Original Article
The Role of Religiosity in Symptom
Expression of Advanced Cancer Patients
American Journal of Hospice
& Palliative Medicine®
2022, Vol. 39(6) 7 05­–709
ª The Author(s) 2021
Article reuse guidelines:
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DOI: 10.1177/10499091211041349
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Sebastiano Mercadante, MD1 , Claudio Adile, MD2,
Marianna Ricci, MD3, Marco Maltoni, MD3,
Giuseppe Bonanno, MD2, and Alessandro Casuccio, BS4
Abstract
Aim: The aim of this study was to assess the religious pattern and its impact on symptom expression in patients with advanced
cancer. Methods: A consecutive sample of advanced cancer patients screened at admission to palliative care. Standard
epidemiological data were recorded. Patients were asked about their religious beliefs, the degree of social relationship to
existing religions, the role of religion in their life, and the frequency of their prayer. The Edmonton Symptom Assessment
Scale (ESAS) and Hospital Anxiety Depression scale (HADS) were assessed. Results: Two-hundred-eighty-three patients
were screened. Age and gender were found to be independently correlated with religious belief (p ¼ 0.042 and p ¼ 0.016,
respectively). Gender (females, p ¼ 0.026), age (p ¼ 0.003), lower Karnofsky performance status (KPS) (p ¼ 0.022), and higher
values of HADS-A (p ¼ 0.003) were independently correlated with the degree of social relationship to existing religions. Gender
(females, p ¼ 0.002), lower KPS (p ¼ 0.005), and higher values of HADS-A (p ¼ 0.04) were independently correlated with a more
relevant role of religiosity. Gender (females, p < 0.0005), lower KPS (p ¼ 0.001), and drowsiness (p ¼ 0.05) were independently
correlated with frequency of prayer. Conclusion: The more the patients have demanding religious issues, the greater the state of
anxiety, particularly in older and female patients with a lower KPS. The religious pattern did not have relevant role in the
expression of other symptoms included in the ESAS.
Keywords
palliative care, advanced cancer, religiosity, anxiety
Introduction
The lives of healthy and severely ill people are based on a
variety of conceptual matrices, consisting of philosophical,
spiritual, and religious convictions, which are particularly relevant in the process of the end of life. At the end of life, patients
experience complex physical, psychosocial, and existential
concerns. They have to face the fear of suffering, disability,
helplessness, isolation, and impending death, that constitute the
individual spirituality.1 Patients’ spirituality may serve as a
buffer against depression, hopelessness, desire for death, and
existential suffering, providing them with a sense of well-being
by giving structure and meaning to their difficult experience.2
Some studies of advanced cancer patients have assessed the
spiritual distress or spiritual pain, which were found to be
associated with poorer quality of life, being younger, lower
Karnofsky performance status (KPS), higher physical distress,
anxiety or depression, and decreased religiosity and religious
coping. 3 Spiritual pain was found in more than 40% of
advanced cancer patients and it was correlated with physical
and psychological distress.4 It has been reported that spirituality, religiosity, and spiritual pain may influence symptom distress, quality of life, and coping strategies of patients with
advanced and terminal illness. On the other hand, spirituality
and religiosity also can be used as integrative therapy to promote general well-being and health.4-7
However, spirituality is a broad concept that may vary in
meaning among individuals.5,6 Spirituality is a concept often
unknown for many subjects and is also unresolved among
anthropologists, sociologists, and philosophers. In some preliminary interviews before starting the study, we recognized
the concept of spirituality was difficult to express for us and
aboveall, to understand for patients.
Religion is a set of beliefs about humanity and divinity
which can be experienced as a sense of belonging, for example
due to family tradition. It influences the development of
attitudes in certain circumstances of life, particularly in the
1
La Maddalena Cancer Center, Via San Lorenzo, Palermo, Sicily, Italy
Private Hospital La Maddalena Palermo, Sicilia, Italy
3
Palliative Care Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori
(IRST) “Dino Amadori”, Meldola, Italy
4
Università di Palermo ITAF Palermo, Sicilia, Italy
2
Corresponding Author:
Sebastiano Mercadante, La Maddalena cancer center, Via San Lorenzo 312,
Palermo, Sicily 90146, Italy.
Email: terapiadeldolore@lamaddalenanet.it
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American
Journal
of Hospice
& Palliative
Medicine
39(6)
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Journal
of Hospice
& Palliative
Medicine
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late-stage cancer, which is associated with a relevant symptom
burden. People could be more confident with this term.
The role of religiosity and the intensity with which it is
experienced with regard to the expression of symptoms have
never been asessed. The aim of this study was to assess the
religious pattern and possible associations with symptom
expression in patients with advanced cancer.
Methods
A consecutive sample of advanced cancer patients admitted to
2 palliative care units in Italy in a period of 6 months (JanuaryJune 2020) was selected. Advanced cancer was determined as a
relapse, a metastasis or a local advanced disease. The protocol
was approved by the local ethical committee. Inclusion criteria
were: age �18 yrs, a diagnosis of advanced cancer. Exclusion
criteria were: incapacity to complete the questions due to cognitive or linguistic problems and a Karnofsly performance status of � 20. Cognitive status was assessed by using the
memorial Delirium Assessment Scale (MDAS).8 All patients
meeting inclusion and exclusion criteria accepted to participate
in the study.
Table 1. Religious Belief, Level of Religiosity, Role of Religiosity
in Patients’ Life, and Frequency of Prayer.
Religious belief
Catholic
Orthodox
Protestant
Muslim
Atheism
Other
Level of religiosity
Non believer
Believer
Believer and practicing
Role of religiosity in patients’ life
Fundamental
Important
Fairly important
Poorly important
Irrelevant
Frequency of prayer
Daily
Weekly
monthly
yearly
never
missed
252 (89%)
4 (1.4%)
9 (3.2%)
3 (1.1%)
12 (4.2%)
3 (1.1%)
15 (5.3%)
177 (62.5%)
91 (32.2%)
52 (18.4%)
89 (31.4%)
78 (27.6%)
48 (17%)
16 (5.7%)
131 (46.3%)
44 ( 15.5%
39 (13.8%)
10 (3.5%)
58 (20.5%)
1
Measurements
Standard epidemiological data, including age, gender, primary
cancer diagnosis, and Karnosky performance status were
recorded. KPS expresses the functional capacity on a scale
from 0 to 100.9
Patients were asked about their religious beliefs (Catholic,
Orthodox, Protestant, Muslim, atheism et al), the degree of
social relationship with existing religions (non believer,
believer, believer and practicing), the role of religion in their
life (fundamental, important, fairly important, poorly important, irrelevant), and the frequency of their prayer (daily,
weekly, monthly, yearly, never). Other measurement tools
included the Edmonton Symptom Assessment Scale (ESAS),
that is a tool assessing the intensity of most common psychological and physical symptoms, largely validated and reliable
for assessing the global symptom burden,10 and HADS (Hospital Anxiety Depression scale), that is a tool consisting of 14
items, with 2 subscales for anxiety and depression. The total
score ranges from 0 to 42, with a higher score indicating severe
depression and anxiety.11
Statistics
The data are expressed as a mean + SD, or frequency (%).
Multinomial logistic regression analysis examined the correlation between patient characteristics (independent variables)
and religious belief, the degree of social relationship to existing religions, the role of religion in their life, and the frequency of their prayer (dependent variables). All variables
that were found to be significantly associated (P � 0.05) at
the univariate analysis were included in a multivariate regression model.
The data were analyzed by the SPSS software, version 22
(SPSS Inc, Chicago, IL, USA). All P-values were bilateral and
P � 0.05 was considered statistically significant.
Results
Two-hundred-eighty-three patients met the inclusion and
exclusion criteria in the period taken into consideration. Onehundred-thirty-three patients were males. The mean age was
63.8 years (range 24-87, SD 11.7), and 133 patients (47%) were
males. The mean KPS was 69.5 (range 30-100, SD 20.6). Primary tumors were in a rank order: gastrointestinal n.70 (24.7),
lung n.45 (15.9%), pancreas n.33 (11.7%), breast n.24 (8.5%),
gynecologic n.21 (7.4%), urinary n.20 (7.1%), prostate n.
9(3.2%), head & neck n.18 (6.4%), liver n.11 (3.9%), brain
n.5 (1.8%), hematologic n.3 (1.1%), others n.24 (8.5%). Data
regarding religious belief, the degree of social relationship to
existing religions, role of religiosity in patients’ life, and frequency of prayer are reported in Table 1. Data regarding ESAS
items, MDAS, HADS-A, HADS-D, and total HADS are
showed in Table 2.
Religious Belief
In the multinomial logistic regression analysis, religious belief
was correlated with age (younger, p ¼ 0.029), KPS (lower
in Catholics, P ¼ 0.035), gender (males were more ateist,
p ¼ 0.014). No statistical correlations between religious belief
and ESAS items, HADS-A, HADS-D, and total HADS were
found (P ¼ >0.05). In the multivariate analysis, age, gender
(females) and KPS were found to be independently correlated
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Table 2. Mean and SD (Standard Deviation) of ESAS Items, MDAS,
HADS-A, HADS-D, and Total HADS (See Text).
Table 3. Univariate and Multivariate Analysis.
Univariate analysis
SD
Pain
Weakness
Nausea
Depression
Anxiety
Poor appetite
Poor well-being
Dyspnea
Drowsiness
Total ESAS
MDAS
HADS-A
HADS-D
Total HADS
3.0
4.9
1.4
2.8
3.5
4.1
4.9
1.4
3.0
28.9
2.2
6.9
7.0
13.9
2.8
2.9
2.3
3.0
3.1
3.3
2.6
2.5
3.1
12.7
2.4
4.5
4.0
7.9
with religious belief (p ¼ 0.042, p ¼ 0.016, and p ¼ 0.027,
respectively) (Table 3).
Multivariate analysis*
Religious belief
Variables
OR 95% CI
p
OR 95% CI
p
Age
Gender
Karnofsky
0.90(0.82-0.99)
0.08(0.01-0.60)
1.03(1.02-1.07)
0.029
0.014
0.035
0.95(0.9-0.97)
0.07(0.01-0.63)
1.04(1.01-1.07)
0.042
0.016
0.027
Level of religiosity
Variables
Age
Gender
Karnofsky
Depression
Anxiety
Total ESAS
HADS-A
TOTAL HADS
OR 95% CI
p
OR 95% CI
p
1.04(1.01-1.06)
1.8(1.1-3.1)
1.03(1.01-1.07)
1.1(1.01-1.2)
1.1(1.01-1.2)
1.03(1.01-1.05)
1.1(1.03-1.2)
1.04(1.01-1.07)
0.006
0.024
0.015
0.029
0.028
0.018
0.003
0.041
1.03(1.01-1.07)
1.9(1.1-3.3)
1.04(1.01-1.07)
0.003
0.026
0.022
1.3(1.1-1.6)
0.003
Role of religiosity in patients’ life
Degree of Social Relationship to Existing Religions
In the multinomial logistic regression analysis, the level of
religiousness was correlated with gender and age (females
and older, p ¼ 0.024 and p ¼ 0.006, respectively), lower KPS
(p ¼ 0.015), depression (P ¼ 0.029), anxiety (P ¼ 0.028), total
ESAS (P ¼ 0.018), HADS-A (P ¼ 0.003), and total HADS
(P ¼ 0.041).
In the multivariate analysis, gender (females, p ¼ 0.026),
age (p ¼ 0.003), lower KPS (p ¼ 0.022), and higher values of
HADS-A (p ¼ 0.003) were independently correlated with
degree of social relationship to existing religions (Table 3).
Variables
OR 95% CI
Gender
Karnofsky
HADS-A
TOTAL HADS
8.9(2.2-35.5)
0.9(0.8-0.95)
1.3(1.1-1.5)
1.1(1.03-1.2)
p
OR 95% CI
p
0.002
0.003
0.004
0.013
9.9(2.4-41.5)
0.93(0.92-0.98)
1.5(1.12.4)
0.002
0.005
0.04
Frequency of prayer
Variables
Gender
Karnofsky
Drowsiness
OR 95% CI
p
OR 95% CI
p
5.6(2.8-11.0) <0.0005
6.5(3.2-13.2) <0.0005
0.97(0.95-0.98) 0.001 0.97(0.95-0.98) 0.001
1.1(1.05-1.3) 0.036
1.1(1.05-1.3) 0.05
Role of Religiosity in Patients’ Life
Discussion
In the multinomial logistic regression analysis gender (females,
p ¼ 0.002), lower KPS (p ¼ 0.003), HADS-A (P ¼ 0.004), and
total HADS (P ¼ 0.013) were correlated with a more relevant
role of religiosity.
In the multivariate analysis, gender (females, p ¼ 0.002),
lower KPS (p ¼ 0.005), and higher values of HADS-A
(p ¼ 0.04) were independently correlated with a more relevant
role of religiosity (Table 3).
The findings of this study revealed interesting aspects on the
role of religion profile on symptom expression of advanced
cancer patients. Most patients were Catholic, according to a
secular tradition of this country. However, belonging to a religious pattern does not often corresponds to the same attitudes
in the relationship of supernatural. Believers are not often practicing, religion may have a minor role in patients’ life, or praying is not considered to be necessary. Thus, it is evident that
there are different levels of religiosity.
Older patients, those with a lower KPS, and females resulted
to be Catholic believers. Females, age, a lower KPS, and higher
values of anxiety were correlated with being believer and practicing. Similarly, a relevant role of religiosity in patients’ life
was more likely to be found in females, in patients with a lower
KPS, and higher levels of anxiety.
Finally, gender, a lower KPS, and drowsiness were strongly
correlated with frequency of prayer. All these data suggest that
the more the patients have demanding religious attitudes or
Frequency of Prayer
In the multinomial logistic regression analysis, the frequency
of prayer was correlated with gender (females, p < 0.0005),
lower level of KPS (p ¼ 0.001), and drowsiness (p ¼ 0.036).
In the multivariate analysis, gender (females, p < 0.0005),
lower KPS (p ¼ 0.001), and drowsiness (p ¼ 0.05) were independently correlated with frequency of prayer (Table 3).
4708
consider important their religion, the greater the state of anxiety. On the other hand religious attitudes might be determined
oppositely according to their level of anxiety. Thus, the more
anxiety religious people feel, the more they are driven to pray.
For example, patients might fail to decrease their anxiety by
superficial religious attitudes or behaviors, although increasing
the frequency of prayer. The relationship between anxiety and
religious attitudes remains to be better explored in future studies. These attitudes were more frequently observed in older and
female patients with a lower KPS. Of interest, these attitudes
did not have relevant role in the expression of other symptoms,
particularly in the ESAS physical items.
The role of religion has been variably assessed in advanced
cancer patients, although the assessment methods and purpose
of studies were different, with a major focus on spirituality, that
could be defined as a personal search for meaning and purpose
in life.1 Some aspects, such as spiritual pain, for example, are
difficult to explore. Studies provided controversial data.3-5,12-17
When tested in our population, it was difficult to understand
and hardly measurable, probably having different meanings in
individuals, particularly those with poor cultural background.
More recently, in a study performed in Latin-American
patients, spirituality and religiosity were associated with positive coping strategies and higher levels of quality of life. Spiritual pain was also frequent and was associated with physical
and psychosocial distress.7
Indeed, the concept of religion involves an organized entity
with rituals and practices about a higher power or God. Previous studies assessed the spirituality, the spiritual distress or
spiritual pain. In the present study a more understandable concept was examined. The religious “intensity” of advanced cancer patients was more objective and easily measurable,
differently from an abstract concept of spirituality, which is
difficult to measure, because it may have different meanings
among patients. The word was clearly understood by patients
during the interviews. Religiosity as a whole has been found to
be associated with a greater level of anxiety.
Existing data in the setting of palliative care are limited.
While early studies showed the religious faith or praying could
help relieve death anxiety or pain in societies which are generally religious,18-20 religion does not necessarily have a positive
effect on health or lead to a reduction in death anxiety.21 Some
papers, prevalently examining religious coping, reported the
religiousness was associated with better quality of life. As a part
of a study of advanced cancer patients assessed for the prevalence of mental illness and patterns of mental health service
utilization, structured interviews showed that a greater use of
positive religious coping may play an important role for the
quality of life of patients. Types of religious coping strategies
used were related to better or poorer quality of life.22 In patients
with advanced cancer receiving palliative radiation therapy,
spirituality and religious coping were associated with improved
quality of life, when patients considered themselves to be
spiritual.23
Prayer was significantly related with pain tolerance, but not
with pain severity.24 A significant association between praying
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Journal
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& Palliative
Medicine
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& Palliative
Medicine
and pain interference and impairment has been reported. Moreover, praying was associated with anxiety and depression
scores.25 It has been reported that very religious patients did
find their faith a source of strength, and religion was of little
help to them.2 On the other hand, physicians have observed that
the absence of religion was associated with higher invasive
behaviors.26 Of interest, in most advanced cancer patients,
spiritual needs were not supported by religious communities
or the medical system, and spiritual support was associated
with better quality of life. Moreover, religious individuals more
frequently wanted aggressive measures to extend life.27
This study has several limitations. Due to the cross-sectional
nature of this study it is difficult to establish causality between
the religious intensity and other physical and emotional symptoms (particularly anxiety). More studies should be performed
to establish if the religion pattern may influence the response to
symptomatic treatments. In this study, most patients professed
Catholics and the number of other religions was limited, so that
differences among religions on a large scale were not reliable
and the possible impact of these differences on symptom
expression unsearchable. The questionnaire used for this study
was not validated, as the many others used in this often ambiguous field. However, this appeared easy to understand, repeatable, and meaningful. Religion can be used in different ways
(for example coping) and this could also lead to more positive
or adverse associations with psychological outcomes. Thus, the
kind of religious coping could affect the linkage between
religiosity-psychological outcomes as well.
Finally, it should be underlined that this paper did not
assessed the role of spiritual or existential issues on patients’
symptom expressions and was based only on religious attitudes. Indeed, the concept of religiousness is more concrete
and a significant relationship with symptoms may be interesting for future research in a secularized society like that of a
Mediterranean country.
In conclusion the findings of this study suggest that the more
the patients have more demanding religious attitudes, the
greater the state of anxiety, particularly in older and female
patients with a lower KPS. The religious pattern did not have
relevant role in the expression of other symptoms included in
the ESAS. There is a need for qualitative data and the use of
validated measures of religiousness, religious coping and spiritual struggle. Further studies in different countries with different religious beliefs should be performed to provide insides on
the role of religiosity in advanced cancer patients.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship,
and/or publication of this article.
ORCID iD
Sebastiano Mercadante
https://orcid.org/0000-0001-9859-6487
Mercadante et
Mercadante
et al
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