Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Room 6349 D1 Baltimore, Maryland 21287, USAUnited States
Staff Clinician, Pain and Palliative Care Service Clinical Center, National Institutes of Health, Bethesda, Maryland 20892, USAUnited States
Department of Anaesthesiology and Critical Care Medicine, Palliative Care Program, the Kimmel Cancer Centre at Johns Hopkins, Core Faculty, The Armstrong Institute for Patient Safety and Quality, The Johns Hopkins School of Medicine, 1800 Orleans Street St. Meyer 297A Baltimore, MD 21287-7294, USAUnited States
Also available as PDF (figures and tables appear in the PDF).
Background: Religion and Spirituality (R/S) may influence cancer patient’s emotional distress, mental health and healing throughout their diagnosis and treatment. Objective: This systematic review examines studies exploring R/S of cancer patients and their family in the perioperative period. Design: We completed a systematic review of the databases MEDLINE, EMBASE, CINAHL, SCOPUS, the Web of Science, and Cochrane library concerning the terms “religion and spirituality” and “cancer surgery”. Inclusion criteria included qualitative or quantitative studies evaluating R/S of cancer patients or their family members within the perioperative period (one month pre- and post-surgery). Exclusion criteria included review articles, grey literature, editorials, case studies and studies evaluating R/S of healthcare providers. Results: Seven publications met criteria for analysis. Five studies described cross-sectional surveys, one used a focus-group approach, and one utilized in-person interviews. Studied popu-lations predominantly were female breast cancer patients. There were considerable heterogene-ity in survey instruments, variables, and outcomes. Based on these studies: 1) Faith and religious beliefs were used as coping mechanisms during the perioperative period; 2) Evangelical Christians tended to differ in religious coping compared to Catholics; 3) R/S correlated with coping styles and distress; 4) There was increased religious coping and religious involvement during the perioperative period; Conclusions: Studies evaluating R/S of cancer patients and their families in the perioperative period are few and heterogeneous in design. Direct comparison is difficult, but data suggests that R/S during the perioperative period may increase as compared to R/S during other stages of cancer diagnosis and treatment.
Keywords: Religion; Spirituality; Religiosity; Tumor; Surgery; Perioperative; Cancer
Many people use religion for comfort and support
when faced with a life-threatening illness such as cancer. Pa-
tients who had previously disregarded religion and spirituality
may search it out when faced with illness.1,3 Carver found that
all forms of coping, including religious coping, peaked early
around the time of surgery for breast cancer patients and then de-
clined over time. Emerging literature also describes the positive
benefits of Religion and Spirituality (R/S) in helping patients
cope with distress, pain and anxiety. For cancer patients, R/S
has been associated with positive attributes, specifically with en-
hanced well-being, decreased depression and anxiety, increased
meaning and feelings of hope, increased optimism and inner
peace and preventing end of life despair. However, Cohen de-
scribed a positive correlation between R/S coping and increased
pain reporting and post-operative analgesic use amongst women
undergoing major abdominal surgery. Though this study was not
specific to oncologic patients, it does suggest that increased R/S
may not necessarily relate to what medical providers consider
“improved outcomes”.6
Religion and spirituality have traditionally been com-
bined in the literature; however they are two separate concepts.7
Religion refers to an organized system of faith beliefs within the
context of structured practices and ways of worship (e.g. Ca-
tholicism, Islam, Judaism) and codified beliefs.8,7 Religion is a
social institution, often culturally based and a way to express
spirituality.7 The concept of spirituality is broader than the con-
cept of religion and refers to a personal connection with some-
thing that provides meaning to one’s life.8,9 Spirituality does not
require specific rituals, practices or even a belief in God but en-
compasses the transcendent and non-worldly quality of relating
to other persons, a God-being or material nature.8 Spirituality
does not have the boundaries of the religious institution but in-
stead is a dynamic concept that refers to the ongoing search to
discover meaning.9 However, for this systematic review, religion
and spirituality are combined as a single concept because this is
how it is presented in the literature and we are unable to separate
the two concepts from the available data.
Many studies examine R/S but only do so several
months after initial diagnosis and/or after months of treatment,
when coping and adjustment mechanism are already in place.
Yet, for many cancers, a first and major treatment option is sur-
gery and this may be a time when R/S needs are high. The peri-
operative physicians, including anesthesiologists, surgeons and
hospitalists, care for patients during this stressful time period,
yet have very little guidance on how to manage the patient’s heighted stress of the day of surgery and the time period immedi-
ately adjacent to it. As an example of a type of cancer surgery for
which there is which there is a major perioperative adjustment
for both the patient and family member, Grandstaff outlines four
crucial periods of adjustment to mastectomy: 1) the days surter surgery when the patient’s partner responds to the surgical
incision and 4) 4 weeks post operatively when the patient and
1,2 partner resolve issues of intimacy and acceptance of physical
changes from mastectomy.
1,3
As Grandstaff notes, there is an exaggeration of stress
immediately prior to surgery, due to apprehension about the sur-
gery, and then for the next several weeks after surgery, but with-
2,5 in one month of surgical treatment. This is the time period that
the perioperative physician provides care. In order to summarize
the studies exploring cancer patient’s perioperative R/S experi-
ence and needs, we completed this systematic review, with the
2 intention of laying the ground work for future studies that will
guide development of interventions for perioperative spiritual
support.
This systematic review includes published studies us-
ing interview, survey or questionnaire studies that examined the
spiritual or religious experiences of patients during the periop-
erative period. We searched MEDLINE, EMBASE, CINAHL, 8,7 SCOPUS, the Web of Science, and Cochrane library as of July
27, 2012. A Johns Hopkins Medical Institution Clinical Infor-
mation’s assisted in defining the search terms and strategy. The
terms used to define each concept included a combination of 8,9 controlled vocabulary and key word terms and phrases such as
“religion” or “religion and medicine” “spirituality” and “sur-
gery” or “resection” or “carcinoma” or “tumor” or “cancer.”
Inclusion criteria included studies: exploring religious
or spiritual experiences, in the English-language, and which in-
volved adults (greater than 18 years of age) with cancer or a po-
tential diagnosis of cancer and which were conducted during the
perioperative period. The perioperative period was defined as
one month prior to or after surgery. We excluded review articles,
studies that did not have data reported and unpublished grey lit-
erature. Dual, independent investigators completed title/abstract
and then full article screens. Disagreements about article inclu-
sion and exclusion were resolved through discussion between
the reviewers.
Formal abstraction sheets were used to extract infor-
mation from included articles. Abstracted data included study
population demographics, type of study, perioperative timing
and outcome. For analysis, the data was divided between pre-
based on their relevance to religion or spirituality, including
support from church or church groups, comparison between re-
ligious groups, religious coping and religious practices. Emo-
tional coping and support was also abstracted and analyzed.
If applicable, comparison between family member and patient
coping was made. Data abstraction and analysis was completed
concurrently by two independent reviewers and any discrepancy
between reviewers was clarified through discussion.
The search strategy returned 1499 articles and de-du-
plication yielded 972 articles for title/abstract screen. Of this, 53
studies were included for full article review which yielded a final 1-3,5,11-13 seven articles (see Figure 1).
Of the seven included studies, six enrolled women with
breast cancer and one study enrolled men with urologic cancers,
primarily prostate cancer. The study populations were ethnically
and geographically diverse with one study conducted in Turkey,
one in South Korea, one in Canada, one in the United Kingdom.
Of the three studies conducted in the United States, one study
specifically focused on Hispanic women while the other two
studies did not have an ethnic focus. Sample sizes were small
and ranged from 20 to 284. One study about breast cancer pa-
tients also included the patient’s spouses.
Alferi SM et N=49 Hispanic women (FL) lower socio- 72.5 % Catholic Prospective Initial interview, post- • Religious involvement al, J Health economic status Average age= 56.37 Evangelical group: study, single surgery interview 7-10 • COPE Psychol19991 yrsEarly stage (stage 0/I/II) breast CA Jehovah’s Witness, arm, single days after surgery, follow • POMS 47% married, 12% separated, 18% Evangelist, Pentecos- center -up interview 3,6, and 12 divorced, 16% widowed tal, Baptist, non-
Biegler K et al, N=115 men (TX); Average age= 58.3 93% Christian One time, cross Pre-op visit, about 7 days • Intrinsic religiosity Integr Cancer yrs89% prostate cancer, 10% renal cancer, (Catholic or Protestant) sectional survey prior (range 1-29 days) • ORA, NORA Ther 20112 1% bladder cancer,71% some college education,75% Caucasian,90% Married or living with partner
Demir F et al. N=20, women (Turkey) with excisional Not noted Phenomenologi- 1 week post-op office Patients were invited to talk about their ex- J Clin Nurs breast biopsy, returned one week later for cal approach follow-up visit. One hour periences. Allowing patients’ own practical 200613 monitoring.
Gall TL et al, N=93 breast cancer N=160 benign 44.1/42.7% Catholic Prospective Pre-diagnosis, 1 week pre- • Religious involvement (pre-diagnosis) Psycho-Oncol- diagnosis,women(Canada)Average 36.6/42.0% Protestant study, single surgery, and 1 month, 6 mo, • Modified RCOPE 10 subscales ogy 20093 Age=60.9/52.7 yrs, 96.8/93.8% Euro- 11.8/11.5% No religion arm, single 1 yr, and 2 yrs post-surgery • POMS Canadian 66.7/70.6% Married or Common center • FACT-B: only emotional well-being law, 14/6.2% Single, divorced Jang, Ji-Eun et N=284; women, breast cancer patients pre 35.2% Protestant Prospective Baseline (within 5 days of • DRI al, Psycho-On- surgery (South Korea) Mean Age= 49.8 26.4% No religion Study, ques- surgery) and 1 year post- • MADRS cology 20125 yrs, mean years education: 11.0 22.2% Buddhists tionnaire and surgery • HADS
Northouse, N= 50; Women, post mastectomy and hus- None noted Prospective, Baseline (1 to 6 days post Structured interview developed by investi- L. L., Cancer bands (Southwestern Michigan) Mean age: qualitative study, surgery) and 30 days gator. Patients describedgreatest concerns Nurs198912 50.4 yrs patients, 52.3 yrs husbands two phase, mul- post surgery. Interviews about illness and reaction to seeing the Ave yrs education= 13-14 tiple centers. conducted separately with mastectomy site; identified most stressful
Thune-Boyle, N= 202 Newly diagnosed breast cancer, 42/44% Protestant Retrospective, Post surgery(average=3 • Single item questions to evaluate R/S I.C.V. et al, J women (UK) N=110healthy, matched, con- 23/22% Catholic between-subject days)Retrospectively beliefs Relig Health trol subjects. 81/84% Caucasian, 44/49% 18/27% No religion design and compared newly diagnosed • ORA and NORA 201111 Married, 15/16% Single, Mean yrs educa- 8/1% Jewish within subject patient’s current religious/ tion: 14.4/14 design spiritual beliefs with beliefs
Coping Responses (COPE, Brief-COPE), Profile of Mood States (POMS), Organized religious activity (ORA): Nonorganized religious activity (NORA),Medical Outcomes Study Social Support Survey (MOS-SSS), Perceived Stress Scale (PSS), Impact of Event Scale (IES), Brief Symptom Inventory-18 (BSI-18), Religious COPE (RCOPE), Functional Assessment of Cancer Treatment-Breast (FACT-B), Montgomery-Asberg Depression Rating Scale (MADRS), Duke Religious Index (DRI), Hospital Anxiety Depression Scale (HADS), European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30)
Table 1. Summary of studies included in the review
Table 2), such as: religiosity/spirituality, patient stress coping,
months after surgery denominational
• Brief COPE • MOS-SSS • Distress: PSS, IES, BSI-18, POMS
interview. worlds and concerns to be revealed.
16.2% Catholics interview • EORTC QLQ-C30
patient and husband phase of illness and factors that helped them to cope
in year prior
Religious Involvement • Items from General Social Survey Alferi1 • Importance of religion, frequency of church attendance, frequency of prayer, extent to which she turned to religion for comfort, extent to which she considers herself spiritual • Frequency of doubts about faith, and degree to which religious beliefs influenced treatment decisions Coping Responses (COPE, Brief- • Alferi used religious coping portion of COPE:Religious coping (Emotional support from the people in my church; going to church or prayer meet- COPE) ings; talking with my priest or minister; trying to find comfort in my religion or spiritual beliefs); Behavioral disengagement (I’ve been giving up Alferi, Biegler1,2 trying to deal with it); Denial ( I’ve been saying to myself ‘this isn’t real’) • Biegler separated coping responses into two categories:Engagement coping: active coping, planning, acceptance, and positive reframing; Avoidant coping: denial and behavioral disengagement Profile of Mood States(POMS, POMS- • Check list of mood-descriptive adjectives SF) • Participants indicate the degree to which they have Alferi, Biegler, Gall 1,2,3 • 6 subscales: tension-anxiety, depression-dejection, Intrinsic religiosity (IR) • Statements about religious beliefs or experience Biegler2 Multidimensional measurement of reli- • Organized religious activity (ORA): 2 item subscale gious/spirituality (ORA, NORA)Biegler, • Nonorganized religious activity (NORA): 3 item subscale Thune-Boyle2,11 Perceived Stress Scale(PSS) Biegler2 • 14 items measuring perceptions of ongoing stress
Impact of Event Scale (IES) • Measures intrusive thoughts or the tendency to ruminate on or avoid thoughts about stressors Biegler2 Brief Symptom Inventory-18 (BSI- • Assess different aspects of psychological distress 18)Biegler2 • Depression, anxiety, somatization Religious involvement • Frequency of religious service attendance Gall3 • Perceived importance of religion in one’s life • Perceived importance of spirituality in one’s life Religious coping(modified RCOPE) • 10 Subscales of RCOPE: Benevolent Religious Reappraisal (redefining stressful event as part of God’s plan); Collaborative Religious coping Gall3 (working together with God); Active Surrender (willingly giving control of events to God); Passive Religious Deferral (passively relinquishing the event to God); Pleading for Direct Intercession (asking for a miracle); Seeking Spiritual Support; Religious Focus (using religious activities as a distraction) Spiritual discontent (disappointment with God); Religious Helping (providing spiritual support to others); Seeking Religious Direction (looking to religion for new meaning and purpose) Functional Assessment of Cancer • only emotional well-being dimension was assessed Treatment-Breast (FACT-B) Gall3 Duke Religious Index (DRI) • Religious activity (RA): organized religious activity + private religious activity Jang5 • Intrinsic religiosity (IR) Montgomery-Asberg Depression Rating • 10 item instrument measuring depression Scale (MADRS) Jang5 Hospital Anxiety Depression Scale • HADS-A: 7 item anxiety subscale (HADS) • HADS-D: 7 item depression scale Jang5 European Organization for the Research • Global QOL and Treatment of Cancer Quality of Life • Different dimensions of functioning Questionnaire Core 30 • Symptom subscale (EORTC QLQ-C30) Jang5 Single item questions • Current belief: “I feel certain that God in some form Thune-Boyle11 • To what extent they considered themselves R/S • Strength of faith Coping Responses (COPE, Brief-COPE), Profile of Mood States (POMS),Profile of Mood States-Short Form (POMS-SF), Intrinsic religiosity (IR),Organized religious activity (ORA): Nonorganized religious activity (NORA), Perceived Stress Scale (PSS), Impact of Event Scale (IES), Brief Symptom Inventory-18 (BSI-18), Functional Assessment of Cancer Treatment-Breast (FACT-B), Montgomery- Asberg Depression Rating Scale (MADRS), Duke Religious Index (DRI), Hospital Anxiety Depression Scale (HADS), European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30), Quality of Life (QOL)
Table 2. Descriptions of outcome measurement instruments used in studies included in review depression, anxiety, Non Organized Religious Activity (NORA), Organized Religious Activity (ORA), POMS (Profile of Mood States) and the COPE Inventory.14 One study used a phenom- enological approach to explore the patient’s perioperative ex- perience.13
All studies, including the study with the retrospec-
tive section, completed at least one interview or questionnaire
in the month prior to or after surgery. None of the studies used
the same timeframe for interview/survey completion. Three of
the studies compared pre and post-surgery outcomes from one
month prior to one month post-surgery. One study included
only post-surgery outcomes and three measured only pre-surgery 13,2,5,11 outcomes. If the studies included time point data outside of
the timeline of our systematic review, that data was not included
in our review. See table 3 for study conclusions pre- and post-
surgery.
In the study of US Hispanic women with early stage
experienced the emotion in the past week anger-hostility, vigor, fatigue, and confusion-bewilderment
and addressed in Gall’s study
exists.”
religious involvement of Evangelical Christians versus Catho-
lics, showing that religiosity and religious coping were higher
for Evangelicals and that for Catholic women, getting sup-
port from Church members predicted higher levels of distress
post-surgery. For both groups, distress decreased post-surgery.1
The second study of US patients used structured interviews of patients and their husbands, and showed that survival was the
greatest concern for both groups and that the uncertainty of the
diagnostic phase before surgery was the most stressful for 80%
of women and 53% of men. Patients also expressed stress during
the time while they waited for the mastectomy, knowing that the 1,3,12 cancer was still present in their bodies, and 44% of husbands re-
ported the day of surgery as the most stressful point. The study of men with urologic cancers was completed at the preoperative
visit and showed that men reporting low R/S and greater edu-
cation had greater perceived stress while those with no college
education engaged in more avoidant coping. Overall, Religion/
Spirituality (R/S) positively correlated with engagement cop-
ing.2
• Compared to Catholics, Evangelical women: reported higher religiosity, levels of all types of religious coping and talking to a minister related inversely to distress • Distress fell pre- to post-surgery (p=.01) • Religiosity correlated withobtaining emotional support from church, attending church or prayer meetings, taking comfort in religion • Compared to Catholics, Evangelical women: reported higher levels of talking to their ministers 1 and less denial Alferi • Higher religiosity correlated with emotional support from church member and attending church denomination of the patients. or prayer meetings • Catholics: getting support from church members at pre-surgery predicted higher levels of distress post-surgery • Evangelical: pre-surgical distress predicted lower attendance of church or prayer meeting post-surgery
• Religion/Spirituality (R/S) positively correlated with engagement coping • Social support inversely correlated with POMS/PSS, positively correlated with engagement coping • Engagement coping positively correlated with IES, BSI, avoidant coping was positively associ- Biegler ated with all measures of distress.
• Those with lower R/S scores, greater engagement coping associated with greater distress • For men who scored high on R/S, there is inverse association between social support and PSS and POMS • Non Caucasian, no college education engage in more avoidant coping • Men reporting low R/S and greater education associated with greater perceived stress
• Fear: that the lump was cancer; of surgery ; their breast would be removed Demir • Spiritual needs: prayed that it would not be something bad; “I prayed even though I’m an unbeliever.”
• Religious coping at pre-diagnosis to 1 wk pre-surgery: Increase in active surrender coping; religious helping; use of religious direction; use of religious focus.
Religious coping as a predictor of concurrent adjustment • Active surrender and collaborative coping predicted less distress • Religious direction coping and pleading predicted greater distress • Better well-being correlated with less pleading and spiritual discontent coping and greater use of religious helping Concomitant change between religious coping and adjustment across time • From pre-diagnosis to 1 wk pre-surgery • Increased spiritual discontent and pleading coping predicted increase in emotional distress • decreased spiritual discontent and increased religious helping predicted increase in emotional At the time of diagnosis with breast cancer, women used religious cop- Gall3 well-being • From 1 wk pre-surgery to 1 mo post-surgery, a decrease in pleading and increase in use of peaked. religious focus coping predicted an increase in well-being Religious coping as a predictor of concurrent adjustment at 1 mo post-surgery • Greater use of spiritual discontent predicted greater distress (p=.0001) • Greater use of collaborative and passive deferral coping and lesser use of spiritual discontent contributed to better well-being (p=.0001) Concomitant change between religious coping and adjustment across time • From 1 wkpre-surgery to 1 mo post-surgery: increase in spiritual discontent and pleading coping predicted increased emotional distress • From 1 wk pre-surgery to 1 mo post-surgery: decrease in pleading and increase in the use of religious focus coping predicted increase in well-being
• Scores on RA were significantly higher in Protestant than Catholic, Buddhist, and no-religious groups, in that order • In all the groups with high intrinsic religiosity (IR), IR was negatively associated with depression Jang • Buddhist group: scores on the RA subscale negatively correlated with the HADS-D scores • Catholic group: scores on the RA subscale were positively correlated with HADS-A scores • Protestant group: scores on the RA subscale were positively correlated with the global subscale of the QLQ-C30 • No religious preference: scores on the IR subscale were negatively correlated with HADS-D • 83% of women and 50% of husbands describe the diagnostic phase before surgery as the most stressful time: uncertainty about whether they had cancer; waiting for the mastectomy • 44% of the husbands reported the day of surgery as the most stressful Factors that helped patients and husbands cope Nort- 12 • Religious belief identified more frequently during the hospital period than at home 1 month later surgery, with patients being concerned about the extent of disease and house for women, 21% during hospitalization, 9% at home; for husbands, 13% during hospitalization recurrence, while husbands worried about the survival of their wives. and 4% at home • Emotional support for patients, 87% during hospitalization, 72% at home; for husbands, 64% during hospitalization, 49% at home
Patients both increased and decreased their R/S beliefs and practices at the time of pared to the year prior • 26% of patients have increased private R/S practices Thune- • 11 21% perceived their strength of faith increased Boyle • 5-12% reported decreases in beliefs • Belief in God was significantly higher at surgery • Strength of faith increased at surgery • Perceived levels of R/S and public R/S practices remained stable.
Profile of Mood States (POMS),Perceived Stress Scale (PSS), Impact of Event Scale (IES), Brief Symptom Inventory (BSI),Hospital Anxiety Depression Scale-Anxiety(HADS-A), Hospital Anxiety Depression Scale-Depression(HADS-D) ,Quality of Life Questionnaire Core 30 (QLQ-C30) , Religious Activity (RA) Abbreviations: Week (wk), month (mo)
Table 3. Major study conculusions and key study summary
Increased religiosity had different effects depending on the religious
The relationship between R/S with coping mechanism s is complex and simplistic correlations may not be sufficient to describe these relationships.
Three major themes emerged from this study including patient’s need for information, fear and spiritual needs.
ing. At the time of surgery, use of support and comfort-related strategies
Intrinsic religiosity was higher among Protestant and Catholics than for Buddhists or those with no religious preference, and increased intrinsic religiosity correlated to decreased HADS scores implying that it is not the religion but the intensity of religion that corresponds to decreased depression.
Patients and their husbands had different concerns around the time of
surgery com-
In UK study, the patients perceived that they had an increased belief in God and strength of faith at the time of surgery, but no change in belief or practices. For most patients, there was an increase in beliefs and religious practices at the time of surgery.
The phenomenological study of Turkish women who
had excisional breast biopsies established three main themes:
fear (that the lump was cancer, fear of surgery, fear breast would
be removed); the need for information (about surgery and ill-
ness); and spiritual needs (prayer that the lump was not some-
thing bad). Baseline results of Jang’s study of South Korean
breast cancer patients showed that Religious Activity (RA) was
higher for Protestants than Catholics, Buddhists and those as-
sociated with no religion. In all groups with high Intrinsic Reli-
giosity (IR), IR was negatively associated with depression. The
study of Canadian breast cancer patients included several data
points, but the data pertinent to this review showed that from one
week before surgery to one month after surgery, a decrease in
pleading and increase in use of religious focus coping predicted
an increase in well-being. Improved well-being correlated with
lesser use of pleading and spiritual discontent coping and a great-
er use of religious helping. The patient population of the breast
cancer patients from the United Kingdom (Protestant, Catholic,
Jewish, no religion) was religiously diverse similar to the patient
population from the South Korean study (Protestant, Catholic,
Buddhist, no religion). The UK patients answered R/S questions
post-surgery and recalled their beliefs in the year prior. Results
showed that R/S beliefs both increased and decreased from the
year prior to surgery to the immediate post-operative period, but
overall, it showed that belief in God was significantly higher at
surgery and that patients’ belief in God was significantly higher
at surgery.11
As identified in this systematic review, the current lit-
erature is limited in its evaluation of R/S of the cancer patient in
the perioperative period. Existing studies are almost exclusively
in women with stage I and II breast cancer. Even though the
studies evaluate patients of different cultures, the studies do not
expand on the effect of ethnicity and culture on religious and
spiritual needs.
Studies examined the stress response and coping, and
their interplay with religiosity and spirituality, including the type
of religious coping employed by the patient. Based on these
studies, patients with higher religiosity/spirituality have better
engagement or active coping but that simplistic associations be-
tween R/S and coping are inadequate to explain R/S needs of
patients for coping and responding to stress. The data stating
that R/S have a positive effect on patient outlook, physical and
mental well-being is variable and this is identified not only when
comparing US to UK cancer patients, but also when comparing
patients of different faiths and different denominations of the
same faith. One consistent theme from several of the studies is
that the perioperative period is a time of exaggerated stress for
patients and their families but the reason for the stressful nature
of the time period is different for patient as compared to fam-
ily member. During the perioperative period, patients expressed
the breast cancer patient expressed increased stress during both
the pre-surgery diagnostic phase and the post-surgical treatment
period.12
Factors of ethnicity and culture, which intrinsically
are linked to religion and religious practices, likely contribute
to variability in how R/S affect patient coping. When compar-
ing US populations with other populations, the Gallup Daily 5 tracking survey from 2011 reports that the US population is pre-
dominantly a Christian nation with 78% adults identifying with
Christianity, 82.5% have some form of religious identity and
92% of Americans say that they believe in God.16 In comparison,
12% of the UK population attends church regularly, 51% with
some belief in God and 12% without doubt of God’s existence.17
Thune-Boyle et al argue that since most studies on the topic of R/S and patient coping have been completed in the US, their
conclusion about R/S are difficult to transfer outside of North
America,11 even to other English-speaking patient populations.
Pertinent to the three studies examining North American popula-
tions, Koenig finds that African Americans are more likely than
other ethnic groups to use religion for coping.18 Within the US
Latino population, patients come from a geographic background
as large at the US itself and the religious and cultural practices
vary even within populations from similar geography with pa-
tients mostly associating with either a Christian evangelical de-
nomination church or Catholicism.1 Even if direct comparison
of the studies completed in the US cannot be made with non-US
studies, Demir’s phenomenological study made a clear argu-
ment that the female patients studied in Turkey needing exci-
sional biopsies have spiritual needs in the perioperative period.13
R/S needs may vary by culture, but across cultures patients have
unique R/S needs in the perioperative period.
One limitation of this review is that these studies fo-
cused on cancer patients with good prognosis: female breast
cancer patients with early stage disease and men with prostate
cancer. Early stage breast cancer (stages I and II) has a 5 year
survival rate of 93%.19 Similarly, the 5 year survival rate is over
99% for all stages of prostate cancer.20 Many patients turn to R/S 17,3 when faced with a life-threatening illness such as cancer17,3 but
the aggressive nature of the cancer may affect a patient’s emo-
tional, spiritual and religious needs. For patients with advanced
or incurable cancer, R/S may take on a different meaning as they
face the inevitability of death. This is in contrast to patients with
cancers of generally good prognosis who face the uncertain fu-
ture of cancer survival.3 Another potential limitation is that these
studies were geographically diverse and thus, generalizability to
specific populations is unclear. Also, we included only English
language studies and thus, may have missed important non-Eng-
lish studies.
spirituality are still immature and current literature could have
been misclassified and not captured in this search. Other impor-
tant key words related to religion and spirituality such as sense
of peace, meaning and purpose of life were not used as part of
the search strategy and thus articles relevant to religion and
spirituality through connection with these terms may have been
missed in the systematic review.
Though inferences can be made from other studies that
are broader in their time frame, more studies are needed that
explore the religious and spiritual needs of perioperative patients
and clinicians. The effect of R/S for oncologic surgical patients
can be variable, having either a beneficial or negative effect on
their outlook and sense of well-being.11 In Nelson’s study on re-
ligion and spirituality in prostate cancer patients, patients were
found to have less depression when they had a sense of mean-
ing and peace but not necessarily more religious involvement.21
Given the variable effect of R/S, future studies could focus more
on spirituality and explore what gives the perioperative patient a
sense of meaning and peace. Further research is needed to iden-
tify factors that make the perioperative time period a uniquely
stressful experience for patients and their families and how re-
ligion and spirituality may affect perioperative coping. Under-
standing more specifically what causes stress for patients during
the perioperative time period may help perioperative providers
better understand the R/S needs of their patients and give more
complete care during the time before and after their oncologic
surgeries.
In the past, spirituality had a recognized role in health
care, but during the 20th century, spirituality and health care
were separated as health care became more scientific and tech-
nological.22 Physicians and other health care providers have
received limited education in their role in caring for the spiri-
tual and religious needs of the oncologic surgical patient, even
though there are currently efforts to bring spirituality back to
medical school education.22 Hospital chaplains should be part of
inter disciplinary teams caring for the oncologic patient and phy-
sicians and other care providers should understand the uniquely
stressful time of the perioperative time frame so that the patients
can receive treatment of their whole person, not just treatment of
their cancer.23 The perioperative time frame is a stressful period
for cancer patients and their family members as they encoun-
ter a diagnosis of cancer, experience the loss of control during
surgery, and face uncertain recovery. Understanding that unique
religious and spiritual needs of the oncologic patient requires
an understanding of the exaggerated stress of the perioperative
period and further research is needed to better understand how
better incorporation of religious and spirituality practices can
improve the perioperative experience for patients, their families,
and their providers
The authors would like to thank Blair Anton Associate Direc-
tor, Clinical Information’s Services William H. Welch Medical
Library Johns Hopkins Medical Institutions, for her assistance
with this systematic review.
The authors have no potential conflicts of interest with respects
to the research or authorship of this article.
JH and JC received no financial support for this research, author-
ship and/or publication of this article. RAA was supported by a
Foundation for Anaesthesia Education and Research grant and
a Johns Hopkins School of Medicine Clinician Scientist Award.
No competing financial interests exist.