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Year : 2014  |  Volume : 10  |  Issue : 3  |  Page : 676-680

Spiritual well-being and its influence on fatigue in patients undergoing active cancer directed treatment: A correlational study

1 Department of Radiation Oncology, Tata Memorial Centre, Mumbai, India
2 Department of Palliative Medicine, Tata Memorial Centre, Mumbai, India
3 Department of Complementary and Alternative Medicine, Bangalore Institute of Oncology, Health Care Global Enterprises Ltd., Bengaluru, Karnataka, India
4 Department of Radiotherapy, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India

Date of Web Publication14-Oct-2014

Correspondence Address:
Naveen Salins
Department of Integrative Oncology, Health Care Global Enterprises Ltd., HCG Bangalore Institute of Oncology, Bengaluru - 560 027, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0973-1482.138125

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 > Abstract 

Introduction: Spiritual well-being and fatigue are key parameters in assessing health related quality of life that determine treatment tolerance, treatment outcomes and reflect patient's coping ability in the illness-wellness disease trajectory.
Materials and Methods: A total of 200 patients on active cancer treatment were enrolled to the study. Functional assessment of chronic illness therapy-spirituality (FACIT-Sp) and FACIT-Fatigue scales were used to assess spiritual well-being and fatigue scores during their cancer treatment. Data were analyzed using one-way analysis of variance and bivariate relationships determined using the Spearman Correlation analysis. Linear regression analysis was performed to determine predictors of fatigue score during treatment.
Results: Mean spiritual well-being score was 20.96 out of 48 and scores were significantly higher in females compared with males (P = 0.03), lower with higher stage (P = 0.008) and lower in head and neck and gastrointestinal malignancies (P = 0.03) when compared with gynecological and breast malignancies. Fatigue was present in all the 200 patients studied and the mean fatigue score was 13.09. Higher fatigue scores were observed in patients with advanced stages of cancer (Stage IV) (F [3,199] = 5.67, P = 0.001). There was a significant inverse relationship between fatigue scores with spiritual well-being (P < 0.001). Spiritual well-being score emerged as a significant primary negative predictor (β = -0.23, P = 0.001) for fatigue scores followed by stage of disease (β =0.23, P = 0.001) and gender (β = -0.18, P = 0.01) as significant secondary predictors.
Conclusion: Fatigue during cancer directed treatment is influenced by spiritual wellbeing, disease stage and gender. Further studies should examine the mediating variables that influence fatigue.

Keywords: Cancer directed treatment, fatigue, spiritual well-being

How to cite this article:
Lewis S, Salins N, Rao M R, Kadam A. Spiritual well-being and its influence on fatigue in patients undergoing active cancer directed treatment: A correlational study. J Can Res Ther 2014;10:676-80

How to cite this URL:
Lewis S, Salins N, Rao M R, Kadam A. Spiritual well-being and its influence on fatigue in patients undergoing active cancer directed treatment: A correlational study. J Can Res Ther [serial online] 2014 [cited 2021 Nov 29];10:676-80. Available from: https://www.cancerjournal.net/text.asp?2014/10/3/676/138125

 > Introduction Top

Around 70-100% of patients being treated for cancer are affected by cancer-related fatigue, which can be more distressing and disruptive to daily activities than the pain associated with the disease itself. [1],[2],[3],[4] Individuals are often reluctant to report fatigue and cancer-care providers frequently do not screen for it because they are uncertain about how to treat the condition. [3] Evidence suggests that high degrees of fatigue during treatment can lead to significant reductions in physical functioning and quality of life (QOL). Fatigue is the most prevalent symptoms in individuals with cancer who receive radiation therapy, cytotoxic chemotherapy, or biological response modifiers. [5],[6],[7],[8]

In contrast to tiredness sometimes felt by a healthy individual, cancer-related fatigue is perceived as being of greater magnitude, disproportionate to activity or exertion and not completely relieved by rest, leaving the patient with an overwhelming and sustained sense of exhaustion. [9] Fatigue is an umbrella term used to describe various sensations or feelings with a variety of expressions of reduced capacity at physical, mental, emotional, or social levels and is also an indicator of distress. [10] Cancer-related fatigue is associated with psychosocial factors, such as anxiety and depression, [11],[12] difficulty sleeping, [13] full-time employment status [14] and low degrees of physical functioning. [15] However, whether it is a cause or an effect of these factors is unknown.

When confronted with such stressors, many cancer patients find comfort in religion/spirituality, which in some cases is associated with positive psychological outcomes and reduction in distressful symptoms. [16],[17]

The bio psychosocial-spiritual model of health views spiritual well-being as an essential component of health related QOL. This model may be particularly useful when applied to healthcare settings or for patients suffering from serious illnesses. It is able to accurately and reliably measure patients' spiritual well-being, or the degree to which patients' spirituality can help them make sense of their lives and feel whole, hopeful and peaceful even in the midst of a serious illness. It also helps both clinicians and researchers with regards to clinical conceptualization and subsequent treatment planning. [18] When cancer threatens the meaning of an individual life, religion and spirituality are often important coping strategies. [19] Fatigue can impact all dimensions of a person's life including physical, psychological, social and spiritual well-being. It is a common distressing symptom in patients with cancer that is often inadequately assessed and addressed. This study assesses spiritual well-being and fatigue in patients with cancer undergoing treatment and evaluates presence of correlation between fatigue and spiritual well-being in various cancer subtypes, stage and treatment modalities. In this study, we will study if fatigue which is an indicator of global distress is affected by spiritual well-being in patients undergoing radiotherapy.

 > Materials and methods Top

This is a prospective study evaluating fatigue and spiritual well-being in patients undergoing cancer directed treatment.


A total of 200 patients undergoing cancer directed treatment in the year 2012 at Department of Radiation Oncology, in a tertiary teaching hospital were considered for the study if they satisfied the selection criteria and gave consent to participate.

Selection criteria

Inclusion criteria

Age >18 years, cancer diagnosis, Active cancer related treatment with a curative or a palliative intent and willingness to participate in the study were considered.

Exclusion criteria

Patients who have completed cancer directed treatment and patients receiving only palliative care were excluded from the study.

Study procedure

Subjects satisfying the selection criteria and consenting to participate in this study were imparted the following self-report questionnaires to evaluate fatigue and spiritual well-being.

Functional assessment of chronic illness therapy-fatigue and spiritual well-being were assessed using the functional assessment of chronic illness therapy (FACIT) measurement system, which is a collection of QOL questionnaires targeted to the management of chronic illness such as cancer. The tools are validated and permission for use is obtained following registration. (www.facit.org). It is a prospective study where the patients were screened at one point of time during their active cancer directed treatment. The oncology residents did the screening after obtaining patients informed consent for the same. The study was approved by Institutional review board.

FACIT-fatigue scale

The FACIT Fatigue Scale is a short, 13-item, easy to administer tool that measures an individual's level of fatigue during their usual daily activities over the past week. The level of fatigue is measured on a five point Likert scale (4 = not at all fatigued to 0 = very much fatigued). [20],[21] FACIT Fatigue Scale has been found to have high internal validity (Cronbach's alpha = 0.96) and high test-retest reliability (intraclass correlation coefficient = 0.95). The correlation between the FACIT and Fatigue Severity Scale was − 0.79 in an earlier study. [22] Thus, the FACIT has demonstrated reliability and sensitivity to change in clients with a variety of chronic health conditions.

FACIT-Sp was developed in 1990s to address the need for a brief, broad measure of spiritual well-being with content not limited to any one religious or spiritual tradition. It consists of 12 items with a maximum score of 48 and there are three sub-domains of spiritual well-being, which help facilitate an in-depth exploration of the components that constitute spiritual well-being (peace, meaning and faith). [23]

Statistical analysis

Data was entered in Microsoft excel and analyzed using statistical package for social science version 16 (IBM corporation). Comparison between various categories of independent variables was done using analysis of variance (ANOVA) and a Bivariate Spearman's correlation analysis was performed between independent and dependent variables.

 > Results Top

A total of 200 patients (123 female patients and 77 male) undergoing active cancer related treatment were included in the study. Average age of patients who participated in the study was 50.4 ± 13.1 years. Among the patients studied Head and neck and gastrointestinal cancers constituted 26.5% (n = 53) each, 19% (n = 38) breast cancers, 18.5% (n = 37) genitourinary cancers and rest constituted 9.5% (n = 19). Distribution of patients and their treatment received are described in [Table 1]. Among the patients studied 4.5% (n = 9) had Stage I, 24.5% (n = 49) had Stage II, 59.5% (n = 119) had Stage III and 11.5% (n = 23) had Stage IV illness.
Table 1: Distribution of cancer type and treatment modalities received

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Data were analyzed using one-way ANOVA to compare fatigue and spiritual well-being scores across different categorical variables such as treatment, malignancy type, gender and stage. There was a significant increase in fatigue scores in Stage IV (F {3,199} =5.67, P = 0.001) compared to other stages. Treatment type, site of malignancy and gender did not influence fatigue and spiritual well-being scores [Table 2].
Table 2: Comparison of fatigue scores and spiritual wellbeing scores between various categories of independent variables using ANOVA

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Bivariate relationships

Bivariate relationships were determined between dependent and independent variables using Spearman's correlation analysis. There was a significant inverse relationship between fatigue scores with spiritual well-being (P < 0.001) and direct relationship with stage (P < 0.001). Spiritual well-being scores were significantly higher in females (P = 0.03), lower with higher stage (P = 0.008) and lower in head and neck and gastrointestinal malignancies (P = 0.03) [Table 3].
Table 3: Bivariate Spearman's correlation (r values) between independent and dependent variables

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Regression analysis

Linear regression analysis with dependent variable as fatigue scores and independent predictors as stage of disease (with four categories), gender with two categories and Spiritual well-being score was regressed onto fatigue scores. Overall the multivariate regression analysis was significant with predictors contributing 13% of variance in the model R2 = 0.13, F change = 9.2, (P < 0.001). Spiritual well-being score merged as a significant primary negative predictor (β = −0.23, P = 0.001) for fatigue scores followed by stage of disease (β =0.23, P = 0.001) and gender (β = −0.18, P = 0.01) as significant secondary predictor [Table 4].
Table 4: Predictors of fatigue using linear regression analysis with stage category, gender and spiritual wellbeing scores as predictors in the model

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 > Discussion Top

The results suggest that there is greater fatigue in cancer patients with Stage IV malignancies compared to other stages. Spiritual well-being did not differ with respect to gender, malignancy type and stage and treatment type. Spiritual well-being scores were higher in females and lower in those with a higher stage of malignancy. Spiritual well-being emerged as a significant primary predictor of fatigue during treatment compared to stage of disease and genders as secondary predictors.

Our findings are similar to earlier studies that show spirituality related to higher levels of distressful symptoms such as pain and fatigue [24] "Meaning in life," one of sub-domains of spirituality has been shown to be associated with physical and social functioning that was mediating less distress as seen in cross sectional studies. [25],[26],[27] Studies have reported spirituality being related to high levels of enjoyment of life irrespective of levels of pain or fatigue. [28] However, the longitudinal studies did not consistently reveal such a relationship. Although this empirical evidence for the role of spirituality in well-being seems overwhelming, several methodological weaknesses have to be addressed that hinder a definite causal conclusion. In another longitudinal study spirituality was related with higher well-being over a 6 month period and QOL did not influence spirituality. [29] Whether patients who have less distressful symptoms are more spiritual or vice versa are difficult to predict. But given the findings both concepts could imply each other.

These associations could also mean that spiritual well-being would imply more connectedness in life that would help them endear to positive health behaviors such as being physically and socially active, going for walks in nature etc., This could give them a purpose and meaning in life and reduce distressful symptoms. Indian study on spiritual well-being in advanced lung cancer showed that there was statistically significant correlation between spiritual well-being and depression, anxiety, five domains of QOL (fatigue, distress and sadness, mood, work, relationship with others) and enjoyment of life. [24] Spiritual wellbeing is a complex dynamic state which has a significant impact on clinical outcomes. [19]

Cancer related fatigue is an overwhelming sense of exhaustion physically, mentally, emotionally which occurs secondary to the disease or due to disease related treatment. It can persist over time and interferes with usual activities of daily living and differs from the tiredness of everyday life, which is usually temporary and relieved by rest. Fatigue is the most common side effect of cancer treatment with chemotherapy, radiation therapy, or selected biologic response modifiers. Cancer treatment-related fatigue generally improves after therapy is completed, but some level of fatigue may persist for months or years following treatment. Research indicates that for at least a subset of patients, fatigue may be a significant issue long into survivorship.

Health related QOL is the extent to which usual or expected physical, emotional and social wellbeing are affected by a medical condition or its treatment. Its assessment requires attention to several dimensions, including physical concerns (e.g. symptoms), functional ability, family well-being, emotional well-being, spiritual well-being, sexuality and social functioning. Hence in cancer treatment multidimensional, multifaceted approach is quintessential for successful treatment outcomes. In patients with cancer, the focus is usually directed at treatment and treatment related issues, managing physical symptoms and comorbidities. Psychological, interpersonal and spiritual well-being issues are seldom assessed and addressed. [30] This study brings out the importance of spiritual well-being in patients with cancer and its impact and correlation on fatigue which is one of the most distressing and difficult to treat symptom.

Spirituality has been defined as, "An inherent quality of all human beings that drives the search for meaning and purpose in life, involves relationship with oneself and others and a transcendent dimension." [31] Research studies has indicated that lower spiritual well-being scores are associated with higher psychological distresses such as increased anxiety, depression and hopelessness. [24]

A study done by Taylor in patients with recurrent cancer with various clinical subtypes showed that the symptom distress was inversely related to spiritual well-being. [32] A similar kind of study done in breast cancer patients showed that lower amount of symptom burden and distress was associated with a better spiritual well-being. [33]

Cancer treatment-related fatigue is reported in 14-96% of patients undergoing cancer treatment and in 19-82% of patients post-treatment [34],[35] Study on distress and fatigue in cancer showed that fatigue was found in nearly half of the patients with distress which is an important noteworthy finding because distress assessment scales (national comprehensive cancer network distress thermometer) have spiritual well-being as one of the assessment parameters. [36]

 > Conclusion Top

Our results are similar to earlier observations that have shown spirituality to be related to different aspects of distress. Fatigue is one symptom that has been shown to be an indicator of distress and spirituality has been shown to affect fatigue in patients undergoing cancer directed treatment. However future studies should explore different aspects of spiritual well-being such as faith, meaning in life and peace and its causal relation to distress in longitudinal studies.

 > References Top

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  [Table 1], [Table 2], [Table 3], [Table 4]


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