though studies point to the importance of religiosity and spirituality in coping with cancer and improving the quality of life of patients, most reported not having their religious and spiritual needs met by the health team. This indicates the need for the hospital team to know and understand the beliefs of the patients, who, when being assisted beyond their therapeutic needs, can thus be comforted in the face of the anxieties and weaknesses caused by their condition.

Final considerations

Spirituality and religiosity are coping methods to deal with the diagnosis and treatment of cancer. The patient’s well-being can be favored by their belief, since this has the potential to act in reducing stress and fatigue and in the positive evolution of their biopsychosocial dimension.

This systematic review showed that most articles identify, in religious and spiritual practices, factors that facilitate treatment adherence and improve patient quality of life. However, it is suggested that further studies be carried out in this area, to ensure the effectiveness of these devices.

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• ²⁰
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• ²¹
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• ²²
  Tsai TJ, Chang CJ, Wang HH. Influence of religious beliefs on the health of cancer patients. Asian Pac J Cancer Prev [Internet]. 2016 [acesso 19 maio 2022];17(4):2315-20. DOI: 10.7314/apjcp.2016.17.4.2315

Publication Dates

• Publication in this collection
  20 Feb 2023
• Date of issue
  Oct-Dec 2022

History

• Received
  7 June 2021
• Reviewed
  10 Aug 2022
• Accepted
  15 Aug 2022