Background Spirituality may aid cancer survivors as they attempt to interpret the meaning of their experience.

Objective We examined the relationship between spirituality, patient-rated worry, and health-care utilization among 551 cancer survivors with different malignancies, who were evaluated prospectively.

Methods Baseline spirituality scores were categorized into low and high spirituality groups. Patient-rated worries regarding disease recurrence/progression, developing new cancer, and developing complications from treatment were collected at baseline and at 6 and 12 months. Follow-up health-care utilization was also examined at 6 and 12 months.

Results Among the survivors, 271 (49%) reported low spirituality and 280 (51%) reported high spirituality. Of the cohort, 59% had some kind of worry regarding disease recurrence/progression, development of new cancers, and treatment complications. Highly spiritual survivors were less likely to have high levels of worries at both 6 and 12 months. Highly worried survivors were significantly more likely to place phone calls to their follow-up providers and had more frequent follow-up visits at 6 and 12 months. No interactions between spirituality and level of worry were noted to affect follow-up health-care utilization.

Conclusion Given spirituality's effect on anxiety, spirituality-based intervention may have a role in addressing cancer survivors' worries but may not improve health-care utilization.

Article Outline

Participants and Methods: Subject Selection and Eligibility; Variables Analyzed; Statistical Analysis

Results: Study Participation; Characteristics of Study Participants; Prevalence of Spirituality and Patient Worry; Relationship Between Spirituality and Patient Worry; Relationship Between Patient Worry and Follow-Up Health-Care Utilization; Relationship Between Spirituality and Health-Care Utilization; Interaction Between Spirituality and Patient Worry With Health-Care Utilization

Discussion

Acknowledgements

References

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.

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)

Relationship Between Spirituality and Patient Worry

At the 6- and 12-month time points, after adjusting for covariates, highly spiritual survivors were significantly less likely to have worries than survivors who reported lower spirituality regarding disease recurrence/progression at 6 months (odds ratio [OR] = 0.61, 95% confidence interval [CI] 0.42–0.89, P < 0.01) and at 12 months (OR = 0.43, 95% CI 0.29–0.63, P < 0.01), complications from treatment at 6 months (OR = 0.50, 95% CI 0.33–0.76, P < 0.01) and at 12 months (OR = 0.54, 95% CI 0.35–0.83, P < 0.01), and development of a different type of cancer at 6 months (OR = 0.65, 95% CI 0.44–0.97, P = 0.04) and at 12 months (OR = 0.50, 95% CI 0.33–0.77, P < 0.01) (Table 3A).

Table 3. Multivariate Analysis Evaluating the Association Between Levels of Spirituality, Patient-Rated Worry, and Follow-Up Health-Care Utilization

A	N	6-MONTH				12-MONTH
		LOW SPIRITUALITY, OR (95% CI)	HIGH SPIRITUALITY, OR (95% CI)	P	N	LOW SPIRITUALITY, OR (95% CI)	HIGH SPIRITUALITY, OR (95% CI)	P
Outcome
Recurrence/progression-related worry	502	1.00	0.61 (0.42–0.89)	0.01	546	1.00	0.43 (0.29–0.63)	<0.01
New primary–related worry	508	1.00	0.65 (0.44–0.97)	0.04	547	1.00	0.50 (0.33–0.77)	<0.01
Complication-related worry	508	1.00	0.50 (0.33–0.76)	<0.01	545	1.00	0.54 (0.35–0.83)	<0.01
B	N	LOW WORRY, OR (95% CI)	HIGH WORRY, OR (95% CI)	P	N	LOW WORRY, OR (95% CI)	HIGH WORRY,OR (95% CI)	P
Outcome
Follow-up frequency	485	1.00	1.81 (1.04–3.12)	0.03	534	1.00	1.49 (1.00–2.22)	0.05
Phone call to follow-up clinic	504	1.00	2.21 (1.48–3.31)	<0.01	543	1.00	1.74 (1.20–2.53)	0.01
Emergency room visit	503	1.00	1.75 (0.90–3.43)	0.10	549	1.00	0.88 (0.52–1.51)	0.65
C	N	LOW SPIRITUALITY, OR (95% CI)	HIGH SPIRITUALITY, OR (95% CI)	P	N	LOW SPIRITUALITY, OR (95% CI)	HIGH SPIRITUALITY, OR (95% CI)	P
Outcome
Follow-up frequency	487	1.00	0.63 (0.37–1.10)	0.11	536	1.00	0.88 (0.60–1.30)	0.52
Phone call to follow-up clinic	506	1.00	0.77 (0.53–1.12)	0.17	545	1.00	0.70 (0.49–1.00)	0.04
Emergency room visit	505	1.00	0.56 (0.30–1.05)	0.07	551	1.00	0.84 (0.50–1.41)	0.50

Models adjusted for age, sex, cancer type, income, type of insurance, and time from last treatment

Relationship Between Patient Worry and Follow-Up Health-Care Utilization

Survivors who were highly worried about disease recurrence/progression, development of another type of cancer, and/or complications from treatment were more likely to visit their providers for follow-up care when compared with survivors who were less worried at 6 months (OR = 1.81, 95% CI 1.04–3.12, P = 0.03) and at 12 months (OR = 1.49, 95% CI 1.00–2.22, P = 0.05). Similarly, survivors who were highly worried were also more likely to place phone calls to their follow-up providers for medical inquiries than survivors who were less worried at 6 months (OR = 2.21, 95% CI 1.48–3.31, P < 0.01) and at 12 months (OR = 1.74, 95% CI 1.20–2.53, P = 0.01). We did not observe differences in emergency room visits between survivors with low and those with high rates of worrying at both 6 and 12 months (Table 3B).

Relationship Between Spirituality and Health-Care Utilization

No significant differences were noted for the frequency of follow-up visits, changes in follow-up providers, and emergency room visits between the levels of spirituality at both 6 and 12 months. However, at 12 months, highly spiritual survivors were less likely to call their follow-up providers for medical inquiries compared to survivors with low spirituality scores (OR = 0.70, 95% CI 0.49–1.00, P = 0.04) (Table 3C).

Interaction Between Spirituality and Patient Worry With Health-Care Utilization

Interaction between patient-rated worry and level of spirituality as it relates to health-care utilization was not statistically significant (data not shown). This suggests that spirituality does not modify the effect of patient worry in producing change in follow-up health-care utilization.

Discussion

Our study examined the relationships between spirituality, patient-rated worry, and follow-up health-care utilization among cancer survivors and found that individuals who possess higher levels of spirituality tend to have less worry of disease recurrence/progression, development of treatment-related complications, and development of new cancers. These findings are consistent with previous research among patients with advanced or terminal cancers that consistently showed such correlations between spirituality and general measures of anxiety.^[10]^,^[15]^,^[17]^,^[19]^,^[30]^and ^[31] Additionally, our study showed that a higher degree of worry about common concerns of cancer survivors is associated with more follow-up visits and calls to health-care providers. However, our data also showed that spirituality by itself is for the most part not associated with follow-up health-care utilization.

It has been documented that psychosocial factors like anxiety and spirituality can influence behaviors.^[32]^,^[33]^,^[34]^,^[35]^and ^[36] Our analysis showed that both discretionary and nondiscretionary indices of health-care utilization increased significantly among highly worried cancer survivors. However, these increases are independent of one's level of spirituality. These results suggest that cancer survivors with a high degree of worry about disease recurrence/progression, development of treatment-related complications, or development of a new cancer produce a change in care-seeking behavior and may concomitantly alter the health provider's need to see the patient. Our results also suggest that while spirituality has an impact on one's level of worry, being less spiritual does not necessarily alter a cancer survivor's care-seeking behavior.

Worried patients present a potential problem for clinicians in that they may need more attention during clinic visits,³⁷ may result in requests for more ancillary/diagnostic tests including imaging modalities,^[38]^and ^[39] or may use more medications ^[40]^and ^[41] or resort to other alternative therapies ^[42]^,^[43]^,^[44]^and ^[45] available to reduce their worries. Given that cancer patients already receive many chemotherapeutic agents for their treatment, many of them are more inclined to undergo alternative therapies.^[16]^,^[43]^,^[46]^,^[47]^and ^[48] Spirituality-based interventions shown to be effective at reducing anxiety and increasing QOL may therefore have a role among cancer survivors. And because spirituality and religiosity are closely linked,²⁹ faith-based interventions may also benefit the patient.

Our study has several implications in the assessment of cancer survivors in multidisciplinary survivorship clinics. While much attention about assessing depression, anxiety, and QOL has been given to cancer survivors, our study shows that the evaluation of one's spirituality may have some merit as well. Participants with low spirituality and a high degree of worry may benefit from activities that enhance spirituality (e.g., yoga, meditation). Because of the increasing number of cancer survivors,^[32]^and ^[49] development of clinic-based spiritual interventions to address common worries of cancer survivors may be appropriate. In addition to the implications for clinical practice, our study has implications for future research. While the literature has shown a correlation between spirituality and religiosity,²⁹ these two concepts are not the same.^[1]^,^[2]^,^[50]^,^[51]^and ^[52] It would have been interesting to compare outcomes by level of spirituality and religiosity, but our data revealed a high degree of correlation between these two concepts. Over 90% of individuals who are spiritual are also religious.^[28]^,^[53]^and ^[54] This may be the reason that some spirituality-based interventions have enhancement of religious activities as main approaches to improve spirituality.^[28]^and ^[53]

While our study has the strengths associated with a prospective study in a relatively large number of cancer survivors treated in a single medical center, it has several limitations. Our participation rate at baseline was only 50%, although our retention rates at 6 and 12 months were on average 80%. Another limitation of our study is that the baseline surveys were conducted at different time intervals from last treatment, although this limitation also allowed us to include all kinds of cancer survivors in terms of disease and time interval from last cancer treatment. Analysis confined to patients who received treatment within the last 5 years (n = 371) showed essentially the same results. We also compared the baseline spirituality scores of the study participants according to time from last treatment to study participation (0–2, 2–5, >5) and showed no statistically significant differences. Additionally, we adjusted for time from last treatment to study participation in the multivariate analyses. Combining all the participants into one analysis allowed for our exploratory analyses to have stronger statistical power. Another limitation of our study is the crude measurement of patient worry. However, in the absence of validated instruments to measure these worries, we felt the measures reflected subjective ratings of common worries by cancer survivors. Health-care utilization would have been ideally measured continuously to better quantify the medical services utilized. However, because we included a heterogeneous group of cancer patients, this measure would be highly variable and depend on the type of disease and treatment received by the patient. Thus, type of disease and time period from last treatment were adjusted for in the multivariate analyses.

In summary, cancer survivors who possess higher levels of spirituality tend to have a lesser degree of worry over disease recurrence/progression, development of treatment complications, and development of new cancers. A higher degree of worry about the common concerns of cancer survivors is associated with more follow-up visits and calls to health providers. However, our data showed that, for the most part, spirituality is not associated with follow-up health-care utilization.

Acknowledgments

The authors thank Linda Bauer, Garrett Frost, and Gregory McFadden for their help in coordinating the study and processing the data. This work was supported by the University of Nebraska Medical Center–Eppley Cancer Center (Support Grant P30 CA 036727) and the Medical Student Research Program. The funding source had no role in the design, collection, analysis, and interpretation of the data or in the writing of the article.

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Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Correspondence to: Fausto R. Loberiza, Jr., MD, MS, 987680 Nebraska Medical Center, Omaha, NE 68198-7689; telephone: (402) 559-5166; fax: (402) 559-6520

¹ PubMed ID in brackets.

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