Spirituality in oncology - a consensus by the Brazilian Society of Clinical Oncology

ABSTRACT

Spirituality is a dynamic and an intrinsic aspect of humanity and is usually intense in cancer for patients, families, and health care teams. Evidence on spirituality, health, and healing have increased over the last decades. This consensus is for those involved in cancer patient care, with concepts and possible strategies for addressing spirituality, with discussion on the relevance, impact, and challenges of spirituality care. The purpose and intent of the consensus are to highlight the need for spirituality inclusion in the complex and delicate trajectory of cancer patients.

RESUMO

A espiritualidade é um aspecto dinâmico e intrínseco da humanidade e costuma ser intensa no câncer para pacientes, familiares e equipes de saúde. Evidências sobre espiritualidade, saúde e cura aumentaram nas últimas décadas. Esse consenso é para os envolvidos no cuidado ao paciente oncológico, com conceitos e possíveis estratégias de abordagem da espiritualidade, com discussão sobre a relevância, impacto e desafios do cuidado com a espiritualidade. O objetivo e a intenção do consenso são destacar a necessidade da inclusão da espiritualidade na complexa e delicada trajetória dos pacientes com câncer.

Keywords:

Neoplasms - Spirituality - Consensus

Descritores:

Neoplasias - Espiritualidade - Consenso

INTRODUCTION

Science moves forward due to the emergence of questions and the search for answers. The encounter of such answers, whether expected or unpredictable, are consequences of a standardized, clear, and reproducible scientific method of investigation. Therefore, asking a good question is a crucial step in the investigation process and, therefore, revisiting questions that have intrigued the scientific community for several years, since remote times when scientists were known as natural philosophers has proved to be an interesting movement in a scientific investigation.

Cancer has an increasing prevalence, according to recent research data carried out by the International Agency for Research on Cancer (IARC), about 19.3 million cancer cases with 10 million deaths by 2020.[1] According to the World Health Organization (WHO), one in five people will develop cancer at some point in their lives.[2] In Brazil, according to estimates by the Instituto Nacional do Cancer (INCA), around 625,000 new cancer cases (including nonmelanoma skin cancer) and approximately 260,000 deaths will occur between 2020 and 2022.[3]

The finitude of organic matter is a bitter reality in the oncologist's routine. The cancer phenotype gathers knowledge accumulated in the genetic code for billions of years, a time when life on Earth was mostly unicellular chaos.[4] Cancer cells mechanisms of resistance, escape and proliferation are highly specialized, becoming fallible when they conquer the organism and corrupt the balance of the systems, as they end up depleting the host's forces that provide the necessary conditions for the maintenance of life.

The journey of cancer is similar to the journey of humanity itself, a constant search for immortality. The insane game of mutations in search of such an objective is the same stimulus that motivates the most accomplished human minds. Mankind, as a rational species, has the intrinsic need for transcendence in their finite life span. The perception of eternity can be experienced through spirituality in the form of meditation, religious practices, prayers, music, contact with nature, relationships, as well as inside the laboratory and in various other situations of spiritual contentment.

These exercises and connections with spirituality can supply cancer patients with improved quality of life and physical health, reinforce trust in the healthcare team, and result in greater adherence and better care in the treatment - a recent increase in publications regarding spirituality and health support such findings.[5]-[7]

What truly motivates scientific research remains a mystery to be revealed. Therefore, the question of this review article, developed together with intensivists, palliative care specialists, clinical oncologists, and radiation oncologists is to demonstrate how spirituality and science associate.

The construction of the most possible concrete answer to such an abstract and challenging topic will explore basic concepts, the importance of team training, impacts on patient care, in addition to the potential protection of the mental health of professionals and family members involved in cancer treatment.

As former questions are answered, new questions arise at the same pace and most scientists dedicate part of their lives, whether eternal or not, to flirting with the unknown and accepting the limited capacity to unravel various obscure points of human nature and all that surrounds it.

This review designed to assist all those who participate cancer patient care and who seek a more tangible explanation for the meaning of our existence. The authors wish the reader an excellent and spiritual read!

MATERIAL AND METHODS

The Brazilian Society of Clinical Oncology President coordinated the Consensus work throughout 2021. The group was composed of physicians with knowledge and activities related to the topic with specialists in oncology, palliative care, intensive care, radiotherapy, and pain control. This group included participants from different areas of the country, including the states of Maranhão, Bahia, Rio de Janeiro, São Paulo, and the Rio Grande do Sul. The participants constituted work subgroups according to the divisions present in this final format. Due to the COVID-19 pandemic, the interactions took place through virtual and digital means. In a first digital meeting, the group established main themes and relevant demands related to spirituality in oncology. Work subgroups reviewed literature and elaborated specific materials with possible discussion by the group for adjustments. The group approved the final material presented here. During the Spirituality in Oncology session at XXII Congress of the Brazilian Society of Clinical Oncology, the Brazilian Society of Clinical Oncology President and some participants presented and partially discussed the consensus.

CONCEPTS AND DEFINITIONS

Spirituality

Spirituality remains difficult to be defined and measured, but there is a general agreement regarding its reference to the connection with a greater reality, capable of offering meaning to our existences through religion or, increasingly in Western civilizations, through meditation, nature, and art. Definitions of spirituality typically merge with other concepts such as religion and psychological well-being, especially relationships with other people, purpose in life, and sometimes paranormal beliefs. The diversity of concepts has been widely recognized and, for some authors, spirituality does not have a clear definition. Therefore, the term is used imprecisely and inconsistently, fluctuating according to religion, culture, and date, proving challenging to standardize.[8]

Historically, spirituality was considered a process developed within a religious context, with institutions designed to facilitate the practitioner's spiritualization. Recently, spirituality has been recognized in a way that is dissociated from religion, as a distinct construction. That is due, in part, to the increasing distance of religious institutions' authority in modern social life and the emphasis on individualism in Western cultures.[9]

Faced with the need to standardize a definition for spirituality in palliative care, a palliative and spiritual care interdisciplinary group defined spirituality as “a dynamic and intrinsic aspect of humanity, through which people search for meaning, purpose, transcendence and experience relationships with themselves, family members, their community, society, nature, and the meaningful or sacred. Spirituality is expressed through beliefs, values, traditions, and practices”.[10]

For the Study Group on Spirituality and Cardiovascular Medicine (GEMCA) of the Brazilian Society of Cardiology, “spirituality is a set of moral, mental and emotional values that guide thoughts, behaviors, and attitudes in the circumstances of intra- and interpersonal relationships. Added to being motivated or not by will and being subject to observation and measurement”.[11] It is important to consider spirituality an intrinsic aspect of humanity, regardless of religious affiliation, which includes atheists, agnostics, or even those with religious affiliation, but without observation and practice of it. Both atheists and agnostics, although not believing or doubtful about the existence of God, have a form of spirituality based on existential philosophy, finding meaning, purpose, and fulfillment, for example, in life itself. Spirituality evokes concerns, compassion, and a sense of connection with something greater than ourselves.[12]

Religion

The word religion stems from the Latin term “religio” which refers to the rereading (of scriptures), the act of (re) connecting, or even re-election (back to a God), inferring connections with a deity, other people, or with beliefs and values. Although the term religion in the past (and in the current theological erudition) was used to capture the institutional and individual dimensions of experience, contemporary references to religion increasingly reflect institutional, social, and doctrinal experiences.[9]

Religion is a multidimensional construction that includes beliefs, behaviors, dogmas, rituals, and ceremonies, and can be performed or practiced in private or public settings. Nevertheless, in some form, resulting from established traditions, which have developed, over time, within a community. Religion was also conceived to facilitate closeness to the transcendent and promote an understanding of one's relationship and responsibility regarding others, especially when living in a community.[13] Religiousness is the depth of an individual's belief and, therefore, the intensity with which such individual follows and practices a religion.

It can be organizational (church or temple participation, or religious services) or nonorganizational, such as praying, reading books, or watching religious programs.

IMPORTANCE

Spirituality is a human necessity considering that it represents the individual's search for connection and transcendence. As a structuring element of human experience, spirituality is potentially linked to the maintenance and strengthening of physical, mental, and social health. The search for spirituality can be intensified in times of crises, losses, and physiological changes, such as pregnancy, aging, and diseases. Spirituality and religiosity are valuable resources used by patients in coping with diseases and suffering.

There is a vast amount of evidence demonstrating a strong relationship between spirituality, religion, religiosity and health, illness, and healing.[14] The majority of the available evidence is often associated to health promotion; and therefore, caution is necessary for the analysis of causality and its applicability in clinical practice. Publications describe that higher levels of spirituality and religiosity are associated with lower prevalence of smoking, lower alcohol consumption, sedentary lifestyle, obesity, diabetes, improved nutrition, increased exercise and pharmacological adherence, contributing to well-being, and health. Mental health studies report that individuals with higher spirituality or religiosity are less likely to develop depression and anxiety and are associated with lower rates of drug abuse and suicide, in addition to better outcomes in psychiatric treatment.[15] Longer longevity and increased survival have also been reported.[16]

The WHO definition of “health” is a state of complete physical, mental and social well-being, understanding the need for comprehensive patient care. Awareness and the provision of adequate spiritual and religious support benefit both patients and multidisciplinary teams, in addition to the healthcare system itself. Around 80% of the world's population has some kind of religious affiliation[17] and, as such, an individual's beliefs and ethical values will influence how one copes with and decides upon adverse situations.

The physician's approach to spirituality may strengthen the doctor-patient relationship, trust, as well as empathy. It is essential to try to comprehend the patient's beliefs, identify aspects that may interfere with healthcare, and assess the individual, family, or social spiritual strength that will allow easier coping with the disease. Other important aspects encompass: detecting negative feelings that may contribute to the illness process or worsening, such as sorrow, resentment, lack of forgiveness, and ungratefulness. However, and of equal importance, attention to positive feelings, such as forgiveness, gratitude, and resilience.[18] is imperative, as well as the recognition of conflicting situations or spiritual suffering that require evaluation and care.

Still, enforcing a spiritual approach to patient care has proved to be somewhat challenging, perhaps due to prejudice, considering a dissociation and a historical competition between science and religiosity, as well as a confusion between religiosity and spirituality. Other arguments cited in the medical literature are lack of time during consultations, fear of exceeding the role of the physician, and lack of training.[19] In fact, a study conducted in Brazil demonstrated low insertion of spirituality in medical curricula and, although medical students recognize the importance of the subject, there are large gaps in medical school training.[20]

Spirituality in cancer patients

It is important to recognize that we cannot underestimate the value of spirituality to cancer patients.[21] [22] In that regard, the first step is to welcome the demands of spiritual nature and, if they are not spontaneous, demonstrate an active and natural interest in the subject, as a manifestation of an active desire to familiarize with the patient. The physician interest in spirituality is one of the ways to try to meet the potential demands that can be associated with formal referrals to chaplaincy, specialists in spiritual support, support groups that work with spirituality, in addition to encouraging the patient to seek assistance or guidance in his religious community, if belonging to one.[23]

Patients diagnosed with cancer experience several moments of crisis throughout their illness.[24] The moment of diagnosis has been reported by patients and family members as one of the most traumatic from the psychological and existential point of view.[25] Life-threatening feelings, physical deterioration, and the interruption of life projects commonly promote the need to rethink values and build new foundations. As such, those with a more elaborated spirituality may cope more easily, possibly with greater treatment adherence and resilience.

Throughout the course of the disease, different physical and psychological deterioration occur. Social and psychological declines tend to accompany physical decline, while well-being and spiritual distress fluctuate with other interferences.[24] In all these stages, the healthcare team, as well as patient beliefs and spirituality, influence decision-making and patient acceptance.[26]

In clinical practice, treatments with varying response rates and different toxicities are used, obtaining results with different impacts. Therefore, it is worth considering that more than 30% of patients express a desire to discuss spirituality, including manifesting interest in spiritual and religious resources, need for guidance in the search for the meaning of life, assistance in finding hope, discussing death and dying, and attaining peace of mind.[27] Patients report a variation between 15 and 50% in approaches to spirituality, and, thus, demands might not be properly met and this valuable resource is neglected.[28] The OASIS (Oncologists Assisted Spiritual Intervention Study) study showed that, in a patient population consisting of 81% of Christians, a 5-minute approach to explore spirituality/religion concerns by four oncologists of three different religions showed a decrease in depression and an improvement in quality of life. In this study, 76% of patients considered the approach very useful or somehow useful.[29]

In cancer survivors, spirituality is also associated with an improved quality of life.[30] Patients who report having strengthened their beliefs and who regard that the cancer diagnosis provided an opportunity for growth were shown to have an improved quality of life when compared to those who felt resentful and with sequelae of diagnosis and treatment.[31] [32]

APPROACH

Initial care

Studies have shown that most patients would like their physicians to address their spiritual concerns.[33] However, this responsibility is not bestowed exclusively upon the medical team; the entire multidisciplinary team involved in patient care should be aware of this demand. The chaplain is the professional with the greatest expertise regarding spiritual care, yet other members of the healthcare team may have a minimal general approach.[34]

The multidisciplinary team should have clear communication to establish how and who will offer spiritual care to each patient and caregiver.[35] Multidisciplinary meetings are often useful for bringing the team together and providing discussions regarding the spiritual aspects of care.

The spiritual approach by the healthcare team may include:

• The practice of compassionate presence - being completely present and watchful for their patients, being supportive of all their sufferings: physical, emotional, and spiritual;

• Active listening to patient's fears, hopes, pains, and dreams;

• Obtaining a spiritual history;

• Awareness of all dimensions of the patient and his/her family members: body, mind, and spirit;

• Incorporate attention to spiritual practices, if appropriate;

• Involve chaplains as members of the multidisciplinary team.[36]

WHO describes the professional evaluation of the patient's spiritual suffering, as well as physical and psychosocial suffering as an ethical obligation, regardless of whether the disease or health condition can be cured or not.[37] Furthermore, the American College Ethics Manual describes the spiritual approach as an indication of good medical practice in end-of-life care.[38] An important point to be highlighted in spiritual care is to avoid proselytizing, that is, the imposition of beliefs and values.[39]

Facilitating strategies: questionnaires for spiritual anamnesis and approach of religiosity and spirituality

A spiritual anamnesis is a history of beliefs or values that explicitly initiates a conversation about the role of spirituality and religion in a person's life. It may express as a relationship with God and/or with nature, art, music, family, or community. In other words, it is the gathering of beliefs and values that allow the individual a sense of meaning and purpose in life.[40]

Many spiritual needs are detected in cancer patients. In a review article, Lazenby et al. (2018)[41] described that meaning, purpose, hope, family and social relationships, support with spiritual practices, and specific religious concerns seem to be consistent with spiritual needs. [Table 1] enlists some of such spiritual needs.

Table 1 Spiritual needs identified in cancer patients

Finding meaning in the disease experience
Finding hope
Practice and assistance with meditation or personal prayer
Relationship with God or something beyond yourself
Finding meaning and purpose in life
Finding meaning in the illness experience
Being connected to God, other people, and nature
Having access to religious and spiritual practices
Having physical, psychological, social, and spiritual well-being
Talking about death and dying
Making the best use of your time
Being independent and treated like a normal person Questioning life's priorities and personal faith

This subject is of extreme importance for critically ill patients, cancer patients, and/or those reaching the end of life. Addressing patient suffering and asking questions that lead patients to think deeply about their experience can be oppressive, but can be useful when executed with sensitivity. It is important to first evaluate whether the patient is willing to initiate conversations regarding spirituality. Establishing bonds and trust allows patients to feel more comfortable discussing such an intimate topic. It can then be helpful to start with an open question to assess patient comfort with spirituality. Additional discussions about spirituality are welcome and open-ended questions such as “how”, “what”, “when” or phrases like “tell me about” are better accepted than questions starting with “why” that may come across as threatening (for example, “why do you believe that?”).

After a question, it is critical to listen to and observe the patient's response, in addition to nonverbal communication.[42]

Some open-ended questions can be useful to initiate discussions and patient interviews and may reveal important spiritual and religious issues.[42] [Table 2] enlists some examples.

Table 2 Examples of spiritual assessment questions and interview tools

What do you see as the purpose of your life now, since your body is not allowing you to do everything you used to do?
What is helping you cope with the disease?
What hopes and dreams do you have for your future? And for your family?
What do you rely on during periods of illness?
Are faith, religion, and spirituality important to you during the disease?
Tell me about a time in your life when you faced a great challenge. How did you get by? Is this resource available to you now?
Do you have someone to talk to about religious subjects? Would you like to explore religious subjects with someone?
Are you in peace?
What is the importance of spirituality or religion to you?
What is your understanding of how things are now with your illness?
What are your hopes (your expectations, your fears) for the future?
When thinking about the future, what is most important to you?

After an initial screening, a more detailed spiritual and religious assessment, in different domains, may be performed. There are specific instruments to be used in this assessment. Although these instruments are often used in the initial evaluation, they should also be used throughout the patient's disease experience, due to the dynamic characteristic of spirituality.

The Duke University Religion Index (DUREL) can be used to approach religiosity. It is validated in Portuguese in Brazil and consists of a five-item scale that evaluates the following religious dimensions: organizational and nonorganizational religious activity and intrinsic religiosity. It also briefly evaluates the involvement and dedication to the individual's religion.[43]

Several tools were developed in order to accurately evaluate spirituality. In a systematic review aiming to verify such tools in the Portuguese language, 20 instruments were found, most of which were translated in Brazil and maintained good internal consistency.[44] However, few scales were evaluated for all their psychometric qualities.

In another review that evaluated a total of 2,641 articles, 25 instruments were included. The authors independently evaluated each instrument and those better rated in the final analysis were the FICA, SPIRITual History, FAITH, HOPE, and the Royal College of Psychiatrists instruments. The use of each instrument should be individualized according to professional reality, available time, patient profile, and questionnaire settings.[45] Some of which are detailed below:

FICA: the FICA tool means Faith, Importance or Influence, Community, and Address in Care. It has adequate psychometric properties and may be used in many clinical conditions. Examples of questions to be used with this tool are: “Which spiritual beliefs are important to you now? What importance does your faith or beliefs have in your life? Are you part of a spiritual or religious community? How would you like your healthcare provider to use this information about your spirituality as they care for you?”

SPIRIT: the SPIRIT tool is used to ask about religious affiliation and the importance of religion in everyday life. In addition, it is used to learn about sensitive areas of care and to plan the end-of-life approach. Each letter has a meaning, i.e.: S - Spiritual belief system/P - Personal (spirituality)/I - Integration with a spiritual community/R - Rituals and restrictions/I - Implications for medical practice/ T - Terminality (planning).

HOPE: this tool includes questions such as: “What do you hold on to during difficult times? What gives you internal support in your life? Are you part of a religious or spiritual community? Do you have any personal practice of spirituality regardless of organized religion? Does your current situation affect your ability to do the things that usually help you spiritually?”. It is also a mnemonic: H - sources of Hope?/O - Organized religion/P - Personal spiritual and practices/E - Effects on medical care and end-of-life issues.

It is also important to mention the World Health Organization (WHO) Quality of Life Spirituality, Religiousness Personal Beliefs (WHOQOL-SRPB) FieldTest Instrument. It is a 32-item instrument that includes spiritual strength, meaning in life, admiration, connection, spiritual strength, hope, optimism, and faith.

A comparative study highlighted some of the advantages and disadvantages of such instruments. The FICA tool is validated and concise, in addition to having suggestions about how to approach discussions about spirituality, interface with health issues, and how to clarify patient expectations regarding the role of health professionals in meeting spiritual needs. Among the potential disadvantages of the FICA tool, the initial question, “what is your faith/belief?” may be interpreted with considerable religious connotations, potentially excluding those with spiritual needs who do not identify with any particular religion.

In addition, since there is no consensus on what “to be spiritualized” means, it is not clear how understandable is the question “do you consider yourself spiritualized?”. Some authors consider this instrument excessively rigid and may limit spontaneity and hinder the progress of the medical consultation. It also does not explore existential issues of patients approaching death, somewhat limiting its application in end-of-life care.[46]

The SPIRIT instrument is a mnemonic and, therefore, can be easier to approach the subject sequentially and logically, in addition to recognizing the differences between religious beliefs when asking which beliefs that are important or not to the individual. It also addresses the importance of a spiritual community, the role that the individual plays within such community, and their expectations. Explicitly addresses the spiritual and ritual practices that are important to the individual. It dedicates more questions to end-of-life concerns than other spiritual instruments, which encourages the patient to communicate any advanced directives regarding treatment, as well as to clarify aspects of care linked to spirituality at the end of life.

Notwithstanding, it lacks a consistent validation, also it is lengthy, and has a religious bias as it emphasizes religious beliefs, activity, and community. Not all patients are willing to answer the questionnaire, because there are direct questions about the extent to which the individual is adherent to the practices of his or her religious belief. While it is clear that sensitivity and good communication skills are prerequisites for the use of any spiritual evaluation instrument, it is possible that such direct questions may be perceived as threatening to the patient at a time when they are vulnerable to belief crises.[46]

The HOPE instrument has the advantage of being mnemonic and accessible. However, the initial avoidance of terms such as “spiritual” and “religious” may prevent barriers to further discussion. The authors use “source of hope, strength, comfort, and peace” as alternative terms. The tool explores the role of these elements in supporting the individual in difficult times, clarifying their importance for the present moment. When using the phrase “for some people...is this true for you?”, the patient may perceive the approach as less threatening and intrusive, easing communication regarding religious matters and spiritual beliefs. It specifically addresses the importance of spiritual practices for the individual, investigating traditional religious practices, as well as others, such as the role of music and nature. There is also an interface between spirituality and health, including end-oflife needs. However, it lacks validation, and has a western cultural bias, especially upon questioning “the type of your relationship with God”. This may be unintelligible to certain cultures. It is time-consuming, as the initial question assumes that a preliminary inquiry has been carried out.[46] Considering the evaluations described above, here are some important recommendations when making a spiritual history:

1. Consider spirituality as a potentially important component of the physical and mental well-being.

2. Address spirituality during the first clinical assessment and continue to address it at follow-up visits, if appropriate. Remember that spirituality is dynamic and accompanies the individual on his journey, from diagnosis to the end-of-life.

3. Respect the patient's privacy regarding spiritual beliefs; do not impose your beliefs on others.

4. Refer to chaplains, spiritual mentors, or resources related to the patient's spirituality, if appropriate.

5. Be aware that your own spiritual beliefs will help you personally in your meetings with all those you care about, which makes the doctorpatient relationship more humanistic.[40]

Observations and deliberations

If in the objective field the facts are lost before the interpretations, imagine in the dimension of human subjectivity, with all its reach and unfolding in the universe of choices in life. It is possible to do an exercise understanding health as a capacity to mobilize internal and external resources to deal with our own nature. A nature that has a physical expression, that is in constant transformation, transitory, perishable, fragile, and finite. There is also human nature, which is less tangible, which crosses “long distances” on the scale of time, whether through works, messages, stories, or mysteriously in the eternity of a possible immortal soul.

There is indeed a mystery. Even if we reduce, model, study and revise that theme, restricting the field of observation, there will always be a mystery. This is the dimension of spirituality. It is also a reason for referring to medicine both science and art. Art deals better with mystery. Even the most materialistic of material individuals will still be able to admit the mystery. Spirituality is revealed in the way one lives and deals with the most varied forms of life. Everyone is together in this process, connected and full of opportunities. The way choices are exercised encapsulates human spirituality: how looks, phone calls, demands, people, the diagnosis, the beginning and the end are received. This is how spirituality is practiced. There are no bibliographic references; it is unique and lived differently by each individual.

Despite the existing controversies and uncertainties regarding outcomes related to spirituality/religion, the importance of human capacity and the need to relate cannot be denied. The pro-social trait was and is a decisive element in its evolutionary process.[47] Spirituality can thus be seen as an expression of nature.

One element that can justify the different outcomes found when comparing spirituality/religion practiced in an organization compared to what is practiced on an individual level is the powerful effect exerted by the group that is established around the individual.[48] [49]

A threatening diagnosis such as cancer can cause feelings of loss of identity due to the limitations in the performance of previously played roles that may eventually occur. Recognizing this transitory nature, even from a biological point of view, can help to preserve the patient's identity. Those who have spiritual/ religious beliefs - a secular spirituality or religion - can access specific reference points that enable patients to recognize their own identity and also rediscover a sense of belonging. In that regard, humanism may be present among agnostics, atheists, and in all religions, being a structural axis in human experience.

When Seligman explains the important elements concerning well-being, using the expression PERMA, as Positive emotions, Engagement, Relationships, Meaning, and Achievements, he is also addressing spirituality.[50] Spirituality crosses paths with positive psychology,[51] with strong correlations between the traits of positive psychology and the level of personal spirituality. The sense of belonging takes place through established connections and is strongly nourished in the field of spirituality/religion.

Addressing spirituality presumes welcoming patients' utmost needs, with a solid doctor-patient relationship construction, and should be understood as an expression of care, in order to offer adequate patient-center care. This construction takes place over time, through welcoming and truly attentive listening, which empathically considers the patients' subjective experience that comes with such a difficult diagnosis. In this regard, it is important patients comprehend that they are seen as more than a diagnosis, but also as people. Once aware of a welcoming listening, the patient will know that he has a professional that will support him in times of crisis throughout his journey.

The anamnesis is a starting point in constructing a legitimate relationship, as familiarizing with the person in all their dimensions is a core element in this process. Information related to spirituality/religion is a component of the anamnesis that must be addressed in a natural and fluid way. The use of specific instruments to support the collection of such information is an important source of support, but should preferably be memorized, so it does not appear to be part of a standardized and mechanical script. The collection of these data can also occur progressively and does not necessarily need to be completed in the first meeting.

Once these issues are approached, it is possible to face a wide spectrum of situations that range from patient refusal to approach the theme to total openness, including interest of the patient in the physicians' own beliefs, and may also reveal guilt, stress, fatalism, and even the identification that this theme is not of interest to the patient.

Healthcare professionals should identify disposable resources, opportunities for supporting decision-making and treatment options, as well as issues that require the involvement of community and family members. Conversations that can be interpreted as a asking for prescription of a religious/spiritual nature such be approached with caution, even if there is an expressed demand on the part of the patient.

The integral care that seeks lenitive actions must understand that, besides physical pain, there may be emotional, mental, and also spiritual pain or suffering. The spiritual dimension also requires acceptance on behalf of the healthcare professional, especially when the patient's beliefs may interfere with therapeutic choices. An adequate rapport between the healthcare team and patient based on trust, hope, and the feeling that the patient is known by the physician can be of upmost assistance.[52]

Chaplaincy

Spiritual support is increasingly recognized as a factor related to the quality of care. The term chaplaincy, well established for over 1,000 years, refers to various types of religious/spiritual and pastoral figures, regardless of their bonds (volunteering or employee). Although it originally refers to a Catholic origin, this support does not solely depend on religious beliefs.[53]

In the hospital setting, chaplaincy presents itself as a source of spiritual support at a critical moment, when the patient's usual routine is interrupted. For patients and family members who have organizational spiritual practices, chaplaincy can mitigate an important gap that occurs with the hospitalization.

Some important factors may be highlighted when chaplaincy is offered along with appropriate clinical support: greater satisfaction with care, improvement in quality of life, reduction of therapeutic obstinacy, and greater referrals in end-of-life care programs (Hospice), in addition to a reduction in the number of deaths in the hospital.[28] [33] [54] [55]

Ideally, the hospital and the entire healthcare team should be aware of the identification of unmet spiritual demands, so that chaplaincy can be called.

IMPACT AND CARE

Diversity of practices, connections, and meanings - nonreligious practices

As stated previously, spirituality is related to quality of life and coping in cancer patients.[56] There is also a potential regarding the process of perception of suffering, coping with adversities, and the development of a critical awareness of experiences, enabling support and resignification of the processes of illness and finitude.[57] Spirituality is a universal human trait that encompasses different ways of being addressed, felt, and experienced, with both religious and nonreligious practices.[58] Some nonreligious practices will be commented on here.

Meditation is a secular practice associated with physiological and cognitive effects in several studies, promoting spiritual awareness and transformation.[59] [60] Eastern and Buddhist traditions have a philosophical and moral system that dialogues with existential anxieties.[60] From such traditions arise practices without religious bonds, such as mindfulness meditation for stress relief and mindfulness-based cognitive therapy, as created by Jon Kabat-Zinn.[61] These practices support health and may be related to spirituality, for example, when working on issues of self-control and reactivity, impacting the relationship of the practitioner with people and with the world around them. Thus, it allows for different experiences of coping with existential questions and with the impacts of illness and treatment.

Among the Indo-Tibetan traditions, Yoga is an important health and spiritual practice, using breathing (Pranayama) as a possibility for developing physical well-being and preparing for deeper meditations. The practice allows resilience to stress and the potential for a compassionate assessment of suffering.[62] A review of 24 phase II and one phase III clinical trials reported that low-impact Yoga, particularly low-impact Hatha Yoga and Restorative Yoga, are feasible and safe, and they are useful in the treatment of sleep disorders, cancer-related fatigue, cognitive impairment, psychosocial distress, and musculoskeletal symptoms in patients receiving chemotherapy and radiotherapy, as well as in survivors.[63]

Art is the result of human creativity and is considered a skill that can be learned by study, practice, and observation, working as a means of expression and also as stimuli, motivating neuroscience and neuroimaging studies.[64] A systematic review on mindfulness-based arts interventions with cancer patients, including 13 studies, eight of which were randomized clinical trials, showed a significant benefit on quality of life and psychological and spiritual well-being.[65] Music therapy can also be promising and a systematic review with seven studies (five randomized) demonstrated association with improvement of spirituality, evaluated in four studies with measures related to spiritual well-being.[66] [67]

Another important coping strategy is contact with nature. This strategy is highlighted in a Swedish cancer patient study and demonstrated two trends for this contact: search for spiritual proximity to God or a supreme being, and search for natural romanticism. Possibly, the influence of culture can help to understand such trends.[68] Another intervention that has been highlighted is animal contact, from pets in general to dog therapy, enabling means of connection and spiritual care, especially in hospitalized patients.[66]

It is also important to highlight relationships as practices devoid of religious bonds. An Australian study evaluated the experiences of spiritual care for patients and family members and indicated the power of relationships for strengthening spirituality from the perception of the individual being treated as a person, remembering his/her abilities, and possible conversations about what his/her considered important.

This study also demonstrated the importance of maintaining contact with friends and family, including various means of communication and interaction.[66]

Religion and coping

Religion can be defined as the set of practices and dogmas performed by a given group, which can influence mental health, habits, and addictions, potentially impacting physical health. As previously discussed, spirituality is part of and contributes to the care of cancer patients and religion is a resource and source of support and meaning.[5] [66] [69]-[72]

However, it is also possible to associate certain religious beliefs in an unfavorable way to coping. As an example, we highlight the association of the disease with punishments or the understanding of the disease as a consequence of guilt.[70]

The term religious coping can be defined as the use of religious strategies to help deal with conflicts and stress arising from an adverse situation or crisis, such as illness, treatment, and possible unexpected outcomes.[73] Therefore, the use of religion, including practices, community support, and scripture interpretations in search of meaning, can occur in a way that favors (positive) or not favors (negative) coping of both the patient and his/her family members. Therefore, coping will have impacts that require attention from the multidisciplinary team for care.

Communication

Throughout the natural history of the disease, cancer patients should be familiarized with the terms used by healthcare professionals in order to enhance communication, ease alignment of expectations, understand the treatment, and facilitate patient care. This process empowers the patient to become the main decision-maker and allows an adequate assessment of the potential treatments offered. Some terms such as healing and hope, miracle and expectation, can dialogue with spirituality. Spirituality, besides helping to cope with suffering, can sustain empowerment and the construction of hope to enable decision making.[57]

It is also worth highlighting the concept of dysthanasia, which is the prolongation of the dying process. The term is also used for useless treatments that do not bring benefits or modify the disease course. Other related terms are therapeutic obstinacy and medical futility.[74] It is important that the construction of effective communication gives way to clarification, welcoming, and explanation of the subjective meanings of some terms, making care objectives and directives more approachable with conciliation and less conflict, respecting the integrity of the human being with its singularity, favoring treatments and dignifying care patient care.

Approaching the family

Families of cancer patients are also involved in care dynamics and issues related to the natural history of the disease including practical issues related to patient care and support, conflicts, and emotional and spiritual suffering. It is important to emphasize that this view must include, besides the family members, caregivers and those belonging to the sphere of patient relationships, who are somehow implicated in support.[75]

A systematic review published in 2020 highlights the strain and burden upon cancer patients. Those individuals are involved in the management of multiple symptoms and various treatment modalities, as well as a set of uncertainties that accompanies the course of the disease. Among the possible strategies to assist caregivers, psychoeducation and cognitive-behavioral approaches stand out as the main interventions. The effectiveness of spiritual interventions is not established due to the limitations of the methodology of the included studies.[76]

In a systematic review published in 2012, on unmet demands from partners and caregivers of people with cancer, spirituality was included among the six domains of needs. A common unmet need is related to feeling there is hope for the future, besides the spiritual support itself. The review highlighted the few studies available on spiritual needs involving family members and caregivers of cancer patients.[77]

Another review published in 2008 evaluated the quality of life of family members and caregivers along the course of the disease, revealing the oscillation and dynamics of quality of life components, including spiritual well-being. The existential questioning associated with the diagnosis of cancer may persist and accompany family members after the end of treatment, especially when patients become cancer survivors. In the context of advanced and end-of-life disease, the strain of spirituality is shown in studies on the impacts of religious coping on quality of life. These impacts continue during mourning.[78]

Regarding religiosity, studies show the importance of understanding the patient family's meaning of religion in both sickness and health with beliefs being an important available resource for coping. Religious symbols throughout the disease and finitude are potentially reinterpreted and reused uniquely impacting in multiple different ways family spirituality and coping.[79]

Therefore, attention to caregiver and family spirituality is of upmost importance as it allows a possibility for approaching the burden of demands during the disease, as well as the impact of spiritual needs. It is worth mentioning that the same ethical and communication principles of the patient's approach such be used, with the caution to detecting possible conflicts that concern the needs and suffering of the patient.

Healthcare team

Awareness of one's spirituality impacts directly on patient care. It is important to recognize the influence of one's uncomfortable feelings and needs in response to the perceived suffering of others.[80] Moreover, the potential for personal development of those who care for people in suffering also occurs through the need to come into contact with one's awareness regarding values, beliefs, attitudes, and finitude itself.[81]

The religion and spirituality in cancer care study showed that healthcare professionals with lower spirituality do not wish to receive training on spiritual care. This article discusses the impact of training for adequate spiritual care through awareness of the importance of spiritual care, education for the identification of spiritual needs, development of competencies that preserve patient autonomy, and also reflections about the spirituality of professionals themselves.[82]

A Brazilian literature review discusses spiritual care not as a set of interventions, but as an attitude of care, with planning of actions that promote well-being and meaning of life. This review highlights the importance of spiritual care regardless of the healthcare professional's own beliefs, reinforcing that the difficulties related to the professional's spirituality may interfere with the ability to offer care. The interdisciplinary model of spiritual care is also discussed, where there is the sharing of responsibility for spiritual matters among all team members, enhancing the scope and quality of spiritual care.[83]

It is understood that approach to spirituality requires empathic communication, suggesting that healthcare professionals should not act with criticism when patients' beliefs and values conflict with their own. It is also important to pay attention to the limits involved in the actions and functions of healthcare professionals. As an example, we highlight the need to differentiate the understanding between spiritual concerns from direct counseling and a certain type of spiritual support to the patient. Some situations may strain these limits, for example, when patients believe that God (or a higher power) is working through healthcare professionals.[84]

Also, regarding the attention to function and limits of action, it should be emphasized that spiritual care, preferably occurring as a team, comprises from access to issues and possible spiritual needs to appropriate referral and support. Anamnesis or spiritual history and the tracking of spiritual needs may be performed by any team member, provided that he/ she is aware of the objectives and strategies, building the appropriate assessment and possible ways for the follow-up. Healthcare professionals should also be aware of the potential of their issues impacted. Then, the appropriate support occurs with the assistance of chaplaincy and/or services and communities related to the patient, considering the particularities and settings of the moment of care.[85] Some aspects of the relationship between the healthcare professional and patients need to be highlighted. The imbalance in this relationship and the loss of the patient's sense of control when facing a severe illness can enhance the role and function attributed by the patient to the healthcare professional. The professional has the moral obligation of reliability and take actions based on the patient's best interests, and one should never explore the patient's weakness or condition of vulnerability. Thus, it is reinforced that proselytizing - the intention of or the action of imposing practices or beliefs on the other - is a violation of the trust placed in such relationship and inadequate to healthcare professionals. Addressing spirituality does not imply finding or suggesting answers to the other's questions, but rather allowing a dialogue in an empathetic way about the spiritual needs of each patient.[81]

In summary, healthcare professionals have the role of aiding and caring for the suffering of cancer patients at any time in the natural history of their illness. The recognition of limits, finitude itself, and impotence in the face of irreversibility enables the professionals to get closer to spiritual needs and care.[85] This care mobilizes its own resources and questioning, and it is important to establishment boundaries that allow attention to spiritual needs in a dignified and ethical way, with a look at the real demands of patients and family members, as well as the healthcare team.

Also, regarding the healthcare team, there is an important discussion and reflection about burnout and compassion fatigue and the potential of spirituality to impact these issues.

Burnout is a term that indicates a human reaction to something external, commonly defined as a work-related syndrome, characterized as emotional exhaustion, depersonalization, and low personal fulfillment. It usually occurs in a situation of high demand coupled with insufficient resources. It is important that burnout is adequately differentiated from other mental health disorders that require specific attention and care, such as major depressive disorder.[86]

Moral injury is a syndrome studied in military populations, associated with events such as suicide, depression, anxiety, abuse of psychoactive substances, and self-destructive behaviors. It is the result of a violation or transgression of moral limits, reflecting the difficulty in dealing with the imbalance between the way certain actions occurred and how they should occur. Due to professional dynamic changes, moral injury is observed in work environments related to healthcare and may be present in high overload situations. Thus, attention to moral injury is also necessary when bringing the discussion about burnout and mental well-being in healthcare professionals.[87]

Compassion fatigue is described as a decrease in the ability of the healthcare professional for caring due to repeated exposure to patient and family member suffering. Among the factors associated with compassion fatigue are working conditions, such as professional environment, work overload, and the intensity of exposures.

These factors should also be present in the discussions about burnout and the mental health of healthcare professionals.[88]

In parallel with the greater presence of spirituality in the care proposed by the biopsychosocial model, the spirituality of the healthcare professional has also been highlighted when discussing possibilities of self-care related to the impacts of professional practice. Thus, spirituality is related as a means of searching for meaning and purpose, besides being a component of the construction of one's identity. It is also considered as a potential variable when facing situations of high demand and complex care.[89]

The care for people in suffering, common in the natural history of cancer, has a potential impact on those involved. This impact may affect the quality of the relationship and the follow-up of patients and family members. Here the authors attempt to prompt a reflection on the possibility of spirituality and the meaning of professional performance as coping variables for healthcare professionals when facing conflicts and work-related strains.[81]

A study conducted in four cancer centers in the United States, with both inpatient and outpatient nursing teams from adult and pediatric patients, evaluated the presence of burnout and possible variables related to stress management through questionnaires. Spirituality was pointed out as the main mechanism for dealing with stress, followed by support among co-workers and religious beliefs.[90]

Another study evaluating healthcare professionals involved in the care of people with cancer, including medical and nursing teams caring for inpatients and outpatients, evaluated variables related to symptoms of burnout and spirituality. Professionals with higher religious self-perception had a lower decrease in empathy, less depersonalization, and less emotional exhaustion in comparison to those with lower religious self-perception.[91]

Another literature review published in 2015, on the approach to spirituality by medical teams, discusses the potential impact on aspects related to end-of-life care and the greater propensity to burnout. Among these aspects, emotional and spiritual needs are highlighted. This review emphasizes the importance of recognizing that training in spirituality communication can benefit teams both in the ability and quality of care and in the personal spiritual growth, that is, in the team self-care.[92]

The process of professional development, including the recognition of vulnerabilities and the recording of uncertainties regarding suffering, makes it possible to sustain the dynamic construction of care practice. Spirituality may configure as a possible mean to access and explore these variables intrinsic to the care process, and may become a resource that, at the same time, preserves the real possibilities of action of the professional. Such suggestion also allows for powerful care for all individuals involved.

Existential matters and psychotherapy

In the philosophical tradition, the sense is defined by Aristotle as the faculty of feeling and undergoing alterations by the work of external or interior factors. Sense includes both the ability to receive sensations and awareness of their existence (“meaning”). Thus, sense can have a definition that brings it closer to meaning, providing, among other explanations, the understanding of emotional and symbolic meaning.[93]

Illness is associated with a potential search for the meaning of suffering. The meaning implied to the same event can have, simultaneously, cognitive, emotional, physical, and spiritual meanings. The spiritual or transcendent meaning may reduce suffering through its contextualization in a broader dimension and by sharing with others. This experience does not need to involve religion.[94]

In a historical context, it is worth mentioning that philosophy and psychology are inserted in the history of the culture of humanity, thus including the long-standing questioning about meaning. Psychology was proposed as a science at the end of the 19^th century, but the scientific project of psychology is complex, with distinct and plural theoretical-methodological approaches to the human being. Each approach contributes with different ways of understanding subjectivities and forms of interventions in specific fields of action.[95]

Briefly, among the various approaches to clinical psychology, three broad categories may be mentioned: psychodynamic, behavioral, and existential. As for the psychodynamic approach, psychoanalysis can be presented, from Breuer and Freud, and Jung's analytical psychology, aiming to interpret latent meanings and unconscious motivations of human actions. The behavioral approach focuses on the behaviors of the human in his relationship with the environment, having Skinner as one of the representatives. The existential approach, influenced by the Phenomenology of the 1950s, aims to understand human existence and considers the meaning of life as a central question, and Carl Rogers and his person-centered therapy as one of the representatives.[96] [97]

Carl Gustav Jung's psychodynamic approach brings, among other important contributions, the psyche as a space of the experience of the numinous, with the numinous term designating a state inspired by transcendence. Transcendence for C.G. Jung can be conceptualized as a function that deals with the union of the conscious and the unconscious contents. This function can occur through symbols and has importance in the process of individuation of a person. Analytical psychology, through the confrontation between meaning and lack of meaning, and numinous experiences, enables a process of individuation that is therapeutically monitored.[98]

On the other hand, the existential approach includes, among other references Viktor Frankl, and logotherapy. Frankl developed, from observation and his own experience in a Nazi concentration camp, the questioning of the meaning of life and the possibility of maintaining inner freedom in conditions of extreme dehumanization. Among the fundamental concepts discussed by logotherapy are the desire for meaning as the primary motivation of an individual's life, frustration, and existential emptiness, and the potential of awareness of the human's responsibility in creating a dynamic meaning for his life.[99]

To illustrate the impact of these approaches, two randomized studies conducted by William Breitbart are of relevance. Breitbart developed meaning-centered therapy using logotherapy in cancer patients. The first study included 90 patients with advanced cancer and group meaning-centered psychotherapy. The second study included 120 patients with individual meaning-centered psychotherapy intervention. Group psychotherapy consisted of eight weekly meetings and the individual psychotherapy consisted of seven weekly meetings, addressing, among other topics, sources of meaning, past legacy, and perspective of future legacy after death. Both psychotherapies had benefits related to spiritual well-being, and the group intervention also obtained results related to the improvement of the sense of meaning, anxiety, and wish to die, and the individual psychotherapy was also associated with improving quality of life and stress.[100] [101]

In summary, the attention and monitoring of spirituality and its existential issues can involve psychology as a science and profession, emphasizing the plurality of possible approaches in terms of theories and techniques. Discomfort and the search for meaning are potentially exacerbated by the suffering during the natural history of cancer. The history of humanity in philosophy and psychology brings the possibility of resources that sustain the possible and necessary reflections about human existence.

Cancer survivors - personal growth potential after the illness process and treatment.

According to the National Cancer Institute (NCI), an individual is considered a cancer survivor from the time of diagnosis through the end of his/her life.[102] In the United States, the number of cancer survivors was approximately three million in 1971, rising exponentially to 16.9 million in 2019.[103]-[105] These numbers are estimated to exceed 22 million by 2030. This increase is attributed to the increased incidence of cancer, resulting from an expanding and aging population, as well as advances in cancer-specific survival due to early detection and treatment.[105]

The patient's continuum of care after a cancer diagnosis represents a period of potentially distressing events, when patients first must adapt to a new routine related to the diagnostic investigation, staging tests, and initiation of specific treatments. Among cancer survivors, in the United States, the 5-year survival rate is found to be more than 67.7%.[106] Even among survivors who remain free of cancer recurrence, the distress caused by the impacts of a cancer diagnosis and the late and long-term effects of treatment tend to last long throughout life.

The distress among cancer survivors may result from the cancer diagnosis itself, its residual impact on the sense of control and/or self-efficacy of survivors, or even from a need not met because of overwhelming amounts of information. All these factors can reduce the quality of life of cancer survivor patients.[107] Distress can present as fear, sadness, anger, concerns about the future, financial and spiritual concerns, or existential concerns.[108] The intensity of patient distress or anguish can range from normal fear and sadness to debilitating depression, anxiety, social isolation, or spiritual crisis. The National Comprehensive Cancer Network (NCCN), National Cancer Institute (NCI), and National Consensus Project for Quality Palliative Care (NCP) endorse routine assessment and documentation of distress among cancer survivors in all healthcare environments, followed by appropriate intervention, if necessary.[108]-[110]

However, although the literature is replete with anamnesis guidelines and distress management related to psychological, social, and physical aspects among cancer survivors, the spiritual components of the distress have been somewhat overlooked. Physicians often forget to address spiritual well-being among survivors, although this has been identified as an important factor in health-related quality of life (HRQoL).

Spiritual distress is a broad concept that is not necessarily associated with specific religious beliefs, practices, or affiliations. As previously mentioned, spirituality remains difficult to be defined and measured with precision, but there is a consensus that it refers to a connection with a broader reality that gives meaning to a person's life. It is experienced through a religious tradition, or, increasingly, in secular Western culture, through meditation, nature, or art.[111] Some definitions emphasize the differences between spirituality and religion,[81] [112] others emphasize their overlapping dimensions,[113] while others favor the concept of religion rather than spirituality in healthcare research since the latter is more difficult to measure accurately. However, both religious and nonreligious people may have a strong sense of spirituality.[109]

Spiritual well-being has been related to the following aspects of HRQoL among cancer survivor patients: lower levels of anxiety, good health habits, hope, greater life satisfaction, and better psychological adjustment.[114] However, according to a review published in 2017, regarding the instruments used to assess the needs for supportive care among breast cancer survivors, of the 82 tools evaluated, only four (4.8%) addressed the spiritual concerns of survivors.[115] Another recently published study aimed to evaluate the performance of healthcare professionals by self-report in the spiritual care of cancer patients.

Of the 340 participants, 82.1% were women, with a mean age of 35 years. In the study, 64.7% were nurses, 17.9% were physicians, and 17.4% were “other” healthcare professionals. There was a difference in the professionals' observations about discussing religion & spirituality (R&S) issues with the patient.

Specifically, nurses asked more often about R&S (60.3%) than physicians (41.4%) (p=0.028). In addition, nurses referred more frequently to chaplaincy (71.8%), while physicians and other professionals more frequently consulted psychology/psychiatry (62.7%, p<0.001). Perceived barriers to discussing R&S topics included potentially offensive patients (56.5%) and time constraints (47.7%).[116] Therefore, raising awareness and training all oncology and primary care healthcare professionals on the importance of evaluating the spiritual well-being of cancer survivors is essential for providing comprehensive care to this population.

Studies have reported a strong association between spirituality and HRQoL. In a holistic view of human beings, the anamnesis of spirituality should be revisited in every interaction made by the members of the multi- or interdisciplinary team, who participate in the care of cancer patients.[81] [117] An increasing number of studies in the cancer scenario have shown that most people diagnosed with cancer want to use or use spirituality to help them cope with cancer diagnosis and treatment, resulting in the possibility of personal growth.[33] [118]

A Brazilian study, published in 2013, reported that 80% of patients wanted to receive spiritual care, and 93% considered spiritual approaches important to help cope with the disease. However, only 16% of the participants reported having talked about the topic with some professional involved in the care.[119] A possible explanation for the use of spirituality as a mechanism for coping with cancer is the fact that spirituality allows patients to assign meaning to their illness and elaborate answers to existential questions.

On that note, Park et al. (2018)[120] described a model in which spirituality is fundamental to shaping a broader and more global belief structure of a person.

Few studies have compared different strategies for assessing spiritual distress followed by interventions among cancer survivors. Therefore, each oncology and/or palliative department must discuss the best strategy with the entire team involved in the development of the survivorship program. The [Figure 1] is a suggestion for managing spiritual needs in the continuum of care of cancer survivors.

Figure 1 Spiritual needs pillars in the survivorship care continuum.

Upon approaching and offering spiritual support for cancer survivors, the lack of data on some minority populations is even more pronounced, including indigenous people, children, and young adults. Nevertheless, it is known that spirituality plays an important role in these populations, and therefore multidisciplinary teams must develop programs flexible and adaptable enough to meet the individual circumstances and demands of each patient.[121]-[123]

Spirituality is an important aspect of the journey of many cancer survivors around the world. While there is still much to be learned, scientific evidence is strong enough to demonstrate that researchers, physicians, and multidisciplinary teams should be aware to the spiritual aspects of cancer survivors' experiences.

CONCLUSIONS AND CHALLENGES

There are several continuing obstacles to be faced in oncology. The journey is trying, and strenuous, but also many triumphs along the way. In various possible situations, either during treatment with curative intent or in those in palliative care, where disease cure is not a possibility, along with the scientific advances in medicine, an important challenge still remains in applying the aphorism attributed to Hippocrates to always comfort and relieve when the expectation of remission is no longer feasible.

These are moments that, as mentioned in the consensus, the exercise and use of the spirituality approach during visits should be stimulated, and can be carried out naturally, and swiftly.

In the past decades, studies on spirituality, religiosity and their influence on health have been increasing in volume and in quality, stimulating discussions such as the ones included in this material. The challenge is how to encourage debates within the academic environment, integrating the subject within regular disciplines during the formation of the healthcare professional and, consequently, improving research methodology of such a broad and simultaneously abstract theme.

Acknowledgment of patients' faiths, beliefs and what brings sense and meaning to life has proven to be challenging for oncologists in general. Along with, identifying the degree of importance of such matters within his life, as well as his doubts and spiritual anguish related to the events during the treatment and his care. Furthermore, consideration should be given to the impact that spirituality has on the decision-making process.

Spirituality can promote a better understanding of finitude, support coping with reality, and the exercise of autonomy, and quality of life. As stated by the writer and expert on human behavior Leo Buscaglia, “No one can give what they do not have”, thus, healthcare professionals must incorporate spirituality into daily practices in order to offer adequate ethical and satisfactory spirituality to patients, as an ally to the strengthening of resilience.

The approach of spirituality by the oncologist strengthens the bond with the patient since he understands that this part of his life is also important for the professional. Therefore, as reported, most patients would like to be asked about their spiritual concerns, either by the doctor or by other members of the healthcare team. Trust and attention to patient spiritual needs are value and strengthen the care relationship. This connection can even stimulate the physician to look at himself, turning to self-knowledge and elaborating questions about life and the good practice of medicine.

The appropriate practice of medicine must be consistent with science. However, healthcare professionals should also be attentive to not attribute magical qualities to spirituality, beyond the current scientific data. There is a fine line between reality and imagination and such magical qualities of the abstract spiritual universe can often be desired by both the patient and the multidisciplinary team. As such, with a conscious healthcare team regarding not only the importance, but also the role of spirituality patients can be shielded from illusions of alternative and unconventional therapies, often of high cost, and lacking evidence of efficacy, in addition to resulting in physical and emotional exhaustion.

Most of the technical information published regarding the benefit of spirituality in cancer patient treatment refers to a significant improvement in their quality of life, with potential better coping with their condition, assurance in both healthcare team and in treatment.[124]

Finally, artificial intelligence and machine learning are being developed within oncology and in various other medical specialties. This is perceived in the performance of tasks previously done by humans, such as image recognition, pathological anatomy, standard, genetic and molecular staging, shared analysis in databases, and deep learning protocols with progressively more accuracy and lower margin of error. For this reason, the spiritual role in care will become even more necessary for a humane interpretation of machine captured data, assisting patients, other human beings, to connect with its essence and translate the message that illness carries.

There are many and continuous obstacles to be faced in oncology. The most important is to observe what becomes as the challenges are overcome.

Conflict of Interests

The authors declare no conflict of interest relevant to this manuscript.

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Publication History

Received: 13 May 2022

Accepted: 03 July 2022

Article published online:
02 August 2022