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

July 2, 2011|The Journal of Community and Supportive Oncology

Table 1. Demographic Characteristics of Cancer Survivors in This Study

	EVALUABLE (N)	LOW SPIRITUALITY		HIGH SPIRITUALITY		P
		FREQUENCY	PERCENT	FREQUENCY	PERCENT
n	551	271	49	280	51
Median age (range)	59 (19–85)			59 (22–83)		0.99
≤40	551	17	6	21	8	0.78
41–60		137	51	135	48
>60		117	43	124	44
Sex
Female	551	112	41	89	32	0.02
Male		159	59	191	68
Race/ethnicity
White	551	256	94	272	97	0.21
Hispanic		6	2	2	1
African American		3	1	4	1
Other		6	2	2	1
Marital status
Single/never married	551	14	5	19	7	0.67
Married		219	81	219	78
Divorced/widowed		38	14	42	15
Education
High school	551	90	33	83	30	0.49
College		105	39	122	44
Postgraduate		76	28	75	27
Religion
Protestant	551	121	45	161	58	<0.01
Catholic		101	37	80	29
Other		36	13	35	13
None/atheist		13	5	4	1
Income (US$)
<25,000	551	37	14	37	13	0.71
25,000–49,999		64	24	61	22
50,000–74,999		59	22	54	19
75,000–100,000		35	13	44	16
>100,000		57	21	56	20
Missing		19	7	28	10
Place of residence
Urban	551	194	72	201	72	0.96
Rural		77	28	79	28
Distance (miles)
≤15	551	108	40	98	35	0.32
15–100		83	31	94	34
100–250		44	16	58	21
>250		36	13	30	11
Employment status
Full time	551	160	59	163	58	0.93
Part time		22	8	27	10
Homemaker		25	9	26	9
Student		3	1	4	1
Retired		48	18	51	18
Other		13	5	9	3
Patient is the primary income provider	551	137	51	132	47	0.42
Insurance
Employer-based	551	149	55	153	55	0.95
Individual-based		47	17	48	17
Medicare/Medicaid		56	21	59	21
Other		17	6	16	6
None		2	1	4	1
Prescription insurance	551	239	88	242	86	0.53
Type of malignancy
Leukemia, lymphoma, multiple myeloma	551	136	50	147	53	0.86
Breast, colon, prostate		101	37	100	36
Lung, pancreatic		34	13	33	12
Median time from diagnosis to study enrollment in years (range)	4.5 (0.5–26.6)			4.2 (0.6–26.6)		0.28
0–2 years	551	56	21	62	22	0.09
2–4 years		70	26	76	27
4–8 years		74	27	93	33
>8 years		71	26	49	18
Median time from last treatment to study enrollment in years (range)	3.6 (0.1–13.6)			3.6 (0.4–18.7)		0.87
0–2 years	551	97	36	99	35	0.84
2–5 years		83	31	92	33
>5 years		91	34	89	32
Affiliation of follow-up provider
University-based	551	193	71	190	68	0.16
Community-based		28	10	31	11
Both		50	18	54	19
Missing		0	0	5	2
Treatment received
Chemotherapy only	551	82	30	89	32	0.93
Chemo + surgery + radiation		125	46	126	45
Stem cell transplantation		64	24	65	23
Prior treatment outside university	551	116	43	126	45	0.60

Statistical Analysis

Participant characteristics were compared according to level of spirituality using a chi-square test for categorical data and the Wilcoxon test for continuous data (Table 1). Multivariate logistic regression models were fitted to evaluate separately the relationship between (1) spirituality with patient-rated worry as the outcome, (2) spirituality with follow-up health-care utilization as the outcome, and (3) patient-rated worry with follow-up health-care utilization as the outcome. In the above models, the following covariates were forced into each model: age, sex, cancer type, time from last cancer-related treatment to study start time, income, and type of medical insurance. These models were also fitted using outcomes ascertained at both 6 and 12 months. Interaction models between patient-rated worry and level of spirituality were also evaluated for an association with follow-up health-care utilization at 12 months to explore the role of spirituality in the relationship between patient-rated worry and health-care utilization. A P value of at least 0.05 was considered statistically significant.

Results

Study Participation

Of the 2,000 participants invited, 1,881 were deemed eligible (minus those who died or had wrong addresses). Baseline questionnaires were returned by 939 participants (baseline response rate of 50%). Seventeen wanted to participate only in the baseline survey. Of the 922 baseline participants, 691 returned the 6-month survey at the time of the analysis for this study, for a response rate of 76% when adjusted for deaths (182 no response, 18 deaths, 25 declined, 12 returned with wrong address). At 1 year, 691 surveys were mailed, with 588 surveys returned (58 no response, 17 deaths, 14 declined, 13 returned with wrong address, and one in hospice); a response rate of 87% was achieved after adjusting for deaths. Thirty-seven participants had missing information on spirituality, leaving a total of 551 included in this study. No differences in age, sex, and type of cancer were noted between patients included and excluded in the current analysis.

Characteristics of Study Participants

Demographic characteristics of the 551 study participants included in this study are shown in Table 1. We found that cancer survivors with low or high spirituality were more similar than different in all but two characteristics: highly spiritual survivors were more likely to be Protestant and male.

Prevalence of Spirituality and Patient Worry

Within our population, 271 (49%) survivors reported low spirituality and 280 (51%) reported high spirituality (Table 1). Also, at baseline, 277 (51%) survivors reported high levels of recurrence/progression-related worry, 190 survivors (35%) reported high levels of new malignancy–related worry, and 178 survivors (33%) reported high levels of treatment-related complication worry. As some participants may have reported one or more types of worry, this translates to 322 (59%) reporting any type of worry. Highly spiritual survivors reported significantly lower levels of high worry concerning recurrence/progression (6-month 27% vs. 38%, P < 0.01; 12-month 21% vs. 38%, P < 0.01), development of a different type of cancer (6-month 22% vs. 31%, P = 0.03; 12-month 15% vs. 26%, P < 0.01), and complications from treatment (6-month 17% vs. 30%, P < 0.01; 12-month 16% vs. 26%, P < 0.01). Highly spiritual survivors reported significantly lower levels for any type of worry at both 6 and 12 months (6 months 37% vs. 54%, P <0.01; 12 months 28% vs. 47%, P < 0.01) (Table 2).

Table 2. Common Worries of Cancer Survivors According to Level of Spirituality

		BASELINE			6-MONTH			12-MONTH
		LOW SPIRITUALITY, N (%)	HIGH SPIRITUALITY, N (%)	P	LOW SPIRITUALITY, N (%)	HIGH SPIRITUALITY, N (%)	P	LOW SPIRITUALITY, N (%)	HIGH SPIRITUALITY, N (%)	P
Recurrence/progression-related worry	Low	106 (40)	160 (58)	<0.01	154 (62)	184 (73)	<0.01	166 (62)	218 (79)	<0.01
	High	160 (60)	117 (42)		95 (38)	69 (27)		103 (38)	59 (21)
New primary–related worry	Low	158 (59)	200 (72)	<0.01	172 (69)	202 (78)	0.03	199 (74)	235 (85)	<0.01
	High	111 (41)	79 (28)		76 (31)	58 (22)		71 (26)	42 (15)
Complication-related worry	Low	166 (61)	203 (73)	<0.01	175 (70)	214 (83)	<0.01	200 (74)	232 (84)	<0.01
	High	104 (39)	74 (27)		74 (30)	45 (17)		69 (26)	44 (16)
Any worry	Low	85 (32)	138 (50)	<0.01	120 (46)	165 (63)	<0.01	142 (53)	198 (72)	<0.01
	High	182 (68)	140 (50)		139 (54)	97 (37)		128 (47)	78 (28)