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Year : 2011  |  Volume : 48  |  Issue : 1  |  Page : 55--59

Spirituality, distress, depression, anxiety, and quality of life in patients with advanced cancer

A Kandasamy, SK Chaturvedi, G Desai 
 Department of Psychiatry, National Institute of Mental Health and Neuro Sciences, Bangalore, Karnataka - 560 029, India

Correspondence Address:
A Kandasamy
Department of Psychiatry, National Institute of Mental Health and Neuro Sciences, Bangalore, Karnataka - 560 029


Objective: To study the influence of spiritual well being (Sp WB) on symptoms of distress, depression, and other dimensions of quality of life in advanced cancer patients receiving palliative care. Materials and Methods: The study was cross-sectional in nature. Fifty patients with advanced cancer from a hospice were assessed with the following instruments: the visual analog scale for pain (VAP), M.D. Anderson symptom inventory (MDASI), Hospital Anxiety Depression Scale (HADS), Functional assessment of cancer therapy - Palliative Care (FACT-pal), and Functional assessment of chronic illness therapy-spiritual well-being (FACIT-sp). We studied the correlations between spirituality and other variables on these scales. Results: Depression and anxiety were negatively correlated with spiritual well-being (Sp WB). Sp WB was significantly correlated with fatigue (r = -0.423, P = 0.002), symptom distress (r = -0.717, P < 0.001), memory disturbance (r = -0.520, P < 0.001), loss of appetite (r = -0.399, P = 0.004), drowsiness (r = -0.400, P = 0.004), dry mouth (r = -0.381, P = 0.006), and sadness (r = -0.720, P < 0.001). Sp WB was positively correlated with all the other aspects of QOL measures. Predictors such as palliative care well-being (t = 2.840, P = 0.008), distress (t = -2.582, P = 0.015), sadness (t = -2.765, P = 0.010), mood (t = 2.440, P = 0.021), and enjoyment in life (t = -3.586, P = 0.001) were significantly correlated with Sp WB, after regression analysis. Conclusions: This study suggests that spiritual well being is an important component of the quality of life of advanced cancer patients, and is closely related to the physical and psychological symptoms of distress. It should be addressed appropriately and adequately in palliative care settings.

How to cite this article:
Kandasamy A, Chaturvedi S K, Desai G. Spirituality, distress, depression, anxiety, and quality of life in patients with advanced cancer.Indian J Cancer 2011;48:55-59

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Kandasamy A, Chaturvedi S K, Desai G. Spirituality, distress, depression, anxiety, and quality of life in patients with advanced cancer. Indian J Cancer [serial online] 2011 [cited 2021 Dec 6 ];48:55-59
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Spirituality has been defined as, 'An inherent quality of all human beings that drives the search for meaning and purpose in life, involves relationships with oneself, others, and a transcendent dimension.' [1] Quality of life (QOL) is believed to include a spiritual dimension as well. Of late, there has been increased interest in the relationship between spiritual needs, spiritual well-being, physical health, and mental well-being, in individuals who are diagnosed with advanced cancer. There is a growing realization that the spiritual needs, spiritual distress, and spiritual well-being of end-stage cancer patients and other individuals diagnosed with terminal illnesses can significantly affect their QOL. [2],[3]

Many research studies have concluded that religiosity, specifically intrinsic religiosity, has a positive association with psychological health. Several researchers have also demonstrated that higher levels of spiritual well-being are associated with lower levels of psychological distress variables, such as, depression, hopelessness, desire for hastened death, and suicidal ideation among severely ill patients receiving palliative care. [3]

In a study of 100 patients with newly diagnosed advanced lung cancer, patients ranked faith in God just beneath their oncologists' recommendations, as the most important factor in their decisions about treatment.[4] Another cross-sectional study on advanced cancer patients found that spiritual well-being was correlated with quality-of-life measures. [5] Similarly, patients in a palliative care hospital reported end-of-life despair if they also reported low spiritual well-being. [6] A needs assessment survey of outpatients with cancer found that many reported unmet spiritual needs, including 40% wanting help in 'finding meaning in life,' 42% in 'finding hope,' and 51% in 'overcoming fears.' [7] Peace of mind, spiritual satisfaction, and social satisfaction were considered to be very important in nearly two-thirds of the cancer patients. [8] However, the spiritual needs of patients with advanced cancer have not been systematically studied.

In view of the all that was mentioned earlier, we undertook the task of assessing how spiritual well-being (Sp WB) is associated with distressing symptoms, anxiety, and depression, in advanced cancer patients. We also studied the influence of spirituality on other dimensions of QOL.

 Materials and Methods

This study was descriptive and cross-sectional in nature. The study sample was recruited from in-patients in a hospice and palliative care center catering to the needs of cancer patients. All the subjects in the study group were diagnosed with advanced cancer (no further curative treatments were available), including all forms and types of cancers. All consecutive admissions in the wards were recruited over a period of three months. On an average, the assessments were done one week after the admission to the hospice. The sample included patients above 16 years of age of both genders, who were cooperative and communicative for the interview. Written informed consent was obtained from the patients. Those who had alcohol or other substance abuse or dependence, a past history of major depressive disorder or bipolar disorder, or any neurological disorder were excluded. The study protocol was approved by the Institute's Ethics Committee. The study sample was assessed using the following instruments.

Visual analog scale for pain - This scale consists of readings from 0 to 10 wherein '0' corresponds to no pain and '10' to the worst pain imaginable. Subjects are instructed to indicate the pain experienced most of the time in the previous week along the scale. The validity and sensitivity of this scale have been documented by earlier workers in cancer patients with pain. [9],[10] M.D. Anderson symptom inventory (MDASI) - This is a self-administered flexible system for assessment of symptoms experienced by subjects with cancer. It consists of two parts. The first part has 13 core symptom items: pain, fatigue, nausea, disturbed sleep, distress (emotional), shortness of breath, lack of appetite, dryness of mouth, sadness, vomiting, and numbness or tingling, which are rated on their presence and severity. The second part has six symptom interference items including general activity, mood, work, relationship with people, walking and enjoyment of life, that are rated based on the level of symptom interference with function. Scores on the MDASI have been shown to be predictive of survival. The items are measured on an 11-point scale (0 - 10), '0' meaning not present / did not interfere and '10' meaning, as bad as you can imagine / interfering completely. [11] Hospital Anxiety Depression Scale (HADS) - This is a brief self-administered scale, which has been specifically designed for use in patients with co-morbid physical illness. It consists of 14 items, seven each recording depression and anxiety. Each item has four possible choices scoring from '0' to '3'. The depression subscale has been constructed in such a way as to largely exclude somatic symptoms. This subscale consists of items that predominantly screen for anhedonia, which is considered a symptom characteristic of the endogenous subtype of depression. [12] Validation studies have established a high internal consistency and reliable factor structure. The scale has been validated in the Indian population in a study that used HADS to screen for depression and anxiety. [13] They also established sensitivity and specificity for various cut-off scores. The study suggested that the best cut-off values for the Indian population are '8' and '7' for depression and anxiety, respectively. A cut-off score of '8'on a depression subscale has a sensitivity of 75% and specificity of 76%, respectively, for a diagnosis of depression.Functional assessment of cancer therapy - Palliative Care (FACT-pal) - FACT - pal is an extension of the original scale FACT - General. The FACT-G (Version 4) is a 27-item compilation of general questions divided into four primary QOL domains: Physical Well-Being (PWB; seven items), which comprises of reports of physical symptoms, Social / Family Well-Being (SFWB; seven items), which has questions assessing social support and communication, Emotional Well-Being (EWB; six items) measures mood and emotional responses to illness; and Functional Well Being (FWB; seven items) assesses the degree to which the respondent can participate in and enjoy normal daily activities. FACT-pal has 19 additional items specific for palliative care patients. Both the total and individual scores have good internal consistency (a = 0.72 - 0.85) and reliability. [14],[15]Functional assessment of chronic illness therapy-spiritual well-being (FACIT-sp) - [16],[17] This is a 12-item instrument with two subscales, one measuring sense of meaning and peace (10 items) and the other assessing the role of faith in illness (two items). A total score of spiritual well-being is obtained from the sum of both subscales. The responses for each item use a five-point Likert-type scale ranging from '0' (not at all) to '4' (very much). All FACIT scales are scored, so a high score is good. To achieve this, the authors suggest reversing the response scores on negatively-phrased questions and then summing the item responses. In cases where individual questions are skipped, scores are prorated using the average of the other answers in the scale.All subjects who consented were interviewed. Their sociodemographic and clinical details were collected, and they were assessed for pain and symptom distress using VAS and MDASI, depression and anxiety using HADS, spirituality using FACT-sp, and QOL using FACT-G and FACT-pal. For those who experienced difficulty in reading, the questions were read out and the responses were noted.

Descriptive statistics were used to summarize the demographic and clinical details of the subjects. Computation of the mean scores on pain, distress, depression, spirituality, and QOL scales was done. The independent sample 't' test was performed for comparison of continuous variables. Correlations between scores on pain, symptoms of distress, depression, spirituality and QOL, and demographic and clinical variables were assessed using the Pearson's correlation.


Around 76 patients were approached for recruitment, for the study. Out of them, five patients had co-morbid neurological conditions. One patient had a past history of depression pre-morbidly and was on treatment for the same. Twenty patients did not consent to participate in the study. Overall, 26 patients were excluded as per the study protocol. The remaining 50 were included in the sample. The distribution of different types of cancers in the sample was as follows: oropharyngeal cancers - 11 (22%), gynecological cancers including cervix, endometrium, and ovary - 11 (22%), lung cancer - 6 (12%), breast cancer - 6 (12%), stomach cancer - 5 (10%), and others - 11 (22%).

The age range of the subjects was 17 to 64 years (mean = 49.74, SD = 10.17). More than half (56 %) of the subjects were women. Male and female patients did not differ significantly except in terms of socioeconomic status, with more males coming from a middle and women coming from a lower socioeconomic background (c2 = 13.99, p = 0.001). At the time of interview 50% of the subjects were living with their spouses and the remaining 50% were single.

The mean spiritual well being (SpWB) score was found to be 24.48. The range of the SpWB score was from 4 to 48. Eight subjects had a score of less than 10. The mean spiritual score of the sample was just above 50%. This indicates that the sample was normally distributed.

Depression (r = -0.862, P = 0.000) and anxiety (r = -0.0645, P = 0.000) correlated negatively with SpWB.

The SpWB scores were negatively correlated with fatigue (r = -0.423, P = 0.002), distress (r = -0.717, P < 0.001), memory disturbance (r = -0.520, P < 0.001), loss of appetite (r = -0.399, P = 0.004), drowsiness (r = -0.400, P = 0.004), dry mouth (r = -0.381, P = 0.006) and sadness (r = -0.720, P < 0.001) [Table 1].{Table 1}

Spiritual well-being correlated negatively with mood (r = -0.630, P < 0.001), work (r = -0.376, P < 0.001), relationships (r = -0.624, P < 0.001), and enjoyment of life (r = -0.681, P < 0.001), variables of the symptom interference subscale of MDASI, which were statistically significant [Table 2].{Table 2}

Spiritual well-being positively correlated with all the other aspects of QOL measures. The values are described in [Table 3].{Table 3}


The mean score of SpWB in this sample was 24.48 (more than 50 %), suggesting that the sample was normally distributed. This could be due to the traditional and spiritual lifestyle of the patients, as has been reported for Indian subjects. [18],[19] Spiritual coping methods have been reported for patients with head and neck cancers in the Indian setting. [8]

For SpWB, the statistically significant correlates include depression and anxiety, all the other five domains of QOL, fatigue, distress and sadness, mood, work, relationship with others, and enjoyment of life. This indicates how SpWB is closely correlated with both physical and psychological indicators of distress. Although the study may not be adequately representative of the community sample, it gives a fair idea about SpWB, and of advanced cancer patients in a palliative care center. It would have been ideal if the assessments were done at the time of admission, during the hospital stay, and during discharge. The current study gives an overview of the quality of life of advanced cancer patients in a hospice. Another issue in the current study is that it included samples with all types of cancer. Once the grade of cancer becomes advanced, it comes under palliative care and there is not much additional information that can be obtained from individual subtypes of cancer patients. Other studies that have looked at palliative cancer population in such a way are by Plumb and Holland et al. and Bukberg and Holland et al.[21],[22]

The study was done in a hospice where all the patients were in an advanced stage of illness. There were a very few such systematic studies done from Hospices in India on this population. Assessment of spirituality as a determinant of the quality of life had been done systematically. The study assessed all the common symptoms of distress including the physical, emotional, and cognitive domains together, and it also assessed how much these symptoms had interfered in the patient's functional status and correlated with the spiritual well being. All the basic domains of the quality of life and palliative care well-being assessed were also correlated with spirituality.

the study gives interesting findings, the cross-sectional design of the study does not allow us to draw any definite conclusions regarding their long-term implications. By definition the symptoms are subjective, so there will be inherent limitations like scoring being influenced by various other factors like the state of mind, environmental influences, and so on. There is no control group for the study group, which is also a drawback of the study. Personality and coping strategies have not been adequately assessed and it is difficult to say if these may have contributed to the patients' perception of their symptoms

In conclusion, spirituality needs to be formally assessed and integrated into the management of patients with advanced cancers and those undergoing palliative care. The attitude of 'therapeutic nihilism' among physicians needs to be changed, and active help should be provided in improving the QOL of the patients that in turn will ease the inevitable process of dying. A longitudinal study from diagnosis onward, although difficult, will provide a clearer picture of the pattern and prevalence of symptoms and their correlation with the spiritual QOL.


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