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Background
Pain is a common and debilitating cancer-related symptom. In palliative care, physical, psychological, social and spiritual factors are thought to contribute to individual experience of pain. Consequently, spiritual care interventions are advocated in the management of cancer-related pain.
Aim To systematically review the published literature concerning spiritual interventions in the management of cancer-related pain.
Methodology Seven databases (Medline, CINAHL, EMBASE, PsycINFO, Cochrane, Scopus and Web of Science) were searched for quantitative studies of pain in patients with cancer receiving spiritual care interventions, with additional reference and citation searches. Research quality and relevance was appraised using Gough’s ‘Weight of Evidence’ framework prior to narrative synthesis.
Results The search identified 12 822 articles, of which 11 were included in the synthesis. Few studies have investigated spiritual interventions in the management of cancer pain: a minority of these demonstrate statistical benefit. Some evidence suggests spiritual care may aid in coping with pain, rather than altering pain intensity. Spiritual interventions are well received by patients with cancer and do not appear to cause harm.
Conclusion Current evidence provides limited support for the use of spiritual care interventions in the management of cancer pain. The paucity and heterogeneity of literature points to a need for high-quality research with judgements of spiritual intervention efficacy made on an individual basis.
PROSPERO registration number CRD42020190194.
- spiritual care
- cancer
- pain
- terminal care
Data availability statement
All data relevant to the study are included in the article or uploaded as online supplemental information. All data generated or analysed during this study are included in this published article (and its online supplemental information files).
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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Key messages
What was already known?
Pain is common in cancer sufferers.
Spiritual interventions can improve pain.
What are the new findings?
Evidence supporting the use of spiritual interventions in managing cancer pain is limited.
What is their significance?
A) Clinical
Clinical efficacy of spiritual interventions in managing cancer pain is unclear.
B) Research
Establishing the efficacy of spiritual interventions in the management of cancer pain requires further research.
Background
Spiritual care represents a core pillar of holistic palliative care, complimenting physical, psychological and social strategies employed in the management of terminal suffering.1 Varied and broad definitions of spiritual care exist; it can be conceptualised as care that ‘responds to the needs of the human spirit when faced with trauma, ill health or sadness’.2 Thus, spiritual care seeks to explore and address broader life concepts including meaning and purpose, relating these to oneself, surroundings and the divine.2 3 While spiritual care is advocated as prominent in the management of terminal illness, it remains a largely neglected and underdeveloped aspect of palliative care.4 Spiritual care thus represents a potentially untapped resource in the management of individual suffering at the end of life.
A significant proportion of palliative care centres on management of cancer related symptoms.5 Given that approximately one quarter of the global population develop cancer at some point in their lifetime, cancer-related symptoms constitute a significant burden of illness and a major role for providers of palliative care.6 7 Pain is one of the most common and debilitating symptoms experienced by people living with cancer, with a prevalence of 66% in advanced, metastatic or terminal cancer, 55% during anticancer treatment and 39% after curative treatment.8 9 Despite this high prevalence, cancer pain remains an undertreated symptom across the developed and developing world.10
Previous randomised controlled trials demonstrate that spiritual interventions can increase pain tolerance and decrease pain related stress and intensity.11 12 In addition, a focus on spirituality improves patient outcomes and quality of life.13 14 As a result, spiritual care is often desired by patients approaching the end of their lives and widely advocated in the management of cancer-related pain in the palliative care literature.8 15–18
However, the evidence supporting the use of spiritual interventions in the management of cancer pain has not been collated systematically to date. Given the evidence of undertreatment of cancer pain and the potential roles spiritual interventions may play in pain management, it was decided to review the current evidence for the potential roles and benefits of spiritual interventions in the management of cancer pain.
Aims and review questions
This review investigates the evidence concerning whether spiritual interventions have a role in management of cancer pain and if so, which offer the most potential benefit, by addressing the following questions.
With regard to quantitative studies of the impact of spiritual interventions in the management of cancer pain:
What interventions are used?
When/for whom are they used?
What is the evidence for their benefit?
What are the views of patients and health professionals concerning their use?
Methods
Searches of seven databases (Medline, CINAHL, EMBASE, PsycINFO, Cochrane, Scopus and Web of Science) from inception to July 2020, were undertaken to locate the literature related to the review questions. Keyword and MeSH search terms were split into three search categories relating to the themes of spirituality, pain, and cancer and combined using the Boolean Search Operators, “OR” (within categories) and “AND” (between categories) (see figure 1, online supplemental reportable search strategy). MeSH terms were exploded to include related subheadings, with synonymous and truncated keyword search terms used additionally in maximising capture. Choice of search terms related to spiritual interventions was guided by pilot searches and a previously published list of spiritual care plans.19 Additional terms related to palliative care were incorporated in the cancer category, reflecting the significant proportion of cancer care occurring in this context that is not always explicitly labelled in such terms.20
Supplemental material
Search terms.
Eligibility criteria and review scope
Defining what constitute a ‘spiritual intervention’ and ‘cancer pain’ proved to be major challenges. Authors of previous systematic reviews concerning spirituality have loosely defined, or have acknowledged difficulty in defining, the term ‘spiritual intervention’.4 21 22 While many therapeutic interventions could be considered ‘spiritual’ within certain contexts, they could also be undertaken in situations lacking of any sense of spirituality. Equally, the individual nature of spirituality means that any single therapeutic intervention may be deeply spiritual to one person and devoid of spiritual meaning to another. Spiritual care is essentially dependent on the user engaging in a form of reflective practice or transcendental experience; surpassing the ordinary and going beyond a certain level of awareness to another level of understanding or experience.23 Study selection was thus necessarily guided by study authors’ descriptions of interventions as a spiritual therapy, as described within the title and/or abstract of identified papers. Interventions targeted at relieving existential distress such as dignity therapy (DT)24 25 that sought to enhancing meaning and/or spiritual well-being such as meaning-centred psychotherapy,26 or founded on sacred belief such as prayer-based/chanting-based/chaplaincy-based therapies,27 28 were considered explicit spiritual interventions by design. Studies of psychosocial interventions or complementary therapies seeking to improve participants’ spiritual well-being or using spiritual well-being outcome measures were considered for inclusion if this information was clear within the title or abstract. Studies of integrative therapies combining physical, psychosocial and spiritual strands in a holistic manner were excluded, as outcomes could not be solely attributable to the spiritual elements of the intervention.
The review addressed the effect of spiritual interventions on pain related to cancer disease itself, excluding pain related to cancer investigations or treatments such as biopsy, chemotherapy, radiotherapy or surgery. Non-physiological dimensions of pain have a heightened role in patients with cancer, in that their experience of pain carries ‘sinister meaning’ beyond a nociceptive sensation.2 Studies of participants undergoing treatment for cancer were included if the spiritual intervention did not target side effects of cancer management: it was usually clear that at least some participants were not receiving active cancer treatment, or that recruitment was not in a treatment setting. Studies of broader concepts of pain such as spiritual pain were beyond the scope of this review.
Studies with participants under the age of 18 were excluded on the basis that the individual-reflective stage of spiritual development occurs in adulthood.29 Studies were excluded unless data could be extracted for a subset of cancer patients or unless over 95% of participants were cancer patients. Remaining inclusion/exclusion criteria are listed in figure 2.
Eligibility criteria.
Titles identified database searches were screened by TH, with abstracts and full-text papers screened independently by two reviewers (TH and JD) against the inclusion and inclusion criteria. Uncertainty concerning study eligibility was managed by allowing them to proceed to the next stage for further scrutiny. Reference searches and citation searches of included studies augmented the original database searches. Included papers were then weighted according to their contribution towards answering the review questions, using Gough’s Weight of Evidence Framework (WoE) (see figure 3).30 Each paper was weighted ‘high’, ‘medium’ or ‘low’ independently by TH and JD, with differences in scoring reconciled through discussion.
Weight of evidence.
Data synthesis
Data synthesis used a narrative approach.31 32 Choice of this approach was guided by pilot searches indicating that the literature was heterogeneous in terms of spiritual interventions used, study designs employed and pain measurement tools used, thus making meta-analysis unsuitable. The narrative synthesis involved three iterative stages:
Development of a preliminary synthesis: TH created textual descriptions of each study from data extraction forms. These descriptions were then grouped together and tabulated in collating results answering each of the research questions. TH then carried out an inductive thematic analysis, identifying main, recurrent and important data pertaining to each review question.31 32
Exploring relationships in the data: TH and JD constructed the interpretive synthesis by independently reviewing the thematic analysis and exploring the heterogeneity of included studies.31 32 Similarities and differences between studies were explored, including variation in methodological approaches, context, population characteristics and results. Results were debated between researchers in reaching consensus. The synthesis was further refined through discussion of results with interdisciplinary academic audiences and SB.
Assessing the robustness of the synthesis: at all stages, the synthesis was informed by Gough’s WoE framework in establishing a credible and relevant narrative.30 32 Conclusions reached in studies rated low weight under WoE D were deemed inadequate unless supported by findings in papers rated medium or high weight.
Results
The search produced a total of 12 822 articles (Medline 1403, Cochrane 642, Scopus 155, PsycINFO 1378, Web of Science 2449, CINAHL 2499 and EMBASE 4296). The titles of all articles generated were read and examined against inclusion/exclusion criteria, with abstracts of possible relevance considered for inclusion. After removal of duplicates and abstract analysis, 27 articles were selected for full-text screening: application of the inclusion/exclusion criteria reduced the number of included articles to 9. Citation searching highlighted 2 further studies suitable for inclusion, bringing the final total of included articles to 11. Throughout the process, reasons for excluding articles were logged. The search is summarised in figure 4.
PRISMA diagram. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.
Summaries of articles included in the synthesis are presented in online supplemental table 1: participants and setting, study objectives and (pain) measurement tools, significant findings and Gough WoE assessment are presented. Two received high weighting, seven medium weighting and two low weighting on Gough’s WoE Framework.30
Supplemental material
What types of spiritual interventions are used?
Types of spiritual intervention included DT (3), prayer-based therapy (1), focused narrative intervention (1), spiritually focused therapy (1), electronic support groups (1), mindfulness-based art therapy (1), peer-helping (1), mindfulness-based stress reduction (1) and spiritually focused music therapy (1).33–43
DT is an individualised reflective psychotherapy, developed with the aim of relieving distress in terminal illness.33 36 42 Prayer-based therapy constituted meetings between researchers and patients where Qur’anic teachings and texts were used in asking patients to adopt religious strategies to manage their mental health and control pain.35 Focussed-narrative intervention was conducted by researchers, who discussed sense of ‘meaning’ alongside spiritual well-being, with participants.38 Spiritually focused therapy constituted weekly group sessions aimed at enhancing spiritual coping, helping to identify and resolve spiritual struggle and strain.34 Electronic support groups sessions were online meetings led by experienced therapists, who facilitated discussions surrounding personal experiences of illness.37 Mindfulness-based art therapy involved construction of collages intended to both ease and accelerate the evolution of intrapersonal meaning with nonverbal creative expression.39 The peer-helping involved collaborative work between patients and caregivers in contributing towards handouts on coping skills for other families coping with cancer.40 The mindfulness-based stress reduction intervention involved an adapted 8-week programme of various mindfulness techniques.41 Spiritually focused music therapy constituted two sessions containing a biographical interview and live performance of a song with high biographical relevance to the patient.42
When and for whom are spiritual interventions used?
Study participants were recruited from a variety of inpatient and outpatient settings, at a range of points in their cancer disease trajectory. Two studies only recruited participants with breast cancer37 and gastrointestinal40 cancers, respectively, while the remainder included participants with all cancer types. Eight studies excluded those with cognitive impairment, highlighting difficulties enacting spiritual intervention protocols in this population. Recruitment and retention of participants posed a challenge in most studies, with drop-out rates broadly in line with other studies of similar patient populations.44 45
What are the benefits of spiritual care?
When considered together, the spiritual interventions had no or only small benefits in alleviating cancer pain. Due to the heterogeneity of spiritual interventions investigated and study designs employed, the spiritual interventions are best appraised individually.
Three studies reported statistically significant improvements in pain scores of participants undertaking the tested spiritual intervention. Lloyd-Williams et al’s study of a focused narrative intervention for suffering of patients with advanced cancer found pain scores to be significantly improved (p<0.01) at 8 weeks, although this was not found at other time points.38 This was correlated with improvements in anxiety and depression scores, with a causative link postulated. Warth et al’s study of a spiritually focused, patient tailored music therapy intervention ‘Song of Life’ found statistically significant reductions in acute pain scores of participants in 15 participants, with concurrent but non-significant benefits in measures of well-being, relaxation and worry.43 Eilami et al’s randomised controlled trial of an Islamic prayer intervention reported strong statistically significant improvements in preintervention to postintervention pain scores, among other measures.35 Problems with the description of study design and statistical methodology resulted in a low WoE.
Lieberman et al found therapist-facilitated electronic support groups resulted in significant postintervention reductions in pain reaction (p=0.001), with no simultaneous improvements in pain interference or intensity37 Qualitative insights from Poletti et al suggest that mindfulness-based stress reduction improves participants’ ability to cope with the pain, rather than alleviate the pain itself.41
None of the spiritual interventions reviewed worsened participants’ pain. Only Houmann et al reported non-significant deterioration in pain scores: their intervention was the longest of all reviewed (median 60 days), with the participants that dropped out after baseline measurements reporting significantly more initial pain (p=0.038) than those remaining in the study.36 Cole reported spiritually-focussed therapy acted to stabilise, rather than improve, pain severity and frequency, although this had low WoE.34
What are the views of patients and health professionals concerning their use?
Five studies included patient evaluation of the intervention.33 34 36 40 42 All three DT studies reported DT was generally viewed positively by participants.33 36 42 In Chochinov et al, DT was reported as more helpful (p<0.001), improved quality of life (p<0.001) and improved sense of dignity (p<0.001) compared with participants in other study arms.33 Houmann et al completed evaluations immediately post DT (T1) and 1 month later (T2), finding that the majority of participants felt DT was helpful (T1=73%, T2=65%) and satisfying (T1=89%, T2=84%). Fewer reported finding that DT made life more meaningful (T1=39%, T2=52%), heightened sense of purpose (T1=52%, T2=48%) or lessened sense of suffering (T1=25%, T2=38%).36 Vuksanovic et al's study of DT and life review (LR, which follows many of the same steps as DT) found most participants in both DT and LR groups rated the interventions as helpful (83.9% and 86.7%, respectively), improving of sense of dignity (58.1% and 60%), beneficial in making life more meaningful (74.2% and 73.3%) and improving sense of purpose (54.8% and 60%). DT was significantly better than LR in being helpful to the participant’s family now or in the future (87.1% vs 33.3%, p=0.002) and in the way that their family saw or appreciated them (77.4% vs 33.3%, p=0.01).42
Mosher et al’s randomised controlled trial of peer-helping combined with standard coping skills therapy vs coping skills therapy alone reported some small statistically significant differences favouring peer-helping combined with coping skills therapy, in terms of intervention satisfaction and helpfulness.40 All but one of the participants receiving spiritually focused therapy in Cole’s study preferred a spiritually focused programme when asked post-intervention.34
In summary, the spiritual interventions were well received by the majority of participants, although all evaluation results are from participants completing the study protocols: importantly, the views of drop-out participants are unknown.
No studies investigated the views of healthcare professionals providing spiritual care.
Discussion
This systematic literature review has identified the limited evidence-base underpinning the current advocation of spiritual interventions in the management of cancer-related pain. Despite an extensive literature search, supported by a professional librarian, it was found that few types of spiritual intervention have been trialled in cancer pain management and that few demonstrate quantitative benefits. Furthermore, the high proportion of low and medium WoE evidence included in the synthesis indicates that any advocation of spiritual interventions in the management of cancer pain is largely based on low or medium quality evidence.
Nonetheless, the potential of spiritual interventions in cancer pain management should not be dismissed on this basis: weak evidence of effect does not equate to evidence of weak effect. It is currently largely unknown to what extent such interventions may be effective analgesic strategies. Further high-quality research is urgently needed, each spiritual intervention-type being individually evaluated.
There are pointers in the literature towards some promising interventions that warrant further investigation. Spiritually focused music therapy was effective in improving acute pain, but was only trialled in a small pilot study.43 A recent meta-analysis of the small body of literature concerning music therapy interventions indicated effectiveness in cancer pain management: a trial of spiritually focused in comparison to conventional music therapy in this population would be very helpful.46 With no adverse effects identified by the present review, further trials could be conducted without impeding current best practice.
Participant evaluations from the reviewed studies and the wider literature indicate that spiritual care is valued by patients.47 Even if it has modest benefits in managing pain, it appears to improve quality of life and psychological symptoms associated with cancer.48 The potential for non-physical factors to modulate pain experience is supported by concurrent improvements in depression, anxiety and pain following narrative intervention.38 49 This complex interplay between participant experience of pain and other physical and non-physical factors needs further investigation, utilising qualitative and quantitative methods, alongside tailored pain assessments that explore broader concepts such as pain frequency, intensity, interference, reaction and tolerability. Spiritual interventions may aid coping with cancer pain without modulating the pain itself.37 41
It is acknowledged that this review is potentially limited by the exclusion of qualitative studies, case studies, conference abstracts, PhD theses and studies not in English. Some pertinent literature may have thereby been overlooked, perhaps particularly our reporting of the views of patients and health professionals which only arises from the included quantitative studies. The carefully considered search strategy encountered difficulties in defining the scope of the terms ‘spiritual intervention’ and ‘cancer pain’. Determining that an intervention is spiritual or that participants have engaged in a spiritual intervention is challenging; improvements in spirituality were only seen in one of the four included studies that utilised FACIT-Sp, a tool designed to measure of spiritual well-being for people with cancer.50
Reviews and research in this area will remain challenging until an agreed definition of the constructs of ‘spirituality’ and ‘spiritual care’ is adopted. Current variability in nomenclature leads to similarly labelled interventions being either deeply spiritual or completely devoid of spiritually.
Conclusion
Our review suggests that most spiritual interventions have little to no benefit in alleviating cancer pain, although some offer promise. However, there is a dearth of high-quality research in this field. Given that spiritual interventions are well accepted, complementary to current practice and appear not to cause adverse effects, further research investigating the relationship between spiritual care and cancer pain is needed. Only then will we ascertain the potential role of spiritual care, and the most effective types of spiritual intervention, in the management cancer pain.
Data availability statement
All data relevant to the study are included in the article or uploaded as online supplemental information. All data generated or analysed during this study are included in this published article (and its online supplemental information files).
Ethics statements
Patient consent for publication
Acknowledgments
The authors wish to acknowledge professor Amanda Howe, who aided in the conception of the research topic and facilitated formation of the research team, and Amy Hindmarch for her guidance in the formulation of the review design and write up. The authors declare no conflict of interest. This research was completed as part of the lead author’s (TH’s) Academic Clinical Fellowship funded by the National Academic Training Office in Norwich, UK. SB is part funded by the National Institute for Health Research (NIHR) Applied Research Collaboration East of England (ARC EoE) programme.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors TH designed the study, conducted the literature search, analysed the results, drafted the manuscript and is guarantor for the content of the study. JD conducted the literature search and analysed the results. MS helped in the design of the study and conducted the literature search. SB designed the study, drafted the manuscript and supervised the review. All authors read and approved the final manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Disclaimer The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.