Spirituality, patients' worry, and follow-up health-care utilization among cancer survivors

Receiving a diagnosis of cancer is a life-changing event. Patients commonly seek understanding of not only the medical aspects of their disease but also how the diagnosis will affect their lives. Often, this quest to understand the meaning behind the unfortunate circumstance of disease is aided by spirituality. Spirituality motivates an individual to find meaning or purpose in his or her life experience.¹ Most studies indicate that spirituality gives meaningful insight to an individual's existence and aids in the interpretation of events and relationships.^{[2], [3], [4], [5], [6], [7], [8] and [9]}

Spiritual beliefs are widespread among cancer patients. Studies have shown that a better quality of life (QOL) is achieved in patients who practice spirituality or have those needs met by their health-care providers. They require less health care as well as experience less anxiety and a greater sense of well-being.^{[10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20] and [21]} One may conclude that spirituality helps patients understand the meaning of their disease and provides the catalyst for significant improvement in health-related outcomes.

Vast amounts of literature affirm spirituality's positive effects on health outcomes for advanced-stage/terminally ill patients. However, very little is known about how spirituality affects the common concerns of cancer survivors. It can be inferred that spirituality continues to aid cancer survivors as they attempt to interpret the meaning of their experience during follow-up care. After completing various cancer treatments, survivors may experience worries of cancer recurrence or progression, worries of developing a different cancer, and worries of developing complications from their initial treatment.²² We explored the relationship between spirituality, patient-rated cancer-related worry, and cancer survivors' follow-up health-care utilization (follow-up doctor visits, phone calls to follow-up providers regarding medical inquiries, and emergency room visits).

Participants and Methods

Subject Selection and Eligibility

Data for this study were obtained from CANCER CARE, an observational cohort study using a self-administered questionnaire designed to evaluate follow-up care among cancer survivors.²³ Participants were seen at the University of Nebraska Medical Center (UNMC) and consented to participate in a data-collection protocol (ONCOBASE) since March 2006. ONCOBASE has a 90% consent rate. To be eligible for the study, participants were at least 19 years of age (age of majority in Nebraska) and completed their cancer treatment at UNMC. Participants varied in time since completion of last cancer treatment. From a list of 5,500 eligible subjects, 2,500 were screened. The list was sorted by date of consent, and the first 2,000 subjects received the study questionnaire. Survey forms were mailed in August 2008 (baseline) and follow-up surveys were mailed in February (month 6) and August 2009 (month 12). Participants were not paid for study participation but were told that a donation to a charitable institution was made on their behalf as an altruistic incentive.²³ The study was approved by the Institutional Review Board at UNMC.

Variables Analyzed

We analyzed the participants' spirituality from baseline surveys using the Functional Assessment of Cancer Therapy–Spirituality Scale (FACT-SP).²⁴ Total spirituality scores were computed for each participant using instrument standard calculations. The cohort was categorized into two groups, consisting of low or high spirituality based on the median calculated score (<47 vs. ≥47) for the entire population. Other variables included in the analyses are shown in Table 1. Patient-rated worry pertaining to (1) disease recurrence/progression, (2) development of a new malignancy, and (3) complications related to treatment were evaluated at baseline and at 6 and 12 months. Respondents were asked to rate their level of worry for each of the above three items using a five-point Likert scale (none at all, little of the time, some of the time, most of the time, and all of the time). Each worry item was categorized as low (none at all to a little of the time) vs. high (some of the time, most of the time, all of the time). Follow-up health-care utilization was assessed at 6 and 12 months and consisted of (1) follow-up clinic visits (low, defined as none or one follow-up visit per year, vs. high, more than one follow-up visit per year), (2) phone calls to follow-up providers for medical issues (no vs. yes), and (3) emergency room visits (no vs. yes). These indices of health-care utilization were selected on the basis of whether they are discretionary (patient-driven) or nondiscretionary (physician-driven).^{[25] and [26]} For example, follow-up clinic visits are mainly nondiscretionary in the sense that the follow-up provider primarily determines the frequency at which they are conducted, while phone calls made to follow-up providers and emergency room visits are inherently discretionary. We also evaluated the relationships between spirituality and QOL (Short Form 12 [SF-12]),²⁷ social support,²⁸ and religiosity (with the survey question [data not shown] “Overall, how much would you say that religious beliefs have influenced your life in the past two months?”), to establish the external validity of our spirituality cut-off score since these constructs have been associated with spirituality.^{[10], [15], [17], [19], [29], [30] and [31]} Our analyses showed a high correlation between our categorization of low or high spirituality with QOL, social support, and religiosity.